Copyright © 2015-2023 Michael P. Loucks

Сам Себя Издат

First publication date: TBD

First revision publication date: TBD

You may contact the author at: author@michaelloucks.com

https://a-well-lived-life.com/

Scripture taken from the New King James Version®. Copyright © 1982 by Thomas Nelson.

Used by permission. All rights reserved.

For Jennifer

Other Books in This Series

Freshman Year

Sophomore Year

Junior Year

Senior Year

Medical School I

Madical Shool II

Medical School III

Medical Schoo IV

Residency I (*)

Work in Progress

Other Books by Michael Loucks

A Well-Lived Life, Series I

Book 1 - Birgit

Book 2 - Jennifer

Book 3 - Pia

Book 4 - Bethany

Book 5 - Stephanie

Book 6 - Kara I

Book 7 - Kara II

Book 8 - Stephie

Book 9 - Anala

Book 10 - The Wife

A Well-Lived Life, Series 2

Book 1 - Bethany

Book 2 - Stephie

Book 3 - Jessica

Book 4 - Elyse

Book 5 - Michelle

Book 6 - Samantha

Book 7 - Sakurako

Book 8 - NIKA

Book 9 - Kami

Book 10 - Bridget

A Well-Lived Life Series 3

Book 1 - Suzanne

Book 2 - The Inner Circle

Book 3 - A New World

Book 4 - Coming of Age

Book 5 - The Pumpkin Patch (*)

Cliimbing the Ladder

Book 01 - The First Rung

Book 02 - The Second Rung

Book 03 - Climbing Higher (*)

From the Files of Doctor Fran Mercer (*+)

A Sailor's Diary

Book 1 - The War Years (*+)

Work in Progress

+ Available exclusively on Patreon or BuyMeACoffee

I. The Doctor is IN (or is he?)

May 25, 1989, Graduation Day, McKinley, Ohio

I accepted the leather-bound diploma from Doctor Warren with my right hand, instead of the usual left, as Rachel was in my left arm and was snuggled against my chest. I tucked it under my arm and shook his hand.

"Congratulations, Mike," Doctor Warren said. "An excellent valedictory oration."

"Thanks."

"She's beautiful. And it was a nice touch to walk her across the stage."

I smiled and nodded, but had to move on, as Tom Meyer's name had been called and he was right behind me. I shook hands with the other deans, then the President of the Medical School Board, and then returned to my seat. Just under fifteen minutes later, Medical School Board President Thomas Abbott gave us our commission to serve our fellow men, and closed the ceremony.

"Dada? Eat?" Rachel asked.

"As soon as we get to Mama," I said. "She has some cookies and juice for you."

I found my extended family and friends, and went to give Rachel to Kris, but Grandma Borodin intercepted. I let her know Rachel was hungry, and Kris gave Rachel's bag to my grandmother. Kris gave me a quick hug, but protocol dictated what I did next. I turned and took two steps to where my bishop was standing.

"Congratulations, Mischa," Bishop JOHN said.

"Thank you, Vladyka."

"A very good speech, one worthy of publication in the church bulletin of every parish in our diocese. It's a message that applies to all Orthodox Christians."

"I'm honored," I said.

"Then with your agreement, I'll have it published."

"I agree."

"Your grandfather looks as if he's about to burst!" Vladyka said with a smile. "I think I've monopolized you long enough!"

"Master, bless," I said.

I turned my hands up, and he gave his blessing, then I turned and took a step over to my grandfather.

"Congratulations, Mike!" my grandfather said.

"This one will result in wearing white, not black," I replied with a smile.

"Speaking of that," he said with a smile.

He handed me a package and nodded that I should open it. I did and found a long white medical coat, signifying a physician, rather than the short one signifying a student. Embroidered in black above the pocket was 'Doctor Michael P. Loucks'.

"Thank you, «Дедушка»," I said.

"You're welcome, Mike! Stefan and I reserved the overflow room at the steak house in McKinley and everyone is invited, including Viktor. I spoke to His Grace and he'll join us, and per your mother, I cleared it with Kris. Your friends are welcome, of course, though I expect Svetlana Yakovovna will want to be with her parents."

I laughed, "I haven't called her that in ages! And yes, she's going to be with her parents and grandparents tonight. Maryam, Fran, Peter, and Nadine all have their parents and others here as well. We're having a get-together at the house on Sunday."

"Congratulations, Mike!" Stefan said, coming over to us.

That started a string of congratulations from everyone else who was there - my mom and dad, my two grandmothers, Paul and Liz, Holly, Jocelyn and Gene, José, Lara, the Korolyovs, Doctor Smith, Doctor Forsberg, Doctor Casper, Doctor Strong, Doctor Roth, and Doctor Gibbs, who looked about ready to pop.

"You should not be here!" I said, looking at her positively huge abdomen.

"My feet and my hemorrhoids agree with you!"

"TMI, Doc!" I chuckled. "You aren't a patient!"

"I'm losing patience with Bobby Junior right now! And with his dad!"

"I bet! Go home, Doc! Doctor's orders!"

"That didn't take long!" she said, laughing. "Did you get your schedule for next week?"

"Yes. I'm on Bobby's three twenty-four-hour shifts starting at 0700 on Monday, Thursday, and Sunday."

"When do you leave for your vacation?"

"The Monday following my last ride-along shift, so Kris will do most of the driving. It's only about six hours, so I'll get a two hour nap before we leave."

"Sorry about that."

"Don't apologize! I want to do this. It'll be instructive and interesting to see what happens before the guys roll the patients out of the squad. It's just too bad they're Squad 2!"

"There are only twelve in the county, so no 'Squad 51' for you!"

"The real bummer is that fire stations no longer have poles to slide down!" I declared.

Doctor Gibbs laughed, "True, but they do have the mandatory Dalmatian!"

"What's his or her name?"

"Brigid, because she's the Irish goddess of the hearth and sacred flame, as well as of water."

"That makes perfect sense."

"Bobby named her."

"I have one for you," I said with a smirk. "Cerberus, the hell-hound and guard dog of the Underworld, comes from the root Indo-European word '∗k̑érberos', which evolved into the Greek word kerberos, which changed to Cerberus when it went from Greek to Latin. That Indo-European root word '∗k̑érberos' means 'spotted'. That means that Hades, Lord of the Dead, literally named his pet dog Spot!"

Doctor Gibbs laughed, hard.

"Don't do that! You'll make me go into labor!"

"I think there might be a doctor or two here to assist," I chuckled.

"More like two hundred! But there is no way YOU are delivering my baby!"

"I'd say 'The Doctor is IN' and ask for 5¢, but the LAST thing I want to do is deliver your baby! Now go home!"

"Yes, Doctor," Doctor Gibbs smirked.

We exchanged a light hug, she left, and I spent a few minutes speaking with Anicka and Milena, then our entourage began filing out of the auditorium. As we were walking to the parking lot, Maryam called my name so she could introduce me to her parents, and more importantly to Matta, who I was sure would be her husband in less than a year. We shook hands, but really didn't have time to talk. He was heading back to Chicago with Maryam's parents, so wouldn't be at the house on Sunday.

"I should go home and change," I said to my grandfather. "We'll meet you there about fifteen minutes after you arrive."

"OK."

Kris took Rachel from my grandmother, and we got her settled in her car seat in the back of my Mustang, then got in so we could head home.

"How do you feel, Mike?" Kris asked as I pulled out of the parking lot.

"As I said to Doctor Casper and Doctor Gabriel, the most important thing was the Match. To me, the Match letter was a bigger deal than the diploma. Graduating without Matching would have been depressing, and graduation has been a done deal since I passed all my core rotations."

"You're not excited?"

"I am, just not as excited as I think you expect me to be!"

"How about later?" she asked in her sultry French accent.

"You always excite me!" I declared.

"Dada Mama kiss!" Rachel giggled.

"Dada is driving," I replied, laughing, then said, "OK, who taught her THAT?" I asked.

"My sister, I bet!" Kris replied. "Like most fifteen-year-olds, she's very curious about that part of life! And I could just see her teaching Rachel to say that to tease you."

"Me?"

"You! She knows better than to tease me!"

I laughed, "Hell hath no fury like the elder sister scorned?"

"You know we really don't torment each other the way you and your sister did, or even the way you and Jocelyn did."

"Or Clarissa?"

"That's more like, well, a married couple, than anything. I'm positive if she were straight, you two would have married long ago."

"You aren't wrong," I replied. "But I've known her orientation since Freshman year. Angie was around then, and you know how I felt...feel about her. Sorry."

"Don't apologize," Kris said. "There is literally nothing you can do to change the past, and I don't feel slighted because you care for Angie and want to help her. I want you to help her."

"Thanks. What did I do to deserve you?"

"You listened to my cousin!" Kris declared mirthfully. "We each now have the doctor best suited for us!"

"I'm curious..."

"Doctor Casper needs a devoted wife who will spend quiet, relaxing time at home with him; you need a partner in crime!"

I laughed, "Clarissa, Jocelyn, or both?"

"Both! And your mom."

"Of course," I chuckled. "The three women who basically ruled my life until Elizaveta and Rachel came along!"

"Clarissa still does, at least outside our house."

"But never in a way that would interfere with my relationship with you," I countered. "She helped shape me into the man I am today. You would not have liked me eight years ago!"

"Eight years ago I was ten!" Kris declared mirthfully.

"You know what I meant!" I countered.

"I do, of course."

"And inside our house?" I asked.

"We both know who's really in charge."

"Rach!" my daughter giggled.

"Uh oh," I said quietly. "We're so dead!"

"Dada?"

"Yes, Rachel?" I inquired.

"«Zha'tim»!"

"I'm not sure what you just said, Rachel," I replied.

Kris laughed softly, "I think she tried to say «Je t'aime»! My sister strikes again!"

"Rachel, «Je t'aime»!" I said.

"Mama! «Zha'tim»!" Rachel declared.

"«Je t'aime, mon petit lapin!»" ("I love you, little bunny rabbit.")

"So it would appear she's going to learn French after all," I said as I pulled into the driveway of our house.

"Is that a problem?" Kris asked.

"Not really," I replied. "We had decided not to teach her Russian, at least as a toddler, but I'm sure she'll pick up the odd phrase here and there from my grandparents or Clarissa, who will, no doubt, revel in teaching my daughter how to tease me in Russian!"

"Clarsa!" Rachel exclaimed. "Love Clarsa!"

"Ok, now I'm positive I'm doomed!" I declared.

"Poor baby," Kris teased.

"Yeah, yeah," I chuckled. "I will admit that I signed up for this willingly."

"Perhaps you just need some personal attention later, after Rachel goes to bed?"

"Perhaps I do!"

I parked, we got out of the car and went into the house. While I took off my graduation regalia, Kris changed Rachel's diaper and packed food in her bag, as there was no way Rachel could eat anything at the steakhouse except perhaps the warm breadsticks they served with the salads and some baked potato.

We had an enjoyable time at dinner with Bishop JOHN, my extended family, including the Korolyovs, José, Lara, and Jocelyn and Gene. After dinner, Kris, Rachel, and I headed home, and once Rachel was in bed, Kris supplied the personal attention she'd promised.

May 26, 1989, McKinley, Ohio

"What do you plan to do today?" Kris asked when we got out of bed on Friday morning and went to the bathroom to take a shower together.

"If they'd let me, I'd work in the Emergency Department, but I can't actually do that before June 1st, when the Residency position is officially available. They couldn't pay me until then, and I wouldn't be covered by malpractice insurance."

"That's such a foolish concept! The state should simply pay compensation to those who are truly harmed and dispense with the silly lawsuits."

"The problem there is that it turns it into a political fight as much as one about medicine. That said, going to court is a losing proposition because juries almost always find for the plaintiff."

"And you told me the insurance companies settle for that reason, so why even bother with insurance companies? You could even simply take the premiums and put them in a pool administered by the state. No more insurance companies and no more court battles."

I laughed, "Oh you poor, naïve French girl!"

"What?"

"Instead of suing the hospital and the insurance company, they'd sue the government or the board that made the decisions, or sue the doctors and hospitals, anyway. It's almost impossible to avoid a lawsuit, no matter what you do."

"But the government could make it so you couldn't go to court, right?"

"Yes, and then there would be lawsuits over that. But you'd never get a law like that passed. Every attempt to reform malpractice is fought tooth and nail by what are politely called 'plaintiff's attorneys' but which most people at the hospital call 'ambulance chasers'. They have serious political clout because they have serious money to donate."

"The entire system is corrupted by money!"

"Perhaps so, but the First Amendment guarantees a right to free speech and free press, and the courts generally include an individual spending their own money to advance a political cause as covered by the First Amendment. I read about a case going to the Supreme Court this year about corporations being able to spend money on politics, and the consensus appears to be that the Supreme Court will allow those restrictions because corporations aren't people."

"Well, obviously!"

"Actually, not so obviously under American law," I replied. "I learned in High School that there are two important points. First, a corporation is owned by individuals who cannot be forced to give up their Constitutional rights to gain some service or benefit from the government. Second, in some things, corporations are treated as individual persons. That's necessary fiction because if that fiction weren't maintained, a lawsuit against IBM or GE would, under our system, necessitate suing every individual stockholder as an owner, rather than suing the corporate entity."

"That's just silly!"

"Maybe so, but that's how things work in our Common Law system. Remember, the basis of our system is different from the French system. Well, except Louisiana, which is based on French Civil Law. All the other states are based on English Common Law."

"How can one state be different?"

"ALL states are different! The laws in Ohio are different from the laws in Indiana, Michigan, Pennsylvania, West Virginia, and Kentucky, even though the states are contiguous with Ohio."

"The system is far too complex, and it should be simple for the national government to pass any necessary laws!"

"The system is actually designed to prevent that," I chuckled. "You don't have to like it, but you do have to accept that's the way things are. Well, at least until the glorious people's revolution hoists the red and black flag over the White House!"

"Are you mocking me?" Kris asked, hands on her hips.

"Me? Would I do that?"

"YES!"

"Perhaps," I chuckled.

We finished our shower, dried off, and dressed.

"You never did answer as to what you planned to do today," Kris said when we went down the hall to get Rachel.

"I think the Tsarina and I will just have some daddy-daughter time. I'll see if I can deprogram her from the French cult your sister is trying to indoctrinate her into!"

"You like this French girl!"

"I also like French kissing her!"

"Of course you do!"

"But neither of those things make it any less vital to teach Rachel the truth about France!"

"And what is that, Michael? Hmm?"

"What's the first thing you teach a French soldier?"

"Uhm, how to march?"

"No. This!"

I raised my hands to the 'surrender' position.

"Oh, please!" Kris exclaimed, rolling her eyes.

"Did you hear about the new French battle tank?" I asked as I began changing Rachel's diaper.

"No."

"Five speeds -- four in reverse; one forward, in case the enemy gets behind them."

"Are you going to keep going?" she asked, tapping her foot.

"New French military rifles for sale! Never fired; dropped once!"

"Perhaps you would like to sleep on the couch?" Kris threatened.

"Why are French main roads lined with trees?" I asked.

"Don't even go there, Michael Loucks!"

"Because the German Army likes to march in the shade!"

"Are you quite through?"

"I'm all out of French military jokes," I said with a grin. "I mean, besides the French military itself!"

"Gilbert du Motier, Marquis de Lafayette, is rolling in his grave!"

"I actually never knew his name," I replied. "He was always referred to by his aristocratic title."

"So, this French girl taught you something!"

"More than one thing, and I've returned the favor."

"To your own advantage!" she said mirthfully.

"And to yours!"

"True!"

I finished changing Rachel's diaper and the three of us went downstairs for breakfast.

"I still don't understand why Americans make fun of the French! We were your allies and helped you defeat the British king and his German mercenaries!"

"I honestly don't know, but I strongly suspect it has to do with World War II and Vichy."

"An outrage, though worse was the «collaboration horizontale»."

"Survival often necessitates setting aside ones' principles in favor of food and shelter. I find it hard to judge someone at risk of starving to death for whatever they might do to obtain food, short of physically assaulting someone or killing them. I assume you've read Les Misérables? Do you think Jean Valjean should have been sentenced to hard labor for taking a loaf of bread when he was hungry?"

"Isn't theft always wrong?"

"Isn't refusing to feed the hungry also wrong? One begets the other, don't you think?"

"Yes, of course, but you're a capitalist!"

"And an Orthodox Christian. The two are not as incompatible as you think they are. I would never refuse to share what I had with someone in need, to the extent of my ability to do so. Remember, 'sell all you have and give to the poor' was about love of riches, NOT a command for everyone to live in abject poverty. And, as we've discussed, in Acts, where Marx cribbed 'from each according to his means; to each according to his needs', it was voluntary, as shown by the incident with Ananias and Sapphira.

"You and I will have two above-average incomes, and we'll happily pay our taxes, tithe, and give generously to charity. But that does not mean we shouldn't enjoy some of the fruits of our labor. After all, as Jesus said in Luke's Gospel -- 'the worker is worth his wages'. Paul repeats it in his letter to Timothy with reference to supporting individuals engaged in Christian ministry. I daresay if ministers are to be appropriately compensated, then so are doctors.

"In the Old Testament, in Fourth Kings, it makes the point that religious leaders were to be compensated by the people so they could dedicate their lives to service to the community. I think there's a clear parallel for physicians. And it's not as if I'm doing this for the money. You heard my 'call to arms' yesterday, and that's the important thing. The compensation comes second, and while I won't turn it down or be embarrassed by it, I will follow the same course with money as I do my medical skills."

Kris smiled, "For somebody who hates politics, you have very strong political convictions."

"I'm an American and I believe in capitalism, so sue me!"

Kris laughed, "Only Americans would use 'so sue me' to make a point! The phrase works because you run to court at the drop of a hat!"

"And, sadly, our justice system provides little justice and plenty of retribution."

"Do you still plan to visit the man who murdered Lee after we come back from our vacation?"

"I'm going to try. I have no idea if he'll see me. I do have to find out the rules for visiting him, because his sentence was life without parole. I know visiting death row inmates is very difficult, and he's in the same prison where they house them."

"The death penalty is barbaric!"

"I agree, and so are the conditions in most prisons in the US. Had I remained a deacon, eventually I would have become involved in prison ministry."

"There's no reason you can't do that as a lay person, is there?"

"With the caveat that I'd be able to bring the Eucharist if I was a deacon, yes. And it's something to consider in three or four years when things calm down with regard to my schedule at the hospital."

"When will you know your schedule?"

"Not long after we return from Tennessee, though the first week is technically orientation week, but I'll start my regular shifts immediately because I don't need orientation on the hospital."

"What do they do for that?"

"The first week is a series of ten, four-hour shifts in each department where the new Resident shadows a PGY2 to become familiar with the other services."

"All Residents?"

"From the Emergency Department, yes. But because I had time on all those services at Moore, I don't need to do it."

"What do the other services do?"

"Nothing at the moment. In the future, Residents from all the major services will spend three months of their first year in the Emergency Department. That way, when we have major incidents, everyone will have recent experience in trauma. The typical Resident outside of trauma almost never does intubation, for example. Neither do the paramedics, for that matter, which is going to change and is why they'll spend time training in the ED in the future."

We finished making our breakfast, ate, and then Kris left for her final day of High School. She had two exams, though she was at absolutely no risk of not having straight A's, and we'd attend her graduation ceremony on Saturday.

"What would you like to do?" I asked Rachel.

"Dada sing!"

"You really are learning a bunch of words!" I said. "I'll get my guitar and play for you."

Rachel was twenty-one-months old, and her vocabulary was growing by leaps and bounds, and she was able to express herself in simple ways, but that was far more than even three months previous. To satisfy her, I got my guitar and sheet music, then sat on the couch in the great room to play for her.

As she often did, Rachel sat on the couch and leaned against me while I played and surprised me by trying to hum along with the guitar. Many of the songs I knew she preferred I knew by heart, but I also took the opportunity to practice some of the newer songs. When I finished playing, I put the guitar and sheet music away, then decided Rachel and I should take a walk.

Instead of putting her in her stroller right away, I held her hand until we reached the end of the driveway. I picked her up and met immediate resistance.

"NO! RACH WALK!"

"We'll try it your way," I replied.

She was determined, and I saw so much of Elizaveta in her personality. It could only be genetic, as except for a few brief seconds, Elizaveta hadn't even held her. Of course, she could have inherited that through me from my mom and grandmother because she had a double dose of Russian X chromosomes! Her Borodin stubbornness lasted about a hundred yards and she plopped down, her little legs clearly tired. I picked her up, and this time she didn't resist going into her stroller.

After our forty-minute walk, I read to Rachel, played with her, and then we had lunch. After lunch, I called Viktor and as he and Yulia were home, I took Rachel to see them, as she hadn't been to see them for several weeks.

When we arrived, I left Rachel with Yulia and Viktor and I went into his study.

"Thank you," I said. "I wouldn't be where I am without your help."

"You're welcome. And thank you for bringing Rachel to see us. What are you doing before you begin your Residency?"

"Next week, I'm going on ride-alongs with EMS as part of the new program. Then Kris, Rachel, and I are going to Gatlinburg, Tennessee, for ten days."

"When you return, we'd like you to join us for dinner at the country club."

"We'd love to," I replied.

"How are things going other the medical school?"

"I'd say they're good. You saw Rachel, and she's healthy and happy, and developing at a slightly advanced pace."

"Elizaveta was like that as well. She was helping Yulia in the kitchen by age three."

"That doesn't surprise me in the least!"

"The anniversary is on a Saturday this year, and I planned to ask Father Nicholas to conduct a graveside memorial service in the morning."

"If you do that, we'll be there."

"May I ask about you leaving the parish?"

"You may, but Father Nicholas didn't tell you why?"

"No."

"We left because I spoke the truth and was taken to task for doing so."

"About?"

"Oksana and Greg Casper," I replied. "Ghost, as Doctor Casper prefers to be called, felt he was being pressured into converting, which, of course, he was. I pointed out that there is nothing in the canons which required him to be chrismated before the wedding. Oksana didn't have a problem with that, but Father Nicholas did, and confronted me about it. When I pushed back, he said he was tired of my attitude, so, in keeping with him being tired of me telling the truth and acting like a Christian, I announced we were transferring our membership to the cathedral."

Viktor sighed, "I do not understand why Father Nicholas feels it necessary to get into confrontations with you at every turn! Father Roman is your spiritual father and confessor, and if Father Nicholas had a problem with you, he should have taken it up with Father Roman, who, I daresay, would not reprimand you for telling the truth. What did His Grace say?"

"That he was happy to have us at the Cathedral. The incident wasn't even mentioned. The same was true for Father Luke. Of course, Kris is happy, because her parents and sister attend services at the Cathedral."

"Does anyone else know the reason for you transferring your membership?"

"I only spoke to Clarissa about it, and I believe Kris only informed her parents, but she didn't give a reason. I didn't want to put Subdeacon Mark in the middle of things, so I simply let him know Kris and I had talked it through and made the decision. I have no idea what Father Nicholas might have said to him, and I don't want to open a can of worms."

"Wise. Shall we spend some time with my granddaughter?"

"If you can wrest her away from her grandmother!"

Viktor did get a chance to hold Rachel and read a book to her before we left. We arrived home just before Kris, who had brought Lyudmila with her to watch Rachel while Kris and I were at the graduation banquet. About two hours later, with me in a suit and Kris in a formal dress, we left the house and headed to the Holiday Inn where the banquet was being held, a reprise of the banquet at the beginning of medical school.

For this one, we were at the head table because I was class valedictorian, though the downside was that meant sitting with the deans rather than with my classmates. On the positive side of the ledger, Matta had stayed, and I had a chance to speak with him for about ten minutes. After that talk, I was even more convinced that he and Maryam would marry, and very soon. Fran had Jason with her, of course, and Clarissa had Tessa, but both Peter and Nadine had come alone.

The banquet has, as most banquets did, had decent food, but nothing special, and the speeches were, for the most part, simply platitudes and congratulations. The one highlight was when Clarissa was given a special award for achieving the highest test score in the history of McKinley Medical School. Later, I received a certificate and plaque for being valedictorian, and Clarissa received a certificate for being salutatorian. Those awards ended the evening, and Kris and I headed home.

May 27, 1989, McKinley, Ohio

"Your turn today!" I declared when Kris and I got out of bed on Saturday morning.

"Yes, but I start school again in July."

"And when you receive your Master's degree in seven years, I'll still be a Resident!"

"Poor baby," Kris teased.

"Careful, young lady!" I said, trying to sound menacing.

"Or what? You'll throw me in bed and ravish me? Oh, darn!"

"Well, that would be punishment...for me!"

"We could stop doing it, if it's so terrible for you!"

"On second thought..."

"I thought as much!" Kris said mirthfully. "Let's take our shower."

We had our usual busy Saturday morning with band practice, grocery shopping, a trip to the bakery, and then lunch at home. After lunch, we put Rachel down for an early nap, and at 3:00pm, we were at the High School football stadium for Kris' graduation. Rachel and I sat with her parents and Lyudmila, and I thought back to my own High School graduation, when I'd finally had the courage to tell Jocelyn how I felt about her.

That had set off a sequence of events that nobody could have predicted, and our lives had been completely upended by a terrible accident that had nearly cost Jocelyn her life. So many things had happened since then, culminating with sitting in the stands watching my second wife graduate from High School.

After the graduation ceremony, we had a celebratory dinner at the Korolyovs, then went to the Cathedral for Vespers. After Vespers, Kris, Rachel, and I headed home. After we put Rachel to bed, Kris poured us each a glass of wine, and we sat together in the great room.

"To both our graduations!" she said.

"«Ваше здоровье»!" I declared. ("Cheers!")

"«Ваше здоровье»!" Kris replied.

We touched the crystal glasses, and each sipped the red wine.

"What class did you decide to take in July?"

"An English elective -- composition. Mom turned in the paperwork yesterday. They just need my final transcript."

"Did they waive the language requirement?"

"Yes, because I'm trilingual."

"I certainly appreciate your oral skills!"

Kris laughed softly, "I don't think you want me to demonstrate those at Ohio State!"

"Most decidedly not! On the other hand, there's tonight!"

"I will if you will!" Kris said mirthfully.

"You don't have to ask twice!" I replied.

May 28, 1989, Circleville, Ohio

On Sunday, Kris, Rachel, and I went to church, but left immediately following the services, taking Lyudmila with us, so we could get home to meet José, Lara, Subdeacon Mark, Alyssa, Elias, and Serafima to set up for a joint graduation party for Kris, Jocelyn, Clarissa, me, and the rest of our study group, as well as Mark and Alyssa, who were both graduating from Taft.

"It's been quite the month!" Subdeacon Mark observed as he and I set up the grill. "You, Clarissa, and Fran graduating from medical school, Robby finishing his Master's, Kris graduating from High School, and Alyssa and I both finishing our undergrad degrees."

"It has," I agreed. "And for me, the culmination of eight tumultuous years."

"I know there's more to your story from before Alyssa and I met you four years ago, but I've really only heard bits and pieces here and there."

"And depending on where you get your information, it may or may not be accurate."

"You're referring to Father Nicholas, aren't you?"

"I'd rather just leave the statement generic."

"You can tell me if I'm out of line for asking, but what happened?"

I considered my options, and the first and most important thing was that I wasn't clergy, and so was free to speak my mind, even if it contradicted something the bishop said, with the exception of specific points of dogmatic belief. I would, of course, be seen by Father Nicholas as a troublemaker, but evidence suggested he was going to see me that way no matter what I did. And I saw no point in hiding something which would be blatantly obvious when Ghost and Oksana married.

"Greg Casper, Oksana's fiancé, made a comment about being strong-armed into being chrismated, with the implication that it was absolutely necessary to be married. I explained to him that wasn't the case, and that so long as he agreed to allow any kids they have to be baptized, and wouldn't interfere with Oksana taking them to church, the priest could not object to the wedding on canonical grounds.

"I made it clear that the two people who had a say in the matter were Oksana and him -- his decision to be chrismated or not, and her decision to marry someone who wasn't chrismated. Because of that, I was called a 'troublemaker' and when I pointed out that I was following the teachings of the church and wasn't about to back down, Father Nicholas told me he was tired of my attitude. That was, as they say, the last straw.

"You most likely know, at least in a general way, all the other times he got on my case for something I did or said which was not actually problematic. Worse was when he got on my case for things I didn't say or didn't do that I was accused of saying or doing. I don't need to give you the details, but there were numerous instances, including the Nativity before last, that led me to not worship anywhere for a time, and then worship elsewhere for several months."

"Father Nicholas has not confided in me at all the way I believe he confided in you."

"And I suspect that's at least partly because we're friends, though much of the confiding was done after I became a deacon, so it's not directly comparable. How is your relationship with Bishop JOHN?"

"Fine, I guess. I mean, I don't see him nor talk to him as often as you did, but again, that was after you were made a deacon. I basically only see him when he visits or at the twice-a-year clergy meetings, of if I'm needed at the Cathedral for some reason."

"That's true for most deacons, too," I replied. "The only reason I had such close dealings with Vladyka JOHN was because of everything that had happened with Bishop ARKADY."

"Let's just say I'm glad I had nothing to do with any of that."

"I wish that had been the case for me," I said.

I lit the kindling under the coals, which I used so I didn't have to use lighter fluid, and then we went back into the house to join the others, with the number of guests eventually swelling to around fifty.

We had a nice afternoon and evening together, along with plenty of food and fellowship. Maryam and I had a chance to speak, and with a blessing from Kris, we walked to the furthest corner of the backyard to speak privately, but not out of sight of others, to maintain proper decorum.

"He's a great guy," I said. "When he asks, say 'yes'."

Maryam laughed softly, "As if I'd say 'no' to the guy I basically chose! I'm not fickle!"

"That is the last word I'd use for you," I replied. "Do you have a timeframe? I'd like to come to your wedding, if I can swing it."

"I'd guess September or October. Obviously, it has to be before Little Lent, and can't be during the Apostles' Fast or Dormition Fast. Would you drive up?"

"I think I'd fly simply because it would be a whirlwind trip where I'd arrive on Saturday and leave Sunday evening, if possible. And that would all depend on my schedule and if Kylie can take part or all of a shift. You know how tough it is during a PGY1 year."

"That's part of the problem for me, too. But I don't want to wait a whole year before..."

She left the word hanging in the air, and her eyes twinkled, make it absolutely clear to me what she was referring to.

"It is addictive!"

Maryam laughed softly, "Not when I was sixteen, but last year? Yes!"

"I wanted to be addicted at sixteen, but I couldn't find a supplier!"

Maryam laughed hard, "Cute! How are things going with Kris?"

"Very well. We have very different political views, but that has led to some very good conversations, rather than conflict."

"You appear to be very happy."

"I am," I replied. "I still miss Elizaveta, but as we discussed, I had to find a way forward, for Rachel's sake."

"And yours, Mike," Maryam said, touching my arm lightly. "It would have been too easy for you to withdraw and hide behind your cassock. As you've said, 'Monk Michael' was not outside the realm of possibilities, but that wouldn't have been good for you."

"No, it wouldn't."

"Especially for the reason given in Stripes!" she teased.

I laughed hard at the reference to a monk not being wildly fucked by teenage girls that I would never have expected from Maryam, though on second thought, in private, I should have expected it.

"Your private self is VERY different from your public self," I observed.

"As we discussed, for a very good reason," Maryam observed.

"True."

"And I haven't been a teenager for a long time!"

"And yet..." I chuckled. "But setting that aside, I'm going to miss you."

"And I'm going to miss you as well. We'll keep in touch. I let Matta know."

"And I let Kris know as well."

"I'll hug you when I leave, but I wanted to say 'goodbye' privately so I could express just how much I care for you."

"It's mutual."

"Then let's rejoin the others," Maryam suggested.

"Let's."

II. Farewells

May 28, 1989, Circleville, Ohio

"You have NO idea how badly I wanted to stick my tongue out at you at the banquet when I received my award," Clarissa declared when we stood next to each other at the snack table

"I saw the look on your face," I replied. "I can read you like a book!"

"And I can play her like a piano!" Tessa declared.

"Sassy as always!" I replied.

"High praise coming from a nut like you!" Tessa exclaimed.

"He may be a nut, but he's my nut!" Clarissa declared.

"You're lucky I share!" Kris said, coming over to the table.

"She's not interested in THAT!" Tessa teased.

"That I do NOT share!" Kris declared.

"Which works well for all involved, doesn't it?" I suggested.

"It does!" Kris declared. "At some point, the four of us need to talk."

"We do," Clarissa replied, turning serious. "But we have a few years before any decisions have to be made."

"When we come back from Tennessee and you two come back from California, we'll have you over for dinner," Kris said.

"That sounds good," Clarissa replied. "Ten days in Napa Valley is exactly what I need before I start my Residency. We'll bring you a couple of bottles of California wine."

"It's OK for cooking, but not drinking," Kris said with a silly smile.

"Funny," I chuckled, "you were drinking California white the other night."

"You're supposed to be on my side!" Kris protested.

"Good luck with THAT," Clarissa smirked. "Petrovich is going to give you more grief than he gives me, and that's saying something!"

"Who? Me?" I asked innocently.

"Yes, you!" Kris and Clarissa both said simultaneously.

"I think I'm going to go hang out with the guys," I said. "It's safer!"

All three girls laughed, and I made a point of joining Bobby, Ghost, Jason, Elias, Subdeacon Mark, Robby, Peter, Gene, Chris, and Pete.

"Be about twenty minutes early tomorrow morning," Bobby said. "I'll meet you there then and get you set up with a locker and rack, and check you out on your bunker gear and the squad."

"Mike Loucks as a fireman," Robby said, shaking his head.

"Mike Loucks is expressly prohibited from running into burning buildings!" I declared. "I have a provisional paramedic certificate based on my MD and passing the paramedic test, but I am NOT a firefighter!"

"Heck, I don't run into burning buildings," Bobby said. "That hero shit is not my gig!"

"But you would, right?" Ghost asked.

"To save someone if that was necessary?" Bobby responded. "Absolutely. That's why I had full firefighter training. But that's not my job any more than doing routine physicals is your job. That said, the rules expressly prohibit Mike from doing that. But to ride in the squad or on either truck, he has to be checked out in bunker gear. Just being near a fire can be dangerous, especially in farm country, where every fire is a potential explosion or chemical release."

"Bunker gear?" Peter asked.

"It's all the protective equipment we use," Bobby said, "including gloves, helmets, boots, trousers, and coats. Respirators aren't technically part of that, because they weren't traditionally kept in a fireman's bunk, but we generally refer to everything we wear on our person as 'bunker gear'. It's all designed to fit over our uniforms, and the uniforms are designed to be comfortable at the station, and eliminate the need for soft linings for the trousers and coats."

"Do you put them on for every response?" Peter asked.

"Paramedics usually don't. We keep our gear in the squad and put it on if we need it on site. The guys on the truck, except the engineers, all put on their turnout gear before they get on the truck. The engineers' gear is in the cab of their vehicle, and they put it on once we get to the site. We discovered it's safer for them to drive in their station uniforms than wearing all the heavy gear, especially their boots."

"How do you get water when you're out in the boonies?" Peter asked.

"Some we bring with. We have a pair of engines which carry the firefighting crew and all the equipment they need, including hoses, ladders, saws, hooks, the 'Jaws of Life', and all the respiration gear. Each engine carries a thousand gallons of water on board. After that, they draw from any available water source - a hydrant, pond, river, swimming pool, or other water source up to two hundred yards away. The county can also dispatch up to five water tenders that carry three thousand gallons of water.

"In addition to those two, we have our rescue squad, which is a combination ambulance and what you might have seen on Emergency. For a fire, MVA, or HazMat, we respond with all three vehicles; for rescue or medical emergency, we respond with two. In addition to the water, we have extinguishers on all three apparatuses."

"What if the water source is too far away?" Peter inquired.

"A water tender will drive to the water source, fill up, and return. It will deliver the water into what's called a drop tank from which the engines will draw. It's not ideal, but we do what we have to do. We can also draw from cisterns. Some of the big houses northeast of town that aren't on city water and either don't have a well or don't have a reliable well, have cisterns they fill with rainwater or have water delivered, and we can draw from those, too."

"What will you do, Mike?" Jason asked.

"Mostly observe," I replied, "but I'm allowed to do anything I could do as a medical student. That gives me one advantage over Bobby, which is that I'm able to intubate a patient. The paramedics will be trained to do that over the next two years. Me going on a ride-along is the first step in a complete rethinking of providing advanced life support, starting with EMS response. The name change - Emergency Medical Services -- finally acknowledged what paramedics do.

"We've come a long way in twenty years from 'scoop and run' ambulance service to paramedics being trained to do significant medical procedures. Eventually, we'll have trauma physicians available to respond to 'mass casualty' events. I'll be one of the first qualified to do that. They're still working out the malpractice and liability insurance problems."

"Problems?" Robby asked.

"Lawsuits," I replied. "Firefighters are indemnified against basically anything they do by state law, so long as they follow procedures or specific orders from county officials, or in the case of EMTs, from doctors. Doctors, on the other hand, are not, even if they respond to the scene of an accident. We can still be sued, and as such, the hospital has to negotiate with their insurance company for covering me when I'm outside the hospital grounds. I have some coverage if I happen upon an accident or illness, but specifically responding as part of a rescue isn't covered."

Ghost nodded and added, "If there is any topic where you'll find physicians in complete agreement, it's malpractice reform. You can't sue a firefighter for failing to rescue you, or for injuries sustained while rescuing you, but even the slightest adverse outcome can lead to a multi-million dollar settlement from a doctor or hospital, even if they weren't really at fault."

"There is," Doctor Gabriel interjected, "always a chance of adverse outcomes, no matter what we do. A perfect example is the drugs used for intubation. They are standard doses and have no significant contraindications. One person in a 100,000 will have an adverse reaction to them, and one percent of those who have a reaction will die. There is no way to know in advance, and no test we can run because intubation has to occur within ninety seconds for an airway obstruction. So we do it. And get sued if something goes wrong, even if it's beyond anyone's control."

"Has that happened?" Subdeacon Mark asked.

"Not since I've been at Moore," Doctor Gabriel replied. "We had one incident at Cook County, but it was never proved it was the intubation drugs. That said, we do have people who never come out of anesthesia, even with reversing drugs. And there's no way to know in advance. Ditto for pulmonary or cardiac arrest during anesthesia. Even testing can't tell you in advance when that will happen. Again, nobody is at fault, but we pay the price."

"So, what's the solution?" Subdeacon Mark asked.

I smiled, "My wife would say fully socialized medicine with the government paying all claims for actual injury."

"What about negligent doctors?" Elias asked.

"A different problem of a completely different character," Doctor Gabriel replied. "All of us, and I mean physicians and non-physicians, should work together to weed out negligent doctors. You don't need malpractice suits to do that, you need good oversight with a mix of physicians and regular citizens."

"And no lawyers!" Ghost added. "Shakespeare had it right!"

I shook my head, "When Shakespeare had Dick Butcher say 'The first thing we do is kill all the lawyers' he was speaking about how a tyrant establishes an autocracy. But I agree, no lawyers on any review board. And adherence to accepted best practices should be a complete and total defense to any claims of negligence or malpractice."

"What he said!" Doctor Gabriel replied. "Though Mike's idea that we currently have socialized medicine is non-conventional."

"Says the man who works for a government hospital which receives significant funding from taxes!" I countered. "Not to mention the very point of insurance of any kind is to pool funds to socialize the risk. I have State Farm for my auto and home, and it's a mutual insurance company, which means at the end of a year, any excess premiums collected over losses and operating costs are returned to the policy holders, minus any money retained for reserves."

"That's not socialism!" Subdeacon Mark protested.

"No, but it's what people here mean when they say 'socialized medicine'. Most proposals do not call for every doctor to be a government employee or for all hospitals to be publicly owned. The proposals are almost always about 'single payer' in the way Medicare and Medicaid operate -- insurance funded by premiums collected as taxes. True socialism is common ownership of the means of production. That's a VERY different thing. Volvo and Ericsson, despite being Swedish companies, are publicly traded on stock exchanges."

"When did YOU start discussing politics in a serious way?" Ghost asked, sounding surprised.

"When he married Kris!" Robby exclaimed. "She's the 'Red' in his bed!"

"She'd reject that nod to the Soviets," I said. "She and my grandfather have the exact same opinion of the USSR and the Communist Party, despite coming from basically opposite sides. He's a liberal, and she's a socialist, to put it in European terms."

Some of the guests began to leave, including Nadine, who was driving home before heading to California. I walked her to her car, where we exchanged a chaste hug.

"Thank you for everything," she said. "If you're ever in California, look me up at UCLA."

"Absolutely. I suspect you won't be coming back to Ohio anytime soon."

"If I'm going to fly for four hours, I'm going to Hawaii, which is only five hours away!"

"I hear you on that! I'll make it to Hawaii at some point, but that's probably ten years from now. As for California, after speaking with Clarissa and Tessa, Kris is interested in visiting Napa Valley, but that's what? Three hundred miles from LA?"

"Closer to four hundred, I think," Nadine replied.

"Let's keep in touch," I said. "You have my address and phone, so just call or write once you have yours. Fran, Clarissa, and I will all be in the area. I already have Peter's home address and phone number, as he plans to live with his parents for the first year. I have Maryam's apartment address and she'll get me her phone number as soon as she's in Chicago. I'll make sure you get all the information for everyone and be the one to keep up with all the addresses and phone numbers."

"Awesome. Thanks again, Mike. I hope to see you in my OR someday, but vertical, not horizontal!"

"The same for my trauma room!"

We hugged again, and she got into her car and drove away. The scenario repeated itself with Peter about ten minutes later, as he was flying home first thing in the morning.

"Thanks for being there for me for four years," I said.

"I was just about to say the same thing!" Peter replied.

"It was fortuitous that we met at the banquet and then were paired for CPR. I'm glad that happened, and I'm glad you were part of our study group."

"Again, I could say exactly the same thing. Come to Atlanta and I'll show you some real Southern hospitality!"

"It'll be at least a year, for obvious reasons. I'm going to miss you."

"I'm going to miss you as well," Peter replied.

We hugged and slapped each other's backs.

"Take care and stay in touch," I said.

"You, too."

He got into his car, which he'd agreed to sell to a Second Year, and as he drove away, Maryam came out of the house. We'd already said what we needed to say, so we hugged carefully, Maryam smiled, and kissed my cheek.

"I'll see you at your wedding, by hook or by crook," I said. "Have a safe trip."

"Enjoy your belated honeymoon!"

"We will."

Maryam got into her car, backed out of the driveway, and, with a wave, drove off. Once her car was out of sight, I went back into the house. The party wound down around 8:30pm, and several couples stayed to help us clean up. When we finished, they left, then Kris and I put Rachel to bed, and went to bed ourselves.

May 29, 1989, McKinley, Ohio

On Monday morning, even though she didn't have school, Kris had been up early with me for our usual joint shower, to say morning prayers with Rachel, and to have breakfast. I'd kissed them both, then headed to Fire Station #2, which was about two miles from Moore Memorial Hospital.

"Morning, Doc!" Bobby said with a grin when he met me in the small parking lot behind Fire Station. "Welcome to Station #2!"

"Also known as the Second People's Hospital for the Insane!" I said with a grin. "After all, only someone who was truly nuts would make a living by running into burning buildings!"

"You do realize we don't ACTUALLY do that very often, right?" a fireman said, coming over to us.

"Doctor Mike Loucks, Lieutenant Jim Greer."

"Lieutenant," I said, extending my hand.

"Doctor," he replied, shaking my extended hand. "Just call me Jim, please. Usually, only our captain is addressed with his rank."

"How many firefighters are on duty at any given time?" I asked.

"A captain, a lieutenant, two engineers, two firefighter-paramedics, and eight firefighters. There is a battalion commander, but he's responsible for three stations and only responds when multiple fire companies respond. He's based in Station #1."

"Let's get inside and get you settled," Bobby said. "A rack, a locker, and bunker gear. Did you get your steel-toed shoes?"

"UPS delivered them on Friday."

"Safety regs require you to wear those at all times, except in the shower or sleeping."

"Got it."

"Your uniforms are here, and ready for you."

We went into the station and Bobby was greeted by other firefighters, some coming on duty, some going off.

"What happens if a call comes in now? Or if the crews were on a call?"

"Until 7:00am sharp, the crew on duty would respond, and if they were out, they'd stay out until they finished the run or were relieved by another unit."

We went to the back of the station where the dormitory and showers were located, and Bobby showed me the rack and locker I'd been assigned.

"Let's get you into your turnout gear. Once I'm satisfied you know how to wear it, we'll store it in the squad with ours. Put your uniform on first."

I changed out of my 'street clothes' and put on the brand new uniform that was hanging in the locker. Once I had it on, I began to put on the bunker gear. I had reviewed my notes from the training class I had and mostly got things right. Bobby provided pointers as I put on the gear, especially about the flaps which covered the zippers on the turnout coat. Once he was satisfied I'd be able to put the gear on properly, I put on the new shoes I'd ordered. Once they were on, we took the gear to the squad and stored it behind the bench seat in the cab, along with my medical bag. Once we'd done that, he showed me where all the gear was stored in various compartments accessible from the outside, along with what was stored in the ambulance portion of the squad.

"One thing I wondered," I said, "is why you don't have the radio hookup they showed in Emergency where Doctor Bracket or Doctor Early would say 'send us a strip' to get an EKG."

"We didn't have the money LA County did when we started."

"What are your standards for defibrillating?"

"No pulse or no heartbeat. Basically, 'shock and see'. Our new ALS ambulance units will have EKG equipment, and the ability to transmit, but that's next year before they begin delivery, and Moore needs to install the new radio and telemetry equipment."

"And for compromised airways, all you can do is bag at the moment, right?"

"Yes. You brought your bag of tricks with you, right?"

"Yes. I have everything I need for intubation in my medical bag. Has your training been scheduled?"

"No. That starts in September, but they don't have individual schedules out. It's going to take some time to get eighty hours of training in."

"Not to mention the 'luck of the draw' with regard to patients needing intubation. You'll need to do six or eight before an Attending will sign off. Do you know how to read an EKG?"

"I think the correct answer is 'no', because other than what I learned in paramedic school, I have no experience."

"That'll take another chunk of time, probably ten hours to become proficient enough to know when administering a shock will work. That said, you pretty much can't hurt someone by shocking them. And CPR is always indicated, except for a suspected flail chest."

"Let's go meet the guys," he said.

"Any female firefighters? I know there is a female paramedic because I've met Julie."

"Only one female firefighter in the county so far, and she's at Station #1. Julie is at Station #3. Did you know that the first paid fire company was in Cincinnati, and was started in 1853, and while it was all men, there were women volunteers?"

"No, I didn't know that! Did you know the first Residency program in emergency medicine was at UC in 1972?"

Bobby introduced me to the other firefighters, some who I knew by sight from the hospital. I already knew Sam Collins, his partner who I saw regularly at the hospital, and who was one of the few African American members of the Fire Department.

"You know, I never asked, but what do you guys do when you aren't on a run?"

"Depends on the time and the person. Some guys play chess, some play bridge, some read, and some watch TV or tapes. We also have a ping-pong table, free weights, and a treadmill."

"How do you handle meals?"

"Each shift is responsible for their own food. In the galley you'll see cabinets labeled by shift, and we make a grocery run when we need to restock."

"How does that work?"

"Usually an engine crew goes to Kroger. The engineer stays in the truck and the four firefighters and the officer go into the store and do the shopping. If there's a call, the guys in the store are called by walkie-talkie and basically drop everything and respond from there."

"Come to think of it, I've seen that on occasion at Kroger. What now?"

"Relax and wait for the call, exactly as you do in the ER! The only difference is you're coming with us, instead of us coming to you."

"OK. I brought medical journals, so at least for this morning, I'll read. What's the scoop on sleeping?"

"Quiet hours are from 10:00pm to 6:00am, so it's up to you. Did you bring an eye mask?"

"I did. I'm used to sleeping when other people are moving around. I bet it's actually quieter here than in the on-call room at the hospital."

"The guys are pretty good about keeping quiet. Use any of the recliners, couches, or chairs. There aren't any assigned spots except for wherever Brigid decides she wants to sit. You move if she wants the recliner or spot on the couch."

"Does she go on runs?"

"Usually with Lieutenant Greer on the second engine."

"I meant to ask before, but why respond with an engine and the squad for purely medical calls?"

"We learned when we first started that having two extra guys is necessary in moving some patients out of second or third floors, and sometimes we have to remove doors. Having an engine crew along allows us to focus on the victim while the other guys deal with any obstacles, or assist in getting someone out of difficult spots. Think about some of the narrow staircases and how well a stretcher would work. In those cases, we'll use a ladder and take someone out a window in a Stokes basket."

"So Emergency wasn't fiction?"

"It was pretty accurate in most cases. Did you know that engineer Mike Stoker was actually an active LA County Firefighter at Station #69 in Topanga Canyon?"

"No, I didn't."

"Basically, they needed someone who could drive and operate an engine and other apparatus and he held a Screen Actors Guild card. The dispatcher for the series, who you mostly heard over the radio, was LA County Dispatcher Samuel Lanier, and the captain in the first season was LA County Fire Captain Richard 'Dick' Hammer."

"You seem to have had more luck with doctors than Johnny did with nurses!" I chuckled. "How was she this morning?"

"Cranky! But I think that's as much not being able to work as it is Bobby Junior being stubborn."

"I was hoping he'd be born before Kris, Rachel, and I leave on vacation."

"I think Lor is as well!"

A klaxon sounded, followed by a loudspeaker call.

"Station 2; structure fire; County Route 25-A at Ferry Market Road."

Some other details were given in jargon I didn't comprehend, and it certainly wasn't time to ask.

"That's us!" he declared, and I followed him towards the squad while Lieutenant Greer acknowledged the dispatcher.

I chuckled to myself that the only thing missing from his radio acknowledgment was 'KMG-365'. We were first out of the station, as we didn't need to put on bunker gear. I had a general idea of where we were headed, and if memory served, it was a farm, which meant it could be a house, barn, or, more dangerously, a silo. It would, at the speed we were moving, take about eight to ten minutes to get there.

"What's the drill when we arrive?" I asked Sam, who was sitting to my right on the bench seat.

"Assess and treat any victims and wait for the engines for anything else. If there's a need for immediate rescue, we'll gear up and go in; you stay by the squad until we come out or you're directed to do something by the Captain or Lieutenant."

"Got it."

"The only exception," Bobby said as he slowed for an unguarded railroad crossing, "is a simple kitchen fire, where we can use extinguishers. But it's usually too late for that by the time we arrive when we respond to the boonies."

"You have to figure," Sam continued, "that by the time someone calls it in, we're dispatched, and arrive for one of these remote runs, it's twenty minutes. At that point, either the fire is out or fully involved. Old barns and farmhouses go like kindling. Remember, keep your helmet on at all times, even if you aren't wearing the rest of your gear."

"Got it."

As we turned west, I could clearly see smoke rising, and when we reached the crossroads, I saw, true to Sam's prediction, a barn that was fully involved. We stopped about fifty yards away, I grabbed my helmet and medical bag and followed SAm out the right-hand side of the squad.

"Where's the fire engine?" a man of about sixty asked.

"About a minute behind us," Bobby replied. "Anyone in the barn?"

"No, and we got the cows and horses out."

"Anyone hurt?"

"Don't think so. None of my hands were in the barn, and my wife and I got the animals out into the pasture."

The two engines pulled up behind us and the crews set to work. Fortunately, there was a large pond next to the barn that appeared to be fed by a well to draw extra water from. Hoses were deployed and water was directed onto the barn, which I was positive was a total loss. Twenty minutes later, there was no longer any black smoke and fifteen minutes after that, Captain Brinker declared the fire out. He sent one engine back to the station while the other crew checked for any hot spots using axes and hooks.

"Squad 2, County Dispatch! Squad 2, County Dispatch!" the radio chirped.

"Squad 2!" Sam answered.

"MVA; County Road 25-A and Thompson Road; Engine 22 responding with you, ETA eight minutes."

Engine 22 was the second engine, which the captain had ordered back to the station, keeping Engine 21 at the scene of the fire.

Sam acknowledge the radio call and, then said "Let's go! That's about two miles from here."

We clambered back into the squad and five minutes later climbed out at the scene of a single-car accident with the car upside down in a drainage ditch. A Sheriff's cruiser was blocking the road, and we pulled up behind it.

"Two victims; no fire!" the Deputy called out.

"Mike, stay by the squad!" Bobby ordered as he and Sam jumped out and ran over to the vehicle.

I put on my helmet and stood next to the squad while they went over to the car.

"Gear up!" Bobby called back. "We're going to need cervical collars and IVs right away."

I got into my gear, grabbed my medical bag, and then followed Bobby and Sam back to the overturned late 60s Ford LTD. I watched as they quickly assessed the patients, inserted IVs, and cervical collars. The engine pulled up just then and the four firefighters and Lieutenant Greer hopped out and came over to us, while the engineer, Carl Voline, stood by the engine.

"Mike, move back," Lieutenant Greer ordered. "We'll get 'em out for you."

I moved about ten feet away, and Bobby and Sam joined me while the firemen assessed the vehicle. I saw Bobby and Sam removing their gear, so I followed suit. The firefighters pried open the driver's door with a crowbar, but couldn't get the passenger door open, so they extracted both victims via the driver's door.

Bobby, Sam, and I went to check on the victims and neither of them had compromised airways, so I simply observed while the paramedics assessed them. The firefighters brought the two transport gurneys from the squad and carefully transferred the victims, one conscious and one unconscious, to them, then rushed them into the back of the squad.

"With me, Mike!" Sam called out.

I followed him into the back with the patients while Bobby got into the cab. One of the firemen shut the door behind us and pounded on it three times to signal to Bobby to go.

"Assess the patient by you, Mike."

I connected the PulseOx sensor to the teenage male and turned on the monitor, then auscultated the patient's chest and abdomen. He clearly needed oxygen, so I hooked up a mask and set the flow to five liters per minute, then checked his BP. The patient had an obvious broken arm, as well as a serious contusion to his temple, likely responsible for his lack of consciousness, but his belly wasn't rigid and his ribs did not appear to be broken. I got my penlight from my bag and checked his pupils and the right one was blown and the left one sluggish.

"How are your patient's pupils?" I asked.

"Sluggish, major contusion to the chest from the steering wheel. No other apparent injuries. Yours?"

"GCS 6; one pupil blown, the other sluggish. Bobby?" I called out.

"Yeah?"

"Call in and ask for neuro to be standing by."

"Got it!"

He made the radio call and about three minutes later, we pulled into the hospital driveway.

"How do we report vitals?" I asked Sam.

"You and I will do it, otherwise I'd give Bobby the most critical patient bullet."

"Mine goes first," I said.

"You got it, Doc!"

A few seconds later, the squad stopped, Bobby jumped out and hurried to the back of the squad to open the door. I disconnected the PulseOx monitor and Bobby and I got my patient out first.

"Late teen male," I called out. "MVA restrained by lap belt; severe contusion and laceration to the right temple; GCS 6; right pupil blown, left sluggish; BP 80 palp; tachy at 110; PO₂ 93% on five liters; IV saline TKO."

"Trauma 1!" Doctor Gabriel replied. "Neuro consult is waiting for us."

He, Felicity, Jamie, and I rushed the patient into the trauma room and I was about to begin hooking up monitors.

"Mike," Bobby said, "You're a paramedic today. Get the oxygen bottle and we're out of here."

I nodded, and as soon as Jamie had the hospital oxygen hooked up, I grabbed the portable bottle and we left the trauma room.

"Sorry," I said.

"Don't be," Bobby replied. "Those trauma rooms are your natural element, and I expect you to go on autopilot."

"If you need the john, use it now in case we get a call on our way back to the station," Bobby advised.

I took his advice and started to go to the locker room, but realized I wasn't acting as doctor or medical student, so I used the public restroom. When I came out the door, I nearly ran into Ellie.

"I see you decided to join the Fire Department instead of being a doctor?" she teased. "Good!"

"That sounds like sour grapes!" I chuckled. "Can't have it, so I don't want it, and I want it out of my sight?"

"Oh, I want it alright!" she said sexily. "But I know better."

I smiled and nodded, then found Bobby and we headed back to the squad where we met Sam. The three of us got into the cab and headed back to the fire station.

"How long do you usually stay on site for a fire?" I asked.

"Until we're released by the officer in command of the site," Bobby replied. "At that point, we're released for dispatch."

"Out of curiosity, what were you expressly told about what I can and can't do?"

"You're officially an observer unless Sam or I expressly assign you a task, and we're only supposed to do that if we're shorthanded, or like today when we have two patients in the squad."

Which was what I had expected to be the case. That meant barring a mass-casualty event or a need for intubation, I was going to be doing a lot of standing around watching, which was not all that different from my Preceptorships. What I was doing really was just observation, and the real involvement would come in training the paramedics to do additional procedures.

"I figured that was the case," I replied. "The main rationale is for me to get used to Fire Department procedures so I can train you guys to do intubations, hook up EKGs, and perform other procedures when that program starts in the fall."

"That's basically what Captain Brinker said to us," Bobby confirmed.

"I'm curious why you guys didn't try to pry open the doors of the car."

"We do have pry bars and other light equipment in the squad, but by the time he had the cervical collars on and the IVs in, the engine was only about two minutes away. If the car had been on fire, we'd have done the extraction. Otherwise, unless we need to perform immediate CPR, we wait for the firefighters."

"That delay could be sufficient for a victim to die," I countered.

"It's a balancing act," Sam interjected. "We do risk our lives, but it's always a calculated risk. In this case, with that ancient LTD, prying open the door gave complete access. But with a compact car we'd likely have had to cut away parts of the frame to extract the victims, and we simply don't have those tools."

"That makes sense," I replied. "I'm just thinking about the Golden Hour and how much of it elapsed while we were on the scene before we transported the victims."

"I hear you," Sam replied. "But even in the city, it's probably about thirty minutes from the call to the dispatch center until the responding unit arrives at the door of the ambulance bay. You figure six minutes transit time, roughly, each way, so twelve minutes is gone right there. Then assessment, initial treatment, and loading into the squad are at least five minutes, often closer to ten. That's a third of the Golden Hour right there, in perfect conditions. I'm not sure there's much we can reasonably do to speed things up."

"Being able to do more procedures on arrival is the key," I replied. "But some things, like clot-busting drugs, are risky, even in the ED."

"Incremental progress," Bobby said. "You made the point that just over a decade ago, it was still 'scoop and run' ambulance service. Soon we'll add intubation to our repertoire, but the biggest problem, and one for which there isn't a solution beyond saline IV, is blood loss."

"That's a tough problem to solve given the requirements for storing blood and blood products like plasma. I haven't seen any articles on pre-hospital transfusions, but I know the military used them successfully in Korea and Vietnam in aid stations. What do you carry in your drug box?"

"Atropine, albuterol, epinephrine, insulin, morphine, naloxone, and nitroglycerin. We also carry Tylenol, aspirin, and of course saline and lactated Ringer's. We'll add a few drugs when we convert to ALS units, but I'm not sure what those will be."

"I'd speculate at least lidocaine as an anti-arrhythmic plus succinylcholine and etomidate for intubation. Those are the obvious ones. Maybe something like Haldol or midazolam. I'll look into it, actually, because we'll need to know to properly train you guys."

We arrived back at the station and had five more runs before quiet time began, none of which were exciting -- two MIs, two MVAs, and a broken limb. I observed on all of them, as without a proper EKG or drugs, there really wasn't anything I could contribute, and Bobby and Sam knew their job. I quietly said abbreviated evening prayers, put on my mask, and turned in for the night just after 11:00pm.

May 30, 1989, McKinley, Ohio

We had one overnight run, just after 2:00am, for an elderly man who had fallen down the stairs at home and had broken his hip. I managed about six hours' sleep, which was more than I'd get in the hospital. At 7:00am, I left the station and headed home.

"Morning!" Kris exclaimed when I walked in, coming to greet me with a kiss.

"Dada!" Rachel exclaimed, toddling over for her own hug and kiss.

"Breakfast in about fifteen minutes," Kris said.

"OK. I'm going to take a quick shower and put on shorts and a t-shirt."

I did that and was back downstairs in ten minutes.

"How was it?" Kris asked.

"Interesting, as far as it goes. I'm an observer, with the main point being to understand how the guys work and what they encounter, so I'm equipped to train them in the Fall."

"Did you get any sleep?"

"About six hours total. We had a run just after 2:00am and were back at the station about 3:15am. I don't plan to nap or anything today."

"OK. I planned to take Rachel to the park. We'll meet Abigail and her nanny there."

"That sounds like a great plan! Mind if I tag along?"

"Of course not!"

Breakfast was ready a few minutes later, and after we ate, we cleaned up, then said morning prayers. At 9:45am we left for the park, where Rachel and Abigail had a great time playing together for an hour, then we returned home for lunch, and after that, we had a lazy day at home.

III. Field Work

May 31, 1989, Columbus, Ohio

On Tuesday, I joined Bishop JOHN for lunch at the Cathedral at his request.

"Thank you for joining me for lunch," he said after I received his blessing.

"It's my pleasure, Vladyka."

We sat down in the comfortable wingback chairs in his office, he said the prayer of blessing, and we began to eat.

"Was there a specific agenda you had in mind?" I asked.

"No, though I would, if you're willing, like to discuss Father Nicholas."

"I'm not sure I'm the best person to give an opinion."

"I've heard from several people, and without naming names, I'm sure you can deduce who, that they are unhappy that he, in effect, ran you out of the parish."

Viktor was almost a certainty, and it wouldn't surprise me if Subdeacon Mark had spoken with Bishop JOHN. Serafima was also a possibility, as she could no longer see her goddaughter regularly at church. It also wouldn't surprise me if Oksana had not said something given Kris was her cousin and given Doctor Casper -- Ghost -- and I were friends and colleagues.

"I think," I said carefully, "that the last four years have been so stressful for the entire diocese, and Saint Michael specifically, that it's difficult to lay blame at the feet of anyone, except perhaps the deposed Robert Langley. Everything stemmed from his behavior. I am not excusing the response of retired Bishop ARKADY, nor of anyone else, simply pointing to the origins of the problem."

There were also the unproven allegations of sexual impropriety against Bishop ARKADY, which privately I believed, but as they had not been investigated nor had they been proven, I kept that opinion completely to myself.

"You have," Kris said, "on a number of occasions, made the point that while we can't control what others do, we're responsible for our own actions."

"Me and my big mouth!" I chuckled.

"You also have a history of being reluctant to assign blame to others, even when they are clearly at fault."

"Because of my own failings," I replied. "For the most part, I'm too busy trying to remove the log from my own eye. I figure when I achieve complete theosis, and thus synergistic perfection, that's the time to worry about other's faults."

"A Christian attitude with which I cannot find fault, and yet, as episkopos, I have a duty to oversee my diocese and to care for the wellbeing of individuals, parishes, and the diocese as a whole. I appreciate your desire to, in effect, shake the dust from your shoes and move on, but I have no such luxury."

"Permission to speak freely?"

Bishop JOHN laughed softly, then said, "As if I could prevent that! I might as well tell the mountain to go cast itself into the sea!"

"My Residents and Attendings at the hospital would agree with you!"

"You are always free to speak your mind and your heart to me, Misha."

"I'm sure you're well aware of the false allegations and that I don't need to rehash them."

"I'm curious as to why you think Father Nicholas would have considered those allegations valid; if you're willing to share."

"I think the best answer to that is, that at times when I was neither betrothed, married, nor a deacon, celibacy was not my strong suit, something of which Father Nicholas, Father Herman, Father Stephen, and Father Roman are all aware."

"I surmise, then, that you confessed and received absolution for your failing in that regard, and that no transgressions of your marital or diaconal vows occurred."

"That's accurate. And it's that history, along with the whisper campaign about Rachel's caregivers, which led Father Nicholas to not give me the benefit of the doubt, so to speak. The most recent incident had to do with Doctor Greg Casper and his upcoming marriage to Oksana Ivashko.

"Had I remained a deacon and that same situation had been brought to my attention, I'd have spoken to Father Nicholas directly, or to you. But as a layman, I felt it was my place to correct a misunderstanding he had, one which, in my opinion, was created intentionally by Father Nicholas. In my mind, something I heard back in High School when studying the Spanish Inquisition..."

"Which nobody expects, right?" Bishop JOHN interrupted with a twinkle in his eye.

I couldn't help but laugh.

"Well," I replied, "I am sitting in a comfy chair!"

"Sorry to interrupt. Please continue."

"No apology necessary! That's exactly the kind of thing I would do myself! In any event, what was said was 'A man converted against his will is of the same opinion still', and I think that's exactly right. Doctor Casper is attending services regularly, and has no objections of any kind to having his children with Oksana baptized, and has many views which align with the Church.

"The problem, at its root, is he felt compelled to convert. It's my firm belief that had Father Nicholas not adamantly insisted he be chrismated, he might well have chosen to do so voluntarily before the wedding. The pressure bothered him, and, to be honest, was completely inappropriate. It would be one thing if Oksana had made that a requirement, as I did for any girl with whom I was serious; it's a different thing when the priest makes it a condition, when the canons require no such thing."

"You did have a habit of what my protestant friends would call 'missionary dating'."

"So sue me," I chuckled. "But to be honest, it worked with Angie, and if not for her illness, my life would have turned out significantly different. The same is true with regard to Kimiko, where the deciding factor for her was not a rejection of Orthodox, but of American culture, such as it is."

"I can see how, from the perspective of a young Japanese woman, our culture would be too chaotic and foreign. Some of our brethren in Russia would certainly agree."

"The elections in Poland this weekend may well be a major turning point in history," I replied. "If the Communist Party loses power, I would say that the Kremlin wall might bear the prophetic phrase 'mene mene tekel upharsin'. My grandfather certainly thinks this will be the crack in the dam, and that nothing will stop the water from bursting through. The fear, of course, is that the CPSU decides to go out with a bang, not a whimper, and the world is destroyed with fire."

"Lord have mercy that is not the case," Bishop JOHN said. "But returning to your thoughts, are you making an accusation against Father Nicholas?"

"Not formally," I replied. "But it is the case that, from what I can tell from my conversations with Doctor Casper, that Father Nicholas misrepresented the canons and teachings of the Church, if not directly, then by omission. But in the end, the problem was not a disagreement about the approach, or even about the canons, but when he said, and I quote, 'this attitude of yours is very tiring'."

"Said in response to what statement?"

"He asked, after I answered his question about Doctor Casper deciding not to be chrismated before his crowning, why it appeared I was bent on causing trouble."

"I responded in my usual fashion, and concluded with a statement that if my behavior was such a problem, Kris, Rachel, and I would worship at the Cathedral in the future. He said I was being overly dramatic, and I replied that he was being overly critical, as he had been for years. That's when he made the 'very tiring attitude' comment. At that point, I said we were going to transfer our membership."

"By 'usual fashion', I'm going to guess a reference to the canons and the Scriptures?'

"I'd covered the canons before, when I'd raised Doctor Casper's concerns. As for the Scriptures, I pointed out that the established clergy of the day called Jesus a troublemaker and that the secular governments called Saint John Chrysostom a troublemaker. I also mentioned Socrates for good measure. I made it clear I wouldn't apologize for speaking the truth, and that's when I said we'd worship at the Cathedral and the conversation proceeded as described."

"You are not afraid to speak truth to power, which is a positive trait, so long as it's done in love. Was their animosity in your heart when you spoke to Father Nicholas?"

"Probably some," I replied. "I planned to discuss that in detail with Father Roman when I see him on the 24th."

"Good. Then I'll leave that in his capable hands. Do you think Father Nicholas is a good pastor?"

"Generally speaking, yes," I replied. "My one objection was him not quashing the rumors, backbiting, and whisper campaign, which required you to step in."

"Yes, and confidentially, I addressed that privately with Father Nicholas. Do you think he should remain as pastor of Saint Michael?"

"I have two responses, first, that's a decision that is WAY above my pay grade! Second, our tradition is that priests serve the same parish for their entire career, if possible."

"A careful answer, as usual. In your mind, what would be sufficient cause to break with that tradition?"

"If the needs of the diocese were such that the priest's unique skills could be put to better use, or, more rarely, if conditions in a parish necessitated a reassignment. What happened at Holy Transfiguration rose to that level."

"But not Saint Michael?"

"Honestly, I believe more harm than good would be done by transferring Father Nicholas, if that's what you're considering. I am a unique, difficult case, perhaps impossible for a parish priest to manage. Possibly for a bishop as well."

Bishop JOHN laughed heartily, "You are not even close to the most difficult! And that is NOT an invitation to try!"

"Darn," I said flatly.

"In all seriousness, Misha, a parish full of outspoken individuals who promoted love, joy, peace, patience, kindness, goodness, gentleness, and self-control would be far preferable to a quiet parish which did not exemplify Christian morals and ethics. Nobody, even those who might object to your methods, could level an accusation against you for not living your life as a Christian should."

"And yet, I'm a sinner."

"What's the saying?" Bishop JOHN asked with a smile. "Join the club? Not to excuse your sin, but you know as well as I do that the Christian life is not an easy one, and we all miss the mark. The joy of our faith is that God loves us and is there to give us a hand up when we stumble every single time, no matter how often we make a misstep."

I nodded, "Something for which I am eternally grateful. Are you considering moving Father Nicholas?"

"On that, I have to keep my own counsel, though you're a wise man, Misha."

"If I may offer advice..."

"Of course."

"See how things are over the next year with the thorn removed from Father Nicholas' side."

"And instead in Father Luke's?" Bishop JOHN asked mirthfully.

"Because I'm not involved in teaching, almsgiving, serving at the altar, or on the council, I doubt there will be any concerns. I say that as the Dimitrijevics have greeted me cordially, and if anyone has a right to complain, it would be them."

"If I understand correctly, it was Danijela's decision not to move forward."

"It's complicated," I replied. "We had agreed on a decision after the one-year memorial of Elizaveta's repose, and Danijela pushed me to decide before then, mainly because I was still seeing Danika Kurian. It's my belief that either Danijela's grandmother, or mine, pushed her to 'close the deal', as it were, and when I demurred, she broke things off. I did speak to Danijela before I had my second date with Kris, and Danijela rejected my overtures, which I felt left me free to continue with Kris."

"Quite a few words to say 'yes'," Bishop JOHN replied with a smile.

"I know," I replied. "But you also know I'm reluctant to place blame solely on anyone else when I've been involved in the matter."

"Something I wish more people would do."

"I typically have a forest in my eye compared to other's splinters."

"A proper attitude, but one which can be taken too far. Should I, never, as a sinful man, correct a member of my flock who strays?"

"Far be it from me to teach theology to a bishop..."

"So, you're changing then?" Bishop JOHN asked with a sly smile, interrupting me.

I laughed, "OK, so I do have a history of doing that! It's not about being sinless, but about being cognizant of one's own sins, and not holding others to a higher standard than the one to which we hold ourselves."

"Quite so. I know your availability is extremely limited over the next year, but would you have time to be involved in the Orthodox Prison Ministry project?"

That made me suspect Subdeacon Mark had been one of the individuals to speak to Vladyka JOHN, though he and I had discussed the topic back in April.

"I believe back in April you said I should take two years before I became involved in anything like that."

"The topic arose recently," he replied, confirming my thought.

"I intend to visit Frank Bush, if he'll see me, sometime after I return from Tennessee."

"If you're willing, I could commission you as a lay chaplain, which would give you more access. No pressure, and if you say 'no', I'll completely understand. I wouldn't make the commission public, though I would need to inform the Metropolitan. It would also let you, if you chose, serve as a chaplain at the hospital."

"That I cannot do," I replied. "The roles are completely separate for a reason, and need to stay that way. I can minister, when appropriate, but being a chaplain at the hospital would interfere with my role as a trauma physician. The division of labor is a critical component of how the hospital functions."

"Ah, OK. It was only a thought."

"Let me confer with Kris," I replied, "but I'm inclined to accept a commission expressly for prison ministry."

"Good. I take it all is well between Kris and you and Kris and Rachel?"

"Other than my wife being a card-carrying socialist, yes!"

Bishop JOHN laughed, "So, divergent politics aside, there are no concerns?"

"None. Our plan is to have a brother or sister for Rachel in June or July of next year."

"God willing, I look forward to that! Children are a blessing for their parents and for the Church."

"I question that when my little tsarina gets her back up about something!"

"What would you have said in the past? That she's a Russian woman?"

"Oh, that she is! She takes after her mother; both, actually. Though my Franco-Russian wife has a different way of applying her Russianness."

"She's a wonderful young woman."

"She is, and I'm fortunate to be her partner. Or, as she put it, when discussing the difference between Doctor Casper and me, he needed a devoted, loving wife to greet him when he arrives home and I need a partner in crime!"

"She's not wrong!" Bishop JOHN said mirthfully.

"This kind of abuse I can get from Clarissa!" I chuckled. "And soon enough from my daughter!"

"And if them, why not your bishop?"

"I'm not even going to try to answer that!"

"What? Michael Loucks lost for words? Now I can die happy, having seen everything!"

I laughed hard, "This is a side of you I haven't seen before."

"You know the reason why, of course."

I sighed, "Because certain people would get their noses out of joint, similar to how they did with me with regard to Rachel's caregivers and my close female friends."

"It's our cross to bear, Misha. But with you I can, as they used to say, let my hair down."

"It's longer than mine! As is your beard!"

"In all seriousness, you need to trim yours for your masks, right?"

"It helps, but I could let it grow out further. It's only in surgery that I wear a special mask with a beard pocket. In the Emergency Department that's not necessary, and we don't generally mask because it's not a sterile environment in the first place, the way an Operating Room is."

"What about your surgical cap?"

"I wear one designed for women with long hair, but they're all the same color and basic design, so it's not something that makes me stand out. Once I finish my first year of surgical Residency, I can choose my own design. That said, we mostly don't wear surgical caps in trauma."

"What color do you wear?"

"Light blue in the Emergency Department. After my second year, when I start my surgical rotation, I'll wear red to distinguish me from the other doctors in the Emergency Department. Attending surgeons usually wear Dark Blue, but Doctor Cutter wants to distinguish trauma surgeons."

"Doctor Cutter? A surgeon?"

"Not just a surgeon, but the Chief of Surgery! A perfect name! It would be like the Navy having a Doctor McCoy as a ship's physician or a ship's captain named Kirk!"

"Unfortunately, our time is almost up," Vladyka said. "I have a 1:00pm meeting that I simply cannot delay. Please let me know if you'll accept the commission, and I'll send you a proclamation as well as inform the Ohio Bureau of Prisons and the Hayes County Sheriff."

"I'll let you know before I leave for Tennessee."

"Excellent."

We finished our lunch, I received his blessing, then headed home.

May 31, 1989, Circleville, Ohio

"This isn't a backhanded attempt to lure you into accepting ordination, is it?" Kris asked after I explained the bishop's offer.

"No. It's actually neutral in that regard, but after today's meeting, I would wager that Vladyka will elect not to offer to ordain me in three years."

"Why is that?"

"I saw a very different side of him today, one he cannot show anyone who is clergy, and possibly not even his brother bishops."

"How so?"

"What I'm about to say is not something that can be shared with anyone."

"OK," Kris agreed.

"Vladyka treated me like a friend," I replied. "Joking, teasing, and generally being irreverent without being ungodly."

"And that makes you certain he won't ask?"

"Certain? No. Reasonably confident? Yes. Even as close as he and I were when I was a deacon, he was never this way with me. There is a protocol for such conversations, and this is the first one that didn't even come close to following the protocol. If you think about it, who can the bishop have as a true friend? With his brother bishops, he has to follow protocol; the same is true of his behavior when he's with his clergy. And most of the laity would never be willing, or possibly even able, to see His Grace as a man."

"But you, the most spiritual person I know, can?" Kris inquired.

"Actually, that's part of why I can," I replied. "Along with knowing the canons and traditions, I also understand the theology. It also helps that I have an understanding of my own sinful nature, and that is my primary focus."

"I'm sure Rachel will appreciate that when she's a teenager!" Kris teased.

"I may revise my views at that point!" I chuckled.

"I doubt you would do that."

"Of course not," I replied. "We'll teach her the ideal, and do our best to help her make wise choices, but in the end, she has to make her own decisions, just as you and I did, and we'll love her unreservedly. And the same is true for the kids we have in the future. In any event, back to the original question -- do you have any objection to me accepting a commission as a lay chaplain?"

"No. I think it's something you'll be very good at, and I know it's important to you to find a way to serve the Church."

"Then I'll inform him tomorrow. That will help when I try to see Frank Bush after our vacation."

"How do you think that will go?"

"Badly, but I have to try."

June 1, 1989, McKinley, Ohio

On Thursday, the first two hours at the fire station were quiet, but just after 9:00am the station was called to a house fire which required a rescue, with three victims brought out suffering from smoke inhalation.

"Mike, I think this one might have a compromised airway," Rob, one of the firefighters, said carefully setting down an unconscious young girl in front of me. "Soot around her mouth and nose."

I put an oxygen mask on her and turned the flow to maximum, which was ten liters, then quickly auscultated to her lungs. She was moving very little air, so I opened my medical bag and took out my equipment to intubate. I moved so I was in the correct spot, then tilted her head. I saw a lot of mucous.

"Bobby," I called out, "do you have suction?"

"No. It's not something we carry on the rig."

I replaced the mask and quickly considered my options. I had an idea and went to the supply box, got an irrigation syringe as well as an IV tube. Connecting the tube to the hypo was a challenged, but I solved that with a hemostat from my bag. My makeshift suction device worked well enough to clear some of the mucous, which allowed me to visualize the vocal cords and pass the endotracheal tube properly. I connected an Ambu-bag to the tube and held it with one hand while I held the diaphragm of my stethoscope to the young girl's chest. I squeezed the bag a few times and had good breath sounds. Given she had only minor burns and no other obvious injuries, I simply bagged her until Sam was finished assessing his patient, a young boy.

"Bag her while I finish my assessment, please," I requested.

I did that and quickly confirmed that her only immediate problem was smoke inhalation, which bagging would help improve. I connected a PulseOx monitor to her finger and saw that her PO₂ was 88%. A minute later it was 92%, which meant she was in relatively good shape, though she might have lung damage.

"She goes first," I said. "And right away."

"OK," Sam said. "Let's load her and go. The other two are conscious and breathing OK with only minor burns. We'll have the Sheriff bring them in."

We got the girl, who I guess was about thirteen or fourteen, onto the gurney, and loaded her into the squad. Bobby hopped into the front seat, I got into the back, Sam closed the doors, then pounded on them, signaling Bobby to go. As we pulled away, I continued bagging.

"Neat trick with the suction," Bobby called back. "I'll have to remember that."

"Hopefully, your new ALS units will have suction in the kit. Actually, do you have an equipment list?"

"We don't, but somebody in the department has to because the orders were placed at the end of last year."

"Could you get me a copy? It would help with planning your training for later this year if I knew what equipment you'll have."

"I'll speak to Captain Brinker and see what I can do."

I began giving him the vitals, and four minutes later we were at the hospital.

"Approximately fourteen-year-old girl," Bobby called out. "Unconscious at the scene of a structure fire; smoke inhalation with soot in her nose and mouth; intubated; PO₂ 94% with bagging; pulse tachy at 110; BP 130/80; first-degree burns on both arms. Two more with first-degree burns but conscious coming in by Sheriff's cruiser."

We unloaded the girl from the squad and I continued bagging as we moved to Trauma 2.

"Trauma 2!" Doctor Casper said. "You did this, Mike?"

"Yes. I had to rig up suction with an irrigation syringe, an IV tube, and a hemostat to clear mucus to visualize the cords, but then the tube went right in, and I had good bilateral breath sounds. Her PO₂ came up from 88% to 92% bagging and improved from there during transport."

"Excellent work, Doctor!"

"Thanks."

As was the case with every transport, once we were in the trauma room, the doctors, nurses, and medical students took over, and Bobby and I left, meeting Sam who had come in with the Sheriff and the two other victims in the corridor. Once they were both in the capable hands of the medical staff, we paramedics headed back to the station.

"How'd you come up with that idea?" Sam asked.

"In autopsy, when Doctor McKnight wanted to draw fluid from a body cavity, he used a device that is basically like what I put together. The difference is the tube is fitted to the syringe with a proper collar with a screw. The hemostat did the trick, and while I couldn't get a lot of suction, I got enough to allow me to visualize the girl's vocal cords so I could pass the endotracheal tube."

"Would she have made it to the hospital if you hadn't done what you did?"

"I'd say she probably would've, if you'd put her on hi-flow O₂ and transported her right away. Her PO₂ was low, but not dangerously low. In Denver, normal PO₂ would be around 92%, so she wasn't that much lower. There was no cyanosis, which is the key. If her lips or under her fingernails had been blue, that would be a different story. Another four or five points would make it dangerous, or if she was cyanotic from carbon monoxide, toxic fumes, or lung damage. The fact that her PO₂ came up with bagging indicates no serious lung damage. She'll cough up a lot of mucous over the next few days, but after that, she should be OK."

"Losing kids is the toughest," Bobby said.

"I agree," I replied.

"Squad 2, County Dispatch!" the radio squawked.

Sam answered, "Squad 2."

"Respond with Station #3, MVA, Route 50, mile marker 111."

"Squad 2, responding; ETA seven minutes."

"Lord have mercy," I said quietly.

"What?" Bobby asked.

"Jocelyn nearly died eight years ago on that stretch of Route 50."

"Who's that?" Sam asked.

"A close friend from the time I was in kindergarten. An elderly man had a stroke, crossed the center line, and hit her head-on. She was choppered direct to OSU."

"I remember you telling me about that," Bobby said.

"How is she?" Sam asked.

"Married, and she graduated from law school last Friday. She starts her job on Monday, and she and her husband will adopt a baby as soon as one is available."

"She's a really smart woman," Bobby said. "I spoke to her last Sunday. Her husband seems like a good guy."

"He is," I confirmed.

We arrived at the scene after Station #3 and three Sheriff's cruisers. The paramedics from Squad 3 were working on two victims and the firefighters were working to extract at least one other victim from a crushed Ford Escort that had collided with a minivan, which I couldn't identify.

"Is that the Doc?" Ralph, one of the paramedics, called out when I jumped out of our squad.

"Yes," Bobby replied loudly.

"You guys take the ones still in the Ford. Doc, come here!"

I hurried over and knelt down next to the patient.

"Male, mid-30s; unconscious restrained passenger; extracted about a minute ago; cervical collar and backboard; obvious tib/fib and forearm fractures; trouble breathing and difficult to bag; pulse thready, BP 80 palp."

I quickly auscultated the patient and was positive he had a tension pneumothorax and possibly a cardiac tamponade from broken ribs. The problem was, I couldn't put in a chest tube in the field and I couldn't do a pericardiocentesis as I'd only seen them done, never performed one.

"Get him into the squad and let's go. I can't do a chest tube or pericardiocentesis in the field. I'll ride with you and do a complete evaluation so the docs can do an immediate pericardiocentesis. We need someone with us to bag."

"John?!" Ralph called. "Let's load 'em and go!"

With assistance from two firefighters, we got the victims onto gurneys and into the squad. I hopped in and sat on the bench on the side with the patient, along with one of the firefighters from Station #3.

"Just bag as best you can," I instructed as I began my exam.

About two minutes after we pulled away, the patient's PO₂ had dropped to 85% and I detected cyanosis, which greatly concerned me.

"Ralph? ETA?"

"About four minutes, Doc!"

"I don't know that this guy has four minutes."

I felt the squad accelerate, but that wasn't going to cut more than a few seconds off the transit time. I could buy him some time with a needle decompression, but I didn't have the appropriate kit with me. I could improvise, though, as I'd read about how it had been done before specific needle-catheter systems had been developed.

"John, I'm going to try a needle decompression," I said.

"You're the doc, Doc!"

"I need a 12-gauge needle," I said.

"In the compartment to your left."

I opened the compartment and found the needle with the pale blue Luer taper, screwed it onto a syringe, removed the plunger, located the second intercostal space, and carefully pressed the needle into the patient's chest.

"Easier to bag," the firefighter announced

The victim's PO₂ reading came up to 89%. I listened and heard breath sounds on both sides of the patient's chest, and his pulse grew stronger. My solution was temporary at best, but it would ensure the patient at least made it to the hospital. By the time we reached Moore Memorial, the PO₂ reading was 91%.

When we stopped, Ralph hopped out of the cab and called out, "The Doc has the bullet!"

He opened the door, and I jumped out, giving the vitals as we moved the gurney out of the squad.

"Male, mid-30s; unconscious restrained passenger; cervical collar and backboard; tib/fib and forearm fractures; tension pneumo due to fractured ribs; emergency needle decompression performed after cyanosis was observed; pulse tachy at 110; BP 100/60."

"Trauma 3!" Doctor Nielson ordered. "Is that a syringe in his chest?"

"I didn't have a proper chest needle and catheter," I replied as we moved the patient into the hospital with the firefighter continuing to bag. "That was a technique described in JEM."

Doctor Nielson gave orders and, as was protocol, I left the trauma room with the firefighter and John.

"Great save, Doc," John said.

"That's on the list of procedures we'll teach you during your ALS certification. How do I get back?"

"2 is on their way here with the final victim," Ralph said, coming out of Trauma 2.

They left, and I went to the nurses' station to wait for Bobby and Sam. They arrived about four minutes later with the victim who'd been extracted from the Ford Escort by the firefighters, and who was obviously in bad shape as Sam was on the gurney doing chest compressions, and Rick, a firefighter, was bagging.

"That was probably futile," Bobby said when he, Sam, and Rick came out of the trauma room a minute later. "Arrested two minutes out. Major head trauma, plus both legs broken, one compound. The impact was on both driver's sides, obviously high speed, and the minivan driver had an airbag. How was your guy?"

"Tension pneumothorax, I resolved with a needle decompression."

"Good thing you were along. Let's head back to the station."

"Bobby!" Ellie called out. "Your wife just came into OB!"

"Sam, put us out of service for fifteen minutes while I check on Lor."

"Will do!"

"Mind if I tag along?" I asked Bobby.

"Not at all."

Sam made the radio call while I followed Bobby to the elevator that took us up to OB. We stopped at the nurses' station to find out which room Doctor Gibbs was in, then quickly walked there.

"I'm here to deliver your baby!" I announced when we walked in.

"Oh, HELL NO!" Doctor Gibbs replied.

"OK, maybe not," I chuckled as Bobby went over to kiss her.

"How are you, Lor?" he asked.

"Eight minutes apart, but my water broke, so I came in."

"Hi, Loretta," Doctor Alice Carmichael said, coming into the room. "Candace is aware and she'll be over in about an hour, and asked me to manage your delivery. OK with you?"

"So long as you keep the PGY1 in the paramedic getup there the hell away from me!"

"Hi, Mike," Doctor Carmichael said. "What's with the uniform?"

"Paramedic ride-alongs," I replied.

"I need to do an exam," Doctor Carmichael said.

"I'll step out," I announced, and went out into the corridor.

Five minutes later, Bobby came out into the corridor.

"Let's go. I'll come back when relief comes in. Shouldn't be a problem, as Doctor Carmichael thinks four to six hours most likely. Why'd you step out?"

"Because your wife is my mentor," I replied. "And I believe she'd prefer I wasn't in the room."

"You're a doctor!" Bobby protested.

"And yet, we only treat family in extremis and are very careful about treating friends. If you ask your wife, she'll agree with me. Anyway, how does this work for you?"

"Normally, I'd have to trade shifts, but cases like this, I can call the Chief's office and they'll find someone to cover the remainder of this shift."

"You know what I just realized?" I asked. "That you guys have it even worse than I do with regard to knowing what happened with a patient. I usually know if they're going to make it or not by the time we're done in the ED, but you guys drop them off and levae."

"Every once in a while someone stops by the station to thank us for a rescue, but otherwise, you're right -- we mostly don't know. Like you, we're just cogs in the healthcare machine!"

I chuckled, "It does seem like that at times!"

We met Sam in the ED, then headed back to the station where Bobby informed Captain Brinker that Doctor Gibbs was in labor, then called for a relief paramedic. About thirty minutes later, Gabe arrived and Bobby headed to the hospital.

June 2, 1989, Circleville, Ohio

The rest of the shift had been what Sam called routine -- minor injuries and possible heart attacks, and just after 6:00am on Friday morning, Bobby called to say that Bobby Junior had been born at 2:04am and both Doctor Gibbs and the baby were fine. At 7:00am, with the shift turnover, I had weighed visiting Doctor Gibbs, but was positive she'd be tired and cranky, so I'd headed home, where Kris and Rachel greeted me with kisses.

"Did you get any sleep?" Kris asked.

"About five hours total," I replied. "I'll be fine without a nap, though I could take one while Rachel takes hers."

"Go get your shower; breakfast will be ready in fifteen minutes."

I went upstairs, took a quick shower, then put on shorts and a t-shirt and went back down to the kitchen.

"Bobby and Loretta had their baby last night," I said. "Mom and Bobby Junior are both healthy."

"How typical! The man does two minutes of pleasurable work, then the woman carries the baby for nine months and labors and delivers, and the man gets equal credit!"

"Two minutes?! Excuse me?!" I protested.

"And another typical male reaction! Question their virility in even the slightest way and they lose their minds! What little they have of them, anyway!"

I rolled my eyes theatrically, then declared, "I have half a mind to prove you wrong!"

"Half a mind is right!" Kris teased. "But that's still more than most men!"

"Ah, then my decision is made," I said firmly. "Rather than demonstrate my prowess, I shall not bother, as, clearly, my efforts are not appreciated!"

"I didn't say that!" Kris countered. "It's just I want to needle you!"

"And what I have for you is bigger than a needle!"

Kris laughed, "You are a very virile and well-endowed man!"

"Thank you! Perhaps I'll relent and demonstrate after all!"

"In all seriousness, though, that doesn't seem like something you've ever had trouble with."

"No. My problem was one of a libido in overdrive."

"I don't mind," Kris replied with a smile.

"You don't mind?!" I asked with faux outrage.

"You are so easy to wind up, Mike!"

"Or," I said slyly, "I know you want to wind me up, so I play along to make you happy!"

"Wait!" Kris protested. "That's what you do with Clarissa, isn't it?"

"It is! And if you ever tell her, I'm going to be very unhappy!"

IV. It's going to be a very busy year!

June 5, 1989, On the Road to Gatlinburg, Tennessee

"What happens now that you've finished your time with the fire department?" Kris asked as she maneuvered her Tempo onto Ohio Route 23.

"Now I have a full twenty-five days off, and perhaps one or two more, depending on when I have my first shift."

"It doesn't start on the 1st?"

"Not necessarily. If I needed orientation, then it would. But I get paid starting the 1st no matter what."

"Do you know the other new doctors? I mean besides Kylie?"

"I know their names only, and where they're from. I haven't met any of them. Besides Kylie, there are four men and one woman, and one of the guys is from India, but went to medical school at UCLA."

"So, including you, five men and two women?"

"I'm technically not a trauma Resident," I replied. "So of the actual trauma Residents, it's four to two, which is an improvement, given there is only one female Resident, Doctor Billings, and only one female Attending, Doctor Gibbs."

"And you're OK with that?"

"I'll say the same thing I did when a similar question was asked about Taft -- you can only draw from the pool of applicants. My class was about two-to-one male over female, which was an improvement, and the ones behind us were less unbalanced. The most common Match for women in my class was pediatrics, followed by OB, and then going into general practice. Surgery, cardiology, and trauma combined had fewer Matches than pediatrics."

"Why?"

"Part history, part conditioning, part personality traits. And, yes, discrimination, especially in surgery."

"And you put up with that?"

"No, I simply acknowledge it to be true. I have spoken up when and where appropriate, just as I did at Taft. Things are changing, slowly, and the medical school is doing more outreach to women and minorities. But a smallish medical school in south-central Ohio is going to be more white and more male than, say, UCLA, simply because of the demographics. We don't have many Hispanics in the area, nor many Asians, just to identify two minority groups."

"What about what you call African Americans?"

"Not represented at the same percentage as they make up the population, but as Doctor Mertens said when I asked, it's an applicant problem, not an admissions problem. They admit a higher percentage of African American applicants than make up the applicant pool. Not to defend our system, but there must be discrimination in France."

"Mostly against immigrants from Africa, especially from Algeria. I believe the main cause is that many of them are Muslim, and do not agree with the absolute secularism which we maintain in French political life, called «Laïcité». It is very much like what you call 'separation of church and state'."

I shook my head, "I don't think so. In our system, the government is expressly forbidden from creating a national church, and that's it. That's been read to not allow it to favor one faith over the other, and I agree. But other than that, 'Free Exercise' means the government may not interfere with religious practice, but faith may not only be public, but openly influence public policy."

"But the 'wall of separation'?"

"That was Thomas Jefferson, and he's been seriously misinterpreted. In context, Jefferson's concern was being compelled to follow a specific religious practice by law, not that religious people expressed political opinions. And remember, at the time, there were still established churches in individual states, because the original Constitution did not prohibit state governments from having established churches, which they did into the 19th century."

"That make no sense at all!"

"It does if you understand the founding concept of the United States to treat every state similar to a country, albeit with a common foreign policy, a common national currency, a free trade zone, and no border controls. It's similar to the Schengen Agreement, with regard to borders, and the recently passed Single European Act with regard to a free trade zone. And I know there are proposals for a common currency, and there is quite a bit of common foreign policy."

"But you are one country!"

"We are fifty sovereign states," I replied. "And the Constitution delegates limited powers to the federal government. The main political argument in the US since 1789 is just how much power the national government ought to have."

"And what do you think?"

"I think the country is too large to be governed centrally with 'one-size-fits-all' policies. What concerns me in southern Ohio may not concern someone in southern California or in Alaska or in Texas. What we have in common is currency and foreign trade, and, in theory, the ethos of the American Dream, true or not."

"Do you believe in it?"

"My family, on my mom's side, lived it, and I'm a product of it. On my dad's side, they were well-to-do from the time they first arrived in Manhattan in the 17th century. My Russian grandparents came here with nothing except the clothes on their back, a few personal items, and a balalaika."

"The one you have, right?"

"Yes. My grandfather gave it to me about four years ago. It will be Rachel's, if she wants to learn to play, which I hope she will."

"She certainly loves sitting with you when you play!"

"Most girls did!" I said.

"Of course!" Kris said, laughing softly. "Boys who played the guitar attracted girls like bees to a flower!"

"I didn't learn to play until college."

"Poor baby," Kris said flatly. "But going back to Europe, I didn't realize you knew so much about European politics!"

"I've picked it up through reading the newspaper, mostly. Our civics classes here, at least when I was in High School, focused on the American system."

"My High School here didn't offer civics, but we did have a course in principles of government, which, of course, was so out of touch with reality that I couldn't stand it!"

"The usual American mischaracterization of socialism and a denial that we have programs which are, in their essence, socialist, by American definitions."

"Yes, of course! Not to mention treating Marx and Engels as 'class enemies' while denying 'class' theory!"

"Americans do tend to suffer cognitive dissonance on that topic. But I suppose I'm a class enemy because I believe the accumulation of capital is, overall, a good thing."

"We'll work on that!" Kris said lightly.

"And I say 'good luck to you in that endeavor'!"

"Changing subjects, we never really discussed what we'd do in Tennessee."

"I believe we should spend time with Rachel, hike, swim, and make love!"

"How do you think Rachel will respond to a brother or sister?" Kris asked.

"With a sister, I think if we make the point she's a 'big girl' and the 'big sister', she'll be fine. She's not keen on boys at the moment."

"That will change!"

"More than likely, but you know Clarissa, so you know that's not a given."

"And your response?" Kris asked.

"Will be to love my daughter," I said firmly, "no matter what."

"And speaking of Clarissa, we should probably discuss her request, so we're in full agreement before we have dinner with her and Tessa."

"I think, in the end, you have the master trump, and the right to play it."

"I'm not sure that's fair to you," Kris said. "To simply say 'no' without approaching it with an open mind, even if the result were to be the same. What is a partnership if one is a dictator? You do not want to be ruled by me any more than I want to be ruled by you, which is to say not at all!

"You know, because I've said it plainly, that there are only two absolutes -- absolutely no secrets and absolute sexual fidelity. And with regard to sex, I've promised to do anything you want, with you, with no limits and no restrictions, and you've made the same promise. Everything else is open to discussion.

"I reject completely all misogynistic practices, and it would therefore be completely out of line to turn the tables, so to speak. I know you like to tease about women controlling your life, but I hope you know that's not true about me, though I do reserve the right to give you guidance."

I laughed, "Guidance from a Russian woman is FAR more than just a suggestion!"

"Good advice ought to be followed, don't you think?"

"As much as it might sound as if I complain about women controlling my life, it's really not a complaint. As Mr. Sokolov told me before I married Elizaveta, God gives us wives to make us better men. I agree, and I don't feel controlled when you suggest a course of action or a change in behavior. My mom, Jocelyn, Clarissa, and Elizaveta never steered me wrong, even if I didn't always take their advice."

"You don't feel as if I'm trying to control you, do you?"

"No, I don't. You've made your views clear, but you've always been willing to hear my side, and consider my views, needs, and desires. I don't feel at all controlled or limited or restrained by our relationship, with the caveats about secrecy and fidelity, with which I wholeheartedly agree."

"I would hope so! I may not be jealous, but I do not share!"

"I learned to share in kindergarten," I replied with a silly smile.

"NOT THAT WAY!" Kris protested, though she laughed after she said it.

"Well, Jocelyn and I did hang our smocks on the same hook so they wouldn't be lonely at night!"

"You were five!"

"I grew up!"

"Allegedly!" Kris teased.

"Jocelyn and Clarissa would agree with you!"

"You know they're teasing, right?" Kris asked.

"Of course. That said, both of them were instrumental in making me the man I am today."

"So I owe them a debt of gratitude?"

"I don't know that 'owe' is the right term," I replied, "but you certainly should be grateful. There were others, too, especially Angie, who had a major impact as well, though mostly in terms of my views on the horrendous state of mental healthcare."

"That really is a focus for you."

"Some would call it an obsession," I replied. "How is it in France?"

"There are plenty of doctors and plenty of services, and they are covered by our health insurance system, but I cannot say how effective it is because I don't know. Have you decided what to do about the doctor who improperly treated her?"

"I spoke briefly to Lara at the graduation party and she and I will speak with Angie's mom later this month. In the end, it's up to her, as I don't want to put the Stephens through an ordeal they'd prefer to avoid. If she's OK, then we'll file a formal complaint with the Ohio Medical Licensing Board and use the malpractice settlement as proof something happened. We'll probably lose before the Licensing Board, but I think it's worth the time and effort, as does Lara."

"If he's a bad doctor, he ought to be identified as one."

"I agree. I'd prefer his license be yanked, but I've been told time and again that's not going to happen, and I'm going to tilt at that windmill despite being warned not to."

"By the psychiatrist at the hospital, right?"

"Among others. Basically, it would be Mrs. Stephens filing the complaint, and Lara bankrolling the attorney, and me providing guidance and input, but doing my best to stay out of the limelight."

"I'm curious whether you would choose to protect yourself or help Angie?"

"That's a difficult question to answer without understanding the exact risks, which I won't know until they occur. I think the best answer is I won't risk my future medical license, but I would risk alienating doctors and administrators."

"But wouldn't that harm your training?"

"Perhaps in some minor ways, but in the end, the literal worst-case scenario would be that I'd obtain my license as a GP and emulate Doctor Evgeni. But I don't see that happening. The psychiatrist absolutely failed to take Angie's best interest into account and literally ignored or discounted the indications that she might have been on the road to recovery, or, perhaps, stability at a level where she could regain her autonomy."

"I don't understand why that's no longer possible," Kris said.

"In part, because she has to be medicated, but in part because the psychiatrist's actions caused a mental breakdown and pushed Angie back to the exact place she had been at her lowest point. It took literally years of concerted effort to get her off the drugs, which is a prerequisite for obtaining a driving license and applying to have her right of self-determination restored. What happened means that task, which was already difficult, will now be impossible, as they'll point to that relapse as a reason to not release her from the guardianship orders."

"As I said when we first discussed this, that doctor is evil."

"Indeed he is."

June 5, 1989, Gatlinburg, Tennessee

Kris pulled into the drive of the Greystone Lodge in Gatlinburg just after 4:00pm, after an uneventful drive from McKinley. Rachel had slept a good portion of the way, as she often did on longer car rides. She parked, we got out, I took Rachel from her car seat, and we went into the lobby.

"We have a reservation under 'Loucks'," I said to the Reception clerk.

She flipped through cards and selected one.

"Doctor Michael Loucks?" she asked.

That was not how I'd made the reservation, and I smelled a rat, though I didn't know which rat it was.

"Yes, along with my wife and daughter."

"Welcome Doctor Loucks! We have you in one of our family suites for nine nights, departing on the 15th. I see the room rate has been paid. I'll need a credit card imprint for incidentals, please."

I handed over my MasterCard and the clerk took an imprint, then handed it back to me.

"Sign here, please," she said, sliding a registration card to me.

I signed and pushed the card back.

"Two keys?"

"Yes, please."

"Is your luggage in your car?"

"It is."

She tapped a bell, and the bellman came over.

"Doctor and Mrs. Loucks have luggage," she said, handing the bellman the room keys. "Doctor Loucks, we can park your car for you, if you like, and bring you the keys."

"Thank you," I replied.

"Enjoy your stay!"

I handed the car keys to the bellman, and we moved aside to wait for the bellman to retrieve our luggage.

"That American custom is annoying!" Kris said quietly. "As if I'm your property!"

"She could have said 'Doctor and Mrs. Michael Loucks' and made it sound worse," I chuckled. "But we're in the South, so you have to expect people to use traditional terms and make traditional assumptions."

"All that does is perpetuate the problem!"

"Maybe so, but we're on vacation, so just let it go and enjoy the hospitality, please."

The bellman retrieved our bags, then showed us to our suite, which had two bedrooms, one which had a bunk bed with side rails. The bathroom had a large tub and a large shower with a bench. And the main room had a 35" television and stereo system.

"We can move the trundle bed to the main bedroom if you wish," the bellman offered.

"Rachel will be fine in this room," I said.

I tipped the bellman, and he said someone would return with our car keys within ten minutes.

"Someone upgraded the room and paid?" Kris asked.

"Yes. Your parents?"

"No. They wouldn't do that without asking me. Viktor Kozlov?"

"I seriously doubt it," I replied. "If Yulia ever found out, she'd be upset."

"Lara?"

"She's one possible suspect, though, like your parents, she'd have said something. The thing is, the only people I told where we were staying were my mom and Clarissa. If I had to put money on it, either Stefan or my grandfather, or both."

"Does it upset you that they didn't tell you? I mean, whoever did it?"

"No. I'm OK with surprises and unexpected gifts. And that's why I don't think it was Lara, because she knows about your distaste for secrets and surprises. May I suggest you simply accept the gift graciously and let it go? I'll find a way to work your preference into a conversation so it doesn't sound critical but makes the point."

"You don't agree with me, do you?"

"I have a somewhat different opinion, but I support your desire to not have surprises or secrets. So, in the end, we'll do it your way because it's something that's important to you, but not particularly important to me."

"OK. What shall we do until dinner?"

"Well, given the Tsarina slept most of the way here, I'd say we should go to the pool."

"She'll be OK?"

"I don't plan to simply toss her in!" I chuckled. "Let me get her bathing suit on."

"What about her diaper?"

"My mom bought her something called a swimsuit diaper. It's basically plastic pants with a cotton liner and then a top."

I changed Rachel, then went to put on my bathing suit, and stopped dead in my tracks as I saw Kris in a pure white bikini.

"Wow!" I exclaimed.

"Thank you, but you've seen me naked!"

"I have, but sometimes leaving a bit to the imagination is sexy!"

"You don't have to imagine!" Kris protested.

"And yet, I stand by the fact that you look sexy in that bikini!"

There was a knock at the door and the bellman handed me the keys to our car. Once I put the keys with my wallet on the table in the bedroom, Kris, Rachel, and I went to the pool. Rachel didn't know what to make of the kiddie pool at first, but soon was splashing and enjoying the water. We spent about thirty minutes at the pool, and, as I didn't want Rachel to burn, we went back to the room and relaxed until dinner, which we ate in the hotel dining room.

"What do you make of the elections in Poland?" Kris asked as we watched the evening news on television after dinner.

"I think the genie is out of the bottle, so to speak, or Pandora's box has been opened. The repudiation of the Communist government is a major threat to the Kremlin, and Poland is a potential powder keg. All we can do is pray it ends relatively peacefully."

"You worry about the Soviet response?"

"I do. Hungary in 1956 and Prague in 1968 are precedents, though I don't think this would turn out the same way. And when it's obvious they will lose, what do the hard-liners in the Kremlin do? I hope they remember their humanity, but I fear they won't."

"I fear you're right," Kris confirmed.

Later in the evening, we said our evening prayers, and after Rachel went to sleep, Kris and I shared a warm bubble bath, then made love before falling asleep in each other's arms.

June 6, 1989, Gatlinburg, Tennessee

"Should we discuss Clarissa's request?" Kris asked as we cuddled in bed on Tuesday evening after a full-day hike and a nice dinner in Gatlinburg.

"It really does come down to your decision," I said. "I don't have any reason to say 'no'."

"Will you tell me why you want to do it?"

"During Junior year at Taft, when Clarissa and I had recognized we were basically soulmates, but with one glaring impediment, we discussed what kind of future we might have together. The obvious answer was going to medical school together, Matching at the same hospital for our Residencies, and then practicing together. Clarissa made the point that she did want to have a baby some day, and we discussed how that might work.

"Remember, at the time, there was no suggestion I would be a deacon, and my plans for marrying were for after my first year of Residency, at the earliest, with the most likely time being during my third year, given dating during my PGY1 year would be difficult at best, and given the amount of hours I'd be working. Had things gone the way we discussed, without Bishop ARKADY's desire to ordain me, it would have happened before I married, even possibly before I was engaged."

"But Clarissa has the same kind of schedule, right?"

"Yes, but there are ways around it, which Maryam considered when she and I discussed a possible future together. It's entirely possible to delay your Match for a year, which she would have done, but in the end, as you know, we decided that trying to raise a family when we both had eight or more years of Residency was a challenge that we both felt was too great.

"One option Clarissa has considered would be having the procedure done sometime midway through her PGY1 year, and then she could take off six weeks during her PGY2 year. Of course, we'd have had a nanny, but on two above-average salaries, we could have afforded that. Obviously, everything changed when Bishop ARKADY proposed ordaining me, and took everything off the table, as it would have been unacceptable for me to procreate outside of marriage as a deacon, even via artificial insemination."

"Did you discuss it with Elizaveta?"

"There really wasn't a point because it simply could not happen."

"Out of curiosity, did Clarissa consider conceiving the usual way?"

"Considered, but once I married, that was out of the question, for obvious reasons. As she said at the time, the physiology works, even if the desire isn't there."

"And it's something you want?"

"It's something Clarissa wanted that I could do for her," I replied.

"But do you want a baby with her?"

"I'm not sure how to answer that," I replied. "I agreed because it was something I could do for her and with her, but it wasn't something I needed to do, as I obviously could have children with whomever I married. I guess what I'm trying to say is that this isn't something I'd put ahead of my marriage to you."

"Did you discuss how the baby would be raised?"

"Not really, other than I'd want to be involved in raising him or her, though my assumption was that the child would live with Clarissa and her partner, who at the time was unknown. When Clarissa starting dating Abby, the entire thing was called into question because Abby did not like me at all."

"Why?"

"Simply because I was a faithful, practicing Christian. Clarissa reminded her time and again that I was loving and supportive, but Abby could never get past the teachings of the Church on marriage and sexual relationships, even if I didn't try to hold her and Clarissa to those standards. In the end, they broke up and Clarissa started seeing Tessa, though by that time, I was married to Elizaveta and a deacon, so even though Tessa was open to the idea, it was a non-starter."

"So you'd be a dad, but your son or daughter would mostly be raised by Clarissa and Tessa?"

"I suppose," I replied. "As I said, we didn't discuss it in detail because of the things that happened to make it basically out of the question."

"I obviously don't have a problem with Clarissa and Tessa raising a child, either one they conceive with outside help or by adoption."

"Ohio would never let them adopt," I replied. "A stupid policy, but the state makes it tough even for single people to adopt, and gay and lesbian couples are basically refused any opportunity. That said, Clarissa wants to conceive, and I obviously support her desire. It really comes down to a question of whether you can accept the situation. If not, say so now, because otherwise, we'll find ourselves in a very bad place."

"I'm not saying 'yes', but I'm also not saying 'no'," Kris replied. "I think we do need to have our conversation with Clarissa and Tessa, then you and I will discuss what to do. Is that acceptable?"

"Yes, it is, so long as you don't feel compelled or pressured to agree."

"I don't. You know I'll speak my mind!"

"I have no doubt about that at all!"

"Perhaps you'd prefer I did something else with my mouth right now?"

"I would indeed!"

June 15, 1989, on the road to Circleville, Ohio

"Did you enjoy the ten days?" I asked as I pulled out of the Greystone Lodge parking lot.

"I did!" Kris exclaimed. "We probably won't have a vacation like this for a number of years because of your Residency, my work towards my degrees, and having two more children!"

"Charlotte Michelle or John Michael?" I asked.

"Those are the names on which we agreed. It's simply a matter of making one of them!"

"Well, we've had plenty of practice, so it's just a matter of lowering the shield!"

Kris rolled her eyes, "A Star Trek reference with regard to sex?"

"I am fully functional in every way, and capable of multiple techniques; a broad variety of pleasuring."

"Star Trek, again?"

"Commander Data from the first season episode The Naked Now, which was a riff on The Naked Time from the Original Series. Thankfully, I'm not like Wesley, who on a planet where they make love at the drop of a hat, gets arrested for trampling flowers!"

Kris laughed, "You seriously do not like the Wesley Crusher character!"

"He's annoying! Though I do love when Worf tells him how to get laid in the second season episode The Dauphin -- 'Go to her door, beg like a human'!"

"As opposed to?"

"Klingons, where the female roars and throws things while the man reads love poetry...and ducks a lot!"

"And how do you see me? Hmm?"

"You do make wonderful sounds when sufficiently motivated!"

Kris laughed, "«La petite mort» makes me feel SO good!"

"And me, as well!"

"Dada kiss Mama!" Rachel exclaimed from the back seat.

"Not right now, young lady! I'm driving!"

"Do you think she knows what we're talking about?" Kris asked.

"I think she detects the tone of voice we use, not the topic. And we do use a different tone when we're talking about sex. That said, she's pretty smart, and she has been in the room when we've fooled around!"

"Not recently!"

"True, but who knows what goes on in the mind of a toddler? They don't have the language to express themselves. Rachel is just beginning to string more than two words together into what passes for speaking in full sentences. That'll accelerate rapidly in the next few months, and by the time she's two, she'll have several hundred words in her vocabulary and understand how to create proper sentences. At that point, she will be able, as is true of every woman in my life, to tell me exactly what I'm doing wrong!"

Kris laughed, "What do you say? It's the Y chromosome?"

"Or as Jocelyn put it, when describing her boyfriend Karl, Dale, and me -- testosterone poisoning."

"There might be something to that! Men do not always consider the risks associated with their behavior."

"Which is why we pay higher premiums for auto insurance," I replied. "My premium dropped by nearly half when I turned twenty-five. Part of that was driving a muscle car, but most of it was being a male between sixteen and twenty-five."

"Speaking of insurance, I never asked, but how does that work for us with regard to medical care?"

"So long as we see doctors affiliated with the hospital, and receive all our care there, it's covered one hundred percent with a $5 copay on prescriptions and a $10 copay on office visits. If we have to go to a doctor outside the hospital who is not affiliated, or to another hospital, it's covered at 80% up to an out-of-pocket maximum of $1000 per person, or $2500 for the family. You should decline whatever insurance OSU offers students as it cannot be anywhere near as good."

"Then I need to find a primary physician affiliated with the hospital."

"Ask Doctor Forsberg when you see her before we begin trying to make a baby."

"Baby?" Rachel asked.

"Uh oh," I said quietly, and Kris laughed.

"A baby brother or sister for you," I then said aloud. "But not soon."

"No baby!" Rachel declared. "Rachel!"

"Well, that deteriorated quickly," I said quietly to Kris.

"Rachel," Kris said, "Mama and Dada love you lots, but they want to have a baby together."

"NO!" Rachel declared.

"You are not going to win this debate," I said quietly to Kris. "Do you know the difference between terrorists and toddlers?"

"No."

"You can negotiate with terrorists!"

Kris laughed hard, "I can't actually argue with that one, given our daughter's stubbornness!"

"She is a Borodin, through and through!" I declared.

"Stubbornness is OK in some things, not in others," Kris said.

"Determination versus stubbornness," I said. "Determination is good; stubbornness is often problematic."

"True.

"That said, I believe the Tsarina expects her wishes to be carried out!" I chuckled. "Maybe distract her with an Oreo and a juice box?"

Kris retrieved a cookie and a juice box from Rachel's bag and gave it to her, which had the usual effect of distracting Rachel from whatever it was that was annoying her. In the end, in about a year, Kris and I would have our first baby together and Rachel would just have to deal with it.

June 16, 1989, McKinley, Ohio

On Friday morning, Kris and I stayed in bed cuddling until Rachel woke up, then we had breakfast and said our morning prayers together. I called Viktor, and he suggested dinner that evening at the country club, though it wouldn't be in a private room. I checked with Kris, and she agreed, so we confirmed for 6:00pm.

"There's no fasting until after Sunday, right?" Kris asked, looking at the calendar.

"Correct. Even though the calendar shows fasting resumes at Ascension, the practice in our diocese is, as our bishop once put it, to 'party until Pentecost'. And then in two weeks we have an abbreviated Apostles' Fast. And, then, of course, the Dormition Fast for the first fourteen days of August."

"Should we do our shopping today?" Kris suggested. "That way, we won't have to rush tomorrow because of the wedding."

"That makes sense," I replied. "We can also stop at the hospital so I can check my schedule."

"Will it change every month?"

"No. It should be the same for six months, but, obviously, things can change if something were to happen with one of the doctors or they need to adjust staffing based on changes in patient loads. We can go whenever you're ready."

"Then let me dress Rachel and we can go."

Five minutes later, we were in my Mustang on our way to the hospital. I was totally not surprised when Rachel attracted all the attention she could handle, which was a lot. I went to the lounge to check my schedule, but I wasn't on it, then remembered I was officially on the surgical service. I went up to the surgical lounge, saw my name on the schedule, wrote the details in my notebook before returning downstairs. When I walked into the Emergency Department, I saw Kris at the nurses' station where Rachel was the center of attention.

"My first shift starts on Monday, July 3rd at 0600 and runs until 1800 on Tuesday," I said, using military time, which Kris was used to from having lived in Europe. "My next shift starts on Thursday morning, and runs until Friday evening, then I have a twelve-hour-hour shift on Saturday from noon until midnight. I'll be able to attend Vespers on Wednesday and the Divine Liturgy on Sunday, and Friday nights are free, too."

"That seems like the best possible outcome," Kris observed.

"I'm fairly certain Doctor Gibbs accommodated church. There was a note for me from Kylie that she'll cover for me on the afternoon of the 4th so I can play the concernt Code Blue has scheduled at the lake."

"You're going to be very tired!"

"Possibly, but I do want to play. And the fact that I have Friday evenings free means there's a good chance we can play gigs."

"Hi, Mike!" Kylie said, coming up to us. "Hi Kris! Hi Rachel!"

"Thanks for leaving a note about the 4th."

"You're welcome. I confirmed with Doctor Northrup that it's OK, because I'd only have about four hours between the end of my shift and when I have to be back for yours, but it'll work out OK. Did you hear about Tim?"

"No, I was happily completely incommunicado for the past ten days!"

"He failed his rotation and was given the option of dismissal or starting over."

"Rotations or coursework?"

"Coursework. He's a First Year again, as of August 1st."

"We'll see if he learned his lesson or not," I replied. "How does it feel to be a doctor?"

"Not all that different," Kylie replied. "Except I get to assign all the scut to the Third and Fourth Years! I don't get my own trauma cases, but I do get walk-ins to handle on my own. Well, obviously I have to clear things with an Attending, but you know what I mean."

"I do."

"How were your paramedic ride-alongs?"

"Mostly observation, but one intubation and one needle decompression for a pneumothorax."

"I heard about that! Just a large-bore needle and a syringe?"

"They don't carry the correct equipment to do that in the current EMS units. They will carry the necessary equipment in the new ones configured for ALS, which is why we'll train them in procedures starting in August."

"Doctor Baxter?" Nurse Kelly said to Kylie. "Four-year-old with a suspected broken wrist."

"Duty calls! See you in two weeks!"

She left to check on her patient, and I managed to rescue Rachel from the clutch of nurses so that she, Kris, and I could head to Kroger to do our grocery shopping. After Kroger, we stopped at the bakery for fresh bread, bagels, and croissants, then headed home for lunch and a quiet afternoon. Rachel had her nap, and then about 5:45pm we left the house for our dinner with Viktor, Yulia, Geno, Anna, and Viktor Gennadyevich. Little Viktor was his usual rambunctious self and Rachel gave him the evil eye throughout the meal.

"Cousin Viktor's behavior appears to not be to Rachel's liking," Viktor observed as dessert was served.

"I'm surprised she isn't rolling her eyes and saying 'Boys!' the way Elizaveta used to say 'Men!'," I replied. "But he's a healthy, active kid, and obviously would much rather be outside playing than sitting in a formal dining room."

"Just as his father and grandfather would!" Yulia interjected. "Except they'd be playing golf!"

"We'll get Mike out there with us again eventually, though I don't think his schedule as a Resident is conducive to playing golf!"

"It's not," I replied. "It should be better next year, and, of course, during my PGY3, I'll be on a surgical team, which means regular Thursday afternoon golf. The surgeons brook no interference with that tradition!"

"How will that work?" Geno asked. "I mean being what amounts to a surgical Intern but in your third year?"

"I'll participate in some scheduled surgeries for teaching purposes, but my main role will be surgical consults and emergency surgery. Basically, I'll identify surgical cases and then assist with the surgery. That frees up regular surgical Residents to participate in scheduled surgeries and to care for patients on their service. Longer term, that's what I and three other trauma surgeons will do. If the program is as successful as I expect it to be, that will be the norm, and there will be enough trauma surgeons, so no general surgeon has to cover trauma."

"And the new Emergency Medicine wing will be finished right about that time," Viktor said. "We break ground on April 16. The final surveys and permits were completed last week."

"I'm very much looking forward to the 'telemetry beds'," I said. "That, combined with the ALS certification for EMS, is going to make a world of difference in patient care. And being a Level I trauma center will make even more of a difference, though that certification has to wait for the new surgical wing, which won't be finished until 1995."

"We're hoping to advance that by a year, at least," Viktor said. "If we can complete everything by the end of next year, we'll start in early '91 instead of '92."

"How long will construction take for the new ER?" Anna asked.

"It will be about eighteen months until it opens," Viktor said. "They broke ground last week, but some of the equipment has a very long lead time and takes significant time to set up and install."

"What are you doing for the next two weeks, Mike?" Geno asked.

"As little as possible! We have a wedding in Cincinnati tomorrow, then next weekend we're going to the monastery so I can visit with Father Roman. Other than that, just resting and relaxing as a family before my Residency begins and Kris begins her degree work at OSU."

"It's going to be a very busy year!" Kris declared.

"That it is," I agreed.

V. And That Makes ME Happy!

June 17, 1989, Milford, Ohio

On Saturday afternoon, just before 1:00pm, I pulled into the parking lot behind Saint Andrew's Catholic Church in Milford. The lot was between Milford Main, the middle school, the church, and the parochial school attached to the church. Kris got out of the car, I got Rachel from the back seat, and the three of us went around to the front of the church, which faced Route 28.

An usher held the door for us and we walked into a traditional Roman Catholic church, complete with pews and an altar which was set so the priest faced the congregation, rather than facing liturgical east. There were statues, rather than icons, and the closest thing to an icon were the reliefs of the Stations of the Cross. Those reliefs were the only thing which adorned the walls and were austere compared to a typical Orthodox church where the walls were literally covered with icons.

We sat in pews on the groom's side, six rows back from the steps that led to the sanctuary, with me holding Rachel in my lap. Normally, she'd be allowed to crawl around the nave at Saint Michael, but that wasn't possible here with the pews and kneelers and a marble floor rather than rugs, though there was a wedding runner in the center aisle.

"Dada? Down!" Rachel demanded, seemingly reading my mind.

"You have to stay in either Mama's or Dada's lap," I said. "Or sit in the pew."

"NO!" Rachel declared. "DOWN!"

"Having fun, Petrovich?" Clarissa smirked from the aisle next to me.

"Maybe you can reason with my toddler! I certainly can't."

"Rachel, want to come to Aunt Clarissa?" she asked.

"YES! Clarsa!"

"I see where I rank!" I chuckled.

Clarissa took Rachel from me, then she and Tessa moved past to sit to the right of Kris. Rachel looked at me and scowled, and I just shook my head. She certainly had a mind of her own, and there was going to be a serious contest of wills, which, from everything I knew, was normal for the 'Terrible Twos', even though Rachel wasn't quite two.

The wedding service was typical of Roman Catholics, with a nuptial mass, with Father Robert Buschmiller as the celebrant. The Roman mass generally followed the same liturgical order as the Orthodox Divine Liturgy, though somewhat simplified, and they used an organ, which was something that was categorically prohibited in an Orthodox temple.

Sticks was acting as José's best man, and Sierra had only her maid of honor, and just the four of them stood at the altar once Sierra's dad had walked her up the aisle. When the service ended, we filed out of the church and a large group of our friends gathered in the parking lot to decide what to do before the reception. It wouldn't start until 4:00pm, which gave us about two hours to kill. It was in Loveland, about twenty minutes away.

"Is there anything close by to do?" Robby asked.

"The Cincinnati Nature Center is in Goshen," I said, "but by the time we get there, and if we allow for time to get to Loveland, we'd have maybe an hour to walk."

"Why don't we go to Frisch's?" Tessa suggested. "I saw it on Route 50 on the way here."

That was the consensus, though I wondered if they could handle close to two dozen people at once. We headed there, and they did manage to seat all of us, using two large booths and a number of tables pushed together. We couldn't all sit together but it did work, and we all ordered coffee, soft drinks, and a snack of some kind, which for Kris, Rachel, and me was a plate of French fries.

"Perhaps the French fries will improve Rachel's attitude towards you!" Kris suggested.

"Until I enforce the limit of how many she's allowed to have!" I said. "But then she's my mom's problem!"

"I wondered if you were bringing her to the reception," Clarissa said.

"My mom is meeting us at the banquet hall and will keep Rachel until we pick her up after the reception. Kris and I didn't think Rachel would do well sitting for four hours and unable to roam freely. Not to mention some adults do not tolerate toddlers at these kinds of events."

"Clarsa? Fry?" Rachel asked, causing everyone at our table to laugh.

"She knows who's boss," Sophia declared.

"Well, Petrovich?"

"I surrender. I mean, it fits, being married to a French woman!"

"«Придурок»!" Kris exclaimed.

"'Jerk'" Clarissa translated for everyone, resulting in laughter.

"«Je t'aime chérie!»," I said.

Kris smiled and kissed my cheek, knowing I was teasing her. Clarissa fed a very happy Rachel a stream of French fries, and about 3:20pm we all left Frisch's to head to Loveland for the reception.

June 17, 1989, Loveland, Ohio

"Congratulations!" I said to José when I finally had a chance to speak to him at the reception.

"Thanks!" he replied as we exchanged a hug.

"How was your vacation?" he asked.

"Relaxing. I never asked -- where are you two going?"

"We fly to Orlando tomorrow morning for six days at a Disney resort. Ever been?"

"No. I haven't been to many places in the US. In fact, I've been to more European countries than I have states! Ohio, Pennsylvania, Kentucky, Indiana, Illinois, and Michigan is it. How did you swing Disney on short notice?"

"Sierra and her parents had planned a vacation and her parents ceded the room to us. That's why we're going there."

"Cool. I noticed you crossed yourself in Orthodox fashion and I saw the priest raise an eyebrow the first time!"

"I may have been exposed to a bad influence!" José replied with a goofy smile. "It's really too bad you aren't in your «ryassa», because that would really have attracted attention!"

"Which is exactly the opposite of the intent, though you aren't wrong."

"I might even hold up my palm for a blessing!"

I laughed, "Not something a deacon can do, though had I'd been made a monk, there are circumstances where it's appropriate."

"That was about as likely as me being a monk!" José chuckled.

"Believe it or not, without Rachel, I'd have seriously considered it."

"You did take that calling seriously, even if it was your secondary calling."

"True. What I can say, though, is 'May God grant you many years'!"

"Thanks, Mike."

"You're welcome!"

We hugged, and he moved on to the next person he wanted to speak to while I returned to the table where Kris and a group of our friends were sitting. We had an enjoyable time, Kris and I danced, and with her blessing, I danced with Clarissa and Tessa, and when the reception ended, Kris and I headed to my mom's to collect our daughter and then head home.

June 19, 1989, Circleville, Ohio

"Did you have any plans at all for this week?" Kris asked at breakfast on Monday morning. "I mean, besides having dinner with Lara and Nathan tomorrow evening?"

"Nothing beyond spending time with you and Rachel. Well, I'll practice playing my guitar, of course, but that entertains the Tsarina, so it's something she and I can do together."

"What is the plan for the weekend?"

"Father Roman expects us for dinner at the monastery," I replied. "We'll leave just after lunch, which will get us there by 5:00pm. We'll have dinner, attend Vespers, and then I'll spend some time with him. On Sunday we'll attend Matins and the Divine Liturgy, then come home after lunch."

"My sister is looking forward to spending the weekend with Rachel!"

"So she can further corrupt her with French?" I asked.

"Oh, stop!" Kris commanded. "You like my French accent!"

"And you know I like to tease you about being French, even if I do like French kissing!"

"Feel free to demonstrate any time!"

"Dada kiss Mama!" Rachel giggled.

With my wife and daughter ganging up on me, there was only one thing to do! I got up, went around to the other side of the dinette table, and gave Kris a deep French kiss that tasted of maple syrup.

"You know, there's another place that needs a kiss like that!" Kris said sexily.

"I bet it doesn't taste like maple syrup!" I chuckled.

"It could!"

"Perhaps Rachel would like to visit your sister this morning!"

Kris smirked and mimicked picking up a telephone, "Hello, Lyudmila?! I want to have my husband cover my «minou» with maple syrup and lick it off! Could you please watch Rachel?"

I laughed, "And how would she respond to that?"

"She'd laugh, of course. It's not as if she's ignorant of such things! She is French, after all! And it's not as if she doesn't know we make love! I'll call her after we finish breakfast. We'll have to take Rachel to my parents' house, though, as Lyudmila can't drive and my parents are both at work."

"And then pick her up before dinner?"

"Perfect!" Kris agreed.

We finished breakfast, said morning prayers, and then Kris called Lyudmila, who was more than happy to take Rachel for the day. Rachel was happy to see Lyudmila, who was her second favorite after Clarissa, and when we were leaving, Lyudmila called out, "Have fun!".

And fun we had, spending the day either in bed or in the large tub, except for lunch. I preferred chocolate fudge to maple syrup, but that didn't detract from the enjoyment of licking maple syrup off my wife, nor hers from licking it off me, nor from the deep French kiss that followed my release which tasted of Kris, me, and maple syrup.

"Is there anything you want to do that we haven't done?" Kris asked as we lounged in a warm bubble bath late in the afternoon.

"Besides making a baby?" I asked.

"Soon!" Kris said happily. "Is there anything else?"

"No. I think you've noticed how I prefer to make love to you."

"Our sitting position?"

"Yes. And, of course, kissing you all over."

"Especially a very specific place!" Kris exclaimed.

"Yes," I agreed. "Are you asking the question because you want to be...more adventurous?"

"We are not inviting another girl into our bed!" Kris declared.

"Been there, done that!" I chuckled. "But you knew about that."

"I did. I just want you to be as physically satisfied as I am."

"I am sure I am," I replied. "Well, perhaps it's better to say I'm as physically satisfied as I could possibly be. That said, I do enjoy play time like we had today."

"You know, one thing I've never heard is how long into pregnancy you can make love."

"It's more about comfort and desire than anything medical," I replied. "At some point, you simply won't feel like doing it because you're tired, uncomfortable, or just don't want to. Medically, until your water breaks, there is no risk from having intercourse, unless you're in a high-risk situation."

"What would that be?"

"The most common one is elevated blood pressure. That's generally not a serious concern unless it spikes significantly. You'll also retain water, so your feet will swell, and in addition to the obvious weight gain and changes to your abdomen, your breasts may get larger, and will likely be more sensitive. I think the short answer to your question is that up through the second trimester. After that, it'll depend on how your pregnancy progresses, which is different for every woman and even for individual children from the same woman."

"That's not how our textbooks or teachers described it."

"They gave you the statistical norms, which are true for all women as a group, but as I say about diagnosing and treating patients, statistics are not determinative for an individual. All they can do is provide a baseline from which you have to develop an individualized treatment plan. The same is true for pregnancy. Doctor Forsberg will guide you through it."

"Not you?"

"I'm not an OB/GYN! I'm expert at making babies, beyond that, I'll send you to an expert in pre-natal care!"

Kris laughed, "I suppose Rachel is evidence that you are, indeed, able to make a baby!"

"Well, at a minimum, I know the correct physiological activities to create the chance of pregnancy."

Kris laughed again, "In other words, you know how to fuck?"

"Yes. But that's not exactly rocket science!"

"I do like your guided missile when it's in my silo!"

I chuckled, "The missile leaves the silo to function!"

"Oh, stop! I was trying to be silly!"

"And you know I am nothing if not pedantic, and I find that to be funny."

"Of course you do!"

June 20, 1989, Circleville, Ohio

"What's up with Rachel?" Lara asked when Rachel didn't want to be held.

"She's in a mood today," I said. "I think it might be that she hasn't seen any of her friends in daycare for three weeks, and her friend Abigail is in Spain."

"She's going back to daycare, right?"

"Yes. Kris starts classes at OSU in less than two weeks, and Rachel will go to daycare at least three days a week. The other days, at least for July and August, Lyudmila will help out. How is summer school?"

"I have the remedial kids who didn't pass math," Lara said. "Nathan has the ones who failed American government."

"That sounds like fun! Not!"

Nathan laughed, "I do have a few kids who are taking the classes as electives so they can participate in drama and speech, or band and choir, which each occupy one class period per quarter."

"Speaking of band, are you going to be able to play on July 4th?" Lara asked.

"Yes. Kylie is covering for me. It's already arranged with Doctor Northrup."

"I'm still shocked at the hours you have to work," Nathan observed. "Who knew?"

"I certainly didn't until I was at Taft working on my undergrad degree."

"What are you planning to study at OSU, Kris?" Nathan asked.

"Political science, and I'll go for a Master's in Public Administration."

"Where are things with your citizenship application?" Lara asked.

"The papers will be filed on July 5th. Then it's a matter of processing which can take months, though our attorney says that with our situation, it should go relatively quickly."

"The main thing is the investigation," I added. "They will want to ensure this isn't a sham marriage solely for citizenship purposes."

"We'll have to lie, of course!" Kris declared with a silly smile.

"Riiiggghhht!" Lara exclaimed. "As if Mike would do that!"

"I suppose it would depend on the emoluments," I chuckled. "Money and sex with a hot French girl in exchange for marriage to get citizenship? You never know!"

"Oh, please! As if I'd do that with anyone except a real husband!" Kris declared.

"Of course," I said slyly, "I am providing money and sex so Kris can get her citizenship! And that helps her parents, too!"

"As if you would trade sex for anything!" Kris retorted.

"Well, there are plenty of cute female medical students and nursing students!"

"I'll send to France for a guillotine, but it won't be the head above your neck which is chopped off!"

"Ouch!" Nathan said, wincing.

"A food processor was suggested by Elizaveta," Lara smirked.

"Remind me NEVER to piss off a Russian woman!" Nathan said, shaking his head.

"Something learned very quickly by anyone who encounters them," I chuckled. "And that started with my mom for me!"

"Oh, please!" Kris exclaimed. "You prefer Russian women!"

"Maybe," I replied with a sly smile.

"You married Elizaveta, and you considered Maryam, Lara, Oksana, Tasha, Danijela, and Danika, all before choosing me!"

"You might have a point," I chuckled.

There were actually a few more, but Oksana didn't know the extent of my relationships with Sara, Tami, Irina, or Susana, not to mention Sheila, though she'd become Orthodox after the fact. I heard the timer on the oven, so I excused myself and went to the kitchen to check the roast, which was ready, so I asked Kris to help get everything on the table, and a few minutes later, the five of us sat down to eat.

I continued to be impressed by Nathan, and really liked him, and I was reasonably certain he and Lara would marry, and probably soon. He'd been coming to church regularly with Lara, which was a good sign. Given her timeframe for kids, I expected them to marry within a year and start a family soon after.

Rachel didn't get out of her mood, so with agreement from Lara and Nathan, the five of us said evening prayers and we put Rachel to bed a bit earlier than usual.

"You say morning and evening prayers every day?" Nathan asked once Rachel was in bed.

"Mike's fastidious in his prayer life," Lara said before I could answer. "He's been that way since I first met him."

"And long before that," I replied. "My mom was fairly consistent, and my grandfather is like me."

"The only time I regularly prayed was when I was little and prayed the morbid 'Now I lay me down to sleep...' prayer. I mean, who teaches a kid to pray 'if I should die before I wake'?"

"I agree," I replied. "That's the last thing I want Rachel to think about."

"Kris, did your family say regular daily prayers?" Nathan asked.

"Yes, very similar to what Mike and I do now with Rachel. I've done it since I was a baby, so it's normal for me. Lara had a different experience growing up."

"My biological dad and my step-mom generally say evening prayers," Lara said, "though not fastidiously. My stepdad, well, he's irreligious in the extreme."

"How are things with your stepdad?" I asked.

Lara shrugged, "He's convinced I've thrown away my life, but you know I don't see it that way. In the Fall I'll have an after-school club to encourage girls to pursue careers in science or technology."

"Then make sure you get in touch with Taft, and send anyone interested in a medical career to see someone at McKinley Medical school. Our incoming group of Residents in trauma is four guys and two girls, which is double the number in the previous two incoming groups. Only one matched for surgery, and Clarissa is one of two in Internal medicine out of six."

"It starts in grade school," Lara said. "I've been talking to the Superintendent about similar clubs in the elementary school. I also want to have women scientist, engineers, and doctors come in and talk to the kids. I already asked Clarissa."

"Cool. You should try to get in touch with Katy Malenkov. I know she's out in the Bay Area in California, but she comes home fairly often. She'd be a great resource."

"I'll do that. She's working for a company that makes computers, right?"

"Sun Microsystems," I said. "It was started by some guys from Stanford, so that got her an 'in' with them."

"I'll call her mom and get her phone number."

"Let me know if you need any introductions at the medical school or the hospital."

"I will!"

June 24, 1989, Monastery of the Dormition of the Mother of God, Rives Junction, Michigan

"How have you been Michael?" Father Roman asked.

"For the most part, very good."

"And the part that isn't?"

"My most recent interaction with Father Nicholas, which I called you about when it happened."

"First, I will say that comparing yourself to Socrates, Saint John Chrysostom, and Our Lord might actually qualify as overly dramatic, given the circumstances."

"I won't dispute that."

"You are not intemperate, or prone to wild swings of emotion, so I have a theory about why you felt it necessary to speak to your colleague and your response to Father Nicholas. I believe, based on how you described the conversation with Father Nicholas, it was your intent to provoke him so that you had an excuse to transfer to the Cathedral, and lay the blame at his feet."

"Except I didn't actually need a reason, given I'm no longer clergy."

"That's not true, Michael. Well, it's true you didn't need a reason for the bishop; on the other hand, you did need a reason for yourself. You had to justify your actions, and Father Nicholas has been your target of choice for six years. Was he actually being overcritical? Stop to think before you answer, and no self-justification or martyrdom, please."

I took a few moments to consider, and while I certainly agreed I had most likely intentionally provoked Father Nicholas during our conversation, I didn't feel I had spoken to Ghost with any sort of ill intent, though I had known it would create a potential conflict.

The question I was asking myself now was whether I had some personal motive in doing so. I didn't think so, but one of the points of having a «старец» was for him to conduct a deep, spiritual examination, much like a medical exam. Like a medical exam, it was diagnostic, with a goal of determining the root cause of «ἁμαρτία» -- 'missing the mark'.

"I would say that it was not unreasonable for me to challenge Father Nicholas for the way he responded to the false accusations against me."

"And, pray tell, Michael, what do the Scriptures, in which you are so well versed, have to say about that? Think carefully."

I was certain he had two points in mind -- how to respond to false accusers, and the standards for clergy. I carefully considered my response before I spoke.

"Two things come immediately to mind," I said. "First, the Holy Apostle Peter wrote:

Servants, be submissive to your masters with all fear, not only to the good and gentle but also to the harsh. For this is commendable, if because of conscience toward God one endures grief, suffering wrongfully. For what credit is it if, when you are beaten for your faults, you take it patiently? But when you do good and suffer, if you take it patiently, this is commendable before God. For to this you were called, because Christ also suffered for us, leaving us an example, that you should follow His steps:

"Who committed no sin, Nor was deceit found in His mouth";

who, when He was reviled, did not revile in return; when He suffered, He did not threaten, but committed Himself to Him who judges righteously; who Himself bore our sins in His own body on the tree, that we, having died to sins, might live for righteousness--by whose stripes you were healed. For you were like sheep going astray, but have now returned to the Shepherd and Overseer of your souls.

"How much of the Scriptures do you have memorized?" Father Roman asked, interrupting me.

"I don't know," I replied. "If I had to hazard a guess, about half the Psalms and about a third of the New Testament."

"I believe you follow the lectionary for your prayers, correct?"

"Yes. The daily Scripture readings as well as the appointed Psalms."

"Continue..."

"Second, the Holy Apostle Paul wrote to Timothy:

Likewise deacons must be reverent, not double-tongued, not given to much wine, not greedy for money, holding the mystery of the faith with a pure conscience. But let these also first be tested; then let them serve as deacons, being found blameless. Likewise, their wives must be reverent, not slanderers, temperate, faithful in all things. Let deacons be the husbands of one wife, ruling their children and their own houses well. For those who have served well as deacons obtain for themselves a good standing and great boldness in the faith which is in Christ Jesus.

Let no one despise your youth, but be an example to the believers in word, in conduct, in love, in spirit, in faith, in purity. Till I come, give attention to reading, to exhortation, to doctrine. Do not neglect the gift that is in you, which was given to you by prophecy with the laying on of the hands of the eldership.

"If I draw a conclusion from those two passages, I'd say you felt, and perhaps still feel, that you were being taken to task for things which you considered not just right, but righteous and holy."

"The accusations were patently false," I replied.

"I want to say something, and I understand that it, in effect, goes counter to the admonishment to 'have no further care' for any sins you confessed, but would you say that the accusations were patently false, or that they were premature?"

"Ouch," I said reflexively.

"As a student of the Scriptures," Father Roman said with a smile, "what would you say now?"

"I don't have them memorized, but Proverbs has several warnings against even walking past the door of the harlot's or the adulteress' house. Similarly, the Holy Apostle Paul wrote to the Ephesians:

Therefore be imitators of God as dear children. And walk in love, as Christ also has loved us and given Himself for us, an offering and a sacrifice to God for a sweet-smelling aroma.

But fornication and all uncleanness or covetousness, let it not even be named among you, as is fitting for saints; neither filthiness, nor foolish talking, nor coarse jesting, which are not fitting, but rather giving of thanks.

"Did you stop there for a specific reason?" Father Roman asked.

"Yes, I did," I replied. "The point I think you were trying to make is that my behavior, even if correct, called my character into question, something against which Paul warns. Also, despite your caveat about 'have no further care' in this instance, I place myself in God's hands, desiring mercy and love. Or, as Paul writes to the Romans, I know the law, and the law is good when it shows me my sin."

"No quote?"

"I could..."

"Not necessary. What I want to point out is that you were a self-admitted fornicator, and had ample warning, and yet..."

I nodded, "I know."

"Yes, Michael, you know, and yet, even after the false accusations, you were determined to prove them ultimately correct. It was, in fact, only a matter of timing. The question is, why, if you know the following verses, and you have the demonstrated ability to remain chaste, why did you fornicate?"

"Honestly? Because I wanted to."

"Thank you for being forthright. I have to ask, Michael, how you know that you won't simply decide you want to commit adultery?"

"Because, and I say this with the caveat that no specific sin is worse than any other, adultery is of a different character than fornication, because in addition to a sin against the body, it would be a sin against my wife, not to mention a complete betrayal of the commitments I made to her. It's also the case that being married provides an outlet for the desire."

"And you've never once been tempted while you were married?"

"No. And that includes both betrothal periods."

"To what do you attribute that?"

"That I could never countenance of such a breach of trust and violation of my word. And that applies across the board in all my endeavors."

"What would you say your primary philosophy is?"

"I think it can best be distilled into the vow physicians make -- 'first, do no harm'."

"And would you say your actions were harmless?"

"The Orthodox answer is an unequivocal 'no'."

"But you disagree?"

"We teach that all sin harms the sinner spiritually, but concepts of harm are also very personalized."

"In other words, it's how you feel that matters?" Father Roman asked.

"I think what I'm trying to say is that perception matters."

"Yes, it does, as you stated before. But whose perception?"

"God's, of course."

"I feel you were going to make some kind of argument that if your partners consented and didn't feel they had done anything wrong, that absolved you of your sin against them. Does it?"

"No, of course not."

"And does their opinion that it was not sinful actually matter?"

"No, it doesn't."

"So, when you confessed, what was it exactly you repented?"

"My inability to control my desire."

"But that's not true, is it?" Father Roman pressed.

"No," I admitted.

"So you see the source of my concern? You are able, when you choose, to suppress your desire to sin sexually. But you also, at times, have chosen to set aside your ability to remain chaste. I am sure Father Nicholas was aware of that propensity, and again, his comments were premature, but not his concern."

"Are you saying we should return to Saint Michael?"

"That is not my place," Father Roman said. "That's between you and Bishop JOHN. On the other hand, I do believe you should sit down with Father Nicholas and talk this out, but only if you can approach him non-confrontationally. You have a habit, when you are convinced you are right, of being extremely confrontational. I don't believe that's how you practice medicine."

"It's not," I replied. "Being a forceful advocate for my patients is not about confrontation, but collegiality. There is a time when confrontation becomes necessary, but it's a last resort, and only when there is imminent risk of death."

"I'll accept that exception, as I have little experience in emergency medicine. I doubt you believe any lives were at risk during your conversations with Father Nicholas."

"They weren't."

"Are you able to do what I've suggested?"

"Yes."

"Good. As for where you attend services, that is, as I said, between you and Bishop JOHN. My opinion, and it's only that, is you are probably best served spiritually at the cathedral. I'd like you to spend the rest of the evening praying and meditating in the chapel, and to keep the monastic hours overnight."

"Yes, Father."

June 25, 1989, Circleville, Ohio

"I'd like to hear your thinking about your desire to have a baby with Mike as the father," Kris said as she, Clarissa, Tessa, and I relaxed in the great room after dinner.

"I've always wanted to have a baby," Clarissa said. "But once I understood my orientation, I was faced with a serious challenge. Unlike Jocelyn and Gene, the state won't allow Tessa and me to adopt, and, honestly, I'd rather have a baby, if possible. After I met Mike, and came out to him, I considered the possibility that I might have one with Mike, given his stated timing on marriage, which was sometime during Residency.

"Your former bishop made a mess of that, and, despite my orientation, Mike and I actually discussed marriage, but, in the end, I couldn't act contrary to my nature. Mike and I discussed alternatives, and finally I asked if he'd be willing to help me conceive through artificial insemination at the time of my choosing, and he agreed. That was before he began seeing Elizaveta, of course. We had no formal plans at that time, and I wasn't contemplating having a baby before I finished Residency, so nothing was said. Of course, you know what happened after that."

"Alternatives? Besides artificial insemination and marriage?"

"Every possible option, including thinking outside the box," Clarissa said. "From conceiving naturally to some kind of setup where I was legally married to Mike and Tessa lived with us."

Kris laughed, "And Mike would be allowed to have sex with both of you, of course!"

"On occasion," Clarissa replied. "But rarely with me, and possibly only to conceive. And that was the thing that Mike couldn't countenance, besides the problems that it would cause at church. I absolutely could have sex with a guy to conceive, and Tessa is bisexual, but Mike needed, and needs, a traditional relationship. And that was something I couldn't ever give him, as much as I might have wanted to."

"Were you going to acknowledge Mike as the baby's father?" Kris asked.

"That's not something we had decided, but Mike was strongly in favor of not keeping it a secret. He would, I'm positive, have insisted on his name being on the birth certificate."

"What about baptism?"

"Without question," Clarissa replied. "I know how important that is to Mike, and you know Tessa and I attend regularly at Saint Michael, though we don't go every Sunday. Whatever other considerations we'd make, we'd raise a child I had by Mike in the Orthodox Church because I know he'd have it no other way."

"What about raising him or her?" Kris inquired.

"We didn't get deeply into that conversation, though we did agree that my partner and I would be the primary caregivers. That was before I met Tessa, by the way."

"Mike made me aware of that."

"What do you think?" Tessa asked, speaking up for the first time.

"As I said to Mike, we'd speak with you, then he and I would discuss it and come to a decision together. As I said to him, I haven't made up my mind one way or the other as yet. How would you see things developing over the years?"

"I'd imagine Mike would be involved," Tessa said, "and that a child Clarissa and I were raising would spend time with the two of you and Mike's other kids. They'd be half-siblings, and I think they should spend time together."

"Out of curiosity, would you have allowed Mike and Clarissa to conceive naturally?"

"Yes, because, and please don't take this the wrong way, it would be about facilitating a baby, not about pleasure, though physiology being what it is, that might end up as part of it. Well, for Mike it's basically necessary, but you know what I mean. And the agreement Clarissa and I have allows expressly for that one possibility, though with Mike being married, it's obviously out of the question for him."

"But not for you?"

"I don't have any specific moral objection to extramarital sex of any kind, so long as both partners consent, and it fits within whatever relationships the individuals have. In other words, who has sex with whom isn't my business, and if a married man has a 'hall pass', then that's between him and his wife. Mike, for practical purposes, has the same view."

"How so?" Kris asked.

"She's referring to my non-judgmental approach," I interjected. "In other words, even if I have specific moral objections to certain behaviors, I tend to mind my own business and not interfere. I won't violate my own firmly held beliefs, but I also won't impose them on anyone else. You and I have a very specific understanding of the boundaries and I not only agreed to them, I endorse them and believe they are correct. But they aren't the only answer to the question. Add to that my own behavior, and as the saying goes, people who live in glass houses shouldn't throw stones."

"Why not quote the Scripture?" Kris asked.

"I can answer," Clarissa said quickly. "Because he knows that they don't carry the same weight with Tessa and me that they do with you and others who are practicing Christians."

"Are you a Christian?" Kris asked.

"I suppose the best answer is that I was baptized in the name of the Trinity, and I believe the basic moral teachings of Jesus, but I'm not sure about anything else."

"She's an agnostic," I said. "Much as I am. The difference is, I default to what the Church teaches to be true, where Clarissa is skeptical."

"WAIT!" Kris protested. "You're agnostic?!"

I smiled, "The word means 'I do not know' and that is my philosophical position. Or, to put it in Scriptural terms -- I do believe, help my unbelief."

"So you have doubts?" Kris asked.

"I've always had doubts," I replied. "It stems from being a scientist at heart, and someone who approaches almost everything with rigorous logic."

"That's what makes Mike a great doctor," Clarissa said. "Single-minded, clear thinking, and not swayed by emotion. I think the parallel with Doubting Thomas is apt -- Mike needs to see the proof to say he 'knows' and until such time he'll say that he's agnostic."

"You never shared that with me, Mike," Kris said disapprovingly.

"I should have," I admitted. "That said, it has no practical effect on anything at all with regard to me being Orthodox, or faithfully praying and attending church."

"Yes, but it is very much about who you are," Kris said. "We can discuss this later."

"OK," I agreed.

"Clarissa, do you have anything else you want me to consider?" Kris asked.

"Just that I love Mike more than anyone on the planet, something of which Tessa is aware. He is, without question, my soul mate, but the universe played a cruel trick on us, if you will, in that I was born lesbian. Or, as Mike irreverently put it, I like pussy just as much as he does!"

"He does like it a lot!" Kris said lightly. "And that makes ME happy!"

VI. I'm Sure You Can!

June 25, 1989, Circleville, Ohio

"Why didn't you feel it necessary to share your true feelings with me?" Kris asked after Clarissa and Tessa left, and after we'd said evening prayers, and put Rachel to bed.

"Because I didn't feel they were particularly relevant, nor did I feel they affected our relationship in any way. I faithfully attend church, faithfully say daily prayers, was ordained a deacon, even though I was laicized, and I'm a catechist, even if I haven't taught in some time."

"Did Elizaveta know?"

"No. Only two people knew -- Clarissa and Lara; Clarissa, before I married Elizaveta; Lara after Elizaveta reposed. And Lara only knew because it came up in the context of a conversation where I referenced Jonah being swallowed by the whale. Lara asked me if I believed that happened and the discussion led to me comparing myself to Doubting Thomas. Clarissa knew because she knew literally everything."

"Because you believe you're soul mates?"

"That was the conclusion we came to, but there was an insurmountable obstacle."

"Just as there was with Angie, yes?"

"Yes. And you know what happened with Elizaveta."

"Are you trying to tell me something?" Kris asked with an arched eyebrow.

"Only that there has been adversity with every young woman with whom I had a deep relationship."

"But isn't that true of all deep relationships?" Kris asked. "Every couple encounters challenges or obstacles and has to overcome them."

"That's true, but I believe I have more baggage than the average spouse."

"If we assume that's true, it's still the case that you chose to be with me. I don't see it as some might, that I was some kind of consolation prize, rather that you saved the best for last, so to speak. You and I both knew immediately that we were meant to be together. And, I know something important which I didn't know then."

"What's that?"

"That you love me! You even said so! In French!"

"I did, though in context..."

Kris put her finger to my lips, "Did you mean it?"

"Yes."

"Then nothing else matters. I know you believe Angie is your one, true love, that you and Clarissa believe you are each other's soul mate, and that you loved Elizaveta. But none of that interferes with the fact that you chose me and that you love me. And I knew it before you said it."

"You're handling all of this very well," I said.

"If you expected differently, you wouldn't have married me."

"True."

"Is there anything about you that Clarissa knows that I don't know? I mean, besides things which are purely related to being doctors."

I considered, and I didn't think so, except for one very specific set of facts.

"Other than knowing most, if not all, of the girls I dated, no."

Kris smirked, "And by 'dated' you mean 'fucked'?"

I laughed, "No, there's a shorter list she knows of the young women with whom I was intimate. I didn't run to her with 'after action reports', but she was an astute observer."

"I know I've agreed not to ask this question, and I fully understand if you refuse to answer, but you and Angie?"

"A single serious kiss. That kiss was when I had the first inkling of her problem, but had zero context to understand what I was observing."

"When did you find out?"

"She wasn't definitively diagnosed until 1984, and that kiss was in Fall 1981. The first serious symptoms showed up in Spring 1982, but it took a long time, a couple of breakdowns, erratic behavior, and eventual hospitalization to definitively diagnose her. Looking back from 1985, the signs were obvious, starting in High School, though I didn't meet her until Freshman year at Taft."

"You hoped she'd recover?"

"Yes, though it was unlikely. That said, she did show signs of recovery until the «мудак» who was treating her decided to intentionally destroy her."

"And he's still practicing, right?"

"Yes. How we proceed will be discussed when we have dinner with the Stephens on Thursday. I'm positive Mrs. Stephens will agree to proceed with a malpractice claim to the State Medical Licensing Board."

"But you don't think you can win, do you?"

"I suppose it depends on what we consider a victory," I replied. "But we're off track from our conversation."

"I think," Kris said, "that Clarissa is what I've heard described as a 'work wife'."

I laughed, "I've never heard that phrase before!"

"My dad heard it at work, about two co-workers. He asked what it meant and then described it for us at dinner that evening as a platonic relationship between a male and female co-worker that takes on aspects of a marriage because they spend so much time working together."

"I'm sure Tessa will be amused that Clarissa has a 'work husband'. But you know it's deeper than that."

"I don't think there's a good description that works, because 'friends' or even 'dear friends' isn't sufficient. And she was one of your main sources of advice, even after you married Elizaveta. From what I can tell, she's been more circumspect about offering advice with regard to me. I surmise that's because I'm, and please do not take this the wrong way, older and more mature."

"Elizaveta was mature for her age," I countered. "What I would say is that she was naïve, not immature, and that her worldview was much, hmm, narrower, I suppose, than yours. We had some struggles at first due to that."

"I surmise that she was uncomfortable with your past behavior?"

"Yes, but that was partly my fault for soft-pedaling how extensive my experience was. That led her to look at all my female friends with a jaundiced eye."

Well, except for Clarissa, because that was something I couldn't reveal to Elizaveta.

Kris smiled and her eyes twinkled, "I simply assume you've fucked every single female you're friends with, and then some!"

"Seriously?" I asked, instantly concerned she might suspect I'd been with Clarissa.

"No, of course not!" Kris said, laughing. "But that's the behavior you just ascribed to Elizaveta, at least indirectly."

"I guess I did, didn't I?"

"Yes, you did. How did she deal with you treating female patients?"

"Not well, if it involved any kind of intimate exams. She had a difficult time differentiating between medical and sexual contexts, and was a bit prudish about sex, except with me in private. Well, after a few days of marriage."

Kris smirked, "What's the American phrase? Having your brains fucked out? That does change one's perspective!"

"You were NOT naïve!"

"No, but I also had zero experience."

"While that's true, you were far better educated and informed. But back to the original topic -- do you want to discuss my agnosticism or Clarissa's request?"

"I'm not sure which is more pressing, actually."

"Why? Nothing has changed in my practice or in my faith from the time you met me. And leaving aside the problems with Bishop ARKADY and the discord at Holy Transfiguration, I'm basically back to where I was before Elizaveta reposed. Fundamentally, saying 'I do not know' has no practical effect on the expression of my faith nor on my belief in an eschaton of union with God."

"Heaven?" Kris asked.

"If you mean in the way it's usually conceived as a place, no, I don't believe that. It's a state of being, and I think the ultimate proof of my point, which is a theologoumenon or private theological opinion, is found in the Icon of the Last Judgment where the same river of fire bathes the saved and the damned. There is no difference between their eternal states except that the saved love God and the damned do not. It is not a place, but the direct experience of the energies of God."

"That is not what the Church teaches," Kris protested.

"Which is why I said it's a theologoumenon. The church has no dogmatic opinion, and before you ask about the Creed, it says «τοὺς οὐρανούς» in Greek, which can be understood as 'the heavens', which makes sense given the Apostles reported that Christ ascended. You know, like a missile leaving a silo!"

"Oh, stop!" Kris said, laughing and shaking her head.

"Hey, I'm not the one who made that analogy! And you know how pedantic I am!"

"I do," Kris said, rolling her eyes. "But in all seriousness, do you have other theologoumenon?"

"More than you can shake a stick at!" I declared. "But as I've said to the few people with whom I've shared those, in any church-related context, I speak the party line. Lara once asked me about Jonah, and I said that in church, I will unequivocally state that Jonah was swallowed by a whale, and I believe that it literally happened. Outside of church, though, I will only state that it's a metaphor for being swallowed up by the world and allowing it to deter you from your ministry."

"How can you have it both ways?"

"That's basically the same question everyone I've expressed my thinking to asks. It depends on whether I am evaluating with the «nous», the eyes of the soul, or to use shorthand, as Mike the scientist and physician. The thing is, that's Orthodox, and we refer to things as 'mysteries', in the sense they are hidden from us, which is the original meaning of the word, not in the sense they are 'mysterious'."

"But if you don't believe..." Kris said, sounding confused.

"I do believe; help my unbelief! I honestly don't think we're going to resolve this tonight, because it's such a deep-seated philosophical position that I have only discussed with a few people, and even then, only in a cursory way."

"Father Roman doesn't know?"

"No. We're not there yet. He's doing triage, which has been true from the first time I met him."

"You didn't say what you two discussed."

"My inability to control my passions, to put it politely."

"Being a boy, to put it succinctly," Kris replied.

"Or, as numerous women said to me, mostly in jest, being a pig."

"Mostly in jest?"

"Yes. I did treat the young women with...let me start over. From a secular and social point of view, I always treated them with respect, I simply took advantage of the multitude of opportunities which presented themselves to a future doctor who played the guitar. Father Roman would, of course, disagree with that assessment that I treated them with respect."

"Because you tempted them into sin?"

"It was a two-way street," I replied. "And not much tempting was necessary on either side. Father Roman's point, and that of the Church, would be that the act of fornication is innately disrespectful to both participants. Father Roman's concern, and it's valid, is that I willfully engaged in fornication when I had the demonstrated ability to remain chaste."

"You were, as they say, a perfect gentleman during our betrothal. And a perfect lover afterwards."

"I was always a perfect gentleman," I replied. "That's what attracted the young women. Please be honest, were you thinking about sex before we married?"

"From the first second I met you!" Kris exclaimed.

"It was mutual! Shall we discuss Clarissa's request?"

"You realize she really wants to conceive naturally, right?"

I nodded, "That was the initial discussion, and had Bishop ARKADY not intervened, that is probably what would have happened. Obviously, that can't happen now."

"Obviously. I don't have a problem with her request, but I think you need to have a clear agreement about it."

"I can't imagine ever disagreeing with Clarissa on anything."

Kris smiled, "Unlike me?"

"Clarissa isn't a socialist!"

Kris smiled, "Nobody's perfect! But in all seriousness, it's not just Clarissa."

"Tessa?"

"And Clarissa's parents. It's not that I expect trouble, but you have to make sure everything is in order, similar to how you did with Rachel and me."

"I'll discuss it with Clarissa, and with Stefan."

"What will he say?"

"Who knows? But it'll be a few years down the road. I'm more interested in what Bishop JOHN will say."

"What do you think?"

"I have no idea, but it will be interesting like so much else in my life."

"I can think of something interesting to do now!"

"And whatever might that be?" I asked.

"As if you don't know!"

"Let's go upstairs and see if we can figure it out."

"I'm sure you can!"

June 27, Southern Ohio Correctional Facility, Lucasville, Ohio

"I'm here to see a prisoner, Frank Bush," I said to the guard at the gate to the prison.

"I'll need to see some identification, please."

I handed over my driver's license, along with the chaplaincy ID that I'd received in the mail on Saturday.

"Profession?" he asked.

"Medical doctor," I replied.

"Doctor and clergy?" he asked.

"Lay chaplain," I replied.

"Relation to the prisoner?"

"No blood relation," I replied. "He murdered my friend."

He raised an eyebrow but didn't say anything.

"Are you carrying any weapons, anything that could be used as a weapon, or any contraband?"

"No."

"When I buzz you through, walk straight up the path to the building and go inside. Don't dawdle or step off the path. When you enter the building, approach the desk and present your ID. Have a good day."

"Thank you."

I heard a buzz, pulled the gate door open, walked through, and walked briskly to the door of the building. When I entered, I removed my fedora and approached the Plexiglass window.

"Doctor Michael Loucks to see prisoner Frank Bush," I said, handing over my ID.

"Good morning. I have you on the visitors list. Have you visited a prisoner here in the past?"

"No."

"OK. I need to go through a series of questions with you, you'll need to be searched, and then pass through a metal detector. You'll meet the prisoner in the visitor's room; the usual thirty-minute limit is waived for chaplains. As a chaplain, you're permitted to see the prisoner's cell, and to use the chapel. First, state your complete name, spell your last name, and provide your date of birth, place of birth, your full address, and your phone number."

I was tempted to ask if he was unable to read the information on my driver's license, but given I actually wanted to get inside, being a smart ass was not the right approach.

"Michael Peter Loucks; L-O-U-C-K-S; born 02-02-1963 in Rutherford, Ohio," I said, then provided my address and phone number.

"Have you ever been convicted of a felony?"

"No."

"Have you ever been arrested or charged with a felony offense?"

"No."

"Do you associate with known criminals, whether or not they've been convicted?"

"In my job, I treat anyone who presents at the Emergency Department, so I can't say. Outside of the hospital, I don't knowingly associate with anyone who has ever been arrested or who I would call a 'criminal'."

"I'll put down 'no'," he said. "Are you carrying with you any firearm, knife, or other weapon, or implement that could be used as a weapon?"

"The only thing in my pockets are my wallet and keys," I replied. "My stepdad is an attorney and advised me to carry nothing except those with me."

"Good advice. You will need to leave those in a locker. Are you carrying anything else with you? A bible, prayer book, or other religious items?"

"I wear my baptismal cross around my neck, but otherwise, no."

"OK. I'll keep your ID cards until you're ready to leave, and return them, along with your other property. I have a form you need to read and sign. The top part lists the prison rules. If you violate any of them, even in a minor way, you'll be asked to leave. The bottom part lists things which are considered criminal activity. If you violate any of those, you will immediately be arrested and charged. Please initial each line in both sections, then sign and date at the bottom."

I accepted the form and skimmed it, then read through it a second time more carefully. There was nothing in either part that concerned me, so I signed the form, dated it, initialed each line, then slid it back to the guard. The guard compared my signature with my driver's license, then used a paperclip to attach the ID cards to the form.

"When the buzzer sounds," he said, "pull open the door, step through, and wait. Once the first door closes, a second buzzer will sound. Pull open the door in front of you, and step through, then wait for the guard to give you instructions. Do not cross the red tape on the floor without being instructed to do so."

"I understand," I said, then moved over to the door.

The buzzer sounded, and I pulled open the heavy metal door, stepped through, then allowed it to shut behind me. I heard loud clicks as the locks reengaged, then waited for the buzzer to sound again. When it did, I pulled open the second door of the 'man trap', then stepped through, stopping before I crossed the red tape on the floor.

"Good morning, Sir," the guard said. "Please step to your right, away from the door, and wait."

I did as instructed, and he came over to me with a small basket. I put my wallet and keys in it, having left my watch in the glove compartment of my Mustang, along with my «chokti». He set the basket aside, then had me walk through a metal detector which pinged.

"What metal do you have on you?" he asked.

"My baptismal cross," I replied.

"Would you show me?"

I nodded, unbuttoned my polo shirt, and lifted the cross from beneath my undershirt.

"Just let it hang down, please," he said. "And hold your arms out."

I did, and he picked up a wand and swiped around me, with it triggering for both the cross and my belt buckle.

"I haven't seen a cross like that before," he said.

"It's a Russian soldier's cross," I replied.

"Loucks isn't Russian, is it?"

"No, it's Dutch. My mom is of Russian descent, and I'm a member of the Russian Orthodox Church."

"OK. I need to frisk you to check for anything which might not be detected by the machine or wand."

I nodded, and he frisked me quickly. I was tempted to say something about not buying me a drink before he ran his hands over my groin, but his job was, at least in that regard, similar to mine -- it had zero to do with sex, and everything to do with doing his job correctly.

"I'll put your wallet and keys in locker #4," he said.

He handed me a small cardboard disc with '4' imprinted on it, which I put in my pocket, then put my wallet and keys into a locker and closed the door, but didn't lock it. I was amused by the fact that he didn't lock it, but given where I was, it wasn't as if someone was going to break in and steal the thirty bucks or so I had in my wallet or my car keys.

"I'm going to escort you to the visitor's room. You have a bit more leeway as a chaplain, in that you're permitted to sit next to, rather than across from the prisoner, and can make physical contact for purposes of prayer, but you need to inform the guard on duty before you do that. Generally, your conversation needs to be audible, but you are permitted to speak quietly for a brief period for penitential purposes. Understood?"

"Yes, I understand," I replied.

"Then follow me, please."

He led me down a hall through another pair of doors configured as a 'man trap', which we were buzzed through, then down another hall to a heavy metal door, which he unlocked and ushered me through. A guard inside directed me to a simple metal stool on one side of a simple metal table, which was on a pedestal. I sat down and waited, and about five minutes later, Frank Bush, dressed in orange prison overalls, was led to the table.

"How are you?" I asked.

"How do you think I am?"

"I suppose that depends on how you mean. Are you getting enough to eat and getting exercise?"

"Yes."

"And you have sufficient reading material and access to a television?"

"Yes."

"Any medical problems?" I asked.

"No."

"Then I believe my answer would be 'as well as can be expected, given the circumstances'. And if any of those things were not acceptable, I'd do my best to rectify them."

"Why?"

"Because," I said, with a soft, friendly smile, "it's the Christian thing to do. I can do nothing else."

"I'm going to hell," he said firmly.

I shook my head, "That's only true if you want to go there. God does not send anyone to hell; we send ourselves. Does that mean you don't pray or attend services?"

"To what end? Nothing I can do can change my eternal fate, and I'm sure not getting out of here standing up."

"These facilities used to be called 'penitentiaries'," I said. "And with good reason. May I ask what you do all day?"

"My prison job is in the laundry, which is three hours every morning. I eat, watch TV, read, play chess, and, when it's nice enough, go out in the yard."

"I played competitive chess in High School, but haven't played much since."

Well, if you didn't count the 'strip chess' games with Grace Simmons!

"Do you have visitors?" I asked.

He shook his head, "No. My wife divorced me, which probably doesn't surprise you. I haven't seen my son or daughter since the trial."

"Melissa Matched, a year late, for internal medicine, at a regional medical center in eastern Kentucky."

"I didn't know that. Does that make you angry?"

"Why should it?" I asked. "She'll succeed or fail, and if she succeeds, it will be because she learned her lesson and reformed. You can do that, too."

"I was convicted of murder," he countered.

"I won't belabor the point, but I'll ask you to recall what Jesus said to Dismas, the penitent thief - 'this day, you will be with me in Paradise'."

"The Bible doesn't name him."

"No, it doesn't. It also doesn't contain a list of books to be included, which comes from tradition. I'm sure you remember the debate I had with Reverend Saddler."

"That fool had no grasp of the Scriptures," Frank Bush said, shaking his head.

"Do you want me to get in touch with Melissa?"

"I doubt she even cares," he replied.

"Well, I care."

"Why?"

"For the same reason I gave before," I replied. "It really is the Christian thing to do."

"Where did you Match?" he asked, changing the subject. "Moore Memorial?"

"Yes, for trauma surgery. My Residency begins on Saturday."

"Top of your class?"

"Yes."

"Melissa said you were extremely intelligent."

I shrugged, "That's only a small part of it. Hard work, dedication, and selfless service are the key to success. And that will determine if Melissa succeeds or fails. Do I have your permission to contact her on your behalf?"

"It won't do any good, but do it if you want to."

"Would you be OK with me visiting you each month?"

"Why?" he asked.

"To play chess, talk, and to give you hope."

"Hope for what? I'll never leave this place upright, and when I do, where I'm going is far worse than any punishment the State of Ohio can mete out."

"Then to talk and play chess."

"Again, why?"

"Because, whatever else may or may not be true, it's the right thing to do. One sinner to another."

"I suppose if we're going to spend eternity together in Hell, an hour a month is OK."

I wasn't going to take his bait.

"I'd like to see your cell and then visit the chapel with you."

"You don't stop, do you?"

"If you won't let me pray for you, then pray for me."

"The only one who would listen to my requests is the devil himself."

"The Scriptures say that God causes the rain to fall both for the just and the unjust. As I said, I'm as much a sinner as you are, so in one sense, we're in the same boat."

"One taking us directly to the gates of Hell without a return ticket."

"AC/DC might have been on a highway to hell, but there is an off ramp. Let me speak to the guard."

I got up and walked over to the guard, explained what I wanted, and after he used his radio to verify that I was, indeed, a chaplain, he escorted Frank and me to a cell in 'C Block'. It was, as I had expected, austere in the extreme, but it was what I didn't see on Frank's shelf that stood out -- he didn't have a Bible.

As I thought about it, that was actually a good thing at the moment, as the only thing he would find there would be condemnation. As a Five Point Calvinist, he'd find no solace and no refuge, despite the Scriptures being full of examples of God's love and mercy.

"Is there anything you need?" I asked. "Or that you want?"

"There's a new Tom Clancy novel that will be released in August. It takes forever for the prison to get new books."

"As soon as it's released, I'll get you a copy."

"You need to have it shipped directly from the bookstore," he said. "You can't carry it in."

"OK. I'll do that. Shall we go to the chapel?"

"You're bound and determined."

"As I said, if not for you, then for me."

The guard led us to the small chapel, which, thankfully, was empty.

"I'm going to say an abbreviated form of the Trisagion prayers, and then Psalm 50, which you know as Psalm 51."

"Why do you use a different numbering system?"

"Because we follow the numbering system in the most ancient texts, which are the Greek versions of the Jewish Scriptures used by Christians from the earliest times. Those differ from the later Hebrew manuscripts, which were never used by Christians before scholarship overrode tradition."

"What are those prayers you mentioned?"

"A formula," I replied. "Not all that different from the one you would have used in your Church, except that there are set petitions before the free-form ones."

I said the prayers while Frank Bush stood quietly next to me. Because he was silent, I gave the responses to the prayers and petitions, and when I completed the abbreviated set, I recited Psalm 50 from memory.

"Next time I visit," I said. "I'd like to play chess, if you're willing."

"Why not?" he asked. "It'll break up the monotony."

"May I leave you with one thought?"

"What's that?"

"If you ask for my forgiveness, I'll give it unreservedly."

"Why would you do that?"

"Because it's the right thing to do."

June 27, McKinley, Ohio

"Doctor," Clarissa said with a smirk when I walked into Frisch's after driving back to McKinley from my visit with Frank Bush.

"Doctor," I replied, then added, "all we need is a third for the Three Stooges routine!"

"True!"

The waitress seated us in a booth and we ordered right away.

"How did it go?" Clarissa asked after the waitress brought us our Cokes.

"Let's just say that it's not a place I'd like to spend a lot of time."

"No kidding! But I meant your conversation?"

"I'd say he's remorseful, but he's also convinced he's going directly to Hell, do not pass 'Go', do not collect $200."

"And you offered a 'Get Out of Hell Free' card?"

I shook my head, "He's not ready to hear the Gospel at this point. That'll take some time, and maybe it'll turn out to be a fruitless endeavor on my part, but that's not the point."

"You're a better person than I am, Petrovich," Clarissa said. "I couldn't do it."

"I'm not better than you, Lissa; we're all in the same boat. And while I know it's trite to say -- I can do all things through Christ who strengthens me."

"Speaking of that, how did things go with Kris after your surprise revelation about your interior life?"

"She was unhappy I hadn't shared that with her, but as I explained, it has no practical effect on the expression of my faith or of my belief in an eschaton of union with God. It did lead to a moment of sheer terror, though."

"How so?"

"Through a winding conversation, we discussed Elizaveta's insecurity based on my past partners and that she looked at all my female friends with a jaundiced eye."

"Except me!" Clarissa exclaimed. "She never even suspected."

"No, she didn't, and I had that thought when I made that comment. Kris' response nearly caused me to have a heart attack. She said, with her eyes twinkling, that she simply assumed that I'd fucked every single female I'm friends with, and then some!"

"WHOA!" Clarissa gasped. "She knows about us?"

"That was my concern, but when I asked if she was serious, she said she wasn't, and she said that was basically what I'd implied to Elizaveta."

"That's a relief. How do you think she'd respond?"

"Given how mature and open-minded she is, and the fact she called you my 'work wife', I'd say she'd have a serious problem with me not telling her, but not actually be surprised that it had happened. And that's the neat trap I've built for myself."

"Now that you know her well enough, you could tell her, but you can't tell her because she'd be very upset that you kept it from her, and that would create a serious problem."

"That is the trap. Damned if I do, potentially damned if I don't, because I didn't trust her enough to tell her at first. But the trap is even deeper."

"How so?"

"If she, at some point, decides that you and I have been together, and I haven't told her, then it'll be even worse than if I had told her after keeping it a secret. And I completely understand her 'no secrets' rule and why it makes so much sense. But, as I said, I'm trapped."

"I'm not sure what to advise, Petrovich. Did you discuss my request?"

"Kris said it was obvious you wanted to conceive naturally."

Clarissa laughed, "And she shut that down immediately, right?"

"Actually, I did, saying that I understood that was your preference but that it obviously couldn't happen now."

"I think she might suspect."

"I think if she did, she'd say something," I replied. "She's not one to stay silent or try to test me. With Kris, what you see is what you get."

"I bet!" Clarissa smirked. "She's hot! Tessa agrees!"

"There are no foursomes in our future, Lissa!"

"Darn," Clarissa replied flatly.

"Uh-huh."

"So, what did she say?"

"She's amenable to your request, but insisted I make sure we have a clear understanding of how things will work going forward."

"You mean with church?"

"That, and what you might call parental rights between an unmarried couple. Obviously, if, God forbid, something were to happen to you and Tessa, I'd want to ensure that legally nobody could interfere in my son or daughter being with Kris and me."

"Which is why you had Kris legally adopt Rachel."

"Exactly. Now, there is literally nothing that anyone could do if something happened to me."

"You mean Yulia?"

"She was the main reason, yes. And our joint wills appoint Elias and Serafima as guardians, with Subdeacon Mark and Alyssa being backups. My grandfather is our executor, with Jocelyn as backup."

"I don't have a problem with any of that."

"You need to discuss it with Tessa so that there aren't any questions. All four of us have to be on the same page and some of it has to be in legal documents. That said, we have plenty of time, right?"

"Yes. There's no point in trying before the end of PGY2. I'm thinking midway through PGY3 would be the right time to start, given it can take several attempts."

"That works for me. Discuss it with Tessa, especially how often you'll attend church, and if you're OK with Serafima and Elias as godparents, and once you two are of the same mind, the four of us will discuss it, and I'll have Stefan draw up the appropriate paperwork."

"Great!" Clarissa declared. "I'm excited!"

"Because you don't have to actually sleep with me to get it done!" I chuckled.

Clarissa rolled her eyes, "I enjoyed the closeness, if not the physical act, though that was pleasurable in it's own way. You know that making love with you was about being spiritually together, not you penetrating me."

"I do," I replied. "But I'm also not going to deny that I found it extremely physically pleasurable."

"Because you're a guy!" Clarissa smirked.

"Right, because you don't like orgasms at all!"

"You do admit it was a very different thing than your other lovers, right?"

"Of course. You're special to me in a way nobody else is."

"And yet, I can't hold a candle to Angie," Clarissa siad wistfully. "Nobody can."

"The universe is a truly fucked-up place," I sighed. "At times, I wonder if it's Loki who is running things rather than God."

"I can see that," Clarissa replied. "It does, at times, seem like a cruel joke -- Sandy, Lee, and Elizaveta."

"Yeah," I replied, thinking of my friends and my first wife.

The waitress brought our food, I said the blessing, and we began eating.

"Are you going to see Frank Bush again?"

"Yes. Once a month to play chess and talk. Nobody has been to see him since he was incarcerated."

"Does that surprise you?"

"Not really, when I think about it. His wife divorced him, neither of his kids has been to see him, and nobody from his church would visit because he's reprobate."

"I do NOT understand that."

"Sadly, I do. It's what happens when you give a French lawyer a copy of the Scriptures, he ignores the entire tradition of the Church, and comes up with his own private theology. His Institutes of the Christian Religion read more like a legal treatise than a theological text, which should come as no surprise, given Jehan Cauvin was a lawyer!"

"I take it that's his French name?"

"In Middle French," I replied. "It's Jean Calvin in modern French, and John Calvin in English. He published first in Latin, then later in French, which fit the notion that scholarly and theological work should be in Latin first, and one's mother tongue second. Luther's Disputation on the Power and Efficacy of Indulgences, better known as the Ninety-five Theses, was in Latin, and was later translated into German."

"Your instant recall of that kind of information is pretty amazing. It's no wonder you were an excellent student."

"We're still technically students, Doctor Saunders! Do you have a medical license? I don't."

"I'll get mine before you get yours!"

"True, given I need two years of surgical Residency before I can take my Boards, and I have two years of trauma before I begin that part."

"Ready for your first shift on Saturday?"

"Champing at the bit! I've enjoyed the time with Kris and Rachel, but I need to be back in the hospital and Rachel needs to see her friends. She's been in a mood and was asking for Abigail."

"They're in Spain, right?"

"Yes, though Joel could only stay two weeks. Milena, Abigail, Anicka, and Derek are there for a month or so."

"That was a fun visit."

"It was. Someday we'll do it again. With our kids."

"I like the sound of that."

"Me, too."

We finished our meal and walked out to the parking lot.

"I think I have to tell Kris," I said. "The risk of her finding out at some point in the future is too great. I'll take my lumps now, rather than risk something fatal to our marriage."

Clarissa was silent for a moment.

"Let me tell her. And tell her I swore you to absolute secrecy."

"She might change her mind," I said.

"Better now than a massive blowup at some point in the future, don't you think?"

"Let me think about it, OK? I'll tell you on Sunday at church."

"Sounds good."

We hugged, and once Clarissa had gotten into her car, I got into mine and headed home.

VII. Red Scrubs

June 29, 1989, Greater Cincinnati, Ohio

"Hi, Ang," I said when she greeted Kris, Rachel, and me at the door.

"Hi, Mike! May I hold Rachel?"

"That's up to her," I replied. "She's discovering her independence!"

"She's almost two, right?" Mrs. Stephens asked from behind Angie.

"At the end of August," I replied as I handed a willing Rachel to Angie.

Kris and I followed Angie as she carried Rachel into the living room, and once Angie was settled, I left the three girls and joined Mrs. Stephens in the kitchen. Mr. Stephens joined us a moment later.

"First," she said, "you should call us Marjorie and Ken."

"And you should continue to call me Mike," I replied. "Are you willing to proceed with the formal complaint to the medical board?"

"Yes," Ken replied firmly. "My only question is who'll be paying the attorney."

"A close friend who has the resources and wishes to remain anonymous," I replied. "I already spoke to my stepdad, and he recommended an attorney from his firm who specializes in malpractice. My friend will pay the bill directly."

"What do we need to do?" Marjorie asked.

"The attorney, Tom Kirkland, will call you in the next few days. He'll want to gather any records you have, and he'll likely subpoena files from Doctor Mercer and Doctor Greenberg. Stefan will provide him copies of the depositions and the settlement agreement."

"And that doesn't prevent us from doing this?" Ken asked.

"No. It says you won't take any legal action, and you aren't. The Ohio Medical Licensing Board is an administrative body, not a judicial one. Doctor Greenberg may try to make that argument, but according to Stefan it's a settled principle in Ohio courts that actions by licensing boards are administrative."

"Do you think he'll have his license revoked?" Marjorie asked.

"It's unlikely, according to everyone with whom I've spoken, but the complaint will go into his records, and that means any additional complaint would be given much greater weight, even if, in the end, he's not disciplined. That said, I think the argument I'm going to make is inescapable, and the board will have no choice but to, at a minimum, issue a reprimand. We'll go for more than that, of course, but sadly, that's the most probable outcome."

"Why?" Ken asked.

"Because he followed the standard treatment protocols, and that is almost invariably sufficient to defeat claims of malpractice. That said, I believe I can show he actually didn't do that, which will, I hope, force the Board to act."

"How do you plan to show that?"

"As I'm positive you know, one of the key symptoms of schizophrenia is not being able to process things long term -- literally everything is 'now'."

"Right," Marjorie said. "Angie wasn't able to think long term."

"And that right there is what Doctor Greenberg got so very wrong. When Angie decided she was going to do whatever was necessary to get to a point where she and I could marry, she was thinking about the future, outside the moment, had made a plan, and was successfully executing it. That is not a sign of someone who is suffering from full-blown schizophrenia and is a strong sign that something has changed. In my opinion, that's why the insurance company settled. They knew they would lose, not just on emotion, but on facts."

"And you saying that, as a doctor, carries weight?"

"They'll argue that I have insufficient experience, but I have the textbooks and peer-reviewed journal articles on my side, not to mention I believe, in the end, Doctor Mercer will confirm. I think she'll testify on our behalf, not Doctor Greenberg's."

"Angie really liked her."

"Me, too, until she listened to Doctor Greenberg instead of all of us. That said, I understand why she did, even if I don't agree. Anyway, I should spend some time with Angie before dinner."

"Thanks, Mike," Marjorie said.

"Yes, thanks, Mike," Ken added.

"You're welcome."

We went back to the living room where Angie had Rachel on her lap and I briefly flashed to an alternate universe where Rachel was mine and Angie's, though I suspected strongly she'd have had red, rather than black, hair. The source of Rachel's black hair could be either side of the family, as all of Elizaveta's family had black hair, as did my mom and grandfather, while I had my dad's sandy brown hair. The odd one out was my maternal grandmother, who had been blonde before her hair had turned white.

"How does it feel to be a doctor, Mike?" Angie asked.

"Not all that different, really. My final rotation in the Emergency Department was basically exactly what it will be like for the next few months, only I don't need close supervision and can work more independently. How are you doing?"

"OK, I guess. I'm working and going to Aikido."

Which was probably about the limit for her, given she was still taking psychoactive drugs, albeit at very low doses. I doubted she'd ever be able to go back to school, or get a better job than her data entry job, but it was something, when the alternative was nothing. I hated the situation and wished there was something I could do other than exacting a pound of flesh from the psychiatrist, but sadly, any last hope had been destroyed by his actions.

"That's good."

"Are you going to have more kids?"

"Angie..." her mom said firmly.

"It's OK," I said to Marjorie, then turned to look at Angie again, "Yes, Kris and I plan to have two more."

"What do you do, Kris?" Ken asked.

"I'm enrolled at Ohio State University in political science with a goal of an advanced degree in Public Administration."

"And you've been in the US how long?"

"Almost eighteen months," Kris replied.

"Her citizenship papers will be filed next week," I added.

"That's fast!" Ken declared.

"They were issued Green Cards based on her dad's job, and a Green Card holder can apply after eighteen months if they're married. Once Kris is approved, then her parents can apply early as well."

A timer rang, and Marjorie asked us all to go to the table while she brought the food to the table. She'd made oven fried chicken, home-style fries, bread, and coleslaw. I was asked to give the blessing, which I did, and then we dug in. The food was excellent, and I ate more than I probably should have, but it was so good that I simply couldn't resist. Dessert was apple pie and ice cream, along with coffee.

When we finished, I offered to help Marjorie with the dishes, which gave Angie more time with Rachel. After we finished the dishes, I spent a bit of time with Angie, and then Kris, Rachel, and I said 'good night' and headed home.

June 30, 1989, Circleville, Ohio

"What are we doing today?" Kris asked at breakfast on Friday morning. "You start your Residency tomorrow, and I start classes on Wednesday."

"I think we should do the grocery shopping today. We really won't have time tomorrow after band practice, and I can't skip that, given we have our concert on Tuesday."

"No, of course not! Grocery shopping today is fine. And a stop at the record store?"

"Yes. I also want to stop at Barnes & Noble and place a pre-order for the book I promised to buy for Frank Bush."

"We should obviously stop at the record store and bookstore before the grocery store, given how warm it is outside."

"Obviously," I agreed.

"What about tonight?"

"No plans, as most of the gang is gone and several others aren't available. You're OK with what Serafima and Alyssa suggested after Vespers on Wednesday evening -- that we restart in the fall with what we used to call Dinner Club, which would be them, us, and Ghost and Oksana, right?"

"Yes, of course! And, as you and I discussed, we'll find time to get together with José and Sierra, Gene and Jocelyn, and Clarissa and Tessa."

"Then let's just stay in, have a quiet family dinner, and once Rachel goes to bed, you and I can take a nice bubble bath."

"«C'est magnifique!»" Kris exclaimed happily. "And after the bubble bath?"

"Anything you want, of course!"

"As it should be!" Kris declared.

"Some day, Rachel will say that to YOU and I'll laugh!"

"She's much more likely to say it to you!"

"Dada? Want Abby!"

"She's in Spain, which is far, far away. She'll be home in about a week."

Rachel crossed her arms and stared at me, but there was really nothing I could do. She'd be back in hospital daycare on Wednesday, which I hoped would improve her mood. We needed more friends with daughters, but so far, except for Abigail, there were only boys, including my nephews. My half-sister and my adoptive niece lived too far away for Rachel to see her regularly.

"I think we need to find a few more girls for Rachel to play with," I said. "But the majority of the babies at Saint Michael, Holy Transfiguration, and the cathedral, and in my family, are boys. Anna has remarked a few times that we need more girls because Viktor Gennadyevich will need a wife!"

"It's a bit soon to worry about that, don't you think?" Kris asked.

"Specifically, yes, but the general problem is that when our young men marry outside the church, they usually leave and attend their wife's church. When our young women marry outside the church, their husbands usually attend our church. So if we have too many boys in the parishes, we have a long-term problem, unless the trend of which church mixed-faith couples attend is reversed."

"I never really paid close attention to that in Paris, but I've heard others here say that."

"In any event, Rachel will have her choice of boys in about thirteen years. But for now, she much prefers the company of girls."

"If I had to spend time with Viktor Gennadyevich, I would, too!"

I chuckled, "He is one hundred percent 'boy' and reminds me of his uncle, more than his dad."

"You mean Joe, not you, right?"

"I was more like Rachel when I was little, and you know I hung out with Jocelyn more than anyone else. And that was true even after Dale and I became friends in second grade, after I had some disagreement with Jocelyn. Whatever the source of our disagreement was, it's lost in the mists of time, but me hanging out with Dale caused Jocelyn to seek me out and that created a trio of fast friends."

"You do have some qualities which are more feminine."

"That's been said before, and I attribute it to a combination of my mom and Jocelyn."

"DADA! WANT ABBY!" Rachel demanded.

"I wish you could understand what it means to say she's in Spain," I said. "You'll see your friends in daycare on Wednesday."

"Why don't you take her on Monday?" Kris asked. "She really hasn't seen her friends in a month. I'll pick her up, and if you're able, we could have dinner together at the hospital."

"Let's give that a shot," I said. "I really do not want an unhappy toddler!"

"Think about my situation," Kris teased. "I have to raise two toddlers!"

"Oh, give me a break!" I chuckled. "I was already housebroken when you met me! You owe thanks to my mom, Jocelyn, Clarissa, and Elizaveta for that!"

"You are useful around the house," Kris observed. "Especially in the bedroom!"

"Gee, thanks," I replied with a grin.

"Would you prefer I said not in the bedroom?" Kris asked lightly.

"No."

We finished our breakfast, cleaned up the kitchen, then got ready to run our errands. Our first stop was Barnes & Noble, where I pre-ordered The Sum of All Fears for Frank Bush and arranged for it to be mailed to him at Southern Ohio Correctional Facility. Per the clerk, it would be shipped directly from their warehouse, rather than to the store first, as the warehouse was fully up to speed on the rules for sending things into prisons.

Our next stop was the record store, though it now carried more CDs and video games than vinyl albums.

"What's new I should listen to?" I asked Johnny.

"Bleach, by Nirvana. They're a grunge band from Seattle. I think they're going to be big."

"You've never steered me wrong. What else?"

"The End of the Innocence by Don Henley or Disintegration by The Cure, which returns to their early 80s style. And The Miracle by Queen."

"Decisions, decisions! How about the new group and Queen?"

"You got it! CDs, correct?"

"Yes."

He retrieved both CDs for me, put them in a bag, and rang up my purchase.

"I read in the paper that you graduated and are officially a doctor now."

"I am. I actually start my first official shift tomorrow."

"Cool. Your daughter is growing like a weed!" he said as I handed him three $10 bills.

"She is! You know, I've never asked, do you have kids?"

"A ten-year-old son."

"Business still good?"

"Being the only dedicated store in town helps, though I get undercut by K-Mart. But my selection is wider, and I do special orders, not to mention my regular customers. Adding video games helped, and I'm going to start carrying video game hardware, too. And I've expanded my used album business. I know you won't sell, but if you know anyone looking to unload vinyl or CDs, let them know."

"Will do."

Jonny handed me my change, I thanked him, and then Kris, Rachel, and I headed for Kroger. We completed our grocery shopping, stopped at the bakery, then headed home. After we put away the groceries, I put on the Nirvana album.

"You like this?" Kris asked.

"I have eclectic tastes," I replied. "Grunge isn't my preferred style, but I do appreciate the talent and artistry. I'd say Johnny is correct and Nirvana will be very popular."

After we listened to the album, we ate lunch, then put Rachel down for her nap. The rest of the day was quiet, and Kris and that evening, I had an enjoyable time in the bathtub and bed.

July 1, 1989, McKinley, Ohio

"How was Disney?" I asked José when he walked into the music room at Taft.

"You think the man even SAW the parks?" Sticks asked.

"I bet he did," I said.

"You'd win that bet," José replied. "Not that we didn't do what Sticks is implying! And yes, we had a great time."

"Shall we practice?" Kim asked. "We need to run through the two sets we're doing on Tuesday."

We did that, and Kim was happy with our practice. When we finished, we hurried to pick up Rachel at her grandparents' and then home for a shower. I dressed, put on the new long medical coat that my grandfather had given me, kissed my wife and daughter, then headed to Dorothea Rhodes Lummis Moore Memorial Hospital for my first shift of my PGY1.

Because I was assigned to the surgical staff, I reported to Doctor Vince Taylor in the Surgical Department at 11:30am.

"We'll dispense with the usual first-day Resident BS," he said. "I've been assigned as your mentor, but I don't think you'll need much mentoring from me for your first two years. Your mentor in the ED is Ghost, and you should go to him for anything related to trauma, and to me for anything else. Doctor Cutter wants you to wear red scrubs."

"Marking his territory, so to speak?" I asked with a grin.

Doctor Taylor laughed, "That's one way to put it, but yes, he wants to ensure that everyone knows you're officially a surgical intern. He feels it's better to differentiate the surgeons from the other doctors in the ED."

"OK. I'll take several sets down to the ED locker room with me, so I don't have to come up here if I need to change."

"Actually, your locker is here," Doctor Taylor said.

"Turf war, right?"

"Good guess. It started as soon as you Matched. I assumed you knew."

"I didn't. I thought there was a requirement for surgical Residents to be supervised by surgeons."

"There is, but you're in a gray area, at least for the next two years. In any event, Doctor Cutter prevailed, but that hasn't stopped Doctor Northrup."

"Wonderful," I sighed. "Day one, and it's already political."

"Just be a doctor and ignore the BS. You can do that as a PGY1. Let the senior Attendings fight it out with the Medical Director. In the end, you're going to be a Board certified surgeon, and that's the master trump."

"Trust me," I said with a smile, "I'll ignore it for as long as I possibly can!"

"See Penny at the nurses' station. She has your ID, your keys, and your pager."

"Keys?"

"We began locking all supply rooms as of last week. Too many consumables were disappearing. Everything has to be logged, not just drugs."

"More paperwork," I said, shaking my head.

"Unfortunately, I think we have to get used to it. Our patient load is up and our funding levels are stagnant."

"Same old story. I did see the construction equipment in what used to be the grassy field outside the ED, so that's something."

"It is, but they should have built the new surgical wing first."

"Well, being on the surgical service, I'm not going to disagree with you, but I disagree with you!"

Doctor Taylor laughed, "I hear you. You're not a surgeon at heart, even if you'll make a very good one."

"Thanks, Doctor Taylor."

"It's Vince, please. All surgical Residents address each other by their first name."

"Thanks, Vince."

"Go see Penny and let me know if you need anything. I can't imagine what it might be, given you've been here for four years, which is longer than I have!"

I shook his hand and went to the nurses' station to see Penny, who was new.

"Hi, Penny," I said. "You have my ID, pager, and keys."

"Doctor Loucks?"

"Mike, please," I said.

"Protocol is to call all doctors by their title," she said.

"Then Doctor Mike, please."

"OK. I understand you were a medical student here, so I'm sure you know about the pager."

"I do."

She handed me the ID, pager, and keys, I thanked her, then headed to the locker room to change. Using the surgical locker room was a minor inconvenience for working in the ED, but, in the end, I was a member of the surgical service, so it made sense. I found the locker with the tag 'M. Loucks' on it, and opened it, finding it empty as was to be expected.

I walked over to the cabinet which held the red scrubs, selected the correct size, changed into them, slung my stethoscope around my neck, clipped on my new photo ID which identified me as 'Doctor Michael P. Loucks' and had the red 'S' symbolizing the surgical service superimposed on the lower left of my photo, while the lower right had the standard Staff of Asclepius.

Normally, surgical Residents wore surgical caps while on duty, and I had several I'd ordered, as they were personalized, but they were not usually worn in the ED, so I simply left them in my locker. Last, I put on my medical coat, which surgeons wore when not in surgery, but which was generally dispensed with by doctors in the ED except when meeting with families.

Properly attired, I shut the locker, attached my combination lock, closed it, spun the dial, and then left the locker room to head to the ED. I took the stairs, something I had resolved to do to get that bit of extra exercise with my schedule, making regular exercise difficult, if not impossible.

"Good morning, Luisa," I said to the nurse at the nurses' station. "Doctor Mike Loucks."

She was new, having just graduated from nursing school in May.

"Good morning, Doctor!" she said brightly. "It's nice to meet you. Doctor Casper is in the lounge."

"Thank you."

I went to the lounge and saw Doctor Casper stretched out on the couch.

"Morning!" I said.

"Hi, Mike," he said, sitting up. "What's with the red scrubs?"

"Doctor Cutter's orders," I said.

"Proving, in his mind, that he has the bigger dick."

"Of all the things I could possibly care less about, I'm not sure there are many I care less about than the relative size of two Attendings' dicks."

"You and me both!"

"Who's the Attending?"

"A new-hire you haven't met - Doctor Isabella Mastriano."

"Italian?"

"Yes. She graduated from OSU and served her Residency in Texas. Loretta spoke to her, so she's been warned about you."

I chuckled, "Of course. Who are the med students?"

"You have Callie Newsom and Gabriella Martin today; Newsom is the Fourth Year. Also, Doctor Gibbs wants you to take the Preceptorship students on Tuesday afternoons."

"I know Callie. Preceptorships should be fun at the end of a thirty-six-hour shift."

"Welcome to PGY1! Anyway, you'll get mostly walk-ins today. See me if you have questions, and Doctor Mastriano will sign your charts."

"Sounds good."

"Hi, Mike!" Nurse Alice said, coming into the lounge.

"Hi, Alice."

"Doctor Casper, EMS four minutes out with a fall from a ladder."

"Thanks, Alice. Which room?"

"Trauma 3 is open."

He got up, and I went to the triage desk to check in with the medical student and nurse who were manning the desk.

"Hi, Doctor Loucks!" Nurse Billie said.

"Hi, Billie."

"Hi, Mik...Doctor," Fred Lawson said.

"Hi, Fred. I'm assigned to walk-ins. I just need to do the handover with Doctor Billings."

"OK. There are two waiting, so they're all yours."

"What do we have?"

"Two days of nausea and diarrhea and a minor arm lac."

"OK. I'll be right back."

"What's with the red scrubs?" he asked.

"As a trauma surgeon, I'm on the surgical service, but assigned to the ED. Surgeons wear red."

"Interesting."

I left the triage desk, checked the board, and went to see Doctor Billings.

"Hi, Doctor Billings," I said as I stepped into Exam 2.

"Hi, Mike. Call me Kayla, please. I'll be finished in two minutes. Meet in the lounge?"

"You got it."

I returned to the lounge and a few minutes later, Doctor Billings came in.

"Nothing to turn over," she said. "I just streeted that sprained ankle and my last admission went up fifteen minutes ago. Ready for your first shift?"

"It doesn't feel that way, actually."

"The golden-haired boy who did more procedures as a Fourth Year than I did as a PGY1! And why do you rate red scrubs?"

"Jackpot," I chuckled. "You and every other person I've spoken to has asked or commented! I'm officially on the surgical team though I'm assigned to the ED. Doctor Cutter wants me to wear red."

"Dick measuring contest between him and Northrup."

"So it would appear. I have two patients waiting on me, so unless there's something else..."

"Nope. I'm outta here!"

We both left the lounge with Kayla heading to the locker room while I went to find Callie and Gabriella, both of whom were standing in the ambulance bay, with Callie smoking.

"Don't you know those will kill you?" I asked Callie.

"It helps with the stress," she replied. "How are you, Doctor?"

"I'm fine. Who's your cohort in crime?"

"Doctor Mike Loucks, Gabriella Martin, Third Year. Gabby, meet Doctor Loucks, PGY1."

"Doctor Mike, please," I said. "Nice to meet you, Gabby. We're catching walk-ins. Come with me."

Callie stubbed out her cigarette and the two of them followed me inside.

"Callie, I'll have you do the H & P."

"Seriously?" she asked. "On your first shift?"

"Yes. My job, in addition to healing, is teaching. I know how to do an H & P. Now we'll see if you do. And Gabby, pay attention, because you'll do one as soon as I'm sure enough about Callie to turn her loose on her own."

"On her own?" Gabby asked. "Don't we have to be supervised?"

"Yes. My definition of supervision is allowing Callie to do an H & P on a walk-in on her own, then verifying her findings. That's how she'll learn."

"Rumor has it that you know everything," Gabby said.

I chuckled, "Let's assume for a moment that's true. It's what you learn after you know everything that counts!"

"Hang on! If you know everything, you can't...wait, Zen, right?"

"Of that same basic idea, but I heard it from a Russian Orthodox monk."

We arrived at the triage desk, so I switched out of friendly teacher mode into doctor mode.

"Who's first?" I asked Fred.

"I'd say nausea," he replied.

"Me, too," I agreed.

"Kaylee Jennings, nineteen; last vitals: pulse 92; BP 120/70; temp 38.6°; no cough or sore throat; ears clear."

"OK. Chart please."

He handed me the chart, and I went to the door to the waiting room and opened it.

"Kaylee Jennings?" I called out.

A pretty girl stood up, as did a woman who I suspected was her mom, and came to the door.

"Hi; I'm Doctor Mike. Ms. Jennings, if you'd follow me," I said to the young woman, then turned to the older woman, "Ma'am, you'll need to wait here, please."

"It's OK, Mom," Kaylee said.

I checked the board, saw that Exam 1 was open, and brought Ms. Jennings there, with Callie and Gabby following me.

"Go ahead, Callie," I said.

"Hi, Kaylee," she said. "What brings you here today?"

That was literally the by-the-book first question to ask and was intentionally open-ended to elicit as much as possible from the patient.

"I've been sick to my stomach and have the runs."

"When did those symptoms start?" Callie asked.

"Thursday night."

"What did you do on Wednesday and Thursday?" Callie asked.

"Not much. A picnic at the lake."

I made a mental bet with myself that she had salmonellosis, or, as it was more commonly known, food poisoning. I almost laughed, thinking back to carrying Lara from the dorm to the infirmary at Taft, but that would have been inappropriate. Callie obviously had the same thought as she asked what Kaylee had eaten, then went through a complete H & P, reporting her findings.

"Preliminary diagnosis is food poisoning," Callie announced.

"I concur," I said. "Kaylee, I need to do a quick exam to check Callie's findings."

"She's not a doctor?"

"No. She's a medical student. This is normal for training."

I did a quick exam, hearing no anomalies in her heart or with her breathing.

"Kaylee and I need to present your case to our Attending," I said. "That's a senior doctor. Gabby, you stay with her."

"OK," Gabby agreed.

Callie and I stepped into the corridor.

"You'll present," I said. "What's your proposed treatment?"

"The choices are oral or IV rehydration, and given she's nauseated, I recommend IV Ringer's."

"Good. Anything else?"

"Ceftriaxone."

I shook my head, "Studies show that has no positive effect on otherwise healthy patients who are not very young or very old. Overuse of antibiotics is a serious problem, so we don't use them unless we have to."

"Patients want them."

"And I want shorter shifts!" I chuckled. "I don't see anyone granting that wish simply because I want it!"

Callie laughed, "Good point!"

"Anything else?"

"Not that I can think of."

"Antiemetic?" I asked.

"Is her emesis sufficient to need that?"

"I asked you first!" I chuckled.

"She hasn't vomited since we brought her into the exam room, so I'd say she doesn't need it."

"Think about that for a second," I suggested.

"She said she couldn't keep anything down. So, in addition to the IV, we give her some juice and see what happens."

"Excellent. How do we confirm our diagnosis?"

"Stool sample or blood test. If I suggest a stool sample, are you going to make me collect it?"

"What do you think?" I asked with a goofy smile.

"I think she needs a blood test!" Callie declared.

I laughed, nodded, and we went to the Attendings' office and I knocked on the open door.

"Doctor Mastriano?"

"You must be Mike Loucks.

"I am."

"What's with the red scrubs?"

"Doctor Northrup's orders," I replied. "We have a patient to present."

"Go."

"Callie?"

"Kaylee Jennings, nineteen-year-old female; pulse 94; BP 124/72; temp 38.6°; nausea and diarrhea onset on Thursday after a picnic at the lake; no cough or sore throat; ears clear. My preliminary diagnosis is food poisoning, likely caused by salmonella. Recommend treatment with IV Ringer's for dehydration and blood test to confirm."

"Antibiotics?"

"Not indicated for healthy adults. She doesn't appear to need antiemetics at this point. Observe for two hours."

"Approved. Let me have the chart to sign."

Callie handed over the chart, Doctor Mastriano signed it, and then handed it back.

"Mike," Doctor Mastriano said, "come see me when you have a break, please."

"Will do."

Callie and I left the office and stopped outside the exam room.

"Thanks for the tip on antibiotics," Callie said.

"All part of the service!" I replied. "Do you know if Gabby has done IVs?"

"I haven't seen her do one, no."

"OK. Then you do it. I'll ask her about it, but not in front of the patient. Blood draw?"

"Same answer."

"OK. You do that, too, and have her take the blood sample to the lab."

"OK."

We went into the exam room and I nodded to Callie.

"Kaylee, we're going to give you IV fluids, and run a blood test to confirm our suspicion that you have salmonella-based food poisoning."

"No antibiotics?" Kaylee asked.

"No," Callie replied. "They're usually not necessary for otherwise healthy adults. We will keep you for a few hours to see how you're feeling, as well as get the results of the blood test. If you'll lie back down, I'll get the IV going and draw the blood."

Callie did a good job on the IV and the blood draw, and as we agreed, asked Gabby to take the blood to the lab. Once that was done, I sent Callie to bring in Kaylee's mom.

"She'll be fine," I said. "We're giving her IV fluids to counteract the dehydration caused by her vomiting and diarrhea while we wait for the blood tests to confirm food poisoning. You can wait here with her. If the tests do confirm it's food poisoning, you can take her home and have her eat broth until her stomach settles. We'll come back to check on her every twenty minutes or so."

"Thank you, Doctor!"

"You're welcome."

Callie and I left the exam room and went to the triage desk.

"Arm lac or migraine next?" Fred asked.

"How long as the arm lac been here?"

"About thirty minutes," he replied.

"How many sutures do you estimate?"

"Five or six at most."

"Callie, may I see your procedure book?" I asked.

She handed it to me and I counted five signed-off sutures during her current rotation.

"OK. I'll do a quick exam, you can suture, and I'll check your work. While you're doing that, I'll see the migraine. I'll ask a nurse to help you; I'll have Gabby help me."

"Great!" Callie declared. "I'm going to enjoy working under you!"

The stress on the word might have been my imagination, but I didn't think so. I elected to simply let it go.

"Fred, we'll take the arm lac chart, please."

"Jack King; forty-eight; vitals normal; five centimeter lac on right forearm."

He handed me the chart, and we went to the door, I called Mr. King, and Callie led him to the new suture room that used to be the Residents' office. I went to the nurses' station and ensure there was an experienced nurse to help Callie. I was assigned Nurse Julie, and she followed me to the suture room.

I did a quick exam saw no contraindications and asked Callie to proceed.

"Call me when you're finished, and I'll sign the discharge papers."

"Will do, Doctor," Callie said.

I left the room and saw Gabby returning from the lab, waved for her to follow me to the triage desk.

"Migraine," I said.

"Take two aspirin and call you in the morning?" Josh, the clerk asked.

"Sadly, that may be about as effective as most treatments we have for migraines. Vitals, Fred?"

"Stephanie Smith, twenty-six; pulse 88; BP 124/74; temp 37°; onset shortly after waking this morning; previous visits in January, March, and May."

"Frequent flyer," I said. "Did you pull her records?"

"No. I can't leave the triage desk."

"OK. Gabby, go to the records room and find me the file for Stephanie Smith. Birthdate..."

"March 22, 1963," Fred said.

"Be right back," Gabby said.

Five minutes later she returned.

"What does it say?" I asked.

"I didn't know I was allowed to look."

"Required, is more like it. Tell me what you see."

She opened the file and flipped through it."

"Each visit is about eight weeks apart, she was treated the first time with a 'migraine cocktail'. What's that?"

"Basically Excedrin, but with higher dosage -- 500mg acetaminophen, 300mg acetylsalicylic acid, and 100mg caffeine."

"The second time, with IV metoclopramide; the third time they added dexamethasone.

"Any red dot on the inside folder?"

"No. Why?"

"That would indicate a drug-seeker," I said. "Claiming migraines or back pain are the most common excuses for asking for opiates. This young woman hasn't done that, so we believe she actually has migraines. Let's bring her in."

Fred handed me the chart and Gabby and I went to the door and called Ms. Smith.

"Hi, I'm Doctor Mike and this is Gabby, a medical student. Let's get you into an exam room."

I checked the board and Exam 3 was open, so we led Ms. Smith there and she climbed onto the exam table.

"What brought you here today?" I asked.

"I have terrible migraines."

"When did they start?"

"The first one was probably about a year ago, and Excedrin knocked them down for the first six months. When that stopped working, I came here, and they gave me a higher dose of the same stuff. The next times I had an IV, but can't tell you what it was."

"Are you sensitive to light or noise?"

"Both," she replied.

"Your migraines seem cyclical," I said. "Do you have any idea what triggers them?"

"No."

"When was your last menstrual period?"

"It should start tomorrow or Monday."

"Is there any chance you're pregnant?"

"No. It's been a couple of months since the last time, and I've had my period."

I went over her medical history, then said, "I'd like to do a physical exam, please."

"Sure."

I started with heart and lungs, then eyes, ears, nose, and mouth, and finally palpation of her abdomen.

"Gabby, let's get a CBC, Chem-20, and a glucose panel," I said, writing those orders on the chart, along with a medication order. "Let's also start her with 500mg acetaminophen, 300mg acetylsalicylic acid, and 100mg caffeine. Ms. Smith, I'm going to check on two other patients and I'll come back after Gabby draws the blood."

"Do you need Doctor Mastriano to sign off?" Gabby asked.

"No," I replied. "Only for scheduled drugs."

"Why would you need approval?" Ms. Smith asked.

"That's normal for Interns," I replied. "That's someone in their first year of Residency."

"You're a brand new doctor?"

"First day, officially, though I've technically been a doctor for over a month."

"First day? Seriously?"

"Yes."

"You're in good hands, Ms. Smith!" Gabby said. "Mike graduated at the top of his class and aced his exams!"

"I wasn't concerned," Ms. Smith said. "I was impressed!"

"I'll be back shortly," I said.

I went to check on Kaylee who was feeling OK and resting comfortably, updated the board, which I'd failed to do earlier, then went to check on Callie, who was almost finished.

"Those stitches look good," I said. "When you finish, fill out the discharge form, bring it to me to sign, then take it to Doctor Mastriano. Discharge if she signs off."

"Will do!" Callie said.

I left and went to check if there were any other walk-ins, but there weren't, so I returned to Exam 3 where Gabby was completing the blood draw. Given it was just the two of us, I went to the drug locker, retrieved the oral tablets, then went to the nurses' station knowing I'd need someone in the exam room when Gabby ran the blood to the lab. Nurse Jessica walked to the exam room with me, and Gabby took the blood to the lab. I administered the medication.

"I'm going to speak to my Attending," I said to Ms. Smith. "Nurse Jessica will stay with you."

I left and went to see Doctor Mastriano. I described Ms. Smith's complaint and what I'd done so far.

"What do you want to do next?" Doctor Mastriano asked.

"IV metoclopramide and dexamethasone. Once the blood test results come back, I'll return with any additional treatment plan."

"OK. Do you have a moment now?"

"Yes."

"Shut the door and have a seat."

I did as she asked.

"First day, first patient, and you have a Fourth Year do the exam?"

"It was impressed on me that teaching is an important part of a Resident's job, and from experience, I found that many Residents don't give their Third Years and Fourth Years enough opportunities. It was the right decision."

"I wasn't challenging, you," Doctor Mastriano said. "I was surprised a PGY1 would do that their first day. You'll have every student clamoring to be assigned to you."

"I don't see that as MY problem!" I chuckled. "I was under the impression Doctor Gibbs had told you about me."

"She did, but that doesn't mean I'm not surprised."

"I believe she should have warned you, not told you about me," I chuckled.

"I believe you're right!"

VIII. What A Stupid Way to Die

July 1, 1989, McKinley, Ohio

"How was your first day?" Doctor Casper asked just before midnight.

"Routine, really. Fourteen walk-ins, with the only truly interesting case being the young woman with the migraines. I had mixed emotions about the MRI, hoping it would show something but dreading what it might show."

"That's a common reaction," Doctor Casper said. "You have a tentative diagnosis that you really hope doesn't pan out. I think you had a leukemia diagnosis in a college-age student."

"Yes. That sucked, though she recovered."

"How do you know that?"

"José married her best friend. It sucks that we don't have an answer for the migraines."

"Yes, but you asked Doctor Mastriano for a neurology consult and they took her, so you did your job. The last three times they simply sent her home after giving her analgesic cocktails."

"But the consult turned up nothing."

"Mike, what's your job? And don't give me any bullshit 'heal the sick' answer, either."

"That is my job," I replied.

"No, that's your calling," Doctor Casper countered. "What is your job?"

"First line emergency care."

"Did you do your job?"

"Yes."

"Then as shitty as this sounds, that's a good day. You cannot heal, cure, or whatever you want to call it, every single person who walks into the ED or is brought in by ambulance. And as shitty as it sounds, and feels, it's not your job. You job is to triage, treat or stabilize, then admit or discharge. You know the catchphrase."

"Treat 'em and street 'em. We've had this conversation before."

"And we're going to have it again until you get it through your thick head that the 'S' on your badge does not stand for 'Superman'!"

"I don't believe I'm Superman," I replied.

"Then don't try to be Superman. How many of your patients walked out of the ED happy today?"

"Thirteen out of fourteen."

"That's a damned good day. How many died?"

"None."

"That's an outstanding day. Days like that are right up there with the pilot's refrain that any landing you can walk away from is a good landing. Do you want to know my count for the past eighteen hours?"

"Go on."

"Eighteen treated, three of them resulted in a consult from McKnight. Want to trade days?"

That was another euphemism that was used in the ED to indicate a patient had died without saying it where other patients could hear.

"No."

"Then in ten minutes, let's get our showers, put on our street clothes, and go home. You're back on Monday, right?"

"0600 for a thirty-six-hour shift."

"You may be the last class of Residents who have those shifts."

"The Libby Zion case."

"Yes. Word is that the end result, when all the smoke clears, is eighty-hour weeks and no more than twenty-four-hour shifts, with at least eighteen hours between shifts. That's what New York is imposing, and I expect, eventually, the Accreditation Council for Graduate Medical Education will adopt the same standard."

"Fortunately, I mostly have eighteen hours between shifts, but I know some of the shifts work out to only twelve hours between thirty-six-hour stints."

"Hi, Mike!" Kylie said, coming into the ED.

"Hi, Kylie."

"How'd your first shift go?"

"I handled fourteen walk-ins. My board is clear."

"Excellent. I'll see you on Monday morning."

"See you then," I said.

July 2, 1989, McKinley, Circleville, and Columbus, Ohio

Just after midnight, Doctor Casper and I left the lounge and walked towards the locker room.

"I'm upstairs," I said.

"Cutter is really pushing the point, isn't he?"

"Yes," I agreed. "But so long as the turf war doesn't have any effect on my training, I can deal with the petty stuff."

He went into the locker room and I headed upstairs to the surgical locker room. I took a quick shower, dressed, then headed home, where Kris was waiting up for me.

"How was your first day being a doctor?" she asked after we exchanged a hug a kiss.

"Not all that different from my last day of being a Sub-Intern," I replied. "The main difference is I can do basic procedures without seeking permission every time, order tests, and prescribe non-schedule drugs."

"Narcotics, right?"

"Yes. Those I won't be able to prescribe until I actually have my medical license, which is after I pass my Boards, which is sometime after PGY4. In theory, I could do it in two parts, if Doctor Cutter would sign off on getting my basic license before I spend any time in the OR, but I'm not sure he will, given the turf war."

"Turf war?"

"A contest over who is actually in control of my schedule and decides the course of my training. Doctor Northrup tried to change things, and Doctor Cutter reacted. The only real effect of their little battle is that my locker is in the surgical locker room, and I wear red scrubs instead of pale blue ones. It's really no big deal from my perspective."

"So, now you have medical students to order around?" Kris asked lightly.

I chuckled, "Yes, but you know me. The key is teaching, not having someone to do scut."

"Male or female?"

"Today? Two females. I'm not sure who I'll have on Monday, but med students are limited to twenty-four-hour shifts, and mine are thirty-six, so I could have as many as six different students during that period, depending on the schedule."

"Any interesting patients?"

"I treated patients who walked in, which means mostly minor stuff. The only really interesting one was a young woman with migraines, but in the end, all I could do was refer her to neurology. The CAT scan we ran showed nothing, so they gave her some stronger medication than you can buy over the counter. I suspect she'll be back. How was Vespers?"

"The same as it's been for over a thousand years," Kris said lightly.

I laughed, "OK, I deserved that. Shall we go to bed? We have to leave for Matins in just over six hours."

"Yes."

We headed upstairs and ten minutes later we were in bed, and two minutes after that, I was sound asleep. When the alarm rang early on Sunday morning, we got out of bed, quickly showered together, then fed and clothed Rachel, and the three of us headed to Dormition of the Mother of God Cathedral in Columbus for Matins and the Divine Liturgy.

Rachel wanted to be with Lyudmila during the services, which to me seemed to be one of her ways of showing independence. She still wasn't in a good mood, and I hoped going back to daycare would help, though I suspect it might take another few weeks until Abigail came home from Spain.

"You had your first day at the hospital yesterday, right?" Father Luke asked at lunch.

"Yes."

"I also heard from His Grace that you visited the man who murdered your friend in prison."

"I did. He was receptive to my visit, but he's locked into his Calvinist mindset and is convinced he's going to Hell."

"Just act in love, Michael."

I nodded, "I didn't take what might be considered his 'bait'. I'll see him again later this month to play chess. I did reach out to his daughter, who hasn't been to see him, but she hasn't returned my call. That could be because she elected not to, or because she's just starting her Residency in Kentucky."

"What's your goal?"

"To provide hope."

Father Luke nodded, and then moved on to speak to another parishioner, while I went to sit with Kris, Rachel, and the Korolyovs to have lunch. After lunch, Kris, Rachel, and I left the cathedral and walked out to the car for the drive home.

When we arrived, there was a message on the machine for Kris from Clarissa, and Kris returned it. I knew what it was about, and still wondered if what Clarissa intended was the right way forward, but I couldn't think of any real alternatives. I didn't know for sure how Kris would handle the revelation, but I hoped the 'privacy exception' would be sufficient to prevent serious problems between us.

Kris returned the call to Clarissa, and just over an hour later, Clarissa and Tessa arrived at the house. I wasn't surprised when Clarissa asked to speak to Kris privately, and they went into the study to talk.

"How do you think this will go?" Tessa asked quietly as we sat on the couch with Rachel playing with her dolls on the floor in front of us.

"Not as badly as if Kris somehow found out ten years from now, or whenever," I replied. "In the range of bad choices, this is the least bad. She's not going to mention you and me, is she?"

"No. I was adamant about that. It would serve no purpose except to create tension where none exists. Does Kris know about any of the other girls you were with?"

"Jocelyn and Tasha, because those two are, more or less, public. But she made it clear she didn't concern herself with what had happened before. And she doesn't see female friends as a risk the way Elizaveta did."

"Kris is very secure in who she is and views the world in a much broader way. Elizaveta was, and I mean no disrespect, very provincial where Kris is cosmopolitan."

"A very French way of putting it," I chuckled.

"But it's true, isn't it? Elizaveta was a very typical rural, religious person, whereas Kris is worldly, and mostly secular in her outlook, though also faithful. In other words, very much like you."

"I see the world through an Orthodox lens."

"Yes, you do, but how do you interact with the world? You're a scientist, not a monk. Think about your approach to miracles."

"I see your point," I replied, "but Elizaveta was growing in that regard, though she still had traditional conservative American values."

"And, as a deacon, that was what you needed. You need something different now."

"I don't disagree."

"Maybe Miss Cosmopolitan will allow you and Clarissa to conceive naturally!"

I laughed, "She's open-minded, but not that open-minded!"

"Just think," Tessa smirked, "It might take dozens of attempts!"

"Which actually wouldn't be as enjoyable for me as you might think, because I know how Clarissa feels about it."

"Weirdly, I believe you. Most guys would be happy to bang the hot lesbian!"

"Which is not how I feel about it. I banged you, but not Clarissa, if that makes sense."

"Of course it does. You and me was just casual sex, and purely physical. It was awesome, but it was just sex. That was not true between you and Clarissa."

"Exactly."

A few minutes later, Clarissa and Kris came out of the study.

"We're going to head home, Petrovich," Clarissa said calmly. "See you at the hospital for lunch tomorrow?"

"Sounds good."

I walked Clarissa and Tessa to the door, but couldn't discern anything from Clarissa, nor could I from Kris' demeanor when I returned to the living room.

"I never would have guessed," Kris said. "But it makes sense."

"Are you upset with me for not telling you?" I asked with a bit of trepidation.

"No. Clarissa pointed out that she swore you to absolute secrecy and it did fall under the exception I allowed for my 'nothing but the truth' rule. You look relieved."

"I am," I replied, after realizing I had been holding my breath. "I wasn't sure how you'd react. I thought you'd be OK, but I wasn't absolutely sure. You're OK with me spending time with Clarissa?"

"She made it clear that she could tolerate doing that with you to make a baby, but has no interest in doing it with anyone except Tessa. I trust both of you."

"Thank you."

"Was it your idea for her to tell me?" Kris asked. "Or hers?"

"Hers," I replied. "I wanted to tell you, but it was something I wasn't allowed to share."

"Which I understand. Given how she feels about you, I don't see how she could have done anything else."

"Is there anyone who would concern you?"

Kris smirked, "Besides the nurse that has had the hots for you for four years?"

I chuckled, "Ellie will just have to make do with her fantasies."

"Did you ever consider it?"

I shook my head, "No, for several reasons, the most important of which was she tried to entice me to cheat, and that, in and of itself, precluded even thinking about it. That was before I'd formulated my rule about relationships in the hospital, which really didn't matter except in terms of ethical behavior and patient care, because I was married to Elizaveta. Once she reposed, I made two firm rules -- I wouldn't date anyone who was on the same service and I would never even consider fooling around in the hospital."

"That happens a lot?"

"It does, unfortunately. And there are no rules against relationships, only against favorable or unfavorable treatment based on those relationships. The problem in my mind is that there is, in effect, no way to know unless someone makes a complaint. We all know about female students who use sex to gain advantage and male doctors who take advantage of female students, but it's difficult to prove. I would just ban any relationships where there was any supervisory or teaching relationship."

"It sounds as if you would prohibit relationships between students and doctors."

I nodded, "Completely. I don't see any way to allow that without opening the door to all sorts of potential ethical violations. Think about how easy it would be for a Resident to coerce sex from a student, given the doctor basically holds the student's medical career in their hands."

"Not quite as easy as playing a guitar," Kris smirked.

I laughed, "OK, but in that case, there is no ethical problem!"

"What will all those poor Code Blue groupies do now that José is married?"

"Cold showers," I chuckled. "Kim and Sticks get hit on, but not at the same level as José did."

"And you?"

"I was not lacking for attention," I replied.

Kris laughed softly, "Of that, I'm sure! Out of curiosity, was there anyone besides Ellie who wasn't a groupie who was persistent?"

"Erin Edwards," I replied. "She, too, was OK with cheating, which is, as I've said, an automatic lifetime ban, as it were. She did try to see me after Elizaveta reposed, but I was completely uninterested."

"Who is she?"

"The daughter of the President of the Hospital Board of Directors. I met her when she was a patient during my OB/GYN Clerkship. In those rotations, though, I couldn't touch patients, nor observe exams directly, if you get my meaning. She persistently hit on me despite me being married. The last time I saw her was about a year ago at Stirred Not Shaken."

"What is it with people willing to cheat?" Kris asked. "It makes no sense to me!"

"I agree. I mean, how could you ever trust someone who cheated with you? Well, I guess in Ellie's case, it's just sex, so that doesn't matter, but Erin strongly indicated she wanted a relationship, not just a roll in the hay. If I had to speculate, though, I'd say it's that the 'other woman' thinks she's so much better that she can hold on to the guy, but that's illogical."

"It makes sense you would see things through the eyes of logic, but attraction isn't based on reason, is it?"

"No. The heart wants what the heart wants," I replied.

"Or in their cases," Kris smirked, "the «minou» wants what the «minou» wants!"

"And you?"

"We could put Rachel down for her nap and you could find out!"

"Sounds great!"

July 3, 1989, McKinley, Ohio

"I hope you're happier after you see your friends in daycare," I said to Rachel as we walked into the hospital at 5:45am.

"Want Abby!" Rachel insisted.

"In about two weeks," I replied. "When she comes home from Spain."

"NOW!" Rachel demanded.

I suppressed a sigh because, as the quip went, the only difference between terrorists and toddlers was that you could actually negotiate with terrorists.

"Good morning, Rachel!" Marcie exclaimed when we walked into daycare. "We've missed you!"

Thankfully, Rachel gurgled happily as I handed her to Marcie.

"She's done with bottles," I said. "She's drinking exclusively from her sippy cup, and it has to be the purple one."

Marcie laughed, "OK. Is it in her bag?"

"Yes. Kris will pick her up around 5:30pm. I'm on until tomorrow evening."

"Ugh. Those shifts are terrible!"

"I do have a few hours off to play with my band at Milton Lake for the Fourth."

"But close to the end of the long shift, you're going to be beat!"

"I know. My goal is to catch a nap overnight, but there are no guarantees."

"We'll take good care of Miss Rachel!"

"Thanks."

I left my daycare and headed up to the surgical locker room to change, then reported to the ED for my shift.

"Morning, Mike!" Kylie said when she saw me in the corridor.

"Morning! How was overnight?"

"Sunday nights are usually quiet. Twelve hours down, twenty-four to go."

"Who's the Attending?"

"Doctor Taylor."

"Anything interesting on the board?"

"No. Sue Townsend, who's going off shift, just streeted her fender-bender. She's in the lounge."

"Thanks."

I went to the lounge and saw a short, stocky doctor with close-cropped brown hair.

"Sue Townsend?" I inquired. "Mike Loucks."

"Nice to meet you! Nothing to see here, so if you're set, I'm gone! I have a date with a bubble bath and a bed!"

"I'm set," I said. "Who are the students?"

"Bob Banks, Fourth, and Len Godwin, Third. They went to get breakfast."

"Thanks."

She left, and I went to the Attendings' office.

"Morning, Doc," I said to Doctor Taylor.

"Well, well, well, if it isn't Doctor Michael Loucks! How was your first shift?"

"Routine. I caught all fourteen walk-ins."

"You're on the regular rotation today, so you'll get a mix of cases. Check any procedures beyond the basics with me, please. I know you can do them, but we do need to follow protocol."

"Understood. OK to have Bob Banks do procedures he's had signed off in his book?"

"Yes. You can give Lawson a shot at the basics, too; he's competent."

"OK. I'll check in at the nurses' station and await my first case!"

"We're glad to have you here," Doctor Taylor said.

"Thanks."

I left the office, checked in with Ellie, and then went to the lounge. About five minutes later, two medical students walked in.

"Bob and Len?" I inquired. "I'm Doctor Mike Loucks."

"I'm Bob," a short, stocky guy with black hair said. "This is Len."

Len was tall and lanky and had blonde hair that was almost white.

"Nice to meet you both. Please call me Doctor Mike, I much prefer that. May I see your procedure books?"

They both handed them to me, and I flipped through them. Bob had done the usual procedures I'd expect a 'competent' Fourth Year to have done, while Len had far fewer, but that was no surprise, given this was his first clinical rotation.

"Have you decided on a specialty, Bob?" I asked as I handed back the books.

"Surgery," he said. "Doctor Roth said I should learn as much as possible from you."

"That should be true of every rotation with every doctor. And that means asking to do procedures, especially as a Fourth Year. I already cleared that with Doctor Taylor. You'll do as many as I can reasonably assign to you. Len, you'll have opportunities as well. Do either of you know how to read an EKG?"

"No," they both said.

"Len, during your Clerkship in cardiology, make sure you ask Doctor Strong to teach you. Bob, are you doing a Sub-I in cardiology?"

"Yes."

"Then do the same. I take it you know how to attach EKG leads?"

"Yes. I've done it."

"You should have written that into your procedure book," I said. "Next time, do so, and I'll sign off. Len?"

"I've seen several done, but haven't ever done it."

"Do you have a diagram in your notebook for the correct placement and lead colors?"

"No."

"Then the first time we do a twelve-lead, take notes, make a drawing, then study it. I'll expect you to know it by the end of the next shift."

"Got it."

"Doctor Loucks?" Nurse Jenny said. "EMS four minutes out with an MI."

"Doctor Mike, please. Which room?"

"Trauma 1 is open."

"Thanks. Meet us in the ambulance bay."

She left.

"Game time, gents. Bob, twelve lead EKG; Len, draw blood for CBC, Chem-20, and cardiac enzymes. Let's go!"

We left the lounge, put on gowns and gloves, and headed to the ambulance bay, where we waited with Jenny for the ambulance to arrive. I smiled when I saw the large white '2' emblazoned on the ambulance, and when it pulled up, Bobby hopped out.

"Hi, Doc! Jerome McArthur, sixty-eight; complained of severe chest pains while at breakfast; pulse tachy at 110, BP 90/60; diaphoretic; PO₂ 94 on five liters by mask; no history of heart trouble; no known medications."

"Trauma 1!"

Bobby and Jim unloaded the gurney, and the six of us began moving towards Trauma 1.

"Mr. McArthur, I'm Doctor Mike. Where is the pain?"

"Chest and left arm," he said, his words muffled by the oxygen mask.

"When did the pain start?"

"During breakfast, maybe thirty minutes ago."

We moved into the trauma room.

"On my count!" I said. "One, two, three!"

We all lifted the sheet and moved Mr. McArthur to the treatment table. Jenny switched the oxygen supply from the portable bottle to the hospital system, and Bobby and Jim left.

"We're going to get you on an EKG, draw some blood, and do an exam," I said to Mr. McArthur. "Do you smoke?"

"No," he replied as Bob cut open his shirt and undershirt to gain access.

"Drink?"

"Socially."

"Exercise?"

"No."

"Are you taking any medication?"

"No. Aspirin if I have a headache, but not today."

As Bob attached the EKG leads and Len drew blood, I performed an exam and on auscultation, I heard 'distant' heart sounds. I called out the vitals to Jenny, who scribed them on the chart. Bob turned on the EKG and I looked at the screen.

"No ST elevation," I said. "Len, call for a cardiology consult, then get that blood to the lab, stat, please."

"What does that mean?" Mr. McArthur asked.

"ST-Elevation is a sign of the most dangerous type of heart attack. You don't show any elevation in the S-T segment of your EKG, which measures electrical activity of your ventricles. What I do see is something called a low-amplitude QRS complex, which measures both electrical activity and contraction of your ventricles. To put it in layman's terms, your heart is struggling to beat."

"Why?"

"That's what a cardiologist will tell us. You aren't in any significant danger right now. How is the pain?"

"Stabbing."

"Jenny, 5 megs sublingual nitroglycerin, please."

"Right away, Doctor!" she exclaimed.

"Jenny is going to put a tablet of nitroglycerin under your tongue, which will help with the pain."

We continued to monitor Mr. McArthur until the cardiologist arrived.

"Well, well, well," Doctor Alana Pace chuckled as she came into the trauma room with a female Third Year. "Pace, Cardiology. What do we have, DOCTOR?"

"Jerome McArthur, sixty-eight; complained of severe chest pains while at breakfast; tachy at 110, BP 90/60; distant heart sounds on auscultation; weak distal pulse in both legs; diaphoretic; PO₂ 96 on five liters by canula; no previous history of heart trouble; no known medications. 5mg nitro sublingual. CBC, Chem-20, and cardiac enzymes ordered. EKG shows low-amplitude QRS complex, suggestive of pericardial effusion or infiltrative myocardial disease. Suggest transthoracic echocardiogram to confirm pericardial effusion."

"Good morning, Mr. McArthur," Doctor Pace said. "I'm Doctor Pace from cardiology. May I examine you?"

"Yes."

She repeated the exam I had done, then asked me to step out. I waved for Bob and Len to follow us into the corridor, as did Doctor Pace's student.

"How confident are you in your diagnosis?" she asked.

"Very," I replied. "He has the classic signs; the EKG and exams are consistent with pericardial effusion. We're waiting on blood tests, but I think the echo ought to be done right away."

"I agree. There's no need to wait for the blood test results. I'll take him, and we'll do the echo upstairs. Excellent diagnosis, Doctor!"

"Thanks."

"I see Cutter has you in red," she said.

"Does everyone know about that little battle?"

"I'd say so, given there was a heated debate at the Attendings' meeting that Doctor Getty told us about. He has no dog in the fight, so to speak, so he just sat back and ate popcorn."

"Of course!"

We went back into the trauma room.

"Mr. McArthur," Doctor Pace said, "Doctor Loucks and I agree you need to have an echocardiogram. That's an ultrasound of your heart and will help us confirm your diagnosis."

"Which is?"

"The most likely condition indicated by your symptoms is pericardial effusion, which is an accumulation of fluid around your heart. It's not technically a heart attack, but it could easily lead to one if not treated. Once we confirm, we'll most likely perform a pericardiocentesis, which means draining the fluid."

"What causes that?"

"Any number of things, and I can't really speculate until we do some tests. Once we confirm the fluid buildup, we'll look for the root cause."

"OK."

"Carol," Doctor Pace said to her student, "call for an orderly and bring Mr. Pace up. No need for an EKG during transport as he's not having an MI."

"Yes, Doctor," she replied.

Ten minutes later, Mr. McArthur was on his way up to Cardiology.

"You made a diagnosis straight from the EKG?" Len asked.

"A preliminary one," I replied. "But ultimately, what we found is secondary to the cause of the effusion. There are strong odds it's not a heart problem, so he might end up in Medicine once Doctor Pace performs the pericardiocentesis, assuming it's not some latent heart disease of which he was unaware."

"That happens?" Len asked.

I nodded, "Unless there are obvious symptoms, what happens today is the most common result -- a trip to the ED due to onset of chest pains. Most effusions aren't symptomatic, at least in a way that the person suffering from them would notice. And if they're due to viral infection, they usually clear themselves with no intervention. Did you make your drawing?"

"Yes."

"Good. Bob, I'll sign your procedure book."

He quickly wrote in the procedure and I signed off, then said, "Let's report to Doctor Taylor."

We went to the Attendings' office, and I let Doctor Taylor know that I'd sent the patient up to cardiology. He reviewed the chart, scribbled a note and his signature, and handed it back. I thanked him, returned the chart to the nurses' station, and Ellie directed me to the triage desk.

"Morning, Alex," I said to the Fourth Year manning the desk. "What do you have?"

"Take your pick! Nothing critical. Toddler with an apparent ear infection; FF with back pain; carpenter with an infected finger."

"I'll take toddlers with ear infections for $500, Alex," I grinned, hoping someone else would catch the Frequent Flier drug seeker.

"Good lord!" Nurse Lily groaned. "That joke!"

Alex handed me the chart, and I went to the door to the waiting room and opened it.

"Ms. Lopez and Arturo?" I called out.

"Us!" a very pretty Hispanic woman called out, standing up and walking over carrying a crying toddler of about three.

I escorted her and her son into the ED, checked the board, and took them to Exam 5, the larger of the two makeshift exam rooms.

"I'm Doctor Mike and these two men are medical students I'm training. What brought Arturo to us today?"

"He's been crying a lot and started pulling on his ear a couple of days ago. This morning, he complained about pain, so my husband suggested taking Arturo to his pediatrician. They couldn't see him until late this afternoon and he's miserable."

"Let's get Arturo on the table and we'll check him out."

I was reasonably certain what I'd find -- otitis media -- but obviously I had to do a complete exam.

"Has Arturo had an ear infection in the past?"

"No."

"Any recent injuries or illnesses?"

"No. He's pretty healthy, except for the usual scrapes a little boy gets playing."

"How is his appetite? Any changes in the past few days?"

"He eats a lot, but he burns it up playing fútbol at the park."

I was positive she meant what we usually called 'soccer'.

"OK to examine him?"

"Yes, of course!"

I turned to the fussy little boy sitting on the exam table, who eyed me warily.

"Hi, Arturo. I'm Doctor Mike and I'd like to listen to your heart and breathing, count your heartbeats, look in your eyes, ears, nose, and mouth, and take your temperature. Is that OK?"

"Mama?" he asked.

"He needs to check you, Arturo." Ms. Lopez said.

"OK," Arturo replied, sniffing with a tear running down his cheek.

I washed my hands, put on gloves, and began my exam by listening to Arturo's heart and lungs, explaining each thing I was doing. I used an otoscope to check his ears and nose, changing the speculum between each ear and each nasal cavity. I used my penlight to check his pupils, and combined with a tongue depressor his tonsils.

Arturo's left tympanic membrane was red and bulging, which was a strong indication of otitis media. I checked his tympanic temperature in his non-infected ear, and determined he had a fever of 38.1°C, or just over 100°F. His pulse was elevated, at 85 beats per minute, but he had no other symptoms.

"I believe Arturo does have an ear infection," I said to Ms. Lopez. "Generally, they resolve without treatment beyond Advil or Tylenol to help with the pain. You should give him over-the-counter children's pain killers and follow up with his pediatrician in two days if he's still complaining about pain."

"No medication?" she asked.

"Most ear infections resolve in less than a week without medical intervention. In addition, it could be from a virus, which would mean antibiotics won't help. Except for infants, the best option is Children's Tylenol or Advil, and allow the infection to run its course. Your pediatrician will decide if further treatment is necessary."

"I could have just waited, then, right?"

I nodded, "Yes, though we prefer you err on the side of caution. You should take his temperature every three hours, and if it reaches 102°F, bring him back right away. I can get you the medication now, but honestly, it'll cost ten times as much if I get it for you as if you stop at the drug store just down the road."

"OK."

"Let me fill out the paperwork, and we'll get you on your way."

Bob, Len, and I left the exam room and went to the nurses' station where I filled out the chart and the discharge form, then took everything to Doctor Taylor for his review and signature.

"Any pressure to prescribe antibiotics?" he asked.

"His mom asked, but seemed to accept my answer that they weren't necessary."

"She'll get them from his pediatrician," Doctor Taylor said, writing notes on the chart and signing it and the discharge form. "But not much we can do about that. OK to discharge."

"Thanks," I said as he handed me the clipboard.

We returned to the exam room, I reminded Ms. Lopez about taking Arturo to his pediatrician, then asked Arturo what kind of candy he liked.

"Skittles!" he said.

I pulled a pack from a fanny pack I had purchased to use in the ED when I wasn't wearing a medical coat, and handed them to him, making his eyes light up.

"Doctor Houdini?" Ms. Lopez asked.

"I have a dozen different things in my pack plus spares in my locker," I chuckled, then turned back to my patient and said, "Arturo, you only eat those when your mom says it's OK."

"Arturo, thank the doctor!" Ms. Lopez said.

"Thank you," he said.

"Ms. Lopez, you can see Patient Services on your way out. It's the office next to the door to the waiting room. They'll get your insurance information and make arrangements for billing them."

"Thank you, Doctor!"

We all left the exam room and Ms. Lopez and her son went to Patient Services.

"I thought antibiotics were routine for infections," Len said.

"They used to be," I replied. "But their efficacy with ear infections is iffy at best, and as I said, if it's viral, they won't do any good. Overuse of antibiotics is a major problem, which should have been covered in your pharma class."

"It was, but they didn't say anything about not prescribing for ear infections."

"OK. Just something to remember."

"Why did Doctor Taylor say her pediatrician would prescribe them?"

"Because it's easy for us here in the ED to say 'no', but pediatricians often give into parental pressure because it's the path of least resistance, not to mention the guidance on antibiotics for ear infections is relatively new."

We went to the lounge and less than a minute later, Nurse Ellie came to the door.

"Doctor Mike?" she called out. "Multi-victim MVA. Doctor Taylor wants you with him and Doctor Foulks."

"On it!" I said. "Bob, Len, let's go!"

We gowned and gloved and met Doctor Taylor in the ambulance bay where Doctor Foulks and his medical students, along with two nurses were waiting.

"Any idea how bad?" I asked Doctor Taylor.

"Two critical," Doctor Taylor said. "One in arrest."

Which meant that a firefighter would be assisting with CPR and the chances of survival were low.

"Nick," Doctor Taylor said to Doctor Foulks, "we'll take the arrest. You take the other one."

"OK," Doctor Foulks agreed.

A minute later the first EMS squad came to a stop in the ambulance bay and a paramedic jumped out.

"Male, fifty-ish; unrestrained driver; cardiac arrest as we prepped him for transport; continue CPR and bagging; obvious head, chest, and leg injuries. IV saline TKO."

"Trauma 3!" Doctor Taylor ordered. "How long was he down?"

"It's been at least twenty minutes," the paramedic replied.

The gurney was removed from the ambulance and a firefighter got on, straddling the patient, performing chest compressions while the paramedic bagged the patient. Doctor Taylor, Bob, Len, Nurse Kelly, and I all rushed the patient to Trauma 3.

"Mike, EKG and monitor! Bob, Foley! Kelly, hang a bag of plasma, draw for a blood gas, type, and crossmatch."

I grabbed the bandage scissors and quickly cut away the patient's shirt while Bob did the same with his jeans. I began attaching the leads which required a bit of contortion on my part so the fireman could continue with compressions.

"Hold compressions," Doctor Taylor commanded.

He quickly listened.

"No heart sounds," he said. "Continue compressions."

I turned on the EKG and quickly scanned it.

"PEA!" I declared. "Atropine and sodium bicarb, IV push."

"Do it, Kelly!" Doctor Taylor ordered. "Mike, he needs a chest tube. You're wearing red and have the 'S' on your badge, and we can't wait for a surgical consult."

That wasn't protocol, but it was technically within the rules, as I was a surgical intern and I was being supervised directly by an Attending.

"Len, chest tube tray!" I ordered.

He brought it to me, ripped it open, and I squirted Betadine onto the correct area.

"Atropine and bicarb are in!" Kelly called out.

"Cease compressions," I ordered.

Once the fireman stopped, I proceeded with the steps Doctor Rafiq had reluctantly taught me.

"Blood in the chest cavity!" I announced as blood came out of the tube.

"Heartbeat!" Bob called out. "Irregular, I think."

The firefighter climbed off the table and I looked over at the EKG and there was, indeed, indications that the patient's heart was beating. While I connected the ThoraSeal, Doctor Taylor auscultated and nodded.

"Faint heart sounds," he said. "Len find the on-call surgical Resident!"

The firefighter and the paramedics left, as CPR was no longer necessary.

"Thoracotomy?" I asked.

"If we can stabilize him," Doctor Taylor replied. "OK, heartbeat is weak but regular, let's intubate and do a full exam. Mike, tube him."

"OK to have Bob try it?" I asked.

"Once. First time or you do it."

"Kelly, intubation tray, please," I requested. "Bob, come stand by me."

"Are you sure, Doc?" he asked.

"I am, but if you aren't, stand aside, watch, and I'll do it and give you step-by-step instructions."

"Uhm, that's probably better."

"OK."

I intubated the patient and hooked the tube to the ventilator.

"Lindsay, surgery," Doctor Lindsay said, coming in with Jack Talbert, a Fourth Year.

It was odd for a Senior Resident to catch an early morning consult, but it happened from time to time. Most likely that meant her scheduled procedure had been canceled.

"Fifty-ish male; unrestrained MVA; arrested on site; CPR; PEA detected; revived with atropine and bicarb; pulse weak at 60; BP 80 palp; vent at eighteen with PO₂ 98%. Blood in the chest cavity; broken right tibia; severe contusion left temple; chest tube is in."

"Who did that?!" Doctor Lindsay asked, surprised.

"The surgical Resident!" Doctor Taylor said. "On my orders."

"Let me check that first, please. Hi, Mike."

"Hi, Doctor Lindsay. I followed Doctor Rafiq's technique."

She examined the tube, the ThoraSeal, and the sutures and nodded. "Looks good."

She did a quick exam and nodded, "We need to find the source of the blood, but he's unstable. Let's give him some pressers and blood and see if we can get his BP up. If not, he'll never survive me opening him up, and might not even make it upstairs."

"Kelly," Doctor Taylor said, "hang a unit; a meg of epi IV push, half a meg every five minutes."

"Yes, Doctor!" Nurse Kelly replied.

"Emergency thoracotomy?" I asked Doctor Lindsay.

"We don't have what we need here in the ED," she said. "You know the protocol."

I did, and when the new ED wing opened and I'd completed enough of my Residency, we would have emergency thoracotomy kits in the ED, but for now, we didn't, and couldn't, per hospital protocol.

The monitor blared, and I looked up.

"V-fib!" I said.

"Mike, charge to 150!" Doctor Taylor ordered.

I flipped the switches on the defibrillator, twisted the dial, then handed Doctor Taylor the paddles and squired gel on them.

"Charged!" I declared when the machine beeped.

"CLEAR!" he commanded.

I removed the vent connection and everyone stood back while he shocked the patient.

"No conversion!" I said once the EKG settled from the massive rush of electrical energy.

"Charge to 200!"

I did and Doctor Taylor shocked the patient again."

"No conversion," I said.

"250!"

I twisted the dial but before the machine beeped and the monitor tone went steady.

"Asystole!" I said.

"A meg of epi down the tube!" he ordered.

I grabbed the vial, as I was closest, drew the liquid into the syringe, then squirted it into the vent tube and reconnected the vent.

"Nothing," I said fifteen seconds later.

"There's no point in flogging him," Doctor Taylor said. "He's had three doses of epi, and another dose isn't going to make a difference. He was down for at least twenty minutes before he got here. Time of death, 08:13."

"I'll get the death kit," Kelly said.

I turned off the EKG and monitor, waved for Bob and Len, and we left the room.

"Why give up?" Len asked.

"At some point, you decide it's hopeless," I replied. "With a potentially severe head injury, internal bleeding, and having been down for thirty minutes, it was a near miracle we got any kind of heartbeat at all. You know the survival rate for CPR, right?"

"Under 20%," he replied.

"And that's for heart attacks. While it won't appear on Doctor McKnight's report this way, his cause of death was not wearing a seat belt."

"What a stupid way to die," Len said.

"I agree."

IX. Three In One Day

July 3, 1989, McKinley, Ohio

"Everything OK at home?" Clarissa asked as we sat down with our lunches in the cafeteria at a table away from most other people.

"Why wouldn't it be?"

"Nobody is that mellow!" Clarissa protested.

"Not only is she that mellow, we have permission to conceive naturally, if you want."

"NO WAY!" Clarissa gasped. "SERIOUSLY?!"

"No," I chuckled. "Of course not!"

"That was mean, Petrovich! Even for you!" Clarissa exclaimed, but I could see in her eyes she wasn't upset.

"How often do I have a 'gotcha' with you?"

"Not very! So she's all good?"

"She is. And as open-minded as my cosmopolitan French wife is, she's not open-minded enough to allow what I teased about. But she's fine with our agreement, and she's not reluctant or concerned."

"She has no idea how badly you want to sleep with me, does she?" Clarissa asked.

"Except I don't, for obvious reasons."

"OK, before you married! Both marriages, too!"

"And yet, it wasn't about sex, which, by the way, is what would concern her, not the act, in and of itself."

"So casual sex is OK?"

"No, of course not, but it wouldn't be casual with you, which both you and I know."

She nodded and then asked, "How was your morning?"

"Fairly typical for the ER, though I did get to put in a chest tube."

"You wheedled it out of the on call?"

"No. Doctor Taylor saw the red scrubs and the surgical 'S' on my badge and instructed me to do it because I was a surgical intern and was being supervised by an Attending, which is the letter of the law. There's a low-intensity war between Cutter and Northrup, and I believe Doctor Northrup lost the battle but might win the war."

"How so?"

"Cutter was so insistent that I'm a surgical intern that Northrup is taking him at his word. Obviously I can't do anything I haven't been trained to do, but I can do chest tubes and emergency pericardiocenteses, because I have been trained to do those. I'm sure that will lead to further internecine combat, but so long as I can stay out of the line of fire, they can fight all they want."

"Does he know about the tube?"

"I'm not sure if Doctor Pace will report it, or if he'll see it on a chart review a week from now, but one way or the other, it will get back to him. Heck, Northrup might tell him just to tweak him."

"You're enjoying the politics?! What's next? Human sacrifice, dogs and cats living together...mass hysteria?!"

"It's working to my advantage at the moment, and to Ellie's disadvantage!"

"How so?"

"My locker is in the surgical locker room!"

Clarissa laughed, "Poor Ellie, she'll have to get her thrills some other way than seeing 'Big Mike'!"

"She's never seen Big Mike!" I countered.

"Tell me she hasn't seen you in your briefs."

"Fine, but she's never seen Big Mike ready for action and she never will!"

"She'd redouble her efforts if she knew!"

"Twice nothing is still nothing," I replied. "How is your shift going?"

"A pair of interesting cases that have everyone stumped. I'm researching, but it would be so much easier if everything was computerized. Some stuff is, but not everything."

"I'll be happy with remote telemetry beds," I replied. "But your challenges are somewhat different from mine."

"I prefer the mental acuity tests to 'can I make the right decision in a split second to save a life'. I could do it if I had to, but you get off on it."

"I don't think I'd go quite that far," I chuckled. "But I certainly prefer the adrenaline rush of the ED to the mostly intellectual exercise of Internal Medicine."

"Including the walk-ins?"

"I have to come down off the adrenaline high at least occasionally!"

"Everything is pretty much exactly as we had hoped."

"Minus Kitten not being here to see it," I said.

"You suffered quite a bit to make it here, Mike, and sacrificed so much. I'm positive she's proud of you, and probably rolling her eyes at times."

"Of that you can be sure!"

We finished our lunches without interruption, which was something I wouldn't be able to count on for years to come. I walked Clarissa to the elevators, then headed back to the ED where Ellie asked me to catch some walk-ins. I found Len and Bob, then went to see Doctor Birch.

"Where are my toddlers?" I asked.

He laughed, "It does seem that way, doesn't it? They're in the lounge. Four students, all Second Years. No First years until August."

"That's something, I guess," I said with a wan smile.

Len, Bob and I went to the lounge and I introduced myself to the four students. I was tempted to call them by numbers -- one, two, three, and four -- but decided that was a bit too much hazing.

"Your task today is simply to observe," I said. "Take notes, ask questions between patents, and stand out of the way. Next week, there will be a quiz."

Three of the four groaned and I wanted to laugh, because as Second Years, they should have been ready for something like that.

I led my small entourage to the admit desk and asked Alex what he had.

"Puking five-year-old; sixteen-year-old with a rash that appears to be poison ivy; twenty-three-year-old construction worker with nail gun injury."

"Nail gun injury?"

"Right through his foot."

"That's going to be surgical, so I'll take him."

"Mr. Logan," Alex said, handing me the chart. "He's in the wheelchair. Vitals normal, only complaint is the nail in his foot."

"Thanks. Len, you push the wheelchair."

"Low man on the totem pole," he chuckled. "Got it."

"Bob, history and physical. I'll confirm, then we'll discuss the plan of action outside the room."

I looked up at the board and saw that Trauma 3 was open. Bob, Len, and I called for Mr. Logan, I introduced myself and my students, then Len and Bob took him to Trauma 3 while I went to the desk and asked for a nurse to join us. The four Second Years followed us and stood clustered in the corner of the room, and Alice, who Ellie assigned, followed me into the treatment room. Bob did a good job on the H & P, and I confirmed his exam.

"Could I get something for the pain?" he asked.

Because there was potential for surgery, the most I could offer was ibuprofen or acetaminophen, as any opiates would create potential interactions with a general anesthetic, should one be necessary.

"Alice, 600mg ibuprofen PO, please," I requested. "Then irrigate and paint with Betadyne."

"Right away, Doctor!" she said, making a note on the chart.

"Mr. Logan, I'll be right back," I said.

"Thanks, Doc."

We stepped out, and I asked Bob for his plan.

"Can you remove the nail?" He asked.

"Technically, I could, but I've never done it before, so I need either a senior surgical Resident or surgical Attending to supervise. What's your plan?"

"X-ray, then remove the nail, clean and irrigate, update tetanus, and a course of antibiotics. Ibuprofen or acetaminophen for pain."

"Any idea about the procedure to remove the nail?"

"No. I've never seen that done."

"OK. Len, call for a surgical consult, please."

Len went to the wall phone and made the call, and five minutes later, Doctor Rafiq arrived.

"Charles Logan, twenty-three, penetrating trauma to the left foot from a nail gun; irrigated and Betadyne applied; recommend x-ray, extraction, tetanus, and a course of antibiotics. If the x-ray shows significant bone involvement, then an ortho consult. I'd like to do the extraction."

"Have you done one?" Doctor Rafiq asked, sounding annoyed.

"No, but I know the technique -- lidocaine times four, clip the exposed portion of the nail distal from the point of extraction, remove with constant pressure, address any bleeding, apply topical antibiotics. No sutures unless surgical repair is necessary due to arterial or veinous damage."

Doctor Rafiq glared at me but nodded his assent.

"Len, call for a portable x-ray, please," I said, and the four of us went back into the room.

"Mr. Logan, this is Doctor Rafiq, a surgeon. We're going to x-ray your foot to confirm it's safe to extract the nail without surgery. Just relax as best you can and we'll get the nail out as soon as possible."

The x-ray tech arrived about five minutes later with the portable fluoroscope, which had a monitor that would give us a real-time image of Mr. Logan's foot. Doctor Rafiq and I examined the image.

"Soft tissue only," I observed. "The nail is in the dorsal interossei between the first and second left metatarsal with no bone involvement."

"I concur," Doctor Rafiq said.

"Lidocaine times four, clip the three centimeters that extend through the plantar, then extract dorsally."

"Proceed."

"Alice, lidocaine times four, please, and a procedure tray."

"Right away, Doctor!"

"Mr. Logan, I'm going to numb your foot with lidocaine. Have you had any problems with local anesthetics, including at the dentist?"

"No. I've had cavities filled and didn't have any trouble."

The procedure was straight forward -- I numbed his foot with lidocaine injected near the nail on both sides, then used 5¼ inch podiatric nail nippers to cut through the part of nail that was protruding from Mr. Logan's foot. Once that was completed, I grasped the upper end of the nail with 5½ Kellys, and slowly and carefully extracted it.

"Minimal bleeding," I observed. "How are you feeling, Mr. Logan?"

"OK. My foot is throbbing, but otherwise, not bad."

"Great. Alice is going to irrigate and dress your wound and give you a tetanus shot. Do you have any allergies to antibiotics or have you had a bad reaction?"

"No," he said, confirming what he'd told Bob during the H & P.

"OK. I'll be back in a few minutes with your discharge instructions."

"Thanks, Doc."

Doctor Rafiq left, and the Bob, Len, the Second Years and I went to the Attendings' office to see Doctor Taylor. I reviewed the injury and procedure, and recommendation for 500mg amoxicillin three times a day for seven days.

"Approved," Doctor Birch said, making a note on the chart and signing it. "Good job, Mike."

"Thanks," I replied.

"You'll need to stay off your foot for at least a week," I said. "Then follow-up with your regular physician. I'll fill out the necessary form for you to provide to your employer, and Patient Services will assist you with the Workman's Comp forms. Len, would you please call for an orderly with a wheelchair; Bob, get a set of crutches, please."

"Right away, Doctor!" Bob acknowledged.

"Will do," Len said.

"Mr. Logan, have you used crutches before?" I asked.

"Yeah, when I was sixteen, I broke my ankle."

I filled out a prescription form, the first one I'd personally written, and handed it to Mr. Logan.

"You can fill this at the hospital pharmacy or any other pharmacy of your choice. Make sure you take the antibiotics as prescribed and take them all, even if there are no signs of infection. For pain, you can use over-the-counter analgesics -- Tylenol and Advil are good choices, and whichever one works better is fine."

"What about Anacin? That's my usual go-to for pain."

"If that works for you, and it doesn't cause you stomach problems, that's fine. We tend to recommend ibuprofen or acetaminophen, which are the ingredients in Advil and Tylenol, respectively, as they have fewer side effects."

"Never had trouble with aspirin, and it's all I've ever used."

"OK. Len will stay with you until the orderly arrives, then escort you to patient services. Do you need to call someone to pick you up?"

"My foreman brought me in. He'll take me home."

"OK. Keep your foot dry until you see your personal physician, but come back if you run a fever over 101°F, or you see any discharge beyond a small amount of blood or clear fluid, or a rash or redness that is spreading, come back right away."

"Thanks, Doc."

"You're welcome, have a nice day."

"You, too."

I left the room, and a minute later, Bob returned with a set of crutches, which he took into the trauma room for Mr. Logan. He came back into the corridor a few seconds later.

"What was up with that surgeon?" he asked quietly. "He was giving you dirty looks the entire time."

"Doctor Rafiq is unhappy that I was allowed to do procedures as a Fourth Year that he wasn't allowed to do as a PGY1, and doesn't agree with Doctor Roth's training program for me. Fortunately, he's not my supervising Resident."

"Who would normally do the procedure you just did?"

"Historically, only a surgeon, but in the past year the policy changed such that after a surgical consult, the trauma specialist can do it. If there had been any bone involvement, we'd have needed an orthopedic surgeon, and they'd have taken Mr. Logan up to the OR. Long term, a trauma surgeon would make the call, and then take the patient up, and consult with an orthopedic surgeon on the extraction and repair."

"What if an artery of vein had been compromised?"

"It depends on the volume of blood, but many times it would require a surgical repair. That's not something I could even contemplate doing for four or five years, at least."

"How do you get your surgical training?"

"After two years in the ED, I'll handle all surgical consults during my shifts and assist with any emergency surgery. I'll have some scheduled procedures as well, as I have to be sufficiently versed in them to pass my surgical Boards. It works out to about eight or nine years, including a Fellowship. Let's catch another walk-in. Len can join us when he's finished with Mr. Logan."

We went to the triage desk and someone had taken the puking five-year-old, and two others had arrived, but neither was sufficiently urgent to jump the queue ahead of the sixteen-year-old girl with suspected exposure to poison ivy.

"Miss Munroe?" I called out.

A tall, athletic blonde who was standing, raised her hand.

"I'm Doctor Mike," I said. "I understand you believe you've come in contact with poison ivy?"

"Yeah, uhm, could I see a lady doctor? It's kind of in an embarrassing place."

"Let me see if someone is available," I said. "If not, do you want to wait?"

"Er, I guess it depends on how long."

"OK. Hang tight and I'll see."

Bob and I went back into the ED and I checked the board. Only Doctor Billings and Doctor Townsend were on shift, and they were in a trauma, so I walked over to Ellie to inquire.

"It's a bad one," she said. "Stabbing victim."

I contemplated offering to switch and take over for Doctor Townsend, a fellow PGY1, but Jill Munroe's situation wasn't serious enough to warrant interrupting a severe trauma. I began walking back to the waiting room.

"Patients are allowed to do that?" Joe, one of the Second Years asked.

I nodded, "Yes. For any reason, too. We, as physicians, cannot choose our patients, but patients can determine who provides their medical care, and yes, that includes for racist or sexist reasons, though in this case, I'd say modesty."

"I didn't see the chart, obviously, so where is the rash?"

"Her buttocks and upper thighs. I suspect you can work out how that might have happened."

"I'd hate to be the guy and have it where I suspect he'd have come in contact with poison ivy!" Len declared.

"I might need to ask you to swap with Leslie to limit the number of guys in the room. It's not about you, but about the patient. It's happened to me a few times."

"Understood."

"Let's see if our young woman will accept me as her doctor, or wants to wait. We'll need a female nurse if Miss Munroe does agree, and we'll probably end up calling for an OB/GYN consult."

"Jill Munroe? Like Charlie's Angels?"

"Never watched it. Which actress was that?"

"Farrah!" Ken, another of the Second Years declared. "Seriously? You don't know that?"

I chuckled, "I know about Farrah, but I never watched the show. My best guy friend had the poster of her in his room."

"Who didn't?"

"Me," I chuckled. "It didn't fit with the icons."

"Icons?"

"I'm Russian Orthodox. Anyway, let's see what she has to say."

I went back into the waiting room with Bob and over to where Miss Munroe was standing in obvious discomfort.

"Doctors Townsend and Billings, the two females on shift, are both in a trauma, and it might be some time before they can see you. You're free to wait if you like. If you'd be more comfortable, I can also have a female medical student assist me, instead of Bob."

"How long do you think?"

"I can't say, but the nurse said the trauma was bad."

"There are only two women doctors in the hospital?"

"Only two in trauma. I could call someone from OB/GYN, but you'd be in line behind any women in labor or needing pre-natal care, and that might take even longer. You could see your own OB/GYN or GP, if either of those is an option."

She contemplated for a moment, "I'll wait."

"OK."

Bob and I returned to the triage desk and I let Alex know.

"Want me to call OB and see if they have someone?"

"Probably a good idea, as we have no idea how long Doctor Billings and Doctor Townsend will be. I'll take the rule-out broken ankle."

He handed me the chart, and Bob and I went back to the waiting room. I first stopped to let Miss Munroe know that we'd called for an OB/GYN, but couldn't give her an ETA, then went over to Miss Lucy Knight, age nineteen, and sitting in a wheelchair.

"Hi," I said. "I'm Doctor Mike and this is Bob, a medical student I'm training, and some other students who are observing. What happened?"

"I missed a step and landed badly. I twisted my ankle. My mom thinks it's broken, but I think it's just a bad sprain."

"We'll do an exam and an x-ray and see what's up. Is this your mom?"

"Yes."

"Mrs. Knight, we'll take good care of her and someone will come let you know when we've finished our exam."

"Can I come back with her?" she asked.

"That's up to Lucy," I said.

"Sure," Miss Knight agreed.

"Bob, if you'll do the honors," I said. "Exam 3 is open."

Bob pushed the wheelchair, and we went to Exam 3 where I conducted the H & P.

"I need to get an x-ray of your ankle," I said. "Is there any chance you're pregnant?"

"What kind of question is that?" Mrs. Knight asked, sounding offended.

"A required one," I replied. "We want to limit exposure of a fetus to x-rays, and we ask that question to help us determine the correct diagnostic procedures and decide on which medications are OK. I meant no disrespect at all. Lucy?"

"No," she said. "No chance."

"OK."

I had Bob call for the portable x-ray, and twenty-five minutes later, after reviewing the fluoroscopy, I had Bob call for an orthopedic consult, as there was a hairline, non-displaced fracture of the ankle. I didn't think it needed to be set, nor did I think it needed surgical intervention, but all fractures required orthopedic review.

"Your mom was right," I said to Miss Knight. "But it's a hairline fracture, so I don't think you'll need anything more than a cast, but I'm going to have a specialist from Orthopedics verify my diagnosis."

"How long will I have to wear a cast?" she asked.

"Let's wait for the orthopedist before we say anything definitive."

"Are you a new doctor?" Miss Knight asked.

"I finished my formal training about a month ago," I replied. "But I've been performing exams and doing procedures for over two years."

"Is that why you're wearing red and everyone else is wearing blue?"

"No, the red scrubs are because I'm a surgical Intern, but I'm assigned to the Emergency Department as a trauma specialist."

"That seems strange."

"My specialty is trauma surgery, which is a combination of emergency medicine and surgery, so I've trained in both areas, and my training will continue for another eight or nine years."

"I thought you said you finished your training!"

"I graduated from medical school a month ago, so now I'm a Resident instead of a Trainee Doctor," I said, using the lay term. "That means I'm properly trained, but need experience before I'm Board certified and could practice completely on my own, rather than be supervised by a senior doctor called an Attending."

"But he's not here," she replied.

"Supervision means I report to him or her, confirm my diagnoses, and then receive approval to perform any procedures that haven't been signed-off, which means I know how to do them and have demonstrated that to their satisfaction. To set your mind at ease, I've been doing basic exams for over two years, and I'm fully trained in everything I might need to do to help you."

"So why call the other doctor?"

"Because broken bones aren't my specialty," I replied. "If you were having a heart attack, I'd treat you but still call for a cardiologist -- a heart doctor -- to confirm my diagnosis and to continue your treatment after you left the Emergency Department. If you were having a baby, I'd call for an OB for the same reason. I'm sure you see an OB/GYN in addition to your regular physician, right?"

"Yes."

"For the same reason," I replied. "Your GP could do the exams, but he or she doesn't have the extensive training in gynecological concerns that an OB/GYN has. Trauma specialists, and trauma surgeons, which is what I am, focus on treating emergency cases, which means diagnosing and stabilizing a patient before we hand them off to another specialist. In your case, you won't need to be admitted, so I'll complete your treatment with help from a nurse once the orthopedist confirms my diagnosis."

"Are you married?" she asked.

"Yes, and I have a daughter who's almost two."

"Jackson, Orthopedics," Doctor Valerie Jackson announced as she came in with a medical student in tow.

"Doctor Mike Loucks," I said. "Lucy Knight, nineteen; vitals normal; complained of ankle pain after a missed step on a staircase. Exam shows swelling and tenderness, but no ecchymosis. Negative exam for Maisonneuve fracture. Fluoroscope shows a non-displaced hairline fracture right posterior malleolus."

"Let me take a look," Doctor Jackson said.

She reviewed the image, then examined Miss Knight's ankle.

"Confirmed," she announced. "I recommend an orthopedic boot and normal ankle protocol."

"Thank you, Doctor," I said.

"Val, please. We're both PGY1s!"

I nodded and she and her student left.

"You're in luck," I said. "No cast, just an orthopedic boot. It fits snuggly and has Velcro closures. You'll be able to take it off to bathe, but you shouldn't put any weight on your ankle. You'll need to follow up with Doctor Jackson in two weeks to ensure the break is healing properly, and she'll decide exactly how long you'll need to stay off your ankle."

"How long could it be?" Miss Knight asked.

"That depends on a number of factors, but the norm for this type of fracture is six to ten weeks. Have you used crutches before?"

"No."

"I'll have the nurse who fits your boot show you how to use them. Let me get everything in motion and I'll come back and see you in a few minutes. What size shoe do you wear?"

"Six."

"OK. Bob, I'll write the order and you'll need to go up to Orthopedics and get a size-six boot, please. Just ask the duty nurse. Then get a set of crutches."

"Will do."

I wrote out the order on a prescription pad and handed it to Bob, then made notes on the chart.

"Be right back," I said to Miss Knight.

"Thanks, Doctor."

"You're welcome."

I stepped out and went to see Doctor Taylor, who reviewed the chart, made his notes, and signed it.

"No pain meds?" he asked, handing me the chart.

"I'd prefer to avoid any opiates if at all possible. I'll recommend ice and ibuprofen or acetaminophen, and have her come back if the pain is severe."

"You're concerned about addiction?"

"Very. I'm not about to deny pain meds to someone who needs them, but I'd prefer to take a staged approach. That's my personal preference, but if you tell me to prescribe something stronger, I won't fight you."

"No, I don't disagree with you. We see too many drug seekers as it is. No need to create more, especially a teenager."

I left his office and went to the nurses' station and asked Ellie for a nurse, and she assigned Jamie, the male nurse. He accompanied me back to the treatment room, and I introduced him to Miss Knight and her mom.

"Jamie will show you how to put on the boot and use the crutches," I said. "You should elevate your ankle as much as possible, and ice it for twenty-minutes at a time, with twenty minutes between applications. I'm writing you a prescription for 600mg ibuprofen, which you should take every eight hours for the next week, then as needed. That will help with the pain and swelling. No weight on that ankle before you see Doctor Jackson in two weeks, and then follow her instructions. Any questions for me?"

"No."

I wrote out the prescription and gave it to her along with the discharge instructions, and then left Jamie to complete her care.

"Mike?" Ellie called out. "Are you free?"

"Yes," I replied. "Jamie will finish up."

"Paramedics are three minutes out with a construction injury. Doctor Taylor needs you in the ambulance bay."

"Let Bob and Len know where to find me," I said.

"OK," she acknowledged.

I put on a gown and gloves, called the Second Years follow me, and hurried to the ambulance bay where I found Doctor Taylor, Nurse Kelly, and Naveen Varma, a fellow PGY1.

"Any idea what's coming in?" I asked.

"Multiple penetrating trauma," he said. "That's all I know."

"Surgical consult?" I asked. "That's way beyond my training and current skill set."

"Already called. You intubate, please. Naveen, EKG and monitor. Kelly, hang two units, then a complete trauma panel; type and cross match."

We both acknowledged his orders and two minutes later, Bobby jumped out of the cab of his rig.

"Bad one, Docs!" he called out. "Jack Nelson, thirty-three; fell from scaffolding on to rebar. Thirty minute rescue requiring saws; significant penetrating trauma to chest and abdomen; BP 90 palp; pulse 120 and thready; resps labored; PO₂ 94 on ten liters; IV saline TKO; morphine x2; GCS 8."

My eyes went wide when they pulled the gurney from the back of the right as I saw three rods of green rebar sticking out of the patient's torso. From their position, I was positive he had at least one compromised lung, and probably severe internal abdominal injuries.

"Trauma 1" Doctor Taylor ordered.

We moved quickly to Trauma 1 and carefully moved Mr. Nelson to the treatment table just as Doctor Roth arrived.

"As soon as he's stable, we'll take him up," Doctor Roth said, then went to the phone.

As Mr. Nelson was unconscious, I dispensed with the intubation drugs and quickly inserted the endotracheal tube and connected the vent, setting it on low pressure.

"Right lung sounds only," I said.

"Left one is penetrated," Doctor Taylor said.

"V-Tach!" Naveen announced, to nobody's surprise.

"What do you want to do, Owen?" Doctor Taylor asked Doctor Roth.

"I can't do anything here, and a chest tube is like a fart in a hurricane at this point. Let's get him upstairs. OK to take Mike with me?"

"He's your Intern!" Doctor Taylor replied. "As was made clear."

"Forget the BS politics and leave that to the Chiefs. Mike, bring Mr. Nelson up."

I acknowledged him, then quickly hooked up the portable EKG and portable vent. Fortunately, Len came in just at that minute.

"Help me with the gurney," I said to him. "We're going to OR..."

"Three," Doctor Roth confirmed. "See you upstairs."

He took off at a trot, because he'd need to scrub in while Len and I fetched a gurney, and then everyone in the trauma room helped move Mr. Nelson to it. I instructed my Second Years to shadow Doctor Taylor, then moved out of the room.

"Ellie," I called out as we rolled by, "I'll be in OR 3 with Doctor Roth," I said. "Have Bob work with Doctor Varma, please."

"I'll tell them," Nurse Ellie confirmed.

"You're doing surgery?" Len asked as we quickly moved towards the elevators.

"Doctor Roth is, but he asked for me to bring up Mr. Nelson up, so I suspect he'll have us scrub in because this is exactly the kind of case I'm training for."

"Is he going to make it?"

"HOLD THAT ELEVATOR!" I called out.

The staff who were about to get into the elevator cleared out of the way, and Len and I pushed the gurney into the waiting elevator. He hit the button for the surgical floor and the doors closed.

"Whether he makes it will be up to God and Doctor Roth," I said. "He has at least one compromised lung, and multiple internal abdominal injuries. I'm not sure what will be first -- fixing the lung or an ex-lap to see just how bad things are."

"No x-ray?"

"They'll use the surgical fluoroscope to get an idea, but only an ex-lap will reveal the extent. And they'll need to open him up to repair what they can. This one bar is in a position that might have compromised his liver, and if that's the case..."

"He won't make it."

"Let's just say it'll take more than extreme surgical skills. If you're a praying man, now would be a good time."

"Do you pray for your patients?"

"Silently for every one of them."

The elevator doors opened, and we rushed Mr. Nelson to OR 3, where Nurse Penny and Doctor Lindsay were waiting.

"Doctor Roth wants you to scrub in," Doctor Lindsay said as we carefully transferred Mr. Nelson to the surgical table.

"What about my student?" I asked. "He's Third Year."

"First rotation and never scrubbed in?"

"Correct."

"Send him back to the ED; we don't have time to sort out sizes and teach him to scrub."

"Sorry, Len," I said. "Go back and see Doctor Varma."

"OK," he replied.

He left, and I went to the scrub room where Doctor Roth was finishing up. I realized I needed a surgical cap, so I stepped through into the locker room and retrieved one of mine from my locker, then Nurse Jackie helped me scrub and gown. Once I was finished with the scrub procedure, I went into the OR where Doctor Roth was discussing anesthesia with Doctor Vandermeer.

"Mike," Doctor Roth asked when they finished the discussion, "how are your arm muscles?"

"I lift free weights as part of my exercise routine."

"OK, you're going to extract each piece of rebar once I view the scope. Smooth, straight motions, and then hand it to Jim, the Third Year who's standing by the door. Once that's done, I'll have you put in a chest tube while I begin the ex-lap with Shelly."

"With a through-and-through penetration, that's not going to re-inflate the lung," I said.

"No, but we'll need it and it's something you can do while we see if we can get the abdominal bleeding under control. I'll talk you through what to do after that."

"OK."

"What do we have?" Doctor Cutter asked, coming in.

Doctor Roth looked at me and I gave the report.

"Thanks, Mike," he said when I finished. "OK, Owen, what's your plan?"

"Shelly and I are going to see if we can stop the abdominal bleeding after we remove the rebar. For the lung, I asked Mike to put in a chest tube, and we'll decide from there what approach."

"Let me take the chest while you take the gut," he said.

"Still want the chest tube?" I asked.

"Yes," Doctor Cutter said. "He'll also need drains, which are similar, and we can teach you that, too. Interesting style choice on the cap."

I'd chosen solid black surgical caps, which had a pocket for my pony tail.

"The good guys wear black in my church," I replied.

"You wore colored cassocks here."

"That's permitted, but black is traditional."

"He's ready," Doctor Vandermeer said. "But I don't like his BP or his tachycardia."

"Let's see what we can do about that," Doctor Roth said.

A masked medical student I didn't recognize wheeled the fluoroscope over and positioned it. Doctor Roth looked intently at the screen.

"OK. Lung is compromised, but ribs are all intact, and the rod is a full six centimeters from his heart. Mike, extract the rod, please."

I stepped over, grasped the rebar with both hands and pulled slowly, trying to keep the metal rod at exactly the same angle as it had penetrated Mr. Nelson's chest and once it was clear, handed it to Jim.

"Some blood," Doctor Cutter observed. "But we'll manage it."

The student repositioned the scope to Mr. Nelson's abdomen as Doctor Roth directed.

"I do not like the looks of this," Doctor Roth said. "What do you think, Shelly?"

"His liver is compromised," she said. "And there is free fluid, suggesting injury to the hepatic portal vein. Let's check the other rod, because he might well bleed out if we pull this one."

"Agreed."

The scope was repositioned to view the third rod and Doctor Roth shook his head.

"His stomach is compromised and at least a partial resection will likely be necessary. We're going to be tied up for at least six hours, if not more. Penny, push our afternoon surgeries, please."

"I'd suggest we can remove this bar," Doctor Lindsay said. "And then do the laparotomy so we have access to the portal vein when we pull the rod."

"I'd say that's the best option," Doctor Roth said. "John?"

"I don't have any better options for you," Doctor Cutter said.

"OK," Doctor Roth said. "Mike, remove the second bar, same as the first."

I nodded and moved into position and once again slowly and carefully extracted the rebar, handing it to Jim.

"Moderate amount blood," Doctor Lindsay observed. "The liver injury is still primary."

"OK," Doctor Roth agreed. "Mike, we're going to do this fast. We'll get him open, I'll signal you, and you get that bar out and get out of the way. Once that's done, you put in the tube then assist Doctor Cutter."

"Yes, Doctor," I said.

"Ten blade," Doctor Roth said to Nurse Penny. "Shelly, stand by with suction. And Kelly, I'll need the needle driver as soon as the rod is out."

Nurse Kelly handed him the instrument and Doctor Lindsay picked up the suction.

"Everyone ready?"

"Move fast, Owen," Doctor Vandermeer said. "He's in bad shape."

"Tell me something I don't know!" Doctor Roth snapped, then said, "Sorry. OK. Here we go!"

He quickly made the necessary incisions and there was a LOT of blood.

"Penny, hang two units on the rapid infuser!" Doctor Roth barked. "Mike, go!"

I stepped up and grasped the rebar and pulled it out, quickly stepping back.

"Suction!" Doctor Roth ordered.

"Mike, chest tube, please," Doctor Cutter ordered as he used the fluoroscope to evaluate his next move.

"Chest tube tray to me, please!" I requested.

Nurse Amy brought it to me and I set to work.

"BP is bottoming out," Doctor Vandermeer announced.

"I'm working as fast as I can," Doctor Roth said. "Penny, hang a third unit."

"V-Fib!" Doctor Vandermeer announced.

"Paddles to Mike at 200!" Doctor Roth commanded. "Jim, pads!"

Jim put the pads on as Amy handed me the paddles, then squirted gel onto them.

"Charged!" Amy declared.

"CLEAR!" I commanded.

Doctor Vandermeer disconnected the vent, and I put the paddles on the pads and triggered the shock.

"No conversion!" Doctor Vandermeer declared.

"250!" I requested.

"Charged!" Amy declared a moment later.

"CLEAR!"

I shocked him again.

"No conversion," Doctor Vandermeer called out. "BP is unmeasurable. No pulse."

"He's lost too much blood," Doctor Cutter said. "We're not getting him back."

"Asystole," Doctor Vandermeer announced.

"Call it, Owen," Doctor Cutter said.

"God damn it!" Doctor Roth swore. "Time of death 14:49."

What had been a frantic, noisy OR was suddenly quiet as machines were turned off and people filed out of the room to the locker room.

"May I ask why you're so upset?" I asked Doctor Roth as everyone stripped off their scrubs.

"Third one of the day," he growled. "The first one had an embolism; the second had a fatal MI."

"It's just one of those days, Owen," Doctor Cutter said. "You have nothing scheduled for the rest of the day, so go home, relax, and tomorrow is a new day."

"OK to return to the ED?" I asked Doctor Cutter.

"Yes. We'll try to bring you up on traumas such as this, but it won't be every time because we can't leave the ED short-staffed."

"Thanks, Doctor Cutter."

I put on clean red scrubs, elected to begin wearing my surgical cap regularly, then headed back to the ED.

X. Call On Line 3

July 3, 1989, McKinley, Ohio

"Hi!" I said to Kris when she and Rachel came to the Emergency Department just before 5:30pm. "How are my girls?"

"She seems a lot happier than she was this morning," Kris said. "Marcie said she had fun playing with her friends."

"Want to come to Daddy?" I asked Rachel.

"NO!"

"What have you done now, Doctor Mike?" Nurse Wendy asked, laughing.

"I am sure the list of my failures as a dad is long and growing," I chuckled. "And once Rachel is able to articulate them, I'm positive I'll be given detailed instructions for improvement!"

Wendy laughed, "That sounds just like my fourteen-year-old son who never misses a chance to explain just how clueless and out of touch I am!"

"Mike, do you have time for dinner?" Kris asked.

"Let me check with Doctor Taylor," I said.

I quickly checked with him and was cleared for my thirty-minute dinner break, that, as with always the case in the ED, I could be paged if I was needed. I signed out, let Kristy know I'd be on break, let Len and Bob know, then accompanied my wife and daughter to the cafeteria.

"How has your day been so far?" she asked as we got into line to get our food.

"Busy and mostly good. We did lose one patient, but in all honesty, he was lucky to be alive when the paramedics got him to us. He fell off scaffolding onto reinforcing bars. Those are the green metal rods they use to make poured cement stronger. The fire department had to cut him from them, and he had three of them lodged in his body when they got him here. His internal injuries were too severe to survive."

"Wow! Does that happen often?"

"Usually construction injuries are things like stepping on a nail, cuts, or broken limbs. This was a first for me."

"What else?"

"A broken ankle, an injury from a nail gun, a broken wrist, and two rule-out MIs, that is, heart attacks. I did miss treating the sixteen-year-old female with poison ivy on her buttocks, upper thighs, and inner thighs."

"Not careful enough making love in the woods?"

"That's my guess," I said. "She requested a female doctor, which I totally understand. Doctor Carmichael came down from OB to treat her. I just wonder about her paramour!"

Kris laughed softly, "I bet that's even MORE uncomfortable!"

"Imagine explaining that to your parents as a teenager!"

Kris laughed again, "Even more uncomfortable!"

"My mom would have laughed," I said. "And would have had no sympathy for the discomfort caused by sinful behavior!"

"God works in mysterious ways?" Kris asked lightly.

"Could be," I chuckled.

I paid for our meals, though mine was subsidized, and we found an empty table. I put down the trays and retrieved a wooden high chair for Rachel, and Kris put her in it. I said the blessing, and we began to eat with Rachel, happily munching on a dinner roll.

"Do you think you'll be able to get any sleep tonight?"

"I'll try, but there are only three of us on overnight, so if it's at all busy, Naveen and I will be up all night and only Doctor Mastriano will get any sleep."

"Is that doctor Italian?"

"Yes, though she went to medical school and served her Residency in the US. How was your day today?"

"Good. My one and only math class, but it should be easy. When I arrived home, there was a message on the machine from the attorney who's helping Angie, Tom Kirkland. He'd like you to call him when you have a chance. He left both his work and home numbers."

"I'll see if I can find time tomorrow morning, otherwise it will have to be Wednesday."

"What time do you want me to have your music and instruments at the lake tomorrow?"

"I'll leave here around noon," I said. "So around then would be good. Just bring them to the band shell."

"My parents and Lyudmila will come with me."

"Great!"

"«Tante»!" Rachel exclaimed.

"My daughter is being corrupted by French women!" I groused good-naturedly.

"It could be worse," Kris replied.

"I'm not sure how," I chuckled. "She's three quarters Russian and a quarter Dutch! That's a dangerous mix!"

"You're half and half!"

"As I said!" I chuckled.

We finished our meal, and I had time to walk Rachel and Kris to the car. I got Rachel settled in her car seat, then kissed her forehead.

"Dada home?" she asked.

"No, Daddy can't come home," I replied. "Daddy has to help sick people. I'll see you tomorrow."

Rachel pouted, but there wasn't much I could do about it. I hugged Kris, we exchanged a quick kiss, and she got into the car. Once she'd driven off, I headed back to the ED. Bob and Len had gone off their shift, and Mary Anderson and Tom Lawson had replaced them.

"Doctor Loucks?" a short blonde with long, braided hair asked as I walked into the lounge.

Next to her was a lanky guy about my height with short brown hair.

"Doctor Mike, please. You must be Mary and Tom. May I see your procedure books, please?"

They handed them over, and I quickly flipped through them. Tom, being a Third Year on his first rotation, didn't have many procedures in his book, but Mary had the usual number for a Fourth Year. Both had EKG diagrams at the end of their notebooks, and I wondered if word had been passed somehow.

"We're catching walk-ins overnight," I said. "So, Mary, you'll be at the triage desk with a nurse. Tom, you'll stay with me and help with histories and physicals."

"Should I go now?" Mary asked.

"Yes. You relieve Alex, who goes off shift in about five minutes. Make sure you go over everyone who's waiting. We'll take a patient in a few minutes."

She left the lounge, and I used the restroom, then Tom and I went to the triage desk.

"What have you got for me?" I asked Mary, who was sitting with Nurse Margie, a brand new nurse who had graduated from nursing school at the end of May.

"Dad versus carving knife, carving knife wins; toddler with croup; and the ever popular 'back pain and I lost my pills'."

"FF?" I asked.

"Three visits in six months; prescribed drugs each time."

"Assessment?"

"I don't have one; Alex did the exam. There is no red dot on the most recent chart."

"I'll take the kitchen injury," I said. "Tom needs suturing practice. I'll come back for the toddler. The drug seeker gets to wait."

"OK," she said, handing me a chart.

"Al Crowe; forty-two; vitals normal; bleeding from injury to left index finger; missing about 2mm of the distal tip."

"Oops," I said.

"Yeah. His kids are a bit freaked out by the blood."

"The family of four over there?" I asked.

"Yes."

I accepted the chart, went to the door and called out, "Mr. Crowe?"

"That's me," he said, standing up.

"I'm Doctor Mike. If you'll come with me, we'll get you fixed up."

He kissed his wife and left her with two boys I guessed were around ten and twelve, and Tom and I escorted him to Exam 1.

"Tom is a medical student doing his clinical rotations," I said. "He's going to perform the exam under my direct supervision, if that's OK with you."

"A student?" Mr. Crowe asked.

"We're a teaching hospital and that's how we train doctors. He's had six years of classroom work, and now is being trained by doctors. I'll be right here the whole time."

"OK."

"H & P, Tom, please."

"What brings you to the hospital today?" Tom asked Mr. Crowe.

"I thought that was pretty obvious!" Mr. Crowe said, holding up his left hand.

"Yes, Sir, but we always ask," Tom said. "What happened?"

"I was slicing a roast and not being careful. I sliced off the tip of my index finger."

"Did you save the fingertip?" Tom asked.

"Didn't even think of that," Mr. Crowe said. "Is that a problem?"

"Most likely not," I interjected. "We generally can't reattach a small piece of tissue. Go ahead, Tom."

He did a competent job of taking the patient's history, including asking about a tetanus shot, which the patient hadn't had in five years. After washing his hands and putting on gloves, Tom performed the auscultation, reporting what he heard, with everything being normal.

"How do you want to proceed?" I asked Tom.

"Irrigate the wound, sterile dressing, elevate, ibuprofen for pain, update his tetanus."

"Proceed," I said to Tom.

"Mr. Crowe," Tom said, "I'm going to examine your finger, rinse it with sterile saline, then apply a gauze dressing. We'll have you keep your hand elevated and wait for the bleeding to stop. Once it does, we'll give you a tetanus booster, and get you on your way. You can take Advil or Tylenol for any pain. Is it OK to examine your finger?"

"That's why I'm here!" he said.

"We always ask permission before touching a patient if they're conscious," I said.

Tom irrigated the wound with saline, then examined it. I looked over his shoulder, and as I had suspected, there would have been no way to reattach the missing tissue, and the wound would heal with only minimal scarring. Tom applied a sterile dressing, then had Mr. Crowe put his hand on the opposite shoulder to elevate it above his heart.

"Mr. Crowe, I need to get the tetanus booster," I said. "I'll be right back."

"Don't nurses do that kind of thing?" he asked.

I nodded, "They do, but it seems silly to bother a nurse who is busy when I have keys to the drug room."

I left the room, went to the drug room, used my key to get in, then went to the refrigerator to get the tetanus booster. I recorded that I'd taken it on the clipboard on the fridge, then returned to Exam 1. I handed Tom the pre-filled syringe, he shook it, opened the package, and after cleaning Mr. Crowe's arm with the included alcohol wipe, administered the injection.

"We're done," I said to Mr. Crowe. "I would like you to stay for twenty minutes so we can ensure the bleeding has stopped. Just keep your hand on your shoulder and we'll come back in about fifteen to twenty minutes to check on you."

"Thanks, Doc! Your student seems to know his stuff."

"Thank you," I said.

Tom and I left the room and walked towards the Attendings' office.

"Not to be impertinent, but aren't you supposed to clear all procedures with the Attending?"

"Every Resident has a set of guidelines as to what they can do without expressly asking, and what we just did falls completely within my list of authorized procedures."

"So the rumors are true that you receive special treatment?"

"I receive treatment commensurate with my demonstrated abilities and skills. That will happen with you, too. Once I'm satisfied you are able to suture, you'll do minor repairs without me standing over your shoulder. Yes, I'll check your work when you finish, but you'll do it without direct supervision. Have you decided on a specialty?"

"No. I want to wait to complete my Clerkships before I decide."

"You'll need to do that a bit sooner than that," I replied. "You'll need to set your Sub-Internship schedule in the Spring. But you still have time to think about it."

"Any advice?"

"Figure out what motivates you and do that," I replied. "It's what will get you through the thirty-six-hour shifts, among other things."

"You're on one of those now, right?"

"Yes. Just over a third of the way through, and there's little chance I'll get to sleep much before 7:00pm tomorrow. I will be ducking out for about four hours to play a gig at Milton Lake, and Kylie Baxter will cover for me."

"She's on until midnight, though, right?"

"Yes. But we have an arrangement that started when we were medical students."

We reached the Attendings' office, and I had Tom report to Doctor Mastriano and have her sign the chart.

"Come see me when you have a chance," Doctor Mastriano said.

"Tom, I'll catch up with you in a few minutes at the triage desk."

"OK," he said and left.

"What's up?" I asked.

"Overnight, do not wake me unless a patient is dying. You can handle anything that comes in either yourself or with a consult."

"I'm not signed off on every procedure," I said.

"Use your best judgment," she said. "I need to get some sleep. I'll sign your charts in the morning before I go off shift at 0700."

"OK," I agreed, deciding I wouldn't win an argument and knowing that I could never get in serious trouble for waking her up, no matter what she might have said.

I left her office and went to the triage desk.

"Anything new?" I asked Mary.

"Eighteen-year-old female reporting that 'it burns when I pee'. Vitals normal but with a slight fever at 38.1°C. Twenty-two-year-old with a forehead lac from, you'll love this, trying to crush a beer can on his forehead. Vitals normal, but has a headache, as you can imagine."

"An interesting variation on 'hold my beer and watch this'," I chuckled. "Let me take the bawling toddler and give the others a break."

Mary handed me the chart, and Tom and I went to the door of the waiting room.

"I'll do this one," I said.

"Your reputation as 'Kid Whisperer' precedes you," Tom said.

"Yes, but also Mom looks harried, so I don't want to do anything to make her stress worse. No reflection on you, just on the circumstances."

"Got it."

I opened the door and called out, "Ms. Travis and Benny?"

The woman who appeared to be about twenty stood up and carried her crying two-year-old over to us.

"Hi," I said. "I'm Doctor Mike and this is my student Tom, who'll observe as part of his training."

"OK," she said.

We went to Exam 2, and I went to the sink to wash my hands.

"What seems to be Benny's problem?" I asked, as I rinsed the soap from my hands.

"He won't stop crying and I'm basically at my wit's end," she said.

That was an indication we'd need a social worker, as a mom in that condition was considered a risk. It was a judgment call, and one I'd make once I'd completed the exam and learned more about the situation.

"Has anything changed with his health recently? Or at home?"

"Not that I can think of," Ms. Travis said.

I dried my hands and put on gloves and went over to the exam table where Benny was lying down, still crying.

"Hi, Benny," I said. "I'm Mike. Does anything hurt?"

He didn't answer or stop crying, which meant I'd have to detect any potential pain via exam, which was an inexact science.

"OK to examine Benny?" I asked.

"Yes, of course," Ms. Travis said.

I did my best to listen to his heart and lungs, though the crying made that difficult. I didn't hear any crackles in his lungs, but I couldn't tell much about his heart. I draped my stethoscope around my neck and removed the otoscope from the holder, put on a fresh speculum and looked into Benny's right ear, seeing a red, bulging tympanic membrane. I changed the speculum, then checked his left year, finding the same thing.

Next, I examined his nose and throat, noting inflamed tonsils. I set the otoscope aside and palpated Benny's neck, finding swollen cervical lymph nodes, with Benny crying harder when I touched them. My final check was his temperature, which was 39°C. I decided to re-examine his tonsils, noting significant exudates, and concluded the most likely diagnosis was streptococcal pharyngitis.

I reviewed the Centor criteria, and Benny scored 5 out of 5 -- no cough; swollen and tender cervical lymph nodes; a fever over 38°C; tonsillar exudates; under age fifteen.

"I believe Benny has strep throat," I said, using the layman's term for my diagnosis. "Has he had diarrhea, been coughing, or had a runny nose?"

"No to the first two, but he's had a runny nose."

"Before or after he began crying?"

"After," she replied.

That meant, most likely, the red eyes and runny nose were related to crying, and didn't provide contraindication for strep.

"I'm going to take a throat culture, but that will take twenty-four hours. Given the symptoms and signs, I'd say the odds are strong that it will be positive. I'm going to prescribe antibiotics. Is he allergic to anything?"

"No. He's normally really healthy and active."

"And he's had all his regular vaccinations?"

"Yes. He saw his pediatrician about a month ago and everything was fine."

"OK. Right now I'll give him some liquid ibuprofen with an eye dropper for the pain, and we'll get you on your way. The lab will call you tomorrow with the results. Benny needs to take the antibiotics as prescribed for ten days, even if he feels better. If you stop, the infection could come back, and possibly be worse. It's vital you don't stop before ten days."

"Pills or liquid?" Ms. Travis asked.

"At his age, we'll go with liquid," I said. "I'm going to prescribe penicillin V, and you'll give him 125mg every six to eight hours, depending on his sleep schedule. I'll give you a discharge sheet that will have all the details. You can fill the prescription at the Walgreens down the street that has a twenty-hour-hour pharmacy. You should also pick up some liquid ibuprofen for his discomfort."

"OK."

"You should also follow up with Benny's pediatrician in seventy-two-hours, but if Benny spikes a fever higher than 102.5°F, bring him back, or if he develops a rash, has trouble breathing, or becomes listless. A nurse will call you with the test results."

"OK," Ms. Travis agreed.

"Let me get the ibuprofen now, and then I'll finish the paperwork so you can be on your way."

"Thanks, Doctor."

Tom and I left, and we went to the drug room where I prepared a dropper of liquid ibuprofen, then returned to the Exam room to administer it to Benny. I was happy he accepted it without fighting, then Tom and I went to see Doctor Mastriano. I presented, and she signed off on the chart with no comments.

On our way back to see Benny, we stopped in to check on Mr. Crowe. The gauze had soaked through, so I had Tom add an additional layer, and we promised to come back and check in ten minutes. We left his room, I went to the nurses' station and got the appropriate antibiotic discharge instructions, filled in the blanks, then wrote out the prescription. We returned to Exam 2, I went over everything with Ms. Travis, then directed her to Patient Services.

"Doctor Mastriano didn't say a word," Tom observed when we left the room.

"You'll find that every Attending is different, as is every Resident. Some want detailed reports, some just want the salient points. Doctor Mastriano appears to trust her Residents."

Or, she was lazy, which was a bigger concern, but I didn't have enough experience with her to know one way or the other. At some point, Naveen and I would compare notes, but he was working with Doctor Williams and handling incoming trauma, though it had been relatively quiet for the past few hours, which meant he was mostly monitoring patients waiting on admission or discharge.

"Tom, I need to speak to Mary, so sit at the desk and take your cues from Margie."

"She's brand new, too!"

"And has two full years of clinical experience compared to your five weeks!"

We went to the triage desk, and I asked Mary to join me in the consultation room, as we Residents did not have an office to use, and wouldn't until construction of the new ED was completed.

"What exam did you do on Benny Travis?" I asked.

"Why?" she asked apprehensively.

"Just answer my question, please."

"He was crying, so auscultation was pretty much useless. I checked his temp and wrote down what his mom said, and it sounded like croup. It wasn't, was it?"

"No, it wasn't. Did you do an otoscope exam of his ears, nose, and throat?"

"No. Was I supposed to?"

I nodded, "Yes. You do an abbreviated physical, but for a crying toddler, the number one thing to check is for otitis media."

"He has an ear infection?"

"No, he has streptococcal pharyngitis, or at least he has all the indications. Do you know the Centor criteria?"

"I know it was taught, but I don't remember."

"Here's a tip -- create flash cards with things like that and review them constantly. CENTOR is a mnemonic which will make it easier. C -- Cough absent; E -- Exudate; N -- Nodes; T -- temperature; OR -- young OR old modifier. Benny scored 5 out of 5. You should have detected all of those on your intake exam."

"Sorry," Mary said, sounding dejected.

"There's no need to apologize," I said. "And actually, I'm the one who should apologize to you for assuming something about which I had no specific knowledge. I should have given you better instructions. Also, I understand the difficulty of treating toddlers, especially very unhappy ones with frustrated moms. Just make sure you do an otoscope exam for any patient under five who doesn't have an obvious physical injury."

"You're not going to write me up, are you?"

"For what? It's only a problem if I have to tell you something more than once. Well, with regard to something like this. For procedures and diagnoses, I expect you to ask questions, even if you've asked them before. That said, my comment about the flash cards is something you should take to heart. Studying isn't just for exams. You need to be able to recall almost everything you've learned the past three years at any time.

"As for your evaluation, it's done on the totality of your rotation, and there are two main factors -- subject matter knowledge and improvement. If nobody has said so before, YOU are responsible for your training, not anyone else. Yes, of course, I have a duty to train you, but I'm sure you've noticed Residents have different styles, and with some of us, you'll need to demand we teach you. Be smart about it, and don't demand something well beyond your experience and skills, but challenge yourself, and your Resident."

"You?"

"I do my best, but there are competing motivators -- I'm graded both on my own work, and on my ability to teach. And, to be honest, I like being a doctor and doing doctor things, including things other doctors believe are scut. I was always happy to do it as a student, though, like every other student, I was champing at the bit to do 'interesting' things. But you know what? Every single thing we do, from running blood to the lab to surgery, is in the interest of the patient, and that has to be our primary concern. What speciality are you considering?"

"I was considering pediatrics, but I don't do well with crying babies or toddlers, so it's either internal medicine or endocrinology."

"Get to know Clarissa Saunders," I said. "She's a fellow PGY1 in Internal Medicine and is my best friend and confidante."

"There were all sorts of rumors about you two, but then she showed up with a girlfriend, which kind of explained things."

"People have WAY too much time on their hands and worry WAY too much about what other people are doing. Focus on medicine and ignore all the hospital scuttlebutt. My advice is to not date anyone at the hospital, and certainly not anyone on the same service. Too much drama and too many opportunities for problems."

"It's not against the rules, right?"

"No, but it should be, at least with regard to students and doctors."

"I agree with you on that one. As my little sister said when we discussed some of the stuff that goes on, it's 'creepy'."

I chuckled, "Not the word I would use, but I understand what she's saying. Let me be clear, it's none of my business unless it affects patient care. Then I'll make it my business."

"Again, I agree," Mary said. "Thanks for not getting on my case."

"That serves no useful purpose unless the student is WAY out of line."

"Tim Burg? I heard you helped flunk him."

"Tim flunked himself," I replied. "I simply gave an honest appraisal of his performance, the same as I'll do for you when I'm asked by Doctor Casper. The Chief Resident collects the input from the other Residents and does the appraisals together with Doctor Gibbs, the Chief Attending."

"She's on leave, right?"

"For another week or so, yes. Let's get back."

We went back to the triage desk and nobody new had come in, so we checked on Mr. Crowe, and I decided he was ready to be discharged so I provided the discharge form, and advised him to see his physician in two days for a wound check, or he could return to the hospital and we'd do it. Once we'd sent him to Patient Services, Tom and I returned to the triage desk.

"I'll take the rule-out UTI/STD," I said. "Tom, get a nurse please, but not Jamie, as we need a female in the room with us. We'll use Exam 2."

"Right away!" Tom replied.

I accepted the chart from Mary and went to the door to the waiting room.

"Miss Frost?"

A thin young woman with long brown hair go up and came over to me.

"Hi," I said. "I'm Doctor Mike. If you'll come with me, please."

She followed me to Exam 2, where Tom and Nurse Julie were waiting. I introduced them, then began my H & P with the usual question -- "What brings you here today?"

"It burns when I pee," she said. "I think I have an infection."

"Have you had a UTI before?" I asked.

"Yes, about two years ago."

"Are you sexually active?"

"Uh, yeah," she said, blushing slightly.

"Were you when you had your first UTI?"

She nodded.

"Is anything else bothering you?"

"No."

"No cough, fever, rash, swollen glands, earache, or nausea?"

"No."

"Is there a chance you could be pregnant?"

"Er, I guess, I mean, I've had sex since my last period, but we use rubbers."

"Have you been tested for sexually transmitted diseases?"

"No! You think I might have one?"

I smiled, "I think I have to ask the question. I'll perform an exam, take some samples, and have them tested both for STDs and for a UTI. The exam will be similar to your gynecological exams, so if you'd be more comfortable with a woman doctor, I can get one."

"Uhm, no, it's OK. My OB/GYN is a guy."

"I'll need you to change into a gown. The three of us will step out while you do that. You can keep your bra on, but you'll need to remove your panties. Once you've changed, just lie down on the exam bed, please."

"OK."

Julie handed her a gown, then she, Tom, and I stepped into the corridor.

"It's not policy," I said to Tom, "but in addition to having a female in the room with you, you should always offer a female patient the option of a female doctor if she needs a pelvic exam. Most don't mind, but some do, and patient comfort is important."

"Poison ivy girl earlier today?" Julie asked. "I heard she waited at least an extra hour for a female from OB."

I nodded, "Her choice, and I did explain she'd have to wait, and she elected to do that."

"'Poison ivy girl'?" Tom asked.

"On her buttocks, upper thighs and inner thighs. Even a Third Year can work out how that happened!"

Tom laughed, "I think a third grader could work that out!"

"Not much difference," Julie teased. "Especially with men!"

"Hey now!" Tom protested.

"She's not wrong," I chuckled. "As every woman in my life takes every opportunity to remind me!"

"We all wondered about her partner," Julie smirked.

"Oh, man," Tom groaned. "That would SUCK!"

"I hope she didn't, after," Julie said, "or she'll have it there, too!"

"What do you do?" Tom asked. "I mean, if it gets in your mouth?"

"Most guys want you to swallow," Jamie observed.

"NOT THAT!" Tom exclaimed. "I meant medically."

"Not much," I said. "Antihistamines for itching, but calamine lotion isn't meant to be taken internally."

"Neither is..." Julie began.

"STOP!" I commanded.

"Spoil sport!" she said with a silly smile.

"I can be as crude and funny as the next guy," I said, "but one slipup in front of Miss Frost, and we'll all be written up. Game faces, please. Tom, have you seen a pelvic exam before?"

"No."

"I'll ask Miss Frost if it's OK for you to observe. If she says 'no', you stand in a place where you cannot see. Got it?"

"Yes, Doctor," he said.

I knocked on the door and the three of us went back in. I washed my hands, put on gloves, then went over to the table.

"I'll do the pelvic exam and swabs first," I announced. "Miranda, Julie will help you get your feet in the stirrups just as would be done at your OB. Tom, as I said before, is a medical student, and I'm training him. Are you OK with him watching me do the exam?"

"Does he have to?"

I shook my head, "No, he doesn't. As I said, you decide, and that includes asking for a female doctor."

"No, it's fine for you to do the exam."

"OK. Julie?"

She helped Miss Frost get her feet into the stirrups, then brought me a gynecological exam tray.

"This might be a bit uncomfortable," I said to Miss Frost. "I need to swab your urethra, in addition to your labia and vagina."

"Go ahead," she said.

I did the exam using three swabs, one of which I pressed slightly into Miss Frost's urethra, causing her to grimace.

"All set," I said. "Let me do the rest of the exam and then we'll discuss options. Julie, draw blood for an STD panel, then Tom, take everything to the lab, please."

I stripped off my gloves, quickly filled out the lab order, then re-washed my hands and put on fresh gloves. I had Miss Frost sit up, and I took her vitals, auscultated her heart and breathing, then had her lie down so I could palpate her abdomen, check her distal pulses, and finally, sit up so I could check her lymph nodes.

"You don't have any other symptoms I can detect," I said. "That doesn't rule out either a UTI or an STD. Do you have more than one partner?"

"No. I've had the same boyfriend for three years and he's the only one."

"And his history?"

"He'd never done it with anyone before me."

"The odds are that you do have a UTI," I said. "I'm going to prescribe oral antibiotics, and if by some chance the STD test comes back positive, we'll call you to have you come here or visit the McKinley Free Clinic for injected antibiotics."

"I live at home," she said.

"Then we'll give you a number to call and we'll make sure nobody calls your house. It's imperative that you call, though, because if we don't hear from you, we're legally required to report a positive test to the County Health Department and they will track you down."

"But how if neither of us has been with anyone else?"

"As I said, it's unlikely, but it's possible to contract certain diseases via blood transfusion, sharing needles, and other risky behavior. Don't fret about it, because I'm fairly certain it's a UTI. In addition to the oral antibiotics, you want to drink lots of fluid, and cranberry juice is a very good choice as it's effective against UTIs."

"I've heard that, but thought it was BS!"

"It has been shown to help," I said. "And it might be preventative, so drinking it every day is a good idea. The other thing is you want to refrain from sexual contact until you finish the course of antibiotics, or about ten days. Not just intercourse, but oral or manual stimulation as well. The other thing is to remember to be careful when you clean yourself after a bowel movement, always wiping back, away from your vagina."

"My mom taught me that when I was little."

"Good. Do you use rubbers every time?"

"Yes. There is no freakin' way I'm getting pregnant while I'm in High School!"

"Good. Do you have any questions?"

"What causes the UTI?"

"Sex, improper hygiene, wearing pads too long during your period, and any number of things. When you have your period, you should change your pad every few hours, even if your flow is light. And make sure you put on clean underwear if there is any leakage. I'd also recommend showering after sexual contact, and fresh underwear as well. But, as I said, no contact, intercourse or otherwise, until you finish the antibiotics."

"Jim is not going to be happy," she groused.

"Jim will live," I replied. "And if he truly cares for you, he'll want you to be healthy. If he complains, send him to me and I'll straighten him out."

She smiled, "Thanks."

"We'll step out so you can dress, I'll complete the paperwork, and we'll get you on your way. You should pick up the prescription at the Walgreen's down the street and take the first dose immediately."

"OK."

Tom, Julie, and I left, and I stepped over to the nurses' station to complete the chart and write out the prescription, then filled out a discharge form for UTIs/STDs, and grabbed a 'Safe Sex' pamphlet published by the Free Clinic. Everything in order, I took the chart to Doctor Mastriano to sign, which she did after a cursory review. That completed, Julie, Tom, and I returned to the exam room, reviewed the discharge information with Miss Frost, and answered a few questions. Tom walked her to Patient Services, and I went back to triage.

"I'll take the back pain," I said. "Unless there's something pressing."

"He's the only patient in the waiting room."

I accepted the chart and went to the door, opened it, and called out, "Mr. Brown?"

He stood up gingerly and slowly walked over to me. I evaluated his movements and either he was a good faker, which was possible, or he was actually in pain. People who were not in pain, but were seeking drugs, often exaggerated their symptoms, believing that was the path to success, when in reality it was the first sign they were faking.

I escorted him to Exam 5, and Tom joined us.

"Mr. Brown, are you able to get onto the exam table?" I asked.

"Yeah, I can," he replied.

"Just sit up at first so I can listen to your heart and lungs, then you can lie down if you're more comfortable."

I washed my hands, put on gloves, and then auscultated his heart and lungs detecting no problems, and at the same time judging his demeanor. I made a small bet with myself that he was actually in pain, and might actually have lost his meds, because his behavior was not that of a typical drug seeker. That said, there were some VERY good con men, and he might be one.

"The triage team said you lost your pills," I said.

"Somebody stole them from my locker at work," he said. "I reported it to my boss, and we filed a police report with the County Sheriff."

"How many pills?" I asked.

"Twenty-four. I had just had it refilled on Friday."

"When did the pain begin?" I asked. "I mean the first time."

"I was playing intramural football when I was at OSU and got hit hard in what was supposed to be flag football."

"When was that?"

"About three years ago, when I was a Junior."

"What do you do for work?"

"Electrical inspector for Hayes County."

"My dad is a building inspector and supervisor in the Property Division in Harding County. Why not go to your regular doctor?"

"He doesn't have hours on Monday, and when I called his service, they couldn't get hold of him. I'll see him tomorrow, so I just need a couple of pills to get me through until tomorrow afternoon."

"Who's your doctor?" I asked.

"Mark Goetz at Medical Practice Associates."

Which was where my friend and personal physician, John Smith, was medical director.

"Do you know the medical director there?"

"You mean Doctor Goetz's boss? Doctor Smith? Yeah, I've met him."

"He's my physician. In order to prescribe pain pills, I need to have my supervisor sign off. Give me about ten minutes to get things sorted and I'll come back with them."

"Thanks, Doc."

We left the room, and I walked over to the nurses' station and picked up the phone. I looked up Doctor Smith's number in my pocket address book and dialed the number. Doctor Forsberg answered, and after asking how I was doing, put Doctor Smith on the phone.

"Hi, Mike! What's up?"

"Hi, Doctor Smith..."

He cut me off, "John. We're colleagues now!"

"John, I have a patient who is seeing Matt Goetz and claims his prescription for pain meds was stolen."

"You know that's a sign of drug seeking, right?"

"Obviously, but the typical drug seeker doesn't file a police report! Anyway, the service said they couldn't reach Doctor Goetz, and I wanted to check."

"Who's the patient?"

"Steve Brown," I said. "He says he's met you."

"Matt consulted with me on him. Matt was going to be unavailable tonight, but they're supposed to call me in that case. I'll deal with the service, but your patient is telling the truth, at least about that. What's your plan?"

"Three pills which will get him through tonight and tomorrow until his afternoon appointment."

"I'd say that's a good plan. I'll let Matt know when I see him in the morning, and he'll follow up."

"Thanks," I said.

"How does it feel to be a doctor?"

"I'd be happier without patients dying," I said. "But otherwise, good."

"A function of your chosen specialty. I take it you had a bad one?"

"Construction worker who fell onto rebar with predictable results."

"Damn."

"Yeah. Are you and Candace free for dinner next week?"

"Sure, what day?"

"Wednesday. And bring the tyke with you."

"Of course!"

We said goodbye, and I hung up, then wrote out the drug order, but didn't sign it, as I wasn't authorized. I took the chart to Doctor Mastriano and gave her the synopsis.

"We don't give drugs to drug seekers," she said firmly.

"And he's not," I replied. "I confirmed with the medical director at Medical Practice Associates, where Mr. Brown's doctor works, and as I said to Doctor Smith, drug seekers don't file police reports. If you want, call the Sheriff and ask, but I believe Mr. Brown. He shows no signs at all of drug seeking."

"Fine," she said.

She signed the chart and the drug order.

"I'll need you to get three tablets from the Schedule Drug locker," I said.

She glared at me, but got up and we went to the drug room. She used her special key to open the Schedule Drug locker and I found the correct bottle, then counted out three tablets and put them in a small envelope. I wrote out the detailed information on the clipboard and Doctor Mastriano signed and I initialed the note that they'd been dispensed to me to give to the patient. I returned to the exam room, gave Mr. Brown the tablets, watched him take one, then quickly went over the discharge instructions before having Tom escort him to Patient Services.

"Mike?" Nurse Bonita called out from the nurses' station. "There's a Doctor Bush on the phone for you, calling from Kentucky. Line 3."

I walked over, picked up the handset, and pushed the button for Line 3.

XI. Get Out Of Here!

July 3, 1989, McKinley, Ohio

"Mike Loucks," I said.

"Mike, it's Melissa Bush. I'm sorry I haven't returned your call. What can I do for you?"

"First, tell me, how are you doing?"

"I'm a doctor, so that's a major plus. I split my time between the Internal Medicine ward and trauma. Eastern Kentucky coal country is not my idea of a great place to live, but it beats the alternative. I take it you're loving every minute of the Moore ER."

"This is my first full shift," I said. "I had a short shift on Saturday, but took a delayed start so I could spend time with my wife and daughter before the full-scale insanity began."

"Why did you call?" she asked. "I'm positive you don't expect us to be friends."

"And there you'd be mistaken," I replied. "Again. Nobody is irredeemable, Melissa, and that includes your dad. I saw him about a week ago."

"He was in the hospital again?"

"No, I went to Southern Ohio Correctional Facility to visit him."

"What the heck?! Why would you do that?"

"There's this book that reminds us of how we're supposed to behave. I believe you've read it once or twice."

"It's all bullshit!"

"Not to get into a theological debate, but 'bullshit' accurately describes the Calvinist interpretation of the Scriptures. It's a good thing I don't buy it, and never have. Sadly, though, your dad thinks he's on a Highway to Hell with no offramp available."

"Well, if such a place actually existed, I'd say that's where he belongs."

"You're no longer a believer?" I asked.

"I was fed a steady diet of that bullshit for twenty-five years and it nearly wrecked my life. It certainly wrecked my mom's and did a serious number on my brother as well."

"And on your dad, too. Fundamentally, that's why he is where he is. I was going to suggest you get in touch with him, but now I'm not sure it's a good idea. He needs love and hope."

"And you thought I was brainwashed? He murdered your friend!"

"Yes, he did, but that does not make him any less a child of God. Misguided and sinful, but still a child of God, and in the end, not all that different from me."

"That's crazy talk."

"If I be a fool for Christ, that is a credit to me," I replied, quoting a monk. "Anyway, I did want to congratulate you on Matching, and I hope you're successful. The people of that area need good medical care."

"They need way more than that!" Melissa protested.

"I don't doubt it, but as has been said to me, we have our roles to play and our jobs to do, and have to do them to the best of our ability, and leave other things to others. It's not that we don't care, but neither of us is a social worker. What kinds of cases do you see?"

"Respiratory problems related to mining, poor nutrition, pregnant teenagers, and drug addiction."

"I suspect that's par for the course for a poor rural county."

"It is. How is your daughter?"

"Healthy and almost two," I replied. "I'm sure you heard I re-married."

"I did."

"Anyone special in your life?"

"Nah, just the usual Friday night hookups with unemployed rednecks at the local bar."

"Now, why don't I believe that?"

"What's not to believe? I'm not the same person I was a year ago."

Nurse Bonita tapped my arm and said, "Doctor Williams needs you in the ambulance bay."

"Sorry, Melissa, but there's an ambulance run. OK to call you again?"

"Suit yourself, but I'm not going to contact my dad."

"OK. Could I get your phone number?"

She gave it to me and I wrote it in my address book. We said 'goodbye' and I hung up.

"Let's go," I said to Tom.

We gowned and gloved and went to the ambulance bay where Doctor Williams, Naveen, his two medical students, and two nurses were waiting.

"Two gunshot victims on their way in," Doctor Williams said. "One's a deputy with an arm wound, which you'll take. Naveen and I will take the guy he shot twice in the chest."

"Any idea what happened?"

"No. But you can expect half the Sheriff's Department will swarm the place and they'll know. Kelly is with you."

An arm would could be anything from grazing to a through-and-through with only soft tissue damage to a shattered bone. None of which were directly life-threatening, and certainly not serious compared to a pair of .357 slugs in the chest. That might well be futile, but, as always, we had to try.

"OK," I said. "Kelly, I'll want a full trauma panel, no matter what. Tom, EKG and pulse oximeter, please. Beyond that, we'll see what we have."

The two EMS squads arrived in quick succession, and the victim with the two gunshot wounds to the chest was extremely critical, as expected, and Doctor Williams and Naveen rushed him inside as the Sheriff's deputy was unloaded.

"Sam Kenseth, thirty-one;" the paramedic called out. "Through-and-through small caliber gunshot wound to the upper right arm; tachy at 110; BP 110/60; PO₂ 99% on nasal canula; IV saline TKO; morphine x1; awake, alert, and oriented times three."

"Take good care of him, Doc!" another Deputy who hopped out of the squad after the gurney.

"Best care anywhere!" I declared, quoting the sign for the 4077 MASH from the TV show. "Trauma 2!"

We quickly brought Deputy Kenseth into the trauma room and moved him to the bed and Kelly connected the nasal canula to the hospital oxygen system.

"Deputy Kenseth," I said. "We need to get your Kevlar off and it's not going to be comfortable if we don't cut the straps.

"Don't cut it," he grunted.

"Tom, bandage scissors," I instructed. "Cut up the sleeve to the shoulder, then across the chest and down the other sleeve. Be cognizant of the wound."

He did as I asked, then hooked up the monitor while I undid the straps on the Kevlar vest. I had the deputy sit up so I could remove it without cutting the straps, and he grunted and grimaced, but his vest was intact.

"Tom, cut away the t-shirt for an EKG," I said as Kelly moved to draw blood from the deputy's good arm.

I did a quick exam, and other than the gunshot wound and slightly depressed blood pressure, likely from the morphine, I found nothing amiss.

"What caliber bullet?" I asked Deputy McCallum, the one who had come in with the patient.

"A snub-nose .32," he said.

"Please tell me it wasn't a Walther PP," I said.

"James Bond, the scumbag ain't!" Deputy McCallum said. "But that pistol fits in a pants pocket."

"Deputy Kenseth, we'll get an x-ray, irrigate the wound, and possibly throw in a couple of stitches on either side. You'll need a tetanus shot and we'll give you antibiotics, but you should be able to walk out of here in a few hours."

"How's the dirtbag?" he grunted.

"He's next door with Doctor Williams and Doctor Varma. I'm sure they'll fill you in when they know something. Mind if I ask what happened?"

"Kid had a trunk full of weed and pills," Deputy McCallum said. "Sam pulled him over for speeding and he came out blasting."

"That doesn't appear to have ended well for him. Tom, call for the portable x-ray, please, then get the blood to the lab."

"Yes, Doctor."

"Kelly, trauma kit with sutures times four."

"Right away!" she said brightly.

"How much time will I miss?" Deputy Kenseth asked.

"That's up to your boss," I said. "From a medical perspective, I'm not going to prescribe anything other than antibiotics. For pain, use over-the-counter Advil or Tylenol. You'll need to have the wound checked in a few days, but the duty nurse from the lockup can do that. On the other hand, if you want some time off, I can write that up for you."

Both Deputies laughed.

"I love all you docs," Deputy McCallum said. "You take good care of us. You're the doc who disarmed the asshole in your waiting room, right?"

"Yes."

"And you turned down the recognition award."

"Let's just say I don't want to draw attention to doing something bordering on foolish."

"Nah, you did the right thing in a room full of people. I heard you had a good wrist lock on the idiot."

"Karate training," I replied.

"Radiology tech is on his way," Tom announced, then left with the blood.

Five minutes later, I had the image on the screen.

"It's your lucky day, Deputy," I said. "No ligament or bone involvement, and no major blood vessels impacted. Four sutures, antibiotics, and you'll be outta here. Have you had any negative reactions to anesthesia, including when you've had dental work?"

"No."

"Forget the drugs, Doc!" Deputy McCallum declared. "Just give him a bullet to bite on."

"There's bravery and then there's stupidity," I replied. "The difference is minor!"

"I'll take the drugs, Doc!" Deputy Kenseth declared. "Pete can bite me!"

"Pass," Deputy McCallum retorted.

"Lidocaine times four, Kelly," I said.

Twenty-five minutes later, after the lidocaine, irrigation with saline, application of Betadine, and four sutures, I was finished.

"Your blood work will be back in about fifteen minutes," I said. "Once we see that's clear, we'll get you out of here. Kelly, would you administer the tetanus booster, please?"

"Right away!" she exclaimed.

I sat down at the table wrote out the prescription for antibiotics, updated the chart, then went to the nurses' station to get the proper discharge form which I filled out, then took everything to Doctor Mastriano, who, if I judged correctly, had not treated a single patient since her shift began. She once again reviewed the chart perfunctorily and signed off.

"What's wrong with her?" Tom asked as we walked back to the trauma room.

"No clue, but that's something for Doctor Gibbs or Doctor Northrup to handle."

Tom went to the lab to get the blood work results while I returned to the trauma room. I went over the discharge information with Deputy Kenseth and gave him the prescription. When Tom returned with the results, which were normal, I informed Deputy Kenseth he could go.

"What about the perp?" he asked.

"Emergency surgery, according to the board," I replied. "Someone upstairs can keep you posted."

"Powers and Green are with the perp, Sam," Deputy McCallum said. "I'm going to get you home to Nancy and the kids."

"She's going to kick my butt for not calling her."

"You're alive and not badly hurt," Deputy McCallum said.

"Not for long! You might see me again soon, Doc!"

I chuckled, "My advice is the next time you get shot at, don't get shot!"

"No shit, Doc! Fortunately, the little bastard was a lousy shot."

"That .32 wouldn't have penetrated the vest," I said. "But in the head, it would have ruined your entire day. Try to avoid showing up here with extra holes in your body, please."

"You know it, Doc!"

We shook hands, and Kelly helped him put on a scrub shirt so he didn't have to leave bare-chested.

"Be sure to have that checked and make sure you take the full course of antibiotics."

"Will do. Thanks for patching me up."

"You're welcome."

I left and went to find Doctor Williams, who was in the lounge.

"How bad?" I asked.

"Two to one, he doesn't make it," Doctor Williams said. "Missed his heart, but he lost a lot of blood and he'll likely lose a lung if he does make it. Your deputy is an excellent shot -- both center mass. How is he?"

"I just sent him home to a wife who might send him back because he didn't call her."

"The man has a death wish!" Doctor Williams said. "Treatment?"

"Irrigation, four sutures, tetanus shot, antibiotics, and over-the-counter NSAIDs for pain. I cleared him for work as soon as he wants to go back, though obviously that's up to his boss."

"You're really averse to pain meds, aren't you?"

I nodded, "Some docs are handing out opiates as if they were Skittles. I think that's a really bad idea. Obviously, I'll suggest them when absolutely necessary, but why exacerbate what's already a growing problem?"

"Good point, but expect some pushback."

"Story of my life so far in medicine," I chuckled.

"You are something of a maverick."

"While there is value in 'this is how we always do it', that's what led to rejection of handwashing, though I'd like to think I'm not as much of an ass as Ignaz Semmelweis was reputed to have been."

"You'd like to think!" Doctor Williams said.

"OK, so I come across as an arrogant, egotistical prick at times, but am I wrong?"

"No. Just remember what my grandma always said -- you catch more flies with honey than with vinegar."

"I prefer to keep the flies away, not attract them!"

"Get out of here"! Doctor Williams ordered.

I chuckled and Tom and I left the lounge.

"That was weird," he observed. "Why say that about yourself?"

"Why not? It's not like I hide it! And in the few hours we've worked together, I bet you've noticed."

"I just figured it was a surgeon thing."

I laughed, "You figured right! That said, I do not have the bedside manner of a surgeon."

"Nobody does," Tom said. "They don't have one!"

I laughed, "Often, too true. Let's go see what Mary has for us."

"Naveen just took the beer can to the forehead," Mary said. "Nothing else at the moment."

"He waited a long time," I said. "Did you call Doctor Mastriano?"

"Yes, but she said she was busy and he could wait for you or Doctor Varma."

Busy my ass, but I couldn't say that to my medical students.

"OK. I'm going to get some fresh air. Send a nurse to get me if anything comes in, please."

Mary acknowledged me and Tom and I went to the ambulance bay. I was surprised when he pulled out a cigarette.

"Seriously?" I asked.

He shrugged, "It helps with the stress and nicotine isn't on the prohibited list like alcohol or pot."

"Just remember, you're going to have to look patients directly in the eye and tell them to quit smoking. If you smell like smoke, you'll come off as a hypocrite."

"I hear you. And what's with Mastriano? Busy? She's sitting in the Attendings' office reading a book!"

I shrugged, "As I said, not my place to say anything to her, but I will mention it to Doctor Gibbs as soon as I see her."

Which would be Wednesday night when she, Bobby, Ghost, and Oksana would join us for dinner.

"Can I ask you something?"

"Always."

"You seemed to be sucking up to the deputies. Why?"

"I have great respect for firefighters and law enforcement," I replied. "While I have serious problems with the excesses of the criminal justice system, the patrol officers are not the problem. I wasn't sucking up, only treating them with the respect I think we owe to the men and women who put their lives on the line to keep us safe. I have several good friends who are firefighters or deputies."

"You've never dealt with a big-city police department, have you?"

"No. Where are you from?"

"New York City, where the cops are all on the take, totally corrupt, and only look out for themselves."

"I hope you've noticed our deputies and city cops aren't like that."

"It is a whole different world from Queens."

"I believe it. Doctor Nielson did his Residency at Cook County in Chicago and says it's night and day different from here. Doctor Taylor said the same thing, but Matched here which made him very happy. Are you going to try to Match back home?"

"Upstate New York or Eastern PA," Tom said. "Basically close to home, but not in the City."

"Mike?" Bonita said, coming out into the ambulance bay. "Mary needs you for a walk-in with facial contusions and lacerations."

"Stub out the cig, Tom," I ordered. "Duty calls."

We went to see Mary at the triage desk.

"Approximately twenty-two-year-old who appears to have been in a bar fight," she said. "He's clearly drunk and his buddies dropped him off and left. He was at least somewhat awake, but appears to have fallen asleep. No ID."

"Those are usually closer to closing time," I observed, accepting the proffered chart. "Tom, get a wheelchair, as I don't think our patient is in any condition to walk."

He left and returned a few seconds later with a wheelchair. We went out into the waiting room and I tried to rouse the patient, whose name we didn't know. He was basically incoherent, from the booze, the beating, or, more likely, a combination of the two, so Tom and I moved him to the wheelchair.

"Exam 2," I said.

Tom began pushing, and I went over to Mary.

"When the Law shows up, send them back."

"What makes you think the cops will show up?"

"Nobody gets this drunk and this beat up in a bar without someone calling the cops."

"I'll send 'em back if they show up."

"Thanks."

I stopped at the nurse's station and asked Bonita to send in a nurse with a banana bag, then went into Exam 2. Tom and I were strong enough to get our patient onto the exam table. Nurse Becky came in with the banana bag and I had her set it up.

"What do we do?" Tom asked.

"Trauma panel with EtOH, and wait for him to sober up. None of his lacerations are bleeding badly, so we wait. Go ahead and draw the blood and take it down to the lab. I'm going to do a quick physical to make sure he's not bleeding internally."

Once Tom drew the blood, I did a basic exam, checking for blood in his eyes, ears, nose, and mouth, and palpated his abdomen. His pulse and breathing were reasonable given his inebriation, though I was concerned about aspiration if he vomited.

"Vitals are acceptable," I said. "No obvious internal injuries. Becky, please stay with the patient, please, and let me know when he comes to."

"Soft restraints, Doctor?" Becky asked.

"I see no need," I replied. "Let's see his EtOH level, then decide what to do next."

July 4, 1989, McKinley, Ohio

I left the exam room and went to check with Mary, but there were no additional patients, so I went to the lounge. I was just over halfway through my thirty-six-hour shift and still had plenty of energy. I'd done twenty-four-hour shifts and been OK, but those additional twelve hours looked to be tough, not to mention I had a concert gig to play on Tuesday afternoon -- actually, later this afternoon, as it was after midnight.

Tom returned with the EtOH results about ten minutes later.

"0.19," Tom said.

"Take another in twenty minutes, please, and add a blood gas. Once those are back, along with the trauma panel, we'll decide what else to do."

"I'll take care of it," Tom said.

He left and about five minutes later, Nurse Peggy came into the lounge to let me know a Sheriff's Deputy was looking for my patient. I went to the nurses' station and saw Deputy Schmidt, who I'd spoken with on several previous occasions.

"Overnight shift before a holiday?" I asked. "Who did you piss off?"

"Hi, Mike! Well, I guess it's Doctor Loucks, now. And I traded similar to how you docs trade, and it was a good deal."

"Doctor Mike, please. What can I do for you?"

"I hear you have Peter Firth in Exam 2."

"I have an African-American twenty-something John Doe who was in a bar fight, but we didn't find an ID. He's basically incoherent at the moment, and we have him on a banana bag, waiting for him to sober up before we treat him further."

"What injuries?"

"Contusions and lacerations consistent with a fist-fight, but no internal injuries were detected. I can't imagine he fought back, given how drunk he was."

"He was beaten up by four guys for talking to one of their girlfriends."

"White guys, I take it?"

"We got two of them, and we're looking for the other two. Can I see him?"

"Yes, though he's not in any state to question at the moment."

"I just want to get a record of his injuries, including a Polaroid."

He held up the camera.

"You assume he's going to press charges?"

"I hope so. Those guys have done this before and managed to walk. This time, though, the bartender swore out a complaint for disorderly conduct and property damage, so we can keep them cooling their heels at least until they see a judge on Wednesday."

We heard a crash from Exam 2 and both Deputy Schmidt and I rushed to the room and saw a turned over stool and the patient on the floor, with Becky standing in the corner. The IV had been pulled out, and I saw a small amount of blood.

"He came to, pulled out the IV, and tried to leave," Becky said.

"Did he strike you in any way?" Deputy Schmidt asked.

"No. He could barely stand."

"Becky," I said, "get some help and we'll move him to a trauma bed."

"Soft restraints, Doctor?" she asked.

"Yes."

She nodded and left, while I checked on Mr. Firth, who had face-planted, and now had a bloody nose, which might well be broken. Two minutes later she was back with two orderlies and a gurney, and between the five of us, we got Mr. Firth onto it, then moved him to Trauma 3. We moved him to the trauma treatment bed and Becky attached the soft restraints to the patient's wrists and ankles, then set up a fresh banana bag, and the orderlies left the exam room.

I performed an exam and instructed Becky to pack Mr. Firth's right nostril with gauze.

"I owe you an apology," I said to Becky. "I should have listened to you when you suggested the soft restraints. I won't make that same mistake in the future."

She smiled, "After twenty years, I have learned a few things."

"Why not insist, then?"

"How well do you think that works with new doctors?"

"Badly, I suspect."

"You suspect correctly," Becky answered with a smile.

"Next time, be more forceful if you think I'm making an error in judgment. I promise it will be received positively. How did you know?"

"I didn't know for sure, but drunks tend not to be coherent when they come around, and it happens often enough that soft restraints are advisable."

"I'll remember that."

"What do you want to do next?"

"He'll need a skull series to see if there are any fractures from the beating he took, as well as the fall. We'll also need to rule out a concussion for the same reason, but we can't be certain about that until his EtOH is undetectable."

"How long do you figure before I can speak with him?" Deputy Schmidt asked.

"Call it three hours or so," I replied.

"I'm going to go back on patrol, then. If you plan to discharge him before I come back, have dispatch call me."

"Will do."

"OK to take the Polaroids?"

"Yes, though after the fall, I suspect you'll have trouble distinguishing his injuries."

"Then let me take your statement now, along with one from the nurse."

"OK."

Both Becky and I described Mr. Firth's injuries when he presented, and I made sure to update the chart to match both our descriptions of the contusions and lacerations. Deputy Schmidt left after taking our statements, and a few minutes later, Mr. Firth struggled against the restraints, groaning.

"You're in the hospital, Peter," I said. "I'm Doctor Mike. Just relax and we'll take care of you."

He continued to struggle and groaned, and I wondered if the beating he'd taken had actually caused brain trauma. I'd likely need a neuro consult, but until his EtOH was below 0.1, they wouldn't send anyone to consult, and they might even insist on waiting until the level of alcohol in his system was undetectable. But I was concerned about doing nothing, and Becky picked up on it.

"You might want to talk to the Attending," she suggested.

I was positive Doctor Mastriano was asleep, and my patient wasn't dying, though if he had a brain bleed or other injury I hadn't appreciated, he could be in real trouble. One thing was certain -- no matter how upset Doctor Mastriano might be, a PGY1 would never be reprimanded for calling their Attending in a case such as this one.

"You're right," I said. "Doctor Mastriano is probably sleeping."

"Well, we aren't!" Becky said.

I got her point, asked her to stay with Mr. Firth, and went to the Attendings' office and knocked on the closed door, waited fifteen seconds, then opened it, to find Doctor Mastriano stretched out on the couch with a sleeping mask over her face.

"Loucks," I said. "I need to discuss a patient."

"He better be dying," she growled, not moving.

"Peter Firth, early twenties; involved in a bar fight; significant facial contusions and minor lacerations; potentially broken nose from a fall; incoherent. I'm concerned about trauma to his brain, and a potential bleed. He might have internal injuries, but no guarding or rebound on palpation."

"EtOH?" she asked, still not moving.

"0.19."

"YOU WOKE ME FOR A DRUNK? GET OUT OF HERE UNTIL HE'S BELOW 0.05!"

"Doctor, I'm concerned that if we wait, he'll suffer neural deficits and possibly herniate. I'd like to get a neuro consult and a CAT scan."

"What part of 0.05 don't you understand?"

I took a deep breath and let it out while I thought about how to proceed. While it was true, I had been cleared to work semi-independently, I still technically needed signed orders, even if I had permission in advance. Nobody would say anything so long as I stuck to things I knew how to do and asked for help when I was concerned or potentially out of my depth. That was the case here, so I decided to press the point in a way to which Doctor Mastriano could not reasonably object.

"I need you to write that order on the chart," I said.

"Gibbs and Ghost both cleared you. Go do your job."

"Doctor," I said. "I insist. I was instructed to ask for help when I needed it, and I need it. If you won't examine the patient, I need you to write your order on the chart."

She removed her mask and sat up. I handed her the chart and pen, she wrote on it, signed it, handed it back without a word, put her mask on, and reclined on the couch. I shut the door and reviewed what she had written -- 'monitor until EtOH is below 0.05'. That meant I could perform blood tests, use life-saving measures, but otherwise not take any actions such as calling for a neuro consult, asking for a CAT scan, or even bothering Doctor Mastriano unless the patient was dying. I felt she was mistaken, but I had written orders, so I returned to the trauma room.

"Monitor until under 0.05," I said. "She expressly stated that order twice and wrote it on the chart."

Becky frowned, but didn't say anything, which indicated her thinking at least paralleled mine. If it were during the day, I'd call neuro and simply talk to an experienced neurologist, but that wasn't possible at the moment, as only a PGY1 was on overnight, and their Attending was at home, on call. While I might convince the PGY1 to wake his or her attending who was at the hospital, I seriously doubted he or she would be willing to make a call about a patient Doctor Mastriano had called 'a drunk' with significant EtOH in his system.

"Neuro checks?"

I shook my head, "Most of the signs would be similar to the effects of his EtOH level. Absent a blown pupil or blood in the auditory canals or nostrils, I don't have anything on which to hang my hat. Let's do a blood glucose stick test and give him D5W if it's low, and get him on a nasal canula."

"You know about the stick test limitations, right?"

"Yes, but I'd prefer not to order the labs because they'll take at least an hour. I'll write it on the chart."

"OK," Becky replied. "Canula first, then glucose."

She attached the canula, then performed a glucose stick test which showed 96, which wasn't too low, and might or might not be diagnostic, given the inexact nature of the stick test and the fact we didn't know when Mr. Firth had last eaten.

"Let's repeat that in thirty minutes," I said as Tom came into the room.

"Mary has a patient for you," he said. "Doctor Varma has three already. Still want the EtOH and ABG?"

"Yes, please. Becky, please stay with Mr. Firth. Tom, come find me once you've taken the blood to the lab."

They both acknowledged, and I went to the triage desk.

"Sixty-nine-year-old male with a syncopal event about forty minutes ago, but vitals are normal. His wife insisted he come in."

"How long has he been here?"

"About ten minutes -- long enough for me to take vitals and send Tom to get you."

"In a case like this," I said. "Consider it similar to a trauma and get them right in, get them on oxygen, and wake someone if you have to."

"Sorry, but that's not listed as an 'immediate care' case."

"It is now," I said. "At least when my students are at the triage desk. I'll raise it with Doctor Casper in the morning."

"OK," Mary replied.

I accepted the chart from her and went out to the waiting room.

"Mr. Temple? I'm Doctor Mike. If you'll come with me, please."

"Can I come, too, Doctor?" a woman of about the same age, who I assumed was his wife, asked.

"If your husband is amenable, yes."

"It's OK," Mr. Temple said.

I escorted them to Exam 4, had Mr. Temple lie on the table, and hooked up a nasal canula to the hospital oxygen supply.

"This is simply precautionary," I said as I fitted it around his head. "What brings you here today?"

"He fainted when he got up to use the commode," his wife interjected. "He didn't want to come in, but I made him."

"A wise precaution. How long was he out?"

"Maybe a minute or so. I was about to call 9-1-1 when he came to and told me not to."

"OK. Any previous lightheadedness, dizziness, or unsteadiness?" I asked Mr. Temple.

"No."

"Do you drink or smoke?"

"I'll have a Scotch on occasion, but I quit smoking about twenty years ago."

"Good for you. How much did you smoke?"

"A pack a day from age fifteen to age fifty. When the Surgeon General came out with the warnings in '66, Nellie insisted I quit. Took a few years, but I did."

"Stopping smoking will immediately improve both your short- and long-term health. Do you exercise?"

"We take an early morning walk every day when it's nice enough. During the winter or if it's raining or too hot, we go to the mall to walk."

"What about your diet?"

"My doctor has me on a high-fiber, low-fat diet. Seems to work OK, though I miss the 12oz steaks!"

"Between 4oz and 6oz would be a better portion," I replied. "Just go for the lean cuts."

"Did you hear that, Nellie?" Mr. Temple asked.

"Confirm that with your personal physician," I said, hoping to stay out of Dutch with his wife. "He knows your entire medical history, so he's better suited to giving you advice."

"He's a smart young man, Jon!" Mrs. Temple said.

"I have a grandma," I chuckled. "And a mom, a wife, and a daughter, so I have good survival skills!"

She laughed, "You learned that at a young age!"

"Well, I'm not sure the women in my life would agree I've learned. When was your last meal, Mr. Temple?"

"Dinner, which was salad, chicken, potatoes, and bread."

"Anything to drink this evening?"

"No."

"Any prostate trouble?"

"Who doesn't at my age? But it's not too bad."

"How many times a night do you get up to urinate?"

"Twice, usually. If I'm careful about how much I drink after dinner, once, but then I get dehydrated by morning."

Which was all typical for a man his age.

"Any recent illnesses, fevers, or coughs?"

"No."

"Any history of heart trouble?"

"None."

"OK. Would it be OK for me to examine you?"

"It would be stupid to come here and say 'no', wouldn't it, young man?!" Mr. Temple asked.

"Indeed it would, but I always ask before I touch someone beyond an oxygen mask or canula, unless it's an emergency. Let me wash my hands and we'll check you out."

I washed my hands, put on gloves, then began an exam, finding nothing except slight crackles in his lungs, and a slightly elevated blood pressure, neither of which were specifically diagnostic in a nearly seventy-year-old man. The crackles in his lungs could well be related to his smoking history, though without an earlier auscultation to compare it to, I couldn't be sure.

"Your heart and lungs sound fine, though you do probably have a small amount of fluid in your lungs, which isn't a problem, though it bears watching. I'd like to put you on an EKG monitor. Would you remove your shirt and t-shirt, please?"

"I'll help," Mrs. Temple said, reminding me very much of my grandmother.

I left the room to get one of the spare EKG monitors and wheeled it into the room as Tom returned from the lab. After checking with Mr. Temple, I had Tom hook up the EKG and pulse oximeter, and then reviewed the EKG, which looked normal.

"Tom, let's get a trauma panel, blood gas, metabolic panel, and cardiac enzymes, please."

"Will do. Anything specific you're looking for?"

"The cause of a syncopal incident. It could be anything at this point."

Tom drew the blood and was about to take it to the lab when Nurse Jackie opened the door.

"Doctor, Mr. Firth is seizing!"

"Tom, go wake up Doctor Mastriano, and I don't care if you have to drag her from the couch!" I ordered. "Mr. and Mrs. Temple, excuse me, please."

Tom and I left the room, and I asked Jackie to send a nurse in to monitor Mr. Temple while I hurried into Mr. Firth's room.

"Bite guard is in," Becky said. "Lorazepam?"

"4 megs, IV push!" I ordered.

She had the drug ready, which didn't surprise me, and injected it into the IV port. The seizure subsided after about a minute, and I immediately checked Mr. Firth's pupils.

"Left pupil is blown," I said. "Right is sluggish. Call neuro for a consult, please."

"Right away, Doctor."

She went to the phone and Tom came in with an angry-looking Doctor Mastriano.

"What happened?" she demanded.

"He seized," I said flatly. "Becky called me and put in the bite guard, then injected 4mg lorazepam on my order. His left pupil is blown and his right is sluggish. I just ordered a neuro consult. Tom, lets get him on an EKG and monitor, please."

"No way to know that would happen," Doctor Mastriano said.

She moved over to the table and examined the patient, then moved so Tom could finished connecting the monitor.

"Come get me after the neuro consult," she said.

"Doctor, I prefer you stay," I said. "This is beyond my experience and training at this point."

"You're fine," she said. "Come talk to me after the consult."

"Tom, get a nurse to take Mr. Temple's blood to the lab, then swap places with Mary. Tell her I need her here, please. No knock on you, but she has a full year of clinical experience."

"Understood."

"Rely on your nurse at the triage desk, please."

He nodded and left, and a minute later, Mary came in. I advised her what had happened, asked her to monitor closely and come get me if there were any changes or when the neurology Resident arrived, and then returned to Mr. Firth's room.

"Sorry about that," I said.

"Is your other patient OK?"

"I stopped the seizure and I have two people with him now, waiting on a neurologist. I'm going to put your EKG in continuous print mode to see if it picks up anything. Other than that, I need to see the lab results because from every sign I have, you're in excellent health for any age, let alone nearly seventy. I should have asked before -- are you taking any medications?"

"A daily baby aspirin which my doctor recommended and prednisone for arthritis."

"Any side effects from that?"

"None that I'm aware of. My doctor ran a bunch of blood tests about a month after I started them ten years ago, then every year since. He said there were no effects on my blood sugar, and none on my bone density."

"Good. No mental confusion?"

"Depends on who you ask!" he chuckled. "I have trouble remembering things on occasion, like where I left my car keys, but otherwise, no."

"I have trouble remembering where I left my car keys at times," I chuckled. "So that might be related to our Y chromosomes!"

"It's testosterone," Mrs. Temple said.

I chuckled, "A friend of mine said all men are suffering from testosterone poisoning."

"She's not wrong!" Mrs. Temple agreed.

"I'm going to check on my other patient, but I'll be back in a few minutes."

I left the room and went to Mr. Firth's room, where nothing had changed. The Resident from neurology arrived while I was reviewing the EKG which showed no abnormalities.

"Cohen, Neurology," a female PGY1 said, coming into the room.

I glanced at her name badged, "Hi, Rebekah, I'm Mike Loucks. This is Mr. Firth, early twenties, brought in after a bar fight. His vitals were normal, but he had significant trauma to the face, with contusions and minor lacerations. He fell and injured his nose. EtOH was 0.19 on admission, down to 0.15 on a repeat test. On a banana bag. 4 megs of lorazepam IV push resolved the seizure. Left pupil is blown, right is sluggish."

"Let me do an exam," she said. "Did you do a Babinski?"

"No," I replied, silently cursing myself for not thinking of that.

She did the exam, including the Babinski, which thankfully was normal.

"I'd say subdural hematoma," she said. "We need to get a CAT scan and I'll take him. Let me call and get authorization for the test and to take someone with high levels of EtOH on our service."

She went to the phone and dialed an outside line, which didn't surprise me, as her Attending wasn't required to be in the hospital overnight. She explained the situation, answered a few questions, then hung up.

"Doctor Baker says I can run the CAT scan and take him on our service," she said. "He'll come in once the CAT scan results are available."

"Let me call for an orderly. Do you have a med student?"

"Fourth Year, who is on the ward."

"OK. I'll have one from the ED go with you to assist."

"Thanks."

We made the arrangements, and I borrowed Naveen's Third Year to go with Mr. Firth, then sent Mary back to the triage desk and Tom rejoined me while I went to report to Doctor Mastriano who listened to what I said, then dismissed me.

"Jesus," Tom said. "What the fuck?"

I shrugged, "I have no clue."

I had some ideas, but I couldn't express them to a medical student. I had to take it to either Doctor Taylor or Ghost. We returned to Mr. Temple's room. I reviewed the EKG and saw my first hint of what might be wrong.

"Mr. Temple," I asked, "did you feel your heart flutter or feel faint about six minutes ago?"

"No. Why?"

"The EKG shows a brief period of atrial fibrillation, which could cause a near-syncopal or syncopal event, that is, cause you to become light-headed or even faint. Have you ever seen a cardiologist?"

"No, never had trouble with my ticker at all. How bad is it?"

"One brief period, especially in someone over sixty-five, is pretty ordinary. It's a fairly common thing, and is only treated medically if it's constant or severe. It's not something to worry about at this point, but you should see a cardiologist to confirm, no matter what we find tonight."

"Why see a heart doctor if it's not serious enough to treat or worry about?" he asked.

"Because he's a smart doctor, Jon!" Mrs. Temple said. "Why take a risk when all it'll cost you is a $20 co-pay?"

"To expand on your wife's comments, it's something a cardiologist will monitor because it can get worse. The cardiologist might well simply have you see your primary care physician to manage this, if anything needs to be done, which, at the moment I don't believe is necessary."

"So that caused me to faint?"

"It could be," I replied. "But I can't know for sure because it could have been a drop in blood pressure, low blood glucose, or a number of other things. Once I see the results of the blood work from the lab, I'll have a much better idea. Do you eat many sweets?"

"Hard candy, but not a lot, why?"

"A spike or dip in blood sugar levels can cause light-headedness. Do you happen to know your blood glucose or Hemoglobin A1C levels?"

"No. I know my doc ran those tests, but all I know is he said they were normal."

"Just try to relax and I'll be back in about twenty minutes with the test results."

"Thanks, Doc."

XII. The Patient Is Our Focus

July 4, 1989, McKinley, Ohio

Mr. Temple's lab results came back and, as I'd suspected, showed absolutely nothing outside the normal ranges for a man of his age. I updated the chart and added some diagnostic notes.

"Now what?" Mr. Temple asked.

"We'll keep you until 6:00am to monitor you, but if there are no signs of problems on the EKG or with your vitals, we'll send you home and you should follow-up with your personal physician. He or she can get your records from the hospital and take it from there. I'll also write a referral to a cardiologist so Medicare doesn't give you grief. If you like, I can turn down the lights and you can try to get some rest, though someone will come check on you regularly."

"Could I get something to drink?" he asked.

"We're fresh out of Scotch," I replied. "But I'll have the nurse get you some ice water or orange juice."

"Orange juice, please."

"Someone will bring that to you right away."

Tom and I left the room and went to the nurses' station where I asked Jackie to see that Mr. Temple received a bottle of orange juice and to take vitals every thirty minutes.

"Is that on the chart, Doctor?" she asked.

"It is," I replied. "Well, not the juice, but the vitals."

She laughed, "Which is, of course, what I meant. I'll note the juice when he drinks it."

"Thanks. Is Doctor Varma still busy?"

"Three patients," she said. "One admission and two monitoring."

The dispatch phone rang, and she picked it up, wrote notes on her notepad, then hung up.

"EMS four minutes out with an MI."

I looked up at the board, "Trauma 2 is free, have a nurse meet us in the ambulance bay, please. Tom, let's go."

We gowned and gloved and headed to the ambulance bay.

"I've never had ten hours like this," he said. "All last month, it was mostly calm overnight."

"I had a few nights like his during my clinical rotations, but they weren't all that common. We are seeing more visits overall since EMTALA passed, but that's not really responsible for overnight. The hospital expansion will barely keep up with the demand at the rate we're going."

"Then what?"

"Waiting times increase, as they are in New York City, Chicago, and LA, and to a lesser extent, Cleveland."

Nurse Kelly came out to the ambulance bay to join us.

"Kelly, I'll want a trauma panel, cardiac enzymes, and blood gas," I said. "Tom, 12-lead EKG and monitor, then Foley if the patient is unconscious."

Both of them acknowledged my orders and a minute later, the ambulance pulled up.

"Leroy Gibson; fifty-nine; working third shift at the water treatment plant; complained of severe chest pain, then collapsed; tachy at 120; BP 80 palp; PO₂ 93% on ten liters; diaphoretic and non-responsive. Saline IV TKO."

"Trauma 2! Tom, cardiology consult first."

"Got it!"

We rushed Mr. Gibson into Trauma 2 and the five of us moved him to the treatment table. Tom called for the cardiology consult while Kelly switched the oxygen feed and I listened to Mr. Gibson's heart and breathing. Tom finished the call and came over and began cutting away Mr. Gibson's shirt, then attached the EKG and pulse oximeter.

"What do you see?" I asked when he turned on the machine.

"It's not a sinus rhythm," he said. "But I don't know more."

"ST elevations," I said, pointing to the phosphor line on the monitor. "STEMI. Kelly, given his estimated weight, 350 megs ASA IV push."

"ASA 350 megs IV push," she repeated.

"Tom, put in the Foley, please."

"I've done exactly one," he said.

"Then you know how. I'll watch and correct anything you've done wrong."

"What size?" he asked.

"Try 18 French," I said. "But cut away his pants and underwear before you get the catheter, as he might not be average in size."

Tom cut away the clothing, I estimated my judgment had been correct, and told Tom. He retrieved the correct Foley and did a competent job of inserting it without need for correction.

"Urine in the bag," he said. "Light yellow, no pink tinge."

"OK. What would you do next?"

He shook his head, "I don't know. You gave him an ASA bolus, he's breathing on his own even if his PO₂ is a bit low and short of an angiogram, I don't know what to do."

"That's it, actually. Cardio will take him and do exactly that, though they might do a cardiac echo instead or in addition. We've done what we can -- he has a heartbeat, is breathing, and has the monitor."

"Shore, Cardiology," a PGY1 with a female Third Year medical student I didn't recognize in tow.

"Hi, Patrick," I said, looking at his name tag. "Mike Loucks. We have Leroy Gibson, fifty-nine; working third shift; complained of severe chest pain, then collapsed; tachy at 120; BP 80 palp; PO₂ 93% on ten liters by mask; diaphoretic and non-responsive. EKG shows classic STEMI. ASA 350 megs IV push; Foley is in with urine in the bag."

"He needs to lose about forty kilos," Doctor Shore said, as he examined Mr. Gibson.

"At least," I agreed.

"Nicki," he said, "call upstairs and tell them we need the cath lab and an Attending."

"Yes, Doctor Shore!" she said, going to the phone.

"I'll take him," he said. "Did your Attending sign off on the chart?"

"No," I replied. "I'm authorized to handle MIs. You can verify that with Doctor Strong or any of the other senior Residents or Attendings. Who's your Attending?"

"Doctor Blackburn."

"He's new, so he might not know, but if he has questions, he can call Doctor Bielski or Doctor Getty to confirm."

"I need the signature."

"OK," I replied. "Let me go wake up Doctor Mastriano. Tom, switch to a portable monitor and stay with Mr. Gibson until he's in the cath lab. I'll be right back with the chart."

I left the trauma room and knocked on the door to the Attendings' office, waited fifteen seconds, then opened the door.

"What?!" Doctor Mastriano asked without getting up.

"Cardiology won't take my STEMI without your signature."

"You're authorized."

"You explain it to the PGY1 cardiologist and his new Attending who wasn't trained at Moore Memorial, because they insist on you signing off."

"Give me the short version."

"Morbidly obese fifty-nine-year-old male complained of severe chest pain, then collapsed at work. EKG shows classic STEMI. ASA IV push."

"Give me the chart," she demanded.

I did, she sat up, took off her sleeping mask, scribbled her approval below my admission note and handed it back. She put her sleeping mask back on and reclined again, so I left without a word and returned to Trauma 2.

"Signed off," I said, handing the chart to Doctor Shore.

"Then let's go!"

We transferred Mr. Gibson to a gurney and Doctor Shore, Nicki, and Tom left to take him to Cardiology. I updated the board, then went to the lounge to get a bottle of water. I considered coffee and decided to pour myself a mug. I drank the bottle of water down, then took my mug of coffee with me to triage.

"Nothing, I see," I said, seeing an empty waiting room.

"Doctor Varma took the last patient about five minutes ago."

"OK. At 0600 you'll switch with Nanette, Doctor Varma's Fourth Year."

"What happened to the man with the syncopal episode?"

"He had one short run of A-fib, but everything else is normal. Smoker's lung, though he quit twenty years ago."

"Wait, if he quit..."

"A pack a day from age fifteen to age fifty," I said. "The damage is often permanent. If he hadn't quit, he'd be in far worse shape, assuming he was still alive. We'll monitor until 0600 then street him if nothing changes. I'll refer him to his personal physician and a cardiologist, but this could be something as simple as a brief bout of vertigo because he had a slight, undetectable viral infection."

"Common cold?"

"Yes. But that's just speculation, as I didn't find any symptoms or signs except the crackles in his lower lungs. He may have had a bout of A-fib when he got out of bed, might have stood up too quickly and had his BP drop, or any number of things, none of which we can justify looking for in the ED. His personal physician is best qualified to manage any testing and investigation in consultation with specialists as necessary."

"And right there is why I don't want to be a trauma specialist. It would drive me nuts."

"Me, too! And it's a VERY short drive! But this is what I've wanted to do since fourth grade. And I've had several doctors remind me of that 'feature' of my chosen speciality because it bugs the heck out of me."

"So why do it?"

"I like the adrenaline rush," I replied. "It's my drug of choice!"

Both Mary and Nurse Bonita, who was taking a few hours at the triage desk, laughed.

"Fourth grade?" Mary asked.

I explained the playground incident and how that had set my course for the rest of my life.

"I didn't decide on medical school until halfway through college when my biology prof at Bowling Green suggested it," Mary said.

We were interrupted as Deputy Schmidt came into the waiting room. Mary buzzed him through, and he came over to the triage desk from the inside, rather than the waiting room side.

"I had to admit your victim," I said. "He had a seizure and neuro took him."

"Well, shit. We did grab the other two dirtbags, and I do have the bartender's statement."

"No security cameras?"

"Outside only, nothing inside. But one of the guys we grabbed has hand injuries consistent with being in a fight. Any idea what happened with Mr. Firth?"

"I could only speculate. If you go up to neuro, they can give you more details, but I doubt he'll be able to give a statement any time soon, or perhaps ever."

"He could die?"

"Yes."

"Then we'll hold the scumbags on attempted murder charges, which means we keep them locked up unless they can raise bail."

"Four white guys?" I asked.

"Yep. According to the bartender, Dirtbag #1's girlfriend talked to the vic and Dirtbag #1 and his friends took exception."

"Someday this racist BS is going to stop," I said. "And that day can't come too soon."

"Don't hold your breath, Doc. This bar has Confederate flags on the walls."

I shook my head, "That's not the symbol of freedom from an oppressive government certain moronic elements think it is. I could see the Gadsden Flag, but the Confederate battle flag makes no sense. Anyway, at least the bartender is cooperating."

"Their liquor license is under supervision for serving underage on at least four occasions in the past two years."

"I'll keep my opinions of stupid laws to myself," I chuckled.

Deputy Schmidt laughed, "And you just gave your opinion! Anyhoo, I'll go up to neurology and see what they have to say. Thanks for taking care of Sam earlier."

"You're welcome. I take it you heard the shooter survived, but is in critical condition."

"Yeah, he'll spend a long time breaking rocks for shooting at a deputy. The County Prosecutor will throw the book at him. The sick part is that he'd probably have been able to plead out the drug rap and get off with a short stint in the county jail. Now he'll do hard time."

"What pills?"

"A whole pharmacy! Uppers, downers, you name it. And a kilo of pot."

"Mule?"

"Good guess. He was coming up from Eastern Kentucky on his way to Columbus."

"Harlan County?" I asked.

"OK, how did you know that?"

"A fellow med student is from Harlan County and told me about it, and another of my fellow students Matched at a regional medical center there."

"Who the heck volunteers to go there?"

"Well, the one who was from there wanted to go back to serve her community; the other one didn't Match last year and took anything she could find."

"Washed out?"

"No, she graduated, but had some personal problems that blocked her from Matching to any of the hospitals of her choice. This time she cast her net as wide as possible to Match."

"Makes sense. I'd have taken a job with any department who would have hired me for my first job, even with one of those Southern cracker J. W. Pepper sheriffs!"

I laughed, "Live and Let Die and The Man With the Golden Gun! Maybe a bit of Buford T. Justice."

"Smokey and the Bandit? He was just incompetent, not an asshole!" Deputy Schmidt retorted. "I need to get upstairs."

"See you later, Deputy," I said.

He left and as there were no patients, I went to the lounge and sat down for the first time since dinner, which had been about ten hours earlier. Tom returned from Cardiology and plopped down on the sofa next to me.

"He's in the cath lab. I returned the portable monitor to the alcove."

"Good. How are you holding up?"

"Fine. I've only been on ten hours or so. You've been on twenty-two, right?"

"Yes. And fourteen to go, though as I said, I'll duck out for four hours and Kylie Baxter, who went off shift at midnight, will cover for me."

"How long have you had your band?"

"Roughly four years," I replied.

"I need to get to a gig of yours. Got any lined up except later today?"

"We'll play at Taft in August and Stirred Not Shaken in September. We only took the one summer gig because of my schedule. We play school dances and clubs, and end up with about ten gigs a year, total. We'd play more, but we all have full-time jobs."

"Doctor Mike?" Nurse Becky said from the door to the lounge. "EMS ten minutes out with DUI MVA."

"How many?"

"Just the driver, per the dispatcher."

"OK. What's free?"

"Trauma 1 and 3."

"I'll take 3," I said. "I'll need a nurse, please."

"OK. Margie will meet you in the ambulance bay in a few minutes."

"Thanks."

She left, and I finished my cup of coffee.

"Wake Doctor Mastriano?" Tom asked.

"Let's see how bad it is first," I replied.

"How do you stay so calm? I feel like I'm about to have a panic attack every time I cover an EMS run."

"You're only five weeks into your first rotation," I said. "It's normal. By this time next year, you'll feel a lot more comfortable. The problem is that what you learn in the classroom is theory, and here the rubber meets the road. It's easy to do diagnosis in the classroom with no real pressure, but here, well, either you thrive on the pressure and get off on the adrenaline high, or you pick a different speciality. Don't sweat the feeling, just take it into account next Spring when you chose your electives. That said, you absolutely want a Sub-I in trauma, as it applies to every single specialty and you'll see a wide range of cases."

"You're like ice, though. I mean, totally unflappable."

"It's a personality trait," I replied. "Look at the other doctors in the ED who you admire. Are any of them emotional or wimpy?"

"No. You're all like automatons. Well, except for, never mind."

"You're entitled to your opinion, and I won't repeat it."

"Doctor Lewis seems awfully high strung," he said.

"And he'll either get past it or burn out and quit or switch to another speciality for his PGY2."

"People actually quit? After they Match?"

"They do. I heard about a PGY3 quitting at Cook County from Doctor Taylor. They literally just walked out of the ED one day, saying they quit, and ever came back."

"But that's seven years! Twelve if you count college! How do you not know?"

"Everyone has a breaking point," I replied. "I'd hit mine in pediatric oncology, which is why I want to stay away from there, period. Doctors who can do that for their whole careers are pretty amazing. I sure couldn't."

"Why?"

"I couldn't deal with kids dying on a regular basis, or worse, some ways, telling them they're going to die and you can't do a damned thing about it. Let's go meet the ambulance."

We left the lounge, gowned and gloved, and went to the ambulance bay.

"But people die in the ED," he said.

"Yes, they do, but nearly all of our patients leave here alive, or with a chance. In oncology in general, and pediatric oncology specifically, most of their patients are dying and are likely to die. At least here in the ED I have a fighting chance to do something other than administer IV poison in doses just low enough to not kill the patient in the hopes it'll kill the cancer cells. It's barbaric, but we don't have any better options. Radiation therapy isn't much better -- microwave the tumor or whatever in the hopes you can kill it before the patient dies from radiation sickness or other organs fail. The only thing worse is psychiatry."

"How so?"

"Whereas oncology is barbaric, it's modern, while psychiatry is medieval and cares more about docile patients than anything. A close friend of mine, well, more, because she was a girl I intended to marry, was diagnosed with schizophrenia while we were undergrads and the treatment she received is right out of the Soviet psychiatric hospitals -- drug them into docility and lock them away. The only reason she's not institutionalized is because I've fought tooth and nail to prevent it. And that has taken serious resources and good lawyers."

"Becky said you needed me," Nurse Margie said, coming out into the ambulance bay.

"Yes. DUI MVA, so trauma panel plus EtOH. Tom, EKG plus monitor, then Foley if the patient is unconscious. I'll intubate if necessary and conduct a primary exam."

The ambulance pulled into the driveway and came to a stop in front of us.

"Kimberly Bond, nineteen, unbelted driver; alcohol on her breath and open container in the car. Hit a telephone pole at low speed. Incoherent, but conscious; tachy at 115; BP 100/70; PO₂ 98% on nasal canula; resps labored at 20; multiple contusions; head hit the windshield; fractured left wrist; possible internal injuries; IV saline TKO; no meds as she's feeling no pain."

"Trauma 3," I said as the five of us moved off. "Tom, do the Foley once you have the monitors hooked up."

"Do you need help, Mike?" Nurse Becky asked.

I considered, "A second nurse would help, but I don't need another doctor right now."

"Julie will be right in."

Five minutes later, Ms. Bond was connected to the various monitors, but I forewent the intubation as she was breathing on her own. I did have Tom put in a Foley, and when nurse Julie came in, she assisted by covering the patient with a sheet and then scribing as I continued my exam.

"I think we need a neuro consult," I said. "And orthopedics, but I suspect she's bleeding internally. Margie, would you get the portable ultrasound, please?"

"You aren't going to call the surgical Resident?" she asked.

I smiled, "See these red scrubs? I am the surgical Resident!"

And I was going to make use of that by simply calling up to get Ms. Bond an ex-lap if I felt she needed one, rather than bothering the on-call surgical PGY1 for a consult who would have no more experience or skills than I did.

"Right away, Doctor."

"What do you see on the EKG, Tom?" I asked.

"I think this is V-tach."

I nodded, "Yes. But it's not high enough to warrant intervention just yet. Why is her BP low?"

"Alcohol impairment or blood loss, possibly both. That's why you want the ultrasound."

"Yes. Julie, get me a unit of plasma, please, and type and cross match. Surgery will need to know that."

"Hang the plasma?"

"No, just get it on the stand. If I see fluid in her belly, we'll give her the blood. Everything else, except her wrist and forehead, are superficial."

"Hi again, Doc," Deputy Schmidt said, coming into the trauma room.

"Are you the only guy working the entire county?" I asked.

He laughed, "No, but they knew I was here and asked me to arrest the driver."

"Consider her under arrest, but I hope you'll forego the cuffs. She's likely going to need surgery."

"She doesn't look like she's going anywhere, so no problem."

"Soft restraints if we need them," I said to Tom and Julie.

Margie returned with the ultrasound and after we set it up, she squirted gel onto Ms. Bond's stomach and I put the transducer against Ms. Bond's skin and moved it around.

"Fluid in Morison's pouch," I said. "Surgical case for sure. Run that unit in, please, Julie."

I handed Margie the transducer and went to the phone and called the surgical scheduling nurse while Julie connected the plasma bag to the IV.

"This is Mike Loucks in the ED. I have a surgical case I'm sending up for an ex-lap after an ultrasound exam showed fluid in Morison's."

"On whose authority?" she asked.

"Mine," I said. "I'm a surgical Intern. We'll bring her up in about five minutes. She's stable, with minor V-tach, but also inebriated. She can't wait, though."

"I'll have to check with Doctor Blake."

"Do that, but we'll be there in five minutes."

I hung up and turned to the team, "Portable monitor and portable oxygen, please."

"Orderly?" Margie asked.

"Tom and I will take her up," I said. "I don't think we should wait."

I quickly wrote my own consultation notes on the chart, signed it, and then we moved Ms. Bond to a gurney. Tom and I moved her from the trauma room to the elevators, and two minutes later were outside OR 1.

"Causing trouble already, Mike?" Doctor Blake asked.

"Hey, if Doctor Cutter insists I'm a surgical Intern, and I have the red scrubs and the S on my badge, I'm going to act like a surgical Intern!"

"What do we have?"

I ran through the report, including vitals and my findings with the ultrasound.

"EtOH levels?"

"They'll be ready in about five minutes. I'll have them call the OR so the gas passer knows what he's dealing with."

Doctor Blake laughed, "Painless?"

"I liked the movie and the TV show!"

"Give the chart to Ben. Can you scrub in?"

"No. We're a bit short in the ED, with just Doctor Varma and me working."

"Who's the Attending?"

"Mastriano."

"Say no more," he said, shaking his head. "We have this. Good catch, Mike. I'll let you know how it went."

"Thanks, Doctor Blake."

"Bill, please."

I nodded, handed the chart to Ben, a Fourth Year, then Tom, and I left to return to the ED. When we arrived, I called the lab and instructed them to call OR 1 with the EtOH levels and send the rest of the labs up when they had them.

"We have the level," he said. "It just came up. 0.22."

"OK. Call that up to OR 1, please. She's about to have an ex-lap."

"Will do."

I hung up and made notes in my notebook as I didn't have the chart to update.

"You cut at least fifteen minutes off the normal time in the ED," Margie observed, coming over to us.

"That's one point of the new trauma surgeon specialty," I replied. "Another is being able to do chest tubes, pericardiocentesis, central lines, and other things that usually require a surgeon. I can't do them all yet, and it'll be a few years, but long-term, we should dramatically improve patient care. I suspect, ultimately, that at least half of all trauma specialists will follow this new path.

"The other change that I'm sure you've heard about is that EMS paramedics are being trained to perform intubations and read EKGs, as well as eventually do chest tubes. And all of us will do ride-alongs that coincide with the training of the EMS paramedics in the ED. We should seriously improve patient outcomes will all of these changes."

"Mike?" Nurse Becky called out. "A deputy is bringing in an arrestee with a dog bite to the arm. They'll be here in about ten minutes. Doesn't sound serious."

"OK. Call me when they arrive, please, and put them in an exam room."

"I'll put them in Exam 5."

"Thanks."

She left, as did Margie.

"What do you think Doctor Blake meant by what he said about Doctor Mastriano?"

"I think she has a reputation and given she's an Attending, I think we should let the Attendings deal with it. I've stuck my nose a few places and had it figuratively whacked with a rolled-up newspaper."

"It doesn't seem to have hurt you."

"No, but it could have," I replied. "It's simply a matter of following protocol. I'll let either Doctor Gibbs or Doctor Gabriel know what happened, and if anything needs to be said, they'll say it."

"So you say less as a doctor than you did as a medical student?"

"Let's just say that my advice is to follow my medical example, not my philosophical or political example. I had a penchant for tilting at windmills, and it took a dozen or so rolled-up newspapers to bring me to a point of being pragmatic and practical. It's more about the approach I take, rather than what I say or don't say, and that's what I'm trying to convey, albeit poorly, apparently."

"No, I understand it, I was just surprised by the fact that you say less from a position of relative power than in one where you totally depended on the approval of the people who you were speaking with."

"I learned. Everyone has different things to learn or change about themselves to become a good physician, beyond medical knowledge. Figure out what it is you need to learn or change, then do it."

"Good advice; now I just have to figure out what it is."

"That's the challenge."

We sat quietly for several more minutes, then Becky came to the door and let us know the deputy was here with his prisoner. Tom and I went to Exam 5.

"Hi, Deputy Foster," I said, looking at his name tag. "Doctor Mike Loucks."

"Hi, Doc. K-9 bite on his right arm during a raid on his farm a few hours ago."

"Let me take a look," I said. "Are the dog's shots up to date?"

"Completely."

"I'll need you to take the cuffs off," I said. "At least from the arm I need to examine."

"Stand up, Weisz," the Deputy said to his prisoner.

Mr. Weisz stood up and turned so the Deputy could remove the handcuffs, though he only removed the right cuff, then attached it to the railing on the treatment bed. It wasn't ideal, but I could work with it.

"Tom, bandage scissors, please."

He got them from a drawer and handed them to me.

"I need to cut away your sleeve, Mr. Weisz."

"Just do it."

I did and saw what was clearly a superficial bite.

"Could I get your full name and age, please?"

"Jim Weisz, thirty-six," he said.

"Tom, start the chart, please," I said.

"Mr. Weisz, have you had a recent tetanus shot?"

"Last year."

"Are you taking any medications?"

"No."

"Using illegal drugs of any kind?"

"I'm not saying shit in front of the deputy."

"I'm not asking specifics, just 'yes' or 'no', and if you've used anything in the past twenty-four hours."

"Never get high on your own supply," Mr. Weisz said.

He was quoting Scarface, a movie I'd never seen, but I knew the line.

"I'll take that as a 'no'," I said. "The wound is superficial, so we'll clean it, apply a topical antibiotic, and then a sterile dressing. You'll need to have the wound checked in seventy-two hours."

"He'll be in our lockup," Deputy Foster said. "Or the Feds might have him. There might be federal firearms charges."

"I'll give you instructions, which I expect the Sheriff to follow," I said firmly. "If the Feds have him, then it's on them."

"I'll make sure the duty nurse at the jail gets the paperwork," Deputy Foster said.

"Tom, saline, an irrigation basin, a tube of triple antibiotic, gauze, and an Ace bandage, please."

Tom got the things from the cabinets and drawers while I washed my hands. I irrigated the wound, applied the triple antibiotic, which consisted of neomycin, polymyxin B, and bacitracin, then wrapped the wound in gauze and secured it with an Ace bandage. I updated the chart, filled out a blank discharge form, and gave it to the deputy.

"He needs to keep it clean and dry," I said. "The Ace bandage should keep it in place and clean, but it'll need to be wrapped if he's going to shower."

"What am I? A sack of potatoes?" Mr. Weisz asked.

"If you're in the lockup, you're not going to be able to care for yourself, and that means this deputy will convey the information to the nurse at the jail. She can't take your word for it. If you need a doctor, she'll call one, but your wound isn't serious. You're all set."

"OK to cuff him?" Deputy Foster asked.

"It'll need to be in front," I said. "And don't tighten the cuff too tight on his right wrist."

"Stand up, Mr. Weisz," Deputy Foster said.

Mr. Weisz complied, Deputy Foster re-cuffed him, with hands in front, instead of behind, picked up the discharge papers, and then marched Mr. Weisz out.

"I don't get it," Tom said once they were out of the room.

"What?" I asked.

"You have a reputation as a soft touch and are always on the patient's side, but in this case, you weren't."

"We insist they remove handcuffs if they interfere with patient care," I said. "In this case, it didn't. Given there was no way I could admit Mr. Weisz, and nothing I could do to improve his situation except have the cuffs in the front, I did what I could. Had he been more seriously injured, I'd have insisted the cuffs be removed completely and would have handled things differently."

"Innocent until proven guilty?"

"Yes, of course, and if I were on a jury, they'd have to prove it to my satisfaction. But this isn't that. I have very little sympathy for people who sell drugs, and, to be honest, I'm tired."

"And you still have over twelve hours to go, right?"

"Yes. And with no sleep overnight, it's unlikely I'll get any before the end of my shift."

"Do you think it will change because of what happened in New York?"

"I think either the medical profession will change things or we'll be forced to change, and I'm not sure which will win out -- preservation of relative autonomy or resistance to change. Even scientific ideas are often resisted. I'm sure you remember the primary example."

"The doctor who discovered that washing our hands and changing clothes cut infant and maternal mortality?"

"Doctor Ignaz Semmelweis," I replied. "Part of the problem was that he wasn't tactful in how he presented the information and thus met resistance. Several doctors have reminded me of that over the course of the past four years. Fast forward and there's resistance to my Residency, and a significant turf war is underway, but look at what happened with the MVA who needed an ex-lap. We cut somewhere between ten and twenty minutes from the time she presented until she was in the OR. That can be the difference between life and death."

"I heard you came up with this idea."

I chuckled, "I wish, but also I don't. Had I actually come up with it, I doubt I'd have made any headway. I cribbed it from a doctor who implemented it at Indiana University Hospital, and later at the University of Chicago Hospital, where he's Chief of Emergency Medicine. He tried to recruit me to the medical school at Indiana University, then encouraged me strongly to apply to Match in Chicago with him."

"That's a prestigious hospital; why not go?"

"Because I want to serve my community," I replied. "I was born and raised one county over, and I'd actually have preferred Matching at the hospital there, but they aren't a teaching hospital. It's also the case that my family and closest friends are all in Southern Ohio, and I needed the support system after my wife reposed."

"What's that word?"

"Reposed? It's the word Orthodox Christians use when someone's mortal life ends because death has no actual power over us, and because the believer is alive in Christ, in eternal union with God."

"Mike?" Nurse Peggy said, coming into the lounge, "EMS four minutes out. Car versus bicycle. They say it's bad."

"Wake Doctor Mastriano," I said.

"She gave express instructions..." Peggy protested.

"And I'm overriding them," I said, interrupting her, "If she has a beef, it's with me. Wake her. What room is available?"

"Take your pick, the trauma board is clear."

"Trauma 1, then," I replied. "Tom, let's go. Peggy, two nurses, please."

"Bonita and me," she replied.

The three of us left the lounge. Tom and I gowned and gloved and Peggy went to wake Doctor Mastriano. It was 5:40am, so only twenty minutes from her 'do not wake me up until' time, and frankly, I didn't give a damn if she was upset or not. I'd heard about lazy and indifferent Attendings, but I'd never run into one. Residents tended to be all over the map, but an Attending had passed their Boards, was licensed, and had survived Residency. There were doctors who were, in effect, eternal Residents, who were not 'good enough' to become Attendings, but Doctor Mastriano had demonstrated to somebody that she was qualified.

"Tom, a lot will depend on how bad this is, but I'm likely going to need to intubate. Your job is to get the EKG and monitor going, then take the blood draw to the lab. Don't wait for anyone to tell you. If I change my mind, I'll tell you."

Peggy and Bonita joined us, both gowned and gloved.

"Doctor Mastriano is awake," Peggy said.

"OK. Bonita, stat trauma panel, and type and cross match. Tom will take the blood to the lab. Peggy, Foley, and then blood if we need it."

They both acknowledged my orders, and a minute later the EMS squad turned into the driveway and pulled up in front of us. Bobby jumped out and called out the vitals.

"Female, approximately twenty, hit-and-run while biking; pulse 120 and thready; BP 80 palp; lungs are compromised, PO₂ 91%, hard to bag; serious head injury; left arm and left leg fractured; GCS 3; IV saline TKO; cervical collar and backboard."

"Trauma 1!" I ordered.

We rushed the patient into the hospital and into the Trauma room, where Doctor Mastriano was waiting. I repeated the vitals as we moved the young woman to the trauma table.

"Doctor Mastriano, primary assessment, please," I said. "I'm going to intubate. Let's go, people!"

Everyone sprang into action, in what to an outside observer would appear chaotic, but which was actually a carefully choreographed ballet. Two minutes later, the patient was intubated, the EKG and pulse oximeter were attached, the Foley was in, two units of plasma had been hung, and Tom was on his way to the lab with the blood.

I was most concerned about the head injury, but it had to wait until we completed the assessment of the patient's internal injuries. There was blood in the urine bag, and her chest injury was impacting her breathing, and unless we controlled the internal bleeding and resolved the respiratory problems, she wouldn't live long enough for neuro to do anything.

"Bonita, ultrasound, please!" I ordered.

"No," Doctor Mastriano said. "Call for a surgical consult."

"I'm a surgical intern," I countered. "Bonita, get the ultrasound."

"And I'm an Attending. Do NOT touch the ultrasound. We need a surgeon."

"Bonita, get the unit," I said. "I'll make the call."

We'd waste precious minutes while someone came down from surgery, so I chose to interpret Doctor Mastriano's orders in the way most favorable to the patient.

"Hi, this is Doctor Mike in the ED. I need Doctor Roth or Doctor Cutter to authorize me to perform a surgical assessment."

"One minute," Nurse Penny said.

"Doctor, that is NOT what I told you to do!" Doctor Mastriano growled.

I put the phone on speaker and a few seconds later Doctor Roth came on the line.

"What's up, Mike?"

"You're on speaker. Car versus bicycle, significant internal injuries. I want to do the surgical assessment but Doctor Mastriano insisted I all for a consult."

"Doctor Mastriano," Doctor Roth said. "Mike is qualified and it'll save at least five minutes. He's authorized. Mike, call and let us know if you're bringing her up."

"Will do," I replied.

I pressed the button to disconnect the call and moved back to the trauma table as Bonita came in with the ultrasound.

"Doctor..." Doctor Mastriano said.

"Not now," I replied. "The patient is our focus. You can chew me out later if you feel it necessary."

Bonita squirted gel onto the patient's abdomen and chest, and I did not like what I saw at all. She had several broken ribs in a classic flail chest, and her heart and lungs were both compromised by those injuries.

"Fluid in the pericardium," I announced. "And in Morison's. Peggy, Bonita, splint the arm and leg, and let's get her up to surgery."

While they did that, I went back to the phone and dialed the surgical scheduling nurse. I gave her the details, and let her know we'd be up immediately. Tom had returned and assisted preparing the patient for transport. A minute later, Tom, Bonita, and I rushed the patient out of the trauma room and headed for the elevators.

"HOLD THAT ELEVATOR!" Tom called out, seeing people about to get on.

As per protocol, one person pressed the hold button while the other three moved out of the way. Two minutes later, we were outside OR 3 where Doctor Blake was waiting.

"What do you have for us, Mike?" he asked.

"Car versus bicycle," I said, then gave the vitals and the actions we'd performed.

"You and your student scrub in," he said. "I'll have you do the pericardiocentesis while Robert and I handle the ex-lap."

"OK. Tom, let's go. Just follow my lead, please."

We went into the scrub room where Doctor Robert Aniston, one of the new Attendings, was scrubbing.

"The famous, or is it infamous, Mike Loucks, right?" he asked.

"And my student, Tom Lawson. Nice to meet you."

"I'd shake your hand, but..."

"Yeah," I replied. "Tom, tear open a scrub pack. You did this for your Preceptorship, right?"

"Yes, but that was over a year ago."

I quickly ran through the steps to scrub, and he followed them. Five minutes later we were in the OR waiting for Doctor Kelsey from Anesthesiology to give the OK to proceed, which she did a minute later.

"I'll talk you through this, Mike," Doctor Blake said. "There's no time for fluoroscopy, so you'll need a cardiac needle with the electrical lead attached via alligator clip. Alice, syringe with a cardiac needle and lead to Mike."

"Bill," Doctor Aniston said, "I'm ready to open."

"Multitasking is my specialty!" Doctor Blake declared. "Go ahead, Robert. Mike, insert the needle between the xiphisternum and left costal margin, and direct it towards the left shoulder at a 40° angle to the skin. Go slowly, and as this is unguided, stop when you hear the warning tone, back off about 2mm, then aspirate. If you don't get fluid, advance the needle slightly and try again."

"Bill, tie off that bleeder," Doctor Aniston ordered.

I began the procedure, moving carefully with Doctor Blake splitting his attention between tying off bleeders and me advancing the needle. I got the tone and the cardiac monitor showed the heart reacting, so I backed off the needle and began aspirating.

"Blood in the pericardium," I said as the fluid began filling the large syringe.

"Pulse and rhythm improving," Doctor Kelsey announced.

"Keep going until the syringe is full," Doctor Blake said. "Then attach a valve in case we need to draw more fluid."

I did as instructed, handing the filled syringe to Alice , who put it in a tray and gave it to a circulating nurse to send down to the lab for analysis.

"Spleen is compromised," Doctor Aniston announced. "Complete resection. Liver lac, but it can be repaired. How's she doing, Jennifer?"

"Better," Doctor Kelsey confirmed. "But don't dawdle."

"Mike, we have this," Doctor Blake said. "Two more of these and we'll sign off on you doing the procedure in the ED."

"Somebody needs to let Doctor Mastriano know."

"Doctor Cutter will take care of that," Doctor Blake said. "You can scrub out."

"Yes, Doctor."

"Bill," he prompted.

"I'll get the hang of it eventually," I said.

Tom and I left the OR, changed into clean scrubs, then headed back to the ED, where an angry-looking Doctor Mastriano was waiting.

XIII. A Long Night during a Long Shift

July 4, 1989, McKinley, Ohio

"I need to discharge Mr. Temple," I said to Doctor Mastriano.

"Do that, then come to my office."

"Yes, Doctor," I agreed.

Mr. Temple had not had a repeat of his syncopal event, nor had he experienced additional bouts of A-fib, so I wrote out the cardiology referral to keep Medicare happy, completed the discharge papers, directed him and his wife to Patient Services, then went to the Attendings' office where Doctor Gabriel was with Doctor Mastriano.

"Give us the room, please," Doctor Mastriano said to Doctor Gabriel.

"Morning, Mike," Doctor Gabriel said.

"Morning, Pete," I replied.

"Rough night?"

"Long, but I'm doing OK."

He left, closing the door behind him.

"If you EVER contradict me or undermine my authority again, I'll bounce you from this program so fast you won't know what happened."

I was tired, and I knew it, and that meant I had to be extra careful in what I said and how I said it, lest I allow fatigue to cause me to say or do something foolish.

"May I please suggest you take this up with Doctor Cutter and Doctor Northrup?" I requested. "My situation is different from all other trauma Residents because of my special program."

"You aren't special. You're a PGY1 and you have neither the experience nor the skills to make the judgments you're making."

"Which is why you slept all night and insisted that I not bother you?" I asked snidely, instantly regretting it.

"This is not about me, Loucks. You directly disobeyed my instructions."

"I'm sorry I mentioned you sleeping all night," I said, intending to twist the knife despite my earlier resolve to be careful. "But, Doctor, I didn't disobey your instructions. You instructed me to call for a consult, which is performed by a surgical Resident. I'm a surgical Resident, and Doctor Roth confirmed that I was authorized to make the assessment."

"You know very well that I meant to have the on-call surgical Resident come down, not to play word games. And then you disappeared for forty minutes!"

"Doctor Blake directed me to scrub in to help with the surgery."

"You're a fucking Intern! You don't touch patients in an OR!"

"I performed a blind pericardiocentesis under Doctor Blake's instruction, with the goal that I'll be able to do those in the ED."

"Not in MY trauma rooms."

"I don't know what to say beyond that you should take it up with Doctor Cutter and Doctor Northrup, or Doctor Gibbs, once she comes back on Friday."

"This is going in your file, Loucks. And I won't stand for a repeat."

"Yes, Doctor," I said, knowing an argument would do me no good.

"You are to confirm every single procedure with me."

"If you insist, I'll be happy to wake you to ask about giving a patient a Tylenol."

"You know what I meant!"

"I heard you say 'every single procedure', Doctor. I'm going to err on the side of caution to ensure there are no misunderstandings or misinterpretations."

"Don't be a smart ass."

"It's not being a smart ass. It's a proper response to being reprimanded for interpreting your instructions in a way you consider incorrect or insubordinate, but which benefitted the patient. May I be dismissed so I may speak with my mentor about this?"

"Doctor Casper is not here."

"No, but Doctor Taylor, is."

"What does he have to do with anything? Casper is your mentor."

"Not Josh Taylor," I replied. "Vince Taylor."

"He's a surgeon, not a trauma specialist!" Doctor Mastriano protested.

"Indeed, and the red scrubs and the 'S' on my badge indicate I'm on the surgical service. May I go?"

"Get out of here!" she growled.

I left and went to the nurses' station and called to see if Doctor Taylor was available. The nurse said he was just about to go into surgery, so I decided to go up and talk with him while he scrubbed.

"Hi, Mike! What's up?"

"Hi, Vince," I replied. "Doctor Mastriano basically put me on double secret probation because I followed the program set by Doctor Cutter."

"She's...no, I can't say that to you. Let me handle it with Doctor Cutter. Can you give me the nutshell in two minutes?"

"Yes."

I explained the events of the previous twenty-four hours, including the contradictory things Doctor Mastriano had said.

"Her shift ends right about now, doesn't it?"

"Yes."

"When are you on with her again?"

"I'm not sure of her schedule, but certainly next week, Monday."

"OK. Who's the senior Attending today with Gibbs out?"

"Brent Williams."

"Explain briefly what happened, and have him clear you to perform the procedures everyone has signed off on. Keep your comments about Mastriano neutral, please."

I nodded, "I will."

"OK. I'll get in touch this afternoon after I speak with Doctor Cutter."

I thanked him, left, and returned to the ED.

"You OK?" Tom asked.

I nodded, "Just part of the turf war, I think. I need to go see Doctor Williams."

I saw him in the Attendings' office, and decided to wait until Doctor Mastriano left before talking to him, so I went to the lounge where Mary was on the couch.

"How do I get off triage and get to work with you more?" she asked.

"There isn't much I can do about the policy," I replied. "Given EMTALA requires us to provide an exam and treat all emergent cases and active labors, we have to have someone trained in H & P handle walk-ins, where before it was done by the clerk, who now has other duties. There's a staffing problem with exclusively using nurses, and that's why more medical students are assigned to trauma now than in the past. Next week, for this shift, Doctor Varma's student will handle overnight, and you'll just have a two-hour shift during the day. Did that happen last month?"

Mary nodded, "Yes, but I also wasn't working with you. You're more willing to allow your students to do procedures than anyone else, and I want to learn."

"I'll do my best when you aren't on the triage desk, but I can't change that."

"It just sucks that Tom got to scrub in on the emergency surgery; no offense Tom."

"None taken," he replied. "But I also won't apologize!"

"Nor should you," I interjected. "Mary, I'll do my best to make sure you get procedures, and we should have plenty of opportunities today, if history means anything. If you'll excuse me, I need to see Doctor Williams. You two should get your breakfast now."

They left, and I found Doctor Williams in the corridor and asked to speak to him.

"I got an earful from Mastriano," he said.

"Vince Taylor in surgery suggested I speak to you about the restrictions Doctor Mastriano placed on me."

"Well, she's not here and if you come ask me about giving a patient Tylenol, you'll regret it!"

"Understood."

"Is it true she blew off a patient with a head injury?"

"She insisted, and wrote on the chart, that I was to wait for his EtOH level to drop before she'd consider any further actions beyond life support."

"He seized and herniated?"

"I didn't get a report from neuro, but that would be my impression based on what I know."

"That's going to be an ugly M & M if he's gorked."

"Yes, it will," I confirmed. "May I raise one other topic?"

"You never stop, do you?" he asked with a sly smile.

"No, which I suspect is part of Doctor Mastriano's problem with me. In any event, this isn't a request or even recommendation, but my Fourth Year asked about less time on the triage desk and more time doing procedures."

"Stop the presses! Breaking news! Medical Student wants more procedures! Film at 11!"

I chuckled, "You kind of mixed your metaphors there with print and broadcast media."

"You are a pain in the ass, Mike!" Doctor Williams declared with a grin. "A great young physician, but a major pain in the ass!"

"All part of my master plan for world domination!" I chuckled.

"I'd actually be OK you with you being Emperor of the World! You care too much about people to be an evil dictator!"

"I suggested you ask Rachel that question in about twelve years!"

Doctor Williams laughed, "I have an eleven-year-old daughter, and I'm positive she thinks I'm a cross between Genghis Khan, Attila the Hun, and Pat Robertson!"

"Two of those aren't so bad," I replied.

Doctor Williams laughed, "Let me guess, you think Robertson is the truly evil one in that trio?!"

"Let's just say that I have significant differences of opinion from the so-called Moral Majority."

"You and me both! And yet, I believe that's the main area of conflict with my daughter!"

"May I ask how old you are?"

"Thirty-three. We had Michelle as my graduation present from UofI. Not the best timing, but I'm very happy we have her. How is your daughter?"

"Asserting her newfound independence," I replied. "Her favorite word is 'no', followed closely by demanding to see her Aunt or her best friend."

"It doesn't get much better! Wait until she discovers boys!"

"Oh, she has, and has ZERO use for them!" I chuckled. "But that will change in about twelve years."

"Or sooner. My daughter decided they were interesting just before her eleventh birthday."

"Lord have mercy!"

"You can say that again!" he replied, then immediately said, "STOP!"

"What? " I asked with a 'What, me worry?' look.

"You were going to actually say it again! I could tell by the look on your face!"

"My reputation precedes me. OK to get my breakfast?"

"Yes. Make sure your students eat."

"I sent them to have their meal when I came to speak with you."

"When are you with Mastriano again?"

"I honestly don't know. I only looked at my schedule.

He pulled open a drawer and pulled out a calendar.

"Saturday," he said. "I'll speak to Doctor Gibbs and Doctor Northrup and let them decide what to do."

"Thanks, Brent."

"You're welcome. Naveen has walk-ins, so you're on trauma and monitoring as soon as you come back."

"OK."

I left the Attendings' office and hurried to the cafeteria where I got eggs, bacon, yogurt, toast, and coffee, then sat down with Mary and Tom, who were already eating.

"How much trouble are you in?" Mary asked.

"The usual amount," I replied. "It won't affect anything for the rest of this shift."

"Tom wasn't sure exactly what happened."

"Neither am I, in the sense that everything seemed more or less OK with Doctor Mastriano during my shift on Saturday."

"She slept all night?" Mary asked.

"I'd prefer we didn't discuss what Doctor Mastriano did last night," I said. "As I mentioned, there's something of a turf war between the ED and Surgery, and it's best if we all keep our heads down as best we can. I'm kind of stuck in the middle with a balancing act, and I need to let the Attendings and Chiefs fight this out and try not to be hit by friendly fire, so to speak."

"But the new specialty makes so much sense!" Mary protested.

"So did hand washing and the germ theory of disease," Tom interjected. "And I'm sure you remember that from Practice of Medicine."

"I just don't get it," Mary said, shaking her head. "Just because something is new doesn't mean it's bad."

"No, but what's the number one rule of thumb in medicine?" I asked. "Not what they taught you in Practice of Medicine, but in reality?"

"Go with what works," Mary replied.

"Exactly. So if something works, the system is designed to stick with it until it's proved that there is a better way. Sometimes that's easy, usually around pharmaceuticals. Sometimes it's difficult, such as with new surgical techniques. Can you tell me why?"

She thought about it for a moment, then nodded.

"Because the system is designed to protect physicians who follow a specific standard of care, and looks askance on variations from that standard, even if they're successful."

"Why?"

"To prevent a 'Wild West' environment where anything goes and there are no standards."

"Yes, and think about what that means for emergency medicine. What's different there?"

"You don't have time to think in many cases."

"Right. What do you know about succinylcholine and etomidate?"

"They're used for intubation," Mary said.

"Why?"

"Adverse effects are exceedingly rare, they're short-lived, and have standard dosage for adults."

"And the value of that?" I prompted.

"You save precious seconds and don't have to worry about contraindications."

"Correct. So if someone came up with a new drug, how would that be received?"

"Skeptically because what we have works and is very, very low risk."

"So even something that is somehow better would be difficult to adopt. Why?"

"Because the new benefits are unlikely to be sufficient to take the risk."

"Yes. And what mentality does that engender?"

"Semmelweis," she replied.

"Here endeth the lesson," I said with a smile. "We need to finish eating and get back."

"Sean Connery in The Untouchables?" Tom asked.

"Yes," I replied.

We finished our breakfast and headed back to the ED where Doctor Fitzgerald and Doctor Lews had come on shift alongside Naveen Varma and me, which was the normal daytime contingent of PGY1s, with Doctor Williams as the Attending and Doctor Gabriel as the senior Resident. The Attendings would work between twelve and eighteen hours, while senior Residents worked between eighteen and twenty-four, and the PGY1s, as much as thirty-six hours. The only doctor with regular hours was Doctor Gibbs, who, as the Chief Attending, worked between ten and twelve hours Monday through Friday.

"Mike," Doctor Williams called out, seeing us walk into the ED.

"Yes?" I inquired.

"Hand lac in Exam 6 if your student wants a procedure."

"Nah," I replied. "What med student ever wants more procedures?"

He laughed, "OK, because, not if."

"Mary, do you feel comfortable doing the procedure with Tom, explaining what you're doing and completing the discharge?"

"Yes!" she exclaimed.

"Then we'll all go in and I'll stand in the corner and observe. Introduce yourself as a Sub-Intern, but don't explain what that is unless asked. If they ask, you say it's a 'trainee doctor'. Introduce me as your supervisor, and Tom as a new student."

"Yes, Doctor!"

"Then let's go."

The three of us went to Exam 6, stopping at the door so Mary could review the chart which was in the holder on the wall.

"Forty-two-year-old male," she said. "Bagel-slicing accident; five centimeter lac on his palm with no tendon involvement and clean margins."

"Before we step in, what are you going to do?"

"Appreciate the wound; irrigate; inject lidocaine, probably times five; paint with Betadine; suture with 4-0 nylon; apply a clean dressing."

"Good," I confirmed. "Tom, what else?"

"Verify his tetanus. Mary should also ask about negative reactions to local anesthesia and allergies."

"Very good. I'll stand aside and only step in if I see something that concerns me."

We went into the room and Mary introduced herself, Tom, and me as I'd instructed. She proceeded exactly along the lines she'd suggested and did an excellent job suturing. Tom administered a tetanus shot, and then Mary discharged the patient.

"How does it feel to be a doctor?" I asked Mary after we returned to the lounge.

"That's the first time I was ever allowed to do everything from start to finish."

"And you did an excellent job. Write it into your procedure book and I'll sign it. Do one more like that, and I'll sign off for you to do them without observation. Tom, you'll get your chance before the end of the month as well."

"Thanks," he replied.

"Doctor Mike?" Nurse Ellie said from the door to the lounge. "EMS five minutes out with failure to fly."

"Thanks, Ellie. Which room?"

"Trauma 4. I'll send you Nancy."

"Thanks."

"Failure to fly?" Tom asked.

"Kid, usually between four and eight, almost always a boy, who fell out of a bunk bed or something similar," I replied. "Let's go."

Five minutes later, the EMS squad arrived.

"Danny Baldwin, six; fell from his bunk bed; BP 110/70; pulse 90; PO₂ 98% on room air; contusion on forehead; no other obvious injuries; unconscious for about two minutes; GCS 11 on arrival, 14 now; cervical collar. His parents are right behind us."

"Trauma 4!" I ordered, and we began moving. "Hi, Danny. I'm Doctor Mike and we're going to take good care of you."

"My head hurts!" he said.

"We'll do our best to fix that!" I said. "Mary, primary survey, please. Tom, pulse oximeter only."

"Trauma panel?" Nurse Nancy asked.

"I think we can dispense with that for the moment," I replied.

The four of us, plus the two paramedics, gently moved Danny to the trauma table.

"Danny, this is my friend Mary," I said. "She's going to check your eyes, ears, nose, and mouth, and listen to your heart and lungs. My other friend Tom is going to put a clip on your finger to measure how fast your heart is beating."

"Will it hurt?" he asked.

"No."

Mary, who already had on gloves, picked up the otoscope and put on a fresh speculum, and began her exam.

"No CSF in either ear; pupils reactive; nasal passage clear and free of fluids; throat clear."

"OK. Tom, Babinski, please. Danny, my friend Tom, is going to rub the bottom of your feet."

Tom did the test and reported his findings.

"Normal flexor, both feet."

"Indicating?" I asked.

"No spinal damage, but it's not definitive."

"Correct. Danny, I need to check your neck," I said. "I'm going to ask my friend Mary to hold your head and you need to keep very still."

"OK," he said.

Mary stabilized Danny's head, and I carefully loosened the cervical collar and appreciated his spine and neck muscles.

"No indication of trauma," I said.

"Everything OK in here?" Doctor Williams asked from the door of the trauma room.

"Just completing the primary exam, and about to remove the cervical collar."

"Proceed," he said. "Call me if you need me."

I removed the collar and asked Bobby to slowly turn his head from side to side.

"Does that hurt at all?" I asked.

"No, but it feels like somebody is pounding on the inside of my head."

"We'll give you some medicine to help. Mary, which analgesic?"

"Liquid ibuprofen or acetaminophen; I know your preference is for ibuprofen, so I'd go with that."

"Dosage?"

"OK to look in my book?" she asked.

"Yes. With kids, we always look it up because drug dosage and contraindications are different from adults."

She quickly paged through her notes, then said, "Estimate about 22 kilos, so 10 milliliters PO."

"Nancy, would you retrieve the ibuprofen for Mary, please?"

"Right away, Doctor."

"Mary, complete the exam, please."

She palpated Danny's abdomen, checked for signs of other injuries, then asked Danny about being in the hospital or going to the doctor, to which he said just for his shots.

"What's your diagnosis, Mary?" I asked when she finished.

"Mild concussion."

"And what would you do?"

"Monitor for two hours then release with instructions to see his family physician, and return if has dizziness, nausea, double-vision, or any other signs of neural compromise."

"And that contusion on his forehead?"

"Ice, as needed, if he'll tolerate it."

"What are you missing?" I prompted.

Mary thought for a moment, "I think that's it."

"Possible skull fracture?" I asked.

Mary frowned, "I should have thought about that. Skull series?"

"Maybe," I replied. "What would be my concern?"

"X-ray exposure. But don't we need to know?"

"It would be preferable, yes, but we need to discuss it with his parents, as well as find out if he's had other x-rays recently."

"What about the new CAT scan?" Tom asked.

"It uses ionizing radiation just like an x-ray," I said. "In fact, more. What we really need is one of the new Nuclear Magnetic Resonance Imaging systems that don't use ionizing radiation; they use magnetism, instead. Unfortunately, they're only in research centers and very large hospitals."

"How do we get one?" he asked.

"It's about money and space, the same as every other thing we need. Would you go see if his parents are in the waiting room and escort them back?"

"Right away!" he replied.

Nancy returned with the liquid ibuprofen and Mary administered it via a small plastic cup, just as Tom brought in Danny's parents.

"Mr. and Mrs. Baldwin," I said. "I'm Doctor Mike."

"How is he?"

"Other than a headache for which we've given him ibuprofen, which is the active ingredient in Advil, everything seems fine. We would like to take a series of x-rays of his head to check for a skull fracture, but I need to ask about other x-rays he's had recently."

"None," Mr. Baldwin said. "No broken bones and his dentist said no x-rays until Bobby has his adult teeth, unless there's a problem."

I nodded, "That's a good policy. There's nothing dangerous about the x-rays, so long as he doesn't have too many. Is it OK to send him to Radiology for x-rays of his head?"

"Yes," Mr. Baldwin said.

"Tom, call Radiology and then take Danny for his x-rays. Wait with him and let me know when the radiologist has the wet read."

"Right away, Doctor," Tom said.

"Mr. and Mrs. Baldwin, one of you can go to Radiology with Danny, and as soon as we get the results, I'll come speak to you."

"Thanks, Doctor."

"You're welcome."

I wrote my orders on the chart, signed it, then said, "Mary, with me, please; Nancy, Tom will handle things for now."

The three of us left the room and Mary and I went to present to Doctor Williams.

"OK to present the case?" I asked.

"Go ahead."

"Mary?"

"Danny Baldwin, age six; fell from a bunk bed; contusion on the right temple; upon exam, no indications of spinal injury; ibuprofen administered for headache; skull series ordered. If no cranial compromise, monitor for two hours, then release with concussion protocols."

"Very good," Doctor Williams said. "Social Services?"

"In my judgment, not necessary," I said. "No signs of abuse or other injuries. He's well-nourished, communicative, and minus the contusion on his temple, completely healthy. No previous hospital visits and he reports only going to the doctor for his shots and checkups. He's seen a dentist recently as well."

"OK. Continue. If the skull series shows anything, what's your plan?"

"Mary?" I prompted.

"Neuro consult," she replied.

"Just so. Let me have the chart, please."

He scanned it, wrote some notes, signed it, then handed it back.

"Good job, Miss Anderson," Doctor Williams said.

"Thank you."

"Mike, how are you holding up?"

"Tired, but I'm OK. You remember I have four hours off for my gig at Milton Lake, right?"

"Yes. Kylie Baxter is covering for you, right?"

"Yes. She'll be here at noon, and I'll be back by 4:00pm to finish out my shift."

"Off at 1800, so you'll miss all the fun of July 4th!"

"Where 'fun' means dealing with people who would win awards for proving Darwin was right!"

Doctor Williams laughed, "That's one way to look at it! Dismissed!"

Mary and I left the Attendings' office and were immediately stopped by Ellie.

"Can you take an ankle injury?" she asked.

"Yes. We're waiting on x-rays for the failure to fly."

"What is it with boys and bunk beds?" Ellie asked.

"What is it with boys and anything?" Mary asked.

"On that note..." I chuckled.

"Exam 2 is open," Ellie said.

Mary and I went to the triage desk and asked for the chart for the ankle injury.

"Seventeen-year-old female," Nanette said. "Track star out for her morning run, encountered a dog, stumbled, and landed badly. Vitals normal. Ecchymosis and swelling appreciated on exam."

"Thanks," I said, accepting the chart. "Mary, get a wheelchair, please."

She retrieved one and then we went out to the waiting room and walked over to the only teenage girl who was with a woman I suspected was her mother.

"Alicia Sanderson?"

"Yes," she said.

"I'm Doctor Mike and this is Mary, a Sub-Intern. We'll help you into the wheelchair and get you to an exam room and take a look at your ankle."

"I can walk with my arm over a shoulder," she said.

"I'm sure you could, but hospital policy dictates a wheelchair."

"Just do that, honey," her mom said.

She glared at her mom, but didn't object to Mary helping her into the wheelchair.

"Can I come with her?" her mom asked.

"That's up to Alicia," I said.

"She's a minor!" her mom protested.

"Yes, and according to the State of Ohio, at age sixteen, she's entitled to make the decision for herself so long as she's not mentally impaired. You can object to treatment, but if she wants it, generally, we're required to provide it by law."

"How is that possible?" her mom asked.

"Because she's in the ER, by law, we're required to provide an exam and treatment. Alicia?"

"Mom, chill," Alicia said. "I'm fine. Just stay here."

Her mom was clearly unhappy, but absent finding Alicia incompetent to consent to an exam, Alicia had the choice.

"We'll update you as soon as we know more," I said. "Mary, let's go."

We went to Exam 2 and Mary helped Alicia onto the exam table while I washed my hands and put on gloves.

"What happened?" I asked.

"I'm on the track team and run cross-country. I'm training over the Summer, which means running 10K every morning. I was close to the end when a neighbor's stupid little dog ran right under my feet and caused me to stumble. I landed badly and my ankle turned. I thought I was OK at first, but then couldn't put weight on it. My neighbor helped me home and Mom brought me here. How long before I can run again?"

"Let me examine you first," I said. "Once we have a diagnosis, then we'll discuss the next steps and rehabilitation. Are you taking any medications?"

"No."

"Any illegal drugs? Including performance enhancers?"

"Not a chance. They drug test at competitions and I'd be banned."

"Any recent illnesses or hospitalizations?

"No. I don't get sick and this is my first injury beyond a muscle pull about four years ago while playing soccer."

"Same leg?"

"No, the other one. Hamstring."

"Are you allergic to anything?"

"My little brother!" she declared.

I chuckled, "I think my little sister had the same opinion of me growing up. OK to do an exam? I need to listen to your heart and lungs, get your BP, then examine your ankle."

"Sure."

She was wearing a thin, cotton t-shirt, so there was no need to have her remove it or even lift it. I auscultated her heart and lungs, finding everything to be normal, then took her pulse and BP, both of which were low, but which was normal for an athlete who ran long distances.

"Lie back, if you would," I said.

She did as I requested and I checked both ankles, appreciating significant swelling, tenderness, and ecchymosis.

"How bad is your pain?" I asked.

"Scale of one to ten, about a six," she replied.

"We'll need to get an x-ray of your ankle. Is there any chance that you're pregnant?"

"Is that an offer?" she asked with a smirk.

Mary laughed, but I managed to maintain my composure.

"It's a standard question we ask before we order x-rays or medication."

"No. I had my period late last week."

"Then Mary will take you for an x-ray. Would you like some Advil?"

"I took Tylenol at home and it helped some."

"Mary, ice pack for Alicia's ankle, then call Radiology for an ankle series. I'll update her mom."

"Right away, Doctor."

I left the room and went to the waiting room to speak to Mrs. Sanderson.

"Her ankle is likely only sprained," I said. "We're sending her for x-rays to confirm that diagnosis."

"How long will that take to heal?"

"For a mild to moderate sprain, she should be able to walk on it in about two weeks, but it will be around twelve weeks before she can return to running."

"Three months?! School starts before then!"

"I understand. I'll refer you to a sports physiologist who can give you a better idea and provide rehabilitative therapy which can improve the recovery time."

"And if it's broken?"

"Potentially much longer," I replied. "But let's not get ahead of ourselves. My exam and what Alicia said makes me believe it's a Grade 1 or Grade 2 sprain, and those are in line with the recovery period I mentioned before. It will probably be an hour before we know for sure."

"I'd like to sit with her."

"Let me ask, and if she agrees, I'll have a nurse bring you back."

"Thanks, Doctor. Can I ask how old you are?"

"Twenty-six," I replied. "I'm a first-year Resident."

"Is that why you're wearing red, instead of blue like everyone else?"

"No. I'm a surgical Intern assigned to the ER," I replied, using the common public reference to the Emergency Department. "Our surgeons wear red."

"Why are you in the ER not surgery?"

"I'm training to be a trauma surgeon, that is, someone who can perform emergency surgical procedures in the ER. It's a relatively new specialty."

"Too bad you aren't ten years older!" she said.

"I'll take that as a complement, but my wife and daughter might have a problem with that comment!"

"You aren't wearing a ring!"

"We generally avoid jewelry on our hands due to wearing exam gloves. I have my ring on a chain around my neck when I'm working in the ER. Let me go see if Alicia is willing to have you sit with her."

I left the waiting room amused by the fact that I'd basically been hit on by both a mother and daughter. I went into the exam room and asked Alicia about her mom and she relented, so I left and asked Ellie to send a nurse to bring Mrs. Sanderson to Exam 2.

"Doctor Mike?" Tom called out.

"Yes?"

"X-rays for our failure to fly are negative for skull fracture."

"Good. How is your patient?"

"No signs of impairment and no complaints other than his headache, though the ibuprofen has made it hurt less, according to him."

"OK. Let's update his parents and we'll monitor him for two hours, I'll have a nurse take vitals every twenty minutes, and then we'll discharge him."

We went into the trauma room and I explained the x-ray results to Danny's parents, and that we'd keep him under observation for two hours. Once they were satisfied, I asked Ellie to have a nurse take Danny's vitals, then went to the lounge to get a cup of coffee. I filled a mug, sat down, and had just taken my first sip when Ellie came to the door.

"EMS four minutes out with a twelve-year-old with a hand injury," Ellie said.

"Fireworks?"

"Firecracker exploded in his hand."

"Wonderful. Did they say how bad?"

"All his digits are still attached, but I don't know more."

"OK. Mary, get Tom and meet me in the ambulance bay. Ellie, who's my nurse?"

"Me, if you'll have me!" she said with a twinkle in her eye. "I need to see two patients a day to keep up with my license requirements."

Of course, she'd put just enough emphasis on 'have' to make it a double entendre, but I let it go as occasional teasing was OK, so long as she wasn't actively trying to seduce me. I took a sip of coffee, put the mug down, knowing it would be cold before I returned, then headed to the ambulance bay, putting on a gown and gloves on the way.

"You totally didn't react to the girl with the sprained ankle hitting on you," Mary said.

"Not the first time I've been flirted with by a patient, or a mom."

Mary laughed, "No way!"

"She asked how old I was and said it was too bad I wasn't ten years older."

"Mother-daughter fantasy?" Mary teased.

"Not anywhere on my list," I replied. "There's a lesson, though, and that is that you need to be stoic in those instances."

"Sorry. I guess I shouldn't have laughed."

"What did I miss?" Tom asked.

"An object lesson," I said. "When I asked a seventeen-year-old female patient if she might be pregnant before I ordered x-rays, she asked if it was an offer. Mary laughed, which she shouldn't have. I simply ignored the obvious flirtation and replied that it was a standard question before x-rays.

"You both will be hit on or flirted with by patients at some point, and you need to be very careful how you respond in those circumstances. What you don't want to do is encourage them, or turn the exam into something that borders on sexuality, or worse, is blatantly sexual."

"I heard you dated a patient," Mary countered.

"After she was no longer a patient," I replied. "I kept the exam completely formal, and she approached me later, after discharge. It's a fine line, I admit, but the key is to keep the exams professional and to not get involved with a patient while they're a patient. And, it's better if they're the one who approaches you after the fact. It's not a violation of policy to become involved after, but if you were, for example, to get their phone number from their records, that's an ethics violation."

"Can I ask a question about that?" Tom inquired.

"Sure."

"How did you handle your OB rotation? I know what they said in Practice of Medicine, but I'm not sure I can simply convince myself that it's 'just anatomy'."

"I had similar concerns," I replied. "And I was very uncomfortable the first time I observed a Foley catheterization of a teenage female. I know this might sound bad, but in the end, it literally is just anatomy and you don't really notice. And, to be honest, I was actually more uncomfortable the first time I handled a penis other than my own. That was WAY stranger and FAR more uncomfortable than seeing female anatomy."

"Uh, yeah," Tom said. "I can see that."

"What is it with guys being so freaked out about that?" Mary asked.

"Honestly?" I replied. "It's probably the social taboo and the fact that teens equate ANY contact like that to be 'gay' and are merciless in their harassment of gay males."

"Men are wimps," Ellie declared mirthfully. "But Mike does have a point, and I think he's probably right. As for being uncomfortable, I think everyone is, at least at first. You either get past it, or you find another profession. Sure, you can find a specialty where it's rare that you would do those things, but you can't graduate from med school without learning those procedures."

The ambulance pulled into the driveway and came to a stop in front of us. The paramedic jumped out and gave the vitals, and described a wound which included burns and minor evulsion.

"Hi, Timmy," I said as we wheeled the patient to Trauma 4. "I'm Doctor Mike. How is your hand?"

"It hurts!"

"What happened?"

"I lit a firecracker, and it exploded before I threw it."

I performed the exam, and after irrigating the hand, I decided to call for a plastic surgeon to examine Timmy's hand. He arrived about ten minutes later, and after conferring, we agreed he'd take Timmy on his service. I went back to the lounge, emptied the cold coffee from my mug, refilled it, then went to use the phone in one of the consultation rooms to call Tom Kirkland, the attorney who was handling Angie's complaint to the State Medical Licensing Board.

"What specifically, do you think he did wrong?" Mr. Kirkland asked after some basic preliminary questions about my relationship with Angie.

"When Angie decided she was going to do whatever was necessary to get to a point where we could marry, she was thinking about the future, outside the moment, had made a plan, and was successfully executing it. That is absolutely not a sign of someone who is suffering from full-blown schizophrenia and is a strong indication that something has changed. In my opinion, Doctor Greenberg ignored that, and that is where the malpractice claim arises."

"You're asserting that she showed signs of recovery and he purposefully and intentionally ignored them?"

"I am, and I'm willing to testify to that."

"You understand what that might mean, right?"

"I do. And I'm willing to take that risk."

"Good. I'll be in touch soon."

"What do you think the chances are?"

"Of a reprimand? Very high. If what you said is accurate, and I have no reason to believe it's not, there's actually a chance of a suspension or revocation of his license. Not a good one, but a chance."

"That's all I'm asking."

XIV. A Long Shift Finally Ends

July 4, 1989, McKinley, Ohio

I had just enough time to finish my phone call and coffee before the x-ray results were back for Alicia Sanderson's ankle.

"I'd call this a Grade 2 sprain," I said, looking at the x-rays with Doctor Williams on the light panel in the Attendings' office. "That was the radiologist's assessment as well."

"Then it's unanimous," Doctor Williams said. "Treatment plan?"

"Wrap in an Ace bandage, crutches, rest with the ankle elevated, ice as necessary, Tylenol or Advil for pain, and a referral to a sports physiologist in the medical building next door for follow-up."

"Make it happen."

I took the x-rays from the viewer, then Tom, Mary, and I left the Attendings' office and went back to the exam room to discuss the results with Alicia and her mom. In the exam room, I put the x-rays on the light panel and turned it on, then explained what we'd found.

"Long-term, it should heal completely with no permanent impairment," I said. "I'm going to refer you to Doctor Jeong Kim, a sports physiologist. You should call his office today and make an appointment for Friday. Until then, rest, keep your ankle elevated, use ice to bring down the swelling, and take Tylenol or Advil for the pain. We'll give you crutches, and you can put no weight on your ankle at all until you're cleared by Doctor Kim to do so."

"When can I run?" she asked.

"Typically, about twelve weeks, but Doctor Kim will discuss that with you after he examines you, and he'll recommend a proper course of rehabilitation. It's very important you follow my instructions, and his, so you don't do any permanent damage to your ankle."

"That stupid dog!" Alicia growled.

"Tom, would you get me an Ace bandage, please?" I asked. "Then get a set of crutches. Alicia is tall, so she'll need the larger size."

He went to the supply cabinet and took out a package with an Ace bandage, opened it, and handed me the bandage, then left to get the crutches.

"OK to wrap your ankle?" I asked.

"Yes," she replied.

I wrapped the Ace bandage tightly around her ankle, using a clip to attach the loose end to the layer below it.

"Leave this on until you see Doctor Kim," I said. "I take it you haven't used crutches before?"

"No."

"Then let me explain. Mrs. Sanderson, you could go to Patient Services while we do this."

"OK," she agreed.

I gave her the discharge papers, and she left. I went through the proper usage of crutches, and when Tom returned, Mary and I helped Alicia practice until she had the hang of moving with them.

"You'll need to sit in the wheelchair," I said. "Policy again."

Alicia rolled her eyes and Mary helped her from the table into the chair, and set the crutches next to her.

"Tom will wheel you out," I said. "Good luck with your rehab."

"Thanks! You have a really soft touch!"

"Thank you," I said. "Tom?"

He wheeled her out and as soon as they were in Patient Services and out of earshot, Mary laughed.

"And just what exactly did she want you to touch?"

"Whatever it was, if I did that, it would result in me dying somewhere between climbing out of my Mustang in my driveway and the front porch of my house!"

"Mike?" Ellie called out. "Doctor Gabriel needs you in Trauma 1."

Tom, Mary, and I went to Trauma 1.

"You asked for me?"

"Probable surgical case. Rafiq is in Trauma 2. Can you do the consult?"

"Yes."

The ultrasound was set up, as he had used it for his assessment. I immediately saw fluid in Morison's, and said so.

"Let me call upstairs," I said.

I called the scheduling nurse and let her know, then Mary and I took the patient up to the OR, but given how busy we were in the ED, there was no way we could scrub in.

"Bummer," Mary said as we returned to the elevator.

"You'll get your chance," I replied. "I felt the same way, by the way. Always ready for more."

"It's your fault! You let me manage two cases and that made me want more!"

"It is addictive," I replied. "Or like Lay's chips -- nobody can eat just one! Remember how concerned you were with missing the toddler with croup?"

"Yes, and obviously you didn't hold it against me."

"You accepted correction and committed not to making the same mistake a second time. That's all we can ask. You weren't given a chance to do any procedures in June?"

"Sutures only," she replied. "I was mostly with Doctor Townsend and Doctor Lewis, and they did everything."

"When you do your evaluation, make sure you note that. There won't be any negatives, and it will help Doctor Gibbs know how to help them."

"I was warned to not say anything seriously negative on evaluations."

"I was never given that advice, and I certainly wouldn't have followed it! Simply be truthful and honest. I want feedback, and if I'm doing something that interferes with your training, I want to know about it, and Doctor Gibbs should absolutely know about it."

"At the risk of you making my life hell because I sound ungrateful, I'd say more procedures!"

"As Doctor Williams said to me earlier, it's not news that med students want more procedures! I'm totally with you on that, and I'll do my best, though the rules are pretty strict about when I can let you handle things. Other times, it's a judgment call."

"Cute teenage girls?"

I laughed, "I did notice, but that wasn't a consideration. It was that I hadn't seen any sprains or fractures in your procedure book, so I felt you should watch one before I ask you to do one or teach one."

"I had seen them, but never had a chance to do anything."

"Next one, then," I said. "How are you on x-rays?"

"Other than the Preceptorship in Radiology and the plates we saw in class, I haven't had a chance."

"Then next set of x-rays, I'll have you look at them before I say anything to see how much you can discern. You notice I took them to Doctor Gabriel before I spoke to the patient, right?"

"Yes. Is that required?"

"In the sense that we're supposed to go to our Attending with anything beyond our comfort level, yes. I haven't seen enough films to be confident in my diagnosis, though I could rely on the radiologist if I elected to do so. I'd rather confirm the finding with my Attending, because every doctor makes mistakes or misses something, and that's as true of radiology as any other service."

We reached the ED and Ellie directed me to triage again.

"Fifteen-year-old male; line drive to the chest during a Little League game; large contusion just over the right nipple; vitals normal."

I accepted the chart and asked Mary to find Tom and meet me in Exam 2, which I saw was open on the board. She walked back into the ED and I went to the door of the waiting room.

"Nick Smith?" I called out.

"Me," a boy in a baseball uniform called out.

I went over to him and introduced myself.

"Is this your dad?"

"My coach," he said.

"Coach Nichols," he said. "I was concerned about the line drive, so I brought him in. I heard about an incident in Cincinnati last year where a kid died after a similar incident."

"You were wise to bring him in. There's a rare condition called comotio cordis that can occur with a blow to the chest at a specific point in the heart rhythm. Let's go back and I'll do an exam. Have you notified his parents?"

"They both work," Nick said.

"Then we'll call them once we check you out. Your coach can come back with you if you want."

"Yeah," he agreed.

The three of us went to the exam room where Tom and Mary were waiting. I introduced them, then went to the sink to wash my hands.

"Tom, history, please."

He completed the history, and then I did the physical exam.

"Everything appears to be OK," I said. "The bruise is pretty nasty, but I don't believe there are any other injuries. I do want to get an EKG just to be sure. If you'd take your jersey off, Mary will attach the leads."

Five minutes later, with a perfectly clean EKG, I was confident Nick was fine.

"You're good to go," I said. "Ice and either Tylenol or Advil for pain."

"Can I play?"

"As long as you're comfortable," I said. "Let me speak to my supervisor and we'll discharge you. Coach, you can use the phone there to call his parents."

Tom, Mary, and I went to find Doctor Williams, and I had Tom present the case.

"No x-rays?" Doctor Williams asked Tom.

"Uhm, Doctor Mike didn't think we needed them."

"And what do you think?"

"Well, he did a physical exam and ran an EKG and didn't find any signs of injury beyond the bruise."

"And what would we do for a broken rib?" Doctor Williams asked.

"Unless a lung or other organ was compromised, monitor and refer to his physician."

"And there were no signs of breathing trouble?"

"I didn't listen, but Doctor Mike said his lungs were clear."

"So, about the x-ray?"

"I don't think it's necessary because it basically wouldn't matter."

"Correct. Good report, Mr. Lawson. May I have the chart, please?"

Tom handed Doctor Williams the chart, and Doctor Williams returned it after making notes and signing it. We returned to the exam room and let Nick and his coach know they were OK to leave, and to return if Nick had any breathing problems or an irregular heartbeat.

"I wasn't sure what to say to Doctor Williams," Tom said after Nick and his coach had left.

"Never be afraid to say that you don't know," I counseled. "I get asked those same questions, only I'm expected to have the complete answer, not need to have it drawn out by questions. But you're a Third Year in your first clinical rotation, so you did fine. Eighteen months from now, you'd be expected to give the same answer, just complete in response to the initial question."

"You had questions like that?"

"All the time. And there were times when I had to say that I didn't know. What I figured out early on is that you have to ask to be taught and you need to be both curious and proactive. Every Resident is different, and you'll find good teachers and ones that aren't good teachers. Your job is to figure out how to learn in both cases."

"How? I mean, if the teacher is bad, how can the student learn?"

"By observing and generally making a nuisance of themselves with questions. If the Resident refuses to answer, you go to your Attending or your advisor at the medical school and let them handle it. But mostly, you should find a way. That's what I did when I had suboptimal teachers. They were good doctors, mind you, just poor teachers. Sometimes you have to go to someone else, and generally nobody will complain about you doing that."

"Is there any way to choose our Residents?" Tom asked.

"Not really," I replied. "And if you truly don't get along with your Resident, it's incumbent on you to find a way to get through the rotation. After all, you can't expect to like every doctor and no doctor is liked by everyone."

"Even you?" Mary asked, with a twinkle in her eye.

"Especially me! I am, as a number of Attendings and Residents will attest, a pain in the ass."

"But you graduated first in your class!" Tom protested.

"Which has nothing to do with not being a pain in the ass! Part of it is what I said before - make a nuisance of yourself, if necessary, to learn. I sure did. Most of the time, it showed the Resident or Attending how serious I was; other times, it simply pissed them off. I've had Residents do thing which might be considered retaliatory or punitive and my response was to grin and bear it."

"Like what, if you can say?" Mary asked.

"A Resident who decided he didn't like me and assigned me shifts that knowingly conflicted with church attendance and only assigned me every single bit of scut available."

"That's not right."

"No, it's not, but I won the battle by not letting it faze me or affect my attitude. In fact, it actually ensured I was the cheeriest I'd been on any Third Year rotation!"

"An interesting way to get revenge," Tom said.

"Indeed. That Resident was more perturbed that I wasn't upset than I was perturbed by the hazing. That is how you deal with the BS."

"Mike?" Ellie called out. "Doctor Williams would like to see you."

The three of us went to his office.

"Your neuro consult gorked," Doctor Williams said. "Expect to be called in front of the M & M a week from Friday."

"Thanks for letting me know," I said.

We left his office and went to the lounge, got a bottle of water, then I basically collapsed onto the couch. I'd been on for twenty-nine hours and had no sleep, and I could feel it. I wondered how I'd get through the concert, let alone the two or three hours afterwards.

"What happens now?" Tom asked.

"You mean the M & M? Have you been to one?"

"No."

"You should attend as many as possible, even coming in if you aren't on shift. If you are, ask for permission to go. It'll usually be granted. You, too, Mary."

"I've been to a couple," she replied.

"Good. The answer to your question, Tom, is that it's a question-and-answer period about interesting or difficult, or, in this case, cases with bad outcomes. What will happen is I'll present the case, then answer questions from other doctors about the management of the case. They'll critique my handling of it, give advice, and try to find the root cause of the problem."

"Why don't you seem nervous?" he asked.

"First, it's not adversarial, but second, think about what I did."

He was quiet and shook his head.

"I insisted Doctor Mastriano write her order on the chart," I said.

"Whoa! That was self-defense?"

"Very much so. In my opinion, she was wrong, so I made her put it in writing. She'll be roasted at the M & M, even though it's not adversarial."

"Roasted how?" Tom asked.

"For sleeping," Mary interjected. "She was more interested in not being disturbed than spending five minutes examining the patient."

"That about sums it up," I said.

"Mike?" Ellie said from the door to the lounge, "Doctor Williams needs you. EMS is three minutes out with a young drowning victim."

"Lord have mercy," I said aloud. "Be right there, Ellie."

"Survival rate?" Tom asked as I got up.

"During the Summer? Near zero if not revived at the scene. During Winter, one in four due to the effects of hypothermia."

We hurried to the ambulance bay, grabbing gowns and gloves on the way.

"EMS is performing CPR en route," Doctor Williams said, conveying that anything we did was likely going to be futile.

"Intubation and EKG?" I asked.

"Yes. Is your student ready for that?"

That question reinforced what I'd surmised.

"Mary is capable," I replied. "I'll guide her."

"Good," Doctor Williams said. "Tom, EKG and monitor."

"Yes, Doctor."

"Mary, tell me the steps for intubation, please," I said.

She took a deep breath, let it out, then said, "Select the correct endotracheal tube based on the patient's physiology, then gently open the patient's mouth, insert the laryngoscope blade, and slide down right side of mouth until the tonsils are visible. Move the blade to push the tongue centrally until the uvula is visible. Next, advance over the base of the tongue until the epiglottis is seen.

"At that point, advance steadily until the tip of the blade is at the vallecula and the epiglottis is visible below it. Lift gently forward and upward to raise the epiglottis and reveal the arytenoid cartilages and vocal cords. Once the cords are visible, insert the tube in the groove of the laryngoscope so that the cuff passes the vocal cords. Once the tip of the tube is at the glottis, remove the stylet and gently advance until the cuff is past the vocal cords. Inflate the cuff to protect the airway from secretions and form a seal around the tube. Then confirm placement."

"Textbook answer, almost word for word," I said. "How do you confirm placement?"

"With a ventilator or bag at one breath every five or six seconds, checking for chest movement and bilateral breath sounds."

"Correct. And if you don't hear them?"

"Reposition the tube, usually withdrawing slightly, unless no sounds are heard, in which case you remove the tube and begin again.

"Good. Do exactly that. Remember, slow and smooth is the fastest way, even though is sounds contradictory."

"Because it's more important to get it right than to be fast and get it wrong."

"Exactly. Thirty seconds sounds like a short amount of time, but it's really a long time in the scheme of things. Again, I know that sounds contradictory, but it's true. If the patient is conscious, what drugs?"

"How old?" she asked.

"Around ten," Doctor Williams said as the Fire Department EMS squad pulled into the driveway.

"For adults, it's weight based," she said. "For a ten-year-old, there's a set dose in my book."

"Look it up now," I said.

She did as the squad came to a stop.

"Ten-year-old male found floating in a pool; unresponsive and not breathing; no vitals; CPR performed after recovery."

I was positive the boy was dead, but that didn't mean we wouldn't try.

"Trauma 1!" Doctor Williams ordered. "How long down?"

"At least twenty minutes," the paramedic said as we rushed the gurney with a firefighter performing CPR while the other paramedic bagged him.

In the room, the six of us quickly moved him to the treatment table and Nurse Amelia took over bagging while I relieved the fireman who was performing chest compressions.

"Intubation kit to Mary!" Doctor Williams ordered. "Mike, stop compressions."

I did as Nurse Jenny brought the kit to Mary, who picked up the laryngoscope and the pediatric endotracheal tube.

"No heart sounds," Doctor Williams announced. "Mike, resume compressions. Jenny, stat pH!"

Tom worked around me to get the EKG leads attached, Amelia got an IV into the boy's arm, and Jenny drew blood for the pH test. As they did that, I watched as Mary used the correct technique to get the tube inserted.

"I'm in!" she said.

"Connect the vent and set it to ten per minute," I said. "Once it's on, I'll stop compressions so Doctor Williams can listen."

"Asystole," Doctor Williams declared. "An amp of epi down the tube, please."

Nurse Amelia squirted the contents of a pre-prepared syringe into the tube, then Mary connected the vent to the tube. I stopped compressions, and Doctor Williams listened.

"Good breath sounds, resume compressions."

We tried for another ten minutes, and couldn't get even a blip on the EKG, nor any heart sounds, and the pH test showed a level incompatible with life.

"Stop compressions, Mike," Doctor Williams said, then listened one last time. "Time of death 11:44."

"Lord have mercy," I said.

"Is there nothing else we can do?" Mary asked.

"No," Doctor Williams said. "After two doses of epi, continual CPR, and a dose of bicarb, his pH level is so low that even if we could get his heart started, he'd be in multiple organ failure. If he was in the water for more than five minutes, he'd have severe brain damage. He was likely dead when the paramedics got to him."

"I'll get the death kit," Amelia said.

"Tom, Mary, have you seen a death kit routine?" I asked.

"No," they both said.

"Then stay and watch. I'm going to go shower and change and Kylie Baxter will be your Resident for the next four hours."

They acknowledged me and went out into the corridor. Kylie came up about two minutes later.

"You look like shit," she said.

"We just lost a ten-year-old drowning victim. Mary Anderson and Tom Lawson are with Amelia in Trauma 1 to witness their first death kit."

"What a shitty way to end the morning."

"Yeah. I'm going to shower, change, and head to the lake. We don't have any patients on the board at the moment, so go see Doctor Williams."

"See you in about four hours," she said.

"Thanks."

I let Ellie know I was leaving, went up to the surgical locker room, showered, dressed, and then headed out to my car for the drive to the lake. I met Kris and Rachel near the band shell, as we'd planned.

"Dada!" Rachel exclaimed happily when she saw me.

I took her from Kris, hugged Kris with one arm and we exchanged a quick kiss.

"How are you doing, Mike?" Kris asked.

"I'm beat," I replied. "And down."

"Bad?"

"Ten-year-old drowning victim didn't make it. That was right before I left."

"Lord have mercy!"

"Yeah," I replied.

"Do you have time to eat with us?"

"Yes."

The three of us sat on a blanket not far from the band shell and quickly ate a picnic lunch before I and the other band members met in the small room set aside for us.

"You look beat, Mike," José said.

"I think I feel worse than I look," I replied. "No sleep since about 5:00am yesterday."

"That's just crazy!"

"Yeah, and I'm also on an adrenaline low because we had a bad trauma right before I left. Ten-year-old boy drowned."

"Damn," he said.

"Yeah."

"How many patients have you seen since your shift started?" Sticks asked.

"I have no clue," I replied. "If I stop and think about it, I could probably count, but I don't keep track. I was constantly busy from 0600 yesterday until I left about forty minutes ago."

"Are you up for playing your signature song?" Kim asked.

"I don't know," I replied. "All I can do is hope my autopilot works."

Fortunately, it did, and I got through the concert with only a few mistakes, but nothing too terrible. When we finished, Kris and Rachel came to see me, I kissed and hugged them, then headed back to the hospital, feeling more tired than I'd ever felt in my life.

"You OK, Mike?" Kylie asked when she saw me. "I can stay."

"No. Go get your nap before your next shift starts. I'll gut out the last two hours. Anything on the board?"

"Badly torn ACL waiting on Ortho. The films are pretty clear, but you know the rules."

"I do. See you in two hours."

She headed for the Internal Medicine on-call room, which would otherwise be empty during the day so she could nap undisturbed, and I went to find Tom and Mary.

"How did it go?" Tom asked.

"I fumbled through a couple of songs, but otherwise, OK. How long did Ortho say they'd be on the consult?"

"At least another thirty minutes," Mary said. "They only have one Resident in the hospital and she's busy."

"Did Doctor Baxter provide any pain medication?"

"Oxycodone PO, after consulting with Doctor Williams."

I nodded, "Necessary for any Schedule II or III drugs. Patient details?"

"Male, forty-nine, playing touch football with his buddies at the lake."

"He's going to regret that," I replied.

"Not as much as he's regretting his wife's reaction. She's all over his case about 'behaving like a kid' when he's 'old enough to know better'."

"Maybe give her a sedative?" I suggested.

Mary laughed, "She's the classic shrew, and I'm saying that as a woman. She annoys me, and I usually agree that guys exercise poor judgment."

"I'm a guy and I agree with that! Hang around the ED enough and you'll see all the evidence you need!"

"Sorry to change the subject," Tom said, "but what electives did you take?"

"I doubled emergency medicine, plus surgery, cardiology, ICU, and pathology."

"Pathology? Why?"

"As Doctor Roth put it, where else can a medical student or intern handle a scalpel every single shift? It was good practice, both in terms of using surgical tools as well as honing my diagnostic skills. I would recommend against the ICU because I was bored to tears. There are basically no procedures, just monitoring, admissions, and transfers. I had thought it would be interesting, but it wasn't."

"What would you have done instead?"

"Probably internal medicine," I replied. "My other option would have been pediatrics. I didn't feel OB was necessary because I was allowed to do normal Fourth Year stuff during my Clerkship."

"How?"

"By being totally prepared, knowing my stuff, and asking. Remember that last one. Show you know your stuff and ask. You'll get plenty of negative responses, but all it takes is one positive one. Another good option would be the Free Clinic, especially if you're going into private practice, as you'll see the same kinds of urgent, but not emergent, cases."

"Why doesn't the hospital set up something like that and direct patients who don't need emergency treatment there?" Tom asked.

"Mary?" I prompted.

"It's illegal to direct someone away from the ED without first giving them an exam and providing stabilizing treatment. The hospital attorney who spoke to us made it clear that even a sign encouraging people to use a clinic could be a violation."

"Seriously?" Tom asked.

"Seriously," she said. "It might be OK to put up a sign that had comparable wait times, but you can't actively encourage them to leave without risking an EMTALA violation."

"Which is why we're seeing an increase in patient presentations in the ED," I said. "We can't ask about the ability to pay because EMTALA says that doesn't matter. There's a debate about whether we can ask for insurance information, which we might be able to, so long as no weight is assigned to insurance or lack of insurance during triage and initial treatment. And it's all speculative at the moment because we're still waiting on the final rule from HHS. But the attorneys insisted we create a policy first, so it's in place when the rule is promulgated."

"Mike?" Ellie said from the door to the lounge. "Do you have time to take a severe sunburn?"

"With this pasty skin, that's about two minutes without sunscreen for me!"

Ellie laughed, "We northern European types burn to a crisp!"

"In the waiting room?"

"Yes. Exam 6 is free."

"We'll handle it, thanks. Mary, go fetch our patient, please. I'm going to use the facilities and I'll meet you in the treatment room. Tom, go with her. Mary, start a chart with history, please."

They left, and I went into the bathroom, emptied my bladder, washed my hands, then washed my face. Once I finished, I went to Exam 6 where Mary was speaking with a teenage girl who on first glance had second-degree sunburn.

"Hi," I said. "I'm Doctor Mike. Mary?"

"Cindy Sundstrom, sixteen," Mary said. "Fell asleep in the sun at Lake Milton."

"Continue your H & P, please," I instructed.

There was nothing remarkable about the young woman's history, and her vitals were slightly out of range, with her pulse at 90 and her BP at 90/60.

"What do you want to do?" I asked Mary.

"IV Ringer's for dehydration, aloe gel, and NSAID for discomfort."

I nodded, "Good plan. Advise your patient."

"Cindy, you're dehydrated, and drinking water won't resolve that as quickly as we would like, so we're going to give you an IV with something called Ringer's Lactate, which will ensure your electrolytes are in balance. We'll also apply aloe gel to your sunburn, and we can give you some ibuprofen to help with the pain."

"Do I really need an IV?" she asked.

Mary looked to me and I nodded, then I said, "Yes, you do. We could try giving you oral electrolytes, but they aren't as effective. Your sunburn is severe, with some blistering, and it covers most of your front, except where your bikini covers you. That can be dangerous, though not life-threatening. Are your parents here?"

"No. They're in Toledo until late tonight. I was with friends."

"Do you have someone to stay with you at home until your parents arrive?"

She smirked, "My boyfriend, but I don't think my dad would approve."

"Being a dad, I suspect you're right, though my daughter is only two. What about another friend?"

"Yes, my best friend. She's in the waiting room with my boyfriend."

"Mary, complete your physical carefully, then treat as you proposed."

Cindy winced when Mary listened to her heart, which Mary reported sounded fine. I needed to confirm, so I did a repeat auscultation and confirmed no problems. Fifteen minutes later, Nurse Jackie came in to apply the aloe, and once that was complete and the entire liter of IV fluid had run in, we discharged Cindy to her friend and boyfriend, with instructions to come back if she felt sick, her skin turned purple, or she was in intense pain, and to see her doctor on Thursday for follow-up.

"She's going to be a hurting puppy," Mary said when we returned to the lounge. "At what point would you admit a patient?"

"She was close," I said. "But her vitals weren't totally out of whack and she had no signs of edema, no nausea, and no coronary or pulmonary compromise. Also, her face wasn't burned because of her hat. She also urinated, which was a positive sign as well. Absent that, I might have kept her longer."

"So it's a judgment call?" Tom asked.

I nodded, "As is just about everything we do except things which can be absolutely confirmed by specific tests. We use differential diagnosis to narrow down the possibilities, then make a judgment call as to the likely cause of the collection of symptoms we've observed. But the most obvious answer may not be correct."

"So what do you do?"

"As much as you can to narrow down the diagnosis, then decide your best options. You've heard the saying 'medicine is an art, not a science', I'm sure."

"Yes."

"It's partly true," I replied. "There is a lot of science, but there is also an art to successful diagnostic skills. That's especially true when clusters of symptoms point in very different directions. Sometimes you go with the most likely answer simply because you don't know and can't prove it's NOT the most likely thing. The key is to avoid taking any actions that might be adverse if you're wrong.

"You can't always do that, but that is the best approach. Something like 95% of the cases you see will have fairly obvious, correct diagnoses. The other 5% will be a mix of difficult diagnoses or cases where the obvious answer is wrong because the correct answer is statistically rare. It's those 5% that are candidates for Morbidity and Mortality conferences.

"A good example is the UTI versus STD diagnosis. We acted as if it was a UTI because that was our best evidence. But, and this is super important -- patients lie. While not suggesting this is the case, the young woman could have cheated on her boyfriend, or been more promiscuous than she reported. If she'd reported a dozen partners, what would I have done differently?"

"Assumed it was probably an STD, right?"

"I'd have leaned more that way, yes. Mary, why would I not have assumed?"

"Because multiple partners means an increased risk for UTIs, along with HPV."

"Exactly. My counsel for her for no intimate relations had a double purpose. Mary?"

"Both to wait for the UTI to clear, but also to limit the chance she'd spread an STD."

"And remember, this isn't judgment about her behavior, simply about the risks associated with having multiple sex partners."

The phone on the wall rang and Tom answered it and said it was Doctor Taylor calling for me.

"Hi, Vince," I said. "What's up?"

"I spoke to Cutter. He'll speak to Northrup. Anything Mastriano adds to your file will be removed once Northrup speaks to her."

"Thanks."

"You're cleared completely."

"Thanks again."

I hung up, then went to sit down.

"Everything OK?" Mary asked.

"It appears so..."

"Mike," Ellie interrupted from the door of the lounge. "No rest for the weary! Four-year-old with a bee sting being brought in by EMS. Anaphylactic reaction, treated by epinephrine autoinjector. Trauma 2 is open. Three minutes.

"Thanks, Ellie."

Tom, Mary, and I got up, left the lounge, put on gowns and gloves, and headed to the ambulance by.

"Treatment plan?" I asked Tom.

"Uhm, mainly supportive for anaphylaxis," he said. "ABC, then monitor, with IV antihistamine if warranted, and albuterol via inhaler if needed."

"Very good. EKG?"

"I'm not sure."

"Only if indicated by tachycardia or signs of tamponade, or severe pulmonary distress. Just the pulse oximeter unless I say otherwise. Mary, be prepared to intubate, but I don't expect you to need to, given someone had an EpiPen handy."

"Those things are lifesavers," she said. "A friend of mine college had one, and it saved her life after she accidentally ate strawberry jam."

"EMS has started carrying them as a regular part of their drug box, and it's made surviving severe allergic reactions much more common," I said. "I think every school nurse should have them, along with every cop. I think the same is true for naloxone, which the paramedics carry, but currently there is no approval for untrained people to administer it."

"That's the OD drug, right?" Tom asked.

"Yes. It's also called Narcan, which is the name you've probably heard. It's fast acting and can reverse the effects of opioids within minutes."

The EMS squad turned into the driveway and pulled up.

"John Tyler, four, stung by a bee; parents administered EpiPen almost immediately; pulse 110; BP 130/80; resps good at eighteen; PO₂ 99% on nasal canula; GCS 15. Mom is in the squad with him."

"Trauma 2!" I said.

They unloaded John, I introduced myself, and we took him to Trauma 2 where five of us moved him to the trauma table as his mom came into the room.

"How are you feeling, Josh?" I asked.

"My arm hurts where the bee stung me," he said. "But mom shot me, so I didn't die!"

"Where did you inject the EpiPen?" I asked his mom.

"Right thigh."

"Josh, I need to listen to your heart and lungs, then my friend Tom here will remove the stinger and wash your arm. OK?"

"Yes."

Other than his fast pulse and slightly high blood pressure, both of which were likely related to the epinephrine injection, he was in very good shape. Once I finished the exam, Tom used topical anesthetic, then removed the stinger with a pair of tweezers, irrigated the small puncture with saline, then put a dab of triple antibiotic on it before covering it with a small bandage.

"You can take Josh home," I said to his mom. "He's in no danger, but I'm going to give you an emergency inhaler with albuterol in case he has any breathing trouble. Two pumps is sufficient, and then call 9-1-1. I doubt you'll need it, but I just want to be safe."

"Can I still see the fireworks?" he asked.

"That's up to your mom," I said.

"Is it OK, Doctor?" she asked.

"There's no medical reason he can't go, though please don't let him run around, and absolutely avoid bees. Do you have a second EpiPen?"

"No."

"OK. We'll get you one of those as well. You should follow up with Josh's doctor just to let him know what happened. He can call here for the treatment records, and he may or may not want to see Josh."

"Thanks, Doctor."

"You're welcome. Give me about ten minutes to fill out the paperwork and we'll have you on your way with the inhaler and a new EpiPen."

"Thanks again."

Tom, Mary, and I left and went to the nurses' station where I filled out the appropriate forms, updated the chart, and then went to Doctor Williams to sign off, which he did. That completed, I retrieved the albuterol inhaler and EpiPen from the drug room and took them to Mrs. Tyler.

"Any other questions?" I asked.

"No. Thank you very much, Doctor."

"You're welcome!" I replied, then turned to Josh and asked, "What's your favorite candy?"

"M&Ms!" he declared.

I pulled a small packet from my fanny pack and handed them to him.

"Only when your mom says it's OK to eat them."

Mrs. Tyler laughed, "Go ahead, Josh. And what do you say?"

"THANK YOU!" he exclaimed, the ripped open the pack and began munching M&Ms.

"You can stop by Patient Services on your way out," I said.

"Thanks again," she said.

Tom escorted them to Patient Services, and I went back to the lounge where Kylie was waiting.

"I am out of here," I said. "So are Tom and Mary. Nothing on the board. We just discharged a bee sting."

I left the lounge, let Ellie, who was also going off shift, know I was leaving, and she walked with me towards the locker room.

"I'm upstairs," I said.

"Bummer!" Ellie exclaimed. "See you later in the week."

"See you then."

I walked upstairs, showered, dressed, then left the hospital, got in my car, and headed home.

XV. A Wise Man Listens to Those With Knowledge and Experience

July 4, 1989, Circleville, Ohio

"DADA!" Rachel exclaimed when I walked into the house, dead tired after having been awake for over thirty-seven hours.

I scooped her up, hugged her, kissed her cheek, then carried her over to Kris.

"How are you feeling, Mike?" Kris asked after we exchanged a quick kiss.

"Beat," I said. "Dinner, then bed."

"It'll be ready in five minutes," Kris said. "Come to the kitchen with me, please."

I followed her to the kitchen with Rachel in my arms.

"Was your afternoon better than your morning?" Kris asked.

"Nobody I was caring for died, so I think the answer is yes. Middle-age man with a torn ACL, teenage girl with a severe sunburn, four-year-old with a bee sting, and an offer to shower with a nurse."

"You'll need a trauma surgeon if you did that!" Kris declared.

"Something I understand quite well! It was Ellie."

"Does she ever quit?"

"Apparently not! But I used the surgical locker room, not the one in the Emergency Department."

"Did you get to see Clarissa at all?"

"No. Our breakfast, lunch, and dinner breaks didn't line up at all. We'll try for Thursday or Friday. Saturday is a bit easier because she can match her break to mine."

"How are your students?"

"Pretty good, but this is the first rotation for the Third Years and the first Sub-Internship for the Fourth Years, so I have to do the normal teaching plus the orientation stuff."

"But didn't they start in June?"

"Yes, but they were with Doctor Mastriano and she's not a very good teacher. I had a run-in with her about a patient; actually, a few patients. She wrote me up, but it'll be removed from my file and she's likely to be called on the carpet at a Morbidity & Mortality Conference because a patient gorked when she refused to allow me to call a neuro consult."

"Gorked?"

"Sorry. Suffered brain damage which is very likely irreversible. If you're OK with it, I can explain more tomorrow after I sleep."

"Yes, of course! Let me get dinner on the table. Put Rachel in her High Chair, please."

"NO!" Rachel declared forcefully. "DADA HOLD RACHEL!"

"Her Majesty, the Tsarina of All Russians, has spoken!" I chuckled. "I think I can manage the stew and bread one-handed. If she eats after we do, that's fine with me if it's OK with you."

"It is."

We ate, and I gave Rachel a piece of French bread to munch, and also fed her some of the stew, though not nearly enough for a normal meal for her. As soon as we finished eating, I handed a protesting Rachel to Kris, and with Kris' blessing, I went upstairs. I made sure the blackout curtains were closed, undressed, and put on my sleeping eye mask for extra protection against light, got into bed and instantly fell asleep.

July 5, 1989, Circleville and McKinley, Ohio

"How are you feeling?" Kris asked when I came downstairs just before 8:00am on Wednesday morning.

"Better," I replied. "Twelve hours of sleep seems to have helped. Where's Rachel?"

"She's on a playdate with Abigail. I set that up because I had no idea how long you would sleep. I'm leaving in a few minutes for class, and I'll pick Rachel up on the way home from OSU. Do you need anything before I leave?"

"Just a hug and a kiss," I replied. "What time will you be home?"

"About 4:00pm."

I walked Kris to her car, we hugged and kissed, and once she had driven away, I went back into the house. I made myself breakfast, and after I had eaten and cleaned up, I checked the menu for the evening, noted we needed a few things, and after I showered and dressed, went to Kroger to pick up a few things, then headed back home.

I really had nothing to do but relax, so around 11:00am I called Clarissa to see if she wanted to have lunch. She agreed, and just before noon, we met at Frisch's.

"I expected you to show up with toddler attached to hip!" Clarissa said when we met in front of the restaurant.

We exchanged a quick hug, then walked inside.

"Kris arranged a playdate for Rachel with Abigail because she had no idea how long I'd sleep. I woke up around 8:00am and Rachel was already at Abigail's house and Kris was ready to leave for her class at OSU."

The hostess seated us in a booth and when the waitress came over, we ordered right away.

"How does fasting work when you have your crazy schedule?"

"With «ekonomia». Health is always the primary concern. When I discussed it with Father Roman, we agreed I'd refrain from red meat on fasting days, but no other restrictions on what I need to eat to stay healthy. For marital harmony, Kris will follow the same rule."

"How are you handling church?"

"Just Sundays for now," I replied. "We could go Wednesdays, but we decided to entertain, and I have Father Roman's blessing on what amounts to minimal attendance, at least for the first few months. Obviously, I can't go on Saturdays, and tonight and next Wednesday, we're having guests. Anyway, how much sleep did you get?"

"About four hours, in a pair of two-hour stints, which I guess is far more than you had."

"You guess correctly."

"Did you have the drowning victim?"

"Yes. He was basically DOA, but you know the drill. That was right before I headed to the lake for our gig."

"Anything else interesting?"

"I asked a seventeen-year-old girl who needed an ankle x-ray if there was a chance she could be pregnant and she wanted to know if it was an offer."

Clarissa laughed, "And you can't be a pig in the ED!"

"Kris might have an objection as well! But you know me. I simply ignored the obvious flirting."

"Flirting? She was asking the cute young doctor to fuck!"

"Whatever," I chuckled. "Not the first and won't be the last. Did you have anything interesting?"

"Just the usual, and with the Fourth, no scheduled admissions or transfers, just the admissions from the ED. We have one interesting case where we're having trouble diagnosing. Doctor Subramani has a conference call with a specialist at Mayo and one at Emory tomorrow. I heard you had a run-in with the new Attending."

"Several, actually. Between you and me, and not to be repeated, she's lazy and I have strong suspicions about her ability to do the Attending job. She's going to get lit up at the M & M a week from Friday."

"Why?"

I explained what had happened with the guy who was beat up in the bar.

"You're covered because you made her write it on the chart," Clarissa observed. "No way she can throw you under the bus on that one."

"Probably not," I replied. "And I will acknowledge during my presentation of the case that I should have listened to my nurse."

"Ellie?" Clarissa smirked.

"She's obviously still interested, but she's also dialed it way back. It wasn't her, though, it was Becky, who's been a nurse nearly as long as I've been alive!"

"And your med students?"

"Mary and Tom are great; the other four are about what you'd expect. The one downside for Mary and Tom is that they were assigned to Doctor Mastriano during the interim period before the new PGY1s started, and she's not a very good teacher."

"Sleeps, can't teach, and lazy?"

"That's my assessment. Hopefully, the M & M will be a wake-up call. If not, the next year is going to suck. I'm on with her again on Saturday. On the plus side, the end result of one of our spats was that I was allowed to do a blind pericardiocentesis in the OR."

"You're not even a week into your Intern year!" Clarissa exclaimed.

"That was Doctor Mastriano's objection, though she called me a 'fucking intern'."

"Think about how rare it is for an Intern to do anything like that."

"And think about how DUMB that historical practice is! The advantage of the new program is that nobody has to 'do what has always been done' because it's never been done before."

Clarissa laughed, "Says the man for whom 'I have never seen it done that way before' is the ultimate reprimand for a clergyman!"

"If you think about it, we're priests and priestesses, and expected to follow tradition -- what has been done always, everywhere, and by all."

"You're saying medicine is Orthodox?"

"I'm saying our rituals and traditions are handled exactly the same way -- anything new is viewed skeptically until accepted by the medical community at large. We have our deanery meetings every Friday, our medical conferences are like synods, and AMA meetings are, in a way, Ecumenical Councils."

"Oh, for the love of God!" Clarissa said, laughing hard. "Seriously?"

"The parallels are there," I said as the waitress brought our food.

I said the blessing, and we began eating.

"Have you heard anything about Kris' citizenship application?"

"Just that it was filed on the 3rd. I believe we provided everything they need, so the next step will be interviews, potentially as soon as next month, but it could be as much as six months."

Clarissa smirked, "That should be interesting. 'Does she swallow?'"

I chuckled, "While the attorney suggested those types of questions might be asked, he felt that Kris formally adopting Rachel would obviate such questions, given no sane person would risk losing custody of their kid for a sham marriage."

"We are talking about you, Petrovich, and sanity was never an option!"

"No kidding!" I chuckled. "But the government doesn't know that! Someone from INS will come to the house, see all the obvious signs of marriage and a family, and that should be it."

"And your «minou»'s politics?"

"Starting that again, are we?" I asked.

"Of course!"

"Being a socialist isn't a cause for denial of naturalization, only advocating the violent overthrow of the government. And despite flying the red and black flag on May Day, she hasn't advocated a violent overthrow of the government."

"Sorry to bring this up, but how are you handling the memorial this year?"

"Viktor arranged with Father Nicholas to have the memorial that morning, which is a Saturday. Kris, Rachel, and I will be there. I'll still be on my current schedule, so I have to be at the hospital from noon to midnight, so we'll have to figure out our family birthday celebration for Rachel, and I'm sure the Kozlovs will want to do something. Kris and Lyudmila are planning a party with Rachel's friends from daycare and church, and that will be on Saturday afternoon while I'm on shift."

"Thereby avoiding a house full of toddlers and their moms!"

"One toddler is a challenge for the two of us! I can't even imagine a dozen little girls!"

"But when they grow up..." Clarissa smirked. "I recall you enjoying graduation parties!"

"That's even MORE reason to be out of the house! But seriously, at forty-two, I'd be ancient in their minds!"

"Mostly, but I think you'll be hit on by cute teenage girls for decades!"

"That does seem to happen to doctors right up into their forties."

"Speaking of one toddler being a challenge, are you still planning on having a baby next July?"

"If I have a baby in July, it'll be in every medical journal on the planet and I'll be famous!"

"You know what I meant, you nut!"

"That's the plan," I replied. "The timing coincides nicely with the end of the thirty-six-hour shifts and weeks longer than eighty hours, though I have a strong suspicion that's about to change."

Clarissa nodded, "Doctor Subramani said she spoke to a friend in New York who said the end result is going to be a limit of eighty hours a week and shifts no longer than twenty-four hours with at least twelve between them. Which means more Residents."

"Which requires more money, and that is a complex mess with federal, state, and local funding sources, plus patient fees and insurance receipts."

"I think we'll be bitching about lack of resources when we retire in forty years or so."

"I was thinking about that, and surgeons typically retire by sixty, or at least significantly reduce their actual surgeries and teach instead. I could work longer in the ED, as I could take regular shifts instead of trauma surgeon shifts, but I think at that point I'll hang out a shingle or work in a clinic. I just don't see retiring from medicine. Doctor Evgeni is nearly eighty and still sees some patients."

"You'd make a great teacher."

"I suspect so, but not seeing patients would frustrate me to no end. It's why I'll never take a job in administration. I'd rather be a locum tenens on contract than Medical Director."

"There's no chance you'll be an eternal Resident! You'll get the Attending slot the second you pass your boards and can put FACS behind your MD! There's no way they'll risk losing you."

I smiled, "And yet, there is one thing that could take me away."

"Rutherford, right? If they become a teaching hospital and upgrade to a Level I trauma center."

"That would be it, and they're on that path, but who knows what will happen over the next decade."

"Want to make a wager?"

"On?"

"That Doctor Michael Peter Loucks, MD, FACS, will be the Chief of Emergency Medicine of Rutherford Hospital before the end of the next decade."

"And what would the bet be?" I asked with an arched eyebrow.

Clarissa laughed, "I can't make it too interesting for you because your «minou» would object."

"Yeah, but if that was what I would get for winning a bet that I wasn't going to have that role, do you think I'd take the job?"

Clarissa laughed, "There is no way you would trade one night with me for your ultimate dream job!"

"Are you sure about that?" I asked with a smirk.

"Positive!" Clarissa declared. "Mainly because you could never collect."

"Truth. Despite the tragic events around Rachel's birth, I fully expect to grow old together with Kris."

"How are things going? And I don't want a flippant answer."

"They're good. We have our areas of disagreement, but they're peripheral, not core. Kris is very different from any girl with whom I've ever been involved and is more mature than most girls her age. We're going through what is likely to be the toughest time we'll ever have to, and she's handling it well. Rachel, on the other hand, is annoyed that she can't see me and alternates between clinging and giving me looks that remind me of Elizaveta when she was unhappy with me."

"Complete with hands on the hips?"

"A couple of times," I chuckled. "It was uncanny how much she reminded me of her...Elizaveta."

"You can say that to me, Petrovich. It won't cause any trouble."

"No, I can't," I countered. "I do not want to send mixed messages to Rachel or Kris. Yes, Elizaveta is Rachel's biological mom, but Kris is the only mom Rachel will ever know, even when she finds out about Elizaveta."

"She's almost two, and at some point, probably not too far in the future, she's going to ask about the icon and prayers. You don't display any pictures, right? I haven't been in your bedroom."

"Much to your chagrin!" I teased. "But no, no pictures. I have albums, of course, but the framed pictures were put away because I didn't want Kris to feel slighted in any way. And being Orthodox, it's the icon that truly matters."

"Theologically, sure, but you don't feel that way. Well, at least not a hundred percent."

"Yes and no," I replied. "The struggle for me is honoring Elizaveta and remembering her, without making Kris feel like my, and I'll use this term with you only, second wife."

"I think you've done a good job balancing things, and Kris has a good head on her shoulders. She accepts your relationship with Angie and your relationship with me, and didn't freak out over our desire to have a baby together. Any woman who can do that is a keeper!"

"And you keep your hands off, Lissa!" I said with a grin.

"I told you I think she's hot, but Tessa and I are as committed as you and Kris are."

"With one exception."

"You had your chance, Petrovich!"

"And you know that wasn't for me, and why."

"Well, if a threesome with Deb and Milena left you nonplussed, I'm not sure what would work besides a monogamous relationship."

"You, Tessa, and me did NOT leave me nonplussed!"

"Except that was all about you and me. Your pleasure with Tessa was directly related to me being there, participating and watching, not having a threesome."

"You might have a point. OK to change subjects?"

"Sure."

"I spoke with the attorney handling Angie's case and he thinks an official reprimand is likely, and that it's even possible we'll get Greenberg's license suspended."

"I hope that's the case! What happens now?"

"The complaint has to be submitted to the Medical Licensing Board. The attorney will interview me to get the details, from my perspective, and I'll testify in my official capacity as a doctor to his errors."

"Risky."

"I know, and I'm going to take the risk. Angie deserved better and while I can't fix what Greenberg did, I can certainly make sure he never does it again."

"Just be smart, Mike."

"Nobody in Surgery or Emergency Medicine is going to cause me trouble for doing the right thing, and I don't care what Psych says, or any other department, for that matter. My guess is that Doctor Greenberg files a nolo contendere with the board in exchange for a reprimand. I won't like it, but it's better than nothing."

"Basically a plea bargain?"

"Basically. The other thing that happened is that Melissa Bush returned my call. She seems to be doing OK, but she's completely rejected Christianity, well, her version of it."

"Do you blame her? You reject it, too!"

"Yes, of course, be she claims to no longer believe in God and to be engaging in promiscuous sex with random guys on Friday nights."

"I don't believe THAT!" Clarissa declared.

"Neither did I, but she made the point that she's not the same person she was a year ago. I let her know I'd seen her dad, and her response was such that I don't believe she has any interest in getting in touch with him."

"Again, do you blame her?"

"No. Her comment was that he'd messed up her life, as well as her mom's and her brother's, and she basically expressed no sympathy for the Gospel message that everyone is redeemable."

"You are the lone voice in the wilderness on that one with regard to Lee."

"I know, but I have to be true to myself, even when it forces conclusions and actions I don't like."

"You're going to see Frank Bush again, right?"

"Yes. On a monthly basis. Maybe at some point I'll do some evangelism at the prison, but I need a sane schedule before I can consider that."

"So a year, at least?"

"Probably. At least at first, I'm just going to visit Frank and play chess with him. I did pre-order a book for him, which I think I told you about. Baby steps."

"I don't think I could do it, but I completely understand why you're doing it. It's you."

"Changing topics, have you and Tessa considered a commitment ceremony of some kind?"

"Marriage?"

"Use that term if you want," I replied. "You know my take on it."

"That so long as nobody tries to force your church to perform weddings for homosexual couples, you won't object, even if the government, at some point, permitted it."

"Exactly. I mean, why should you and Tessa have fewer rights and privileges simply because of something you can't control any more than I can control? It's not a 'lifestyle' despite the claims of some on the right."

"We haven't really discussed it. Hey, you could do the ceremony at this point!"

"I could but that might get me the wrong kind of attention from Father Luke, Father Roman, and Vladyka JOHN. How is your dad taking everything?"

"I think he'll lose it when I announce I'm pregnant, but chill by the time I present him with a grandson or granddaughter. Speaking of that, how are things with the Kozlovs?"

"They're fine. Rachel will spend time with them on Saturday afternoons. She still doesn't like her cousin Viktor, mainly because he's so rambunctious."

"She does prefer girls..." Clarissa smirked.

"I don't think it's about sex at age two!"

"It's always about sex!" Clarissa teased. "Wasn't that the primary goal of your life from Freshman year?"

"No. Being a doctor was more important. It did come a close second, though. But fourteen is different from two!"

"Except the interactions with the opposite sex start very young, and they're all practice for the future."

"Given my relationship with Jocelyn in kindergarten, I can't really disagree."

"Any progress with them on adoption?"

"They're very close, and once Jocelyn passes the bar next month, I expect them to receive a baby or toddler in a reasonable timeframe."

"I've heard there aren't that many babies or toddlers available."

"A lawyer and a nuclear physicist with a Master's and working on his PhD are basically the perfect couple."

"What is she doing?"

"Mostly studying for the Bar, but she also is writing briefs and handling motions and filings in simple cases."

"Have you heard from Maryam, Peter, or Nadine?"

"No, but I figure they're in the same boat we are, so I'm not surprised. I'm sure I'll hear from Maryam in the next few weeks with a wedding date."

"That fast?"

"They've known each other for close to ten years," I replied. "So it's not too surprising."

We finished our lunch and when we left the restaurant, we exchanged a quick hug and then got into our Mustangs. I decided to swing by Doctor Blahnik's house and see if she was home, but there was no answer at the door, so I headed back to Circleville. Once I arrived home, I put on some music, then went to the kitchen to prep the vegetables and peel the shrimp for the stir fry we were serving our guests, and put the rice in the rice cooker we'd been given as a wedding gift.

Kris arrived home with Rachel, and the three of us relaxed together on the couch while I explained what had happened with Doctor Mastriano as I'd promised Kris I would do.

"You're sure you aren't in any trouble?" she asked when I finished explaining.

"Positive. Well, not about that. The reason I insisted on her writing her orders on the chart was that she refused to even examine the patient, and I was concerned. As a PGY1, having written orders on a chart is a perfect defense. Someone might say I should have disobeyed Doctor Mastriano's instructions, but I can't get in any real trouble for not doing that."

"What would you do the next time?"

"Make a nuisance of myself until she checked the patient herself or I'd call for a consult and make my argument to the Resident from the consulting service. But in the end, the Attendings decide and they have the final say."

"But didn't you say you did things you were told not to do?"

"By Doctor Mastriano, but she's not my Attending -- that's whoever is the surgical Attending. Yes, she supervises me and assigns my work, but in the end, I answer to Doctor Cutter, the Chief of Surgery. And that's what's caused the turf war, of which this is likely part."

"It all seems so silly."

"It is, but anything new in medicine causes tumult. On the plus side, I did get to do a surgical procedure -- a pericardiocentesis, which is draining fluid from the sac around the heart."

"What causes that?"

"In this case, severe injuries from an MVA, a motor vehicle accident. The young woman hit her chest on the steering wheel."

"Did you save her?"

"I honestly have no idea. I performed the procedure and left her with the other surgeons, which is going to be a fairly common occurrence. And I don't have time to check on every admission."

"Dada?" Rachel, who was on my lap, said.

"Yes?"

"Git-arr?"

I handed Rachel to Kris and went to get my guitar. I played six songs for Rachel, ones I knew she liked, which included one I'd never play with Code Blue -- Baby Beluga, a Raffi song. When I finished, Kris and I went to the kitchen to work on Dinner, and a few minutes later, the doorbell rang, signifying that at least some of our guests had arrived. Ghost and Oksana were at the door, and I saw Loretta and Bobby pull into the driveway.

Once everyone was inside, I offered a glass of wine to anyone who wanted one, and everyone except Loretta accepted. I poured the wine, gave everyone a glass, then began preparing the stir fry, cooking the shrimp first, then adding the vegetables and the sauce I'd made. When it was ready, Bobby helped me bring everything to the table, and we all sat down to eat.

"Ready to come back to work?" I asked Doctor Gibbs.

"I'm going slightly stir crazy at home, so yes, I am! Fortunately, Bobby's mom is available to watch Bobby Junior until he's old enough for the hospital daycare."

"Mike, did you see the scheduled for paramedic training?" Bobby asked.

"No."

"Starting September 1st, we'll work weekly six-hour shifts at the hospital until we reach fifty hours and you docs sign off that we can intubate and read EKGs. They also published the drug list, and we'll have lidocaine, succinylcholine, etomidate, and midazolam."

"Good. Chest tubes?"

"Not this round, because Doctor Cutter isn't ready to sign off on that."

I nodded, "That procedure is more complicated than intubation. It's rare for Fourth Year medical students to do it, and even Interns."

"Says the PGY who did one while he was a med student!" Ghost said.

"And who'll teach his Fourth Years who double on trauma to do them."

"Just don't feed his ego!" Doctor Gibbs ordered. "It's big enough already!"

"Mike isn't conceited!" Oksana protested. "He's the most humble person I know."

"Cousin, you don't see 'Doctor Mike'!" Kris declared. "He's a very different person from the one you saw at church or I usually see at home."

Ghost and Loretta looked at each other and broke up laughing.

"For sure!" Doctor Gibbs said.

"He's a surgeon," Ghost said. "Having a big ego is a prerequisite!"

"I have Clarissa for this kind of abuse," I chuckled. "I don't need it from all of you! Not to mention she's had eight years of practice! And if she's not sufficient, the Tsarina will absolutely point out every minor failing!"

"How are the wedding plans coming along?" Loretta asked.

"Who knows?" Ghost said with a smile. "I took Mike's advice and I'm just along for the ride! Oksana's mom is handling everything!"

"A wise man listens to those with knowledge and experience," I observed.

"Physician, heal thyself!" Loretta said, causing everyone to laugh hard.

July 6, 1989, McKinley, Ohio

"Morning, Mike!" Doctor Lindsay said when I walked into the surgical locker room on Thursday morning.

"Morning, Doctor Lindsay!"

"Shelly, please. I heard you did a blind pericardiocentesis on Tuesday."

"Drunk driver MVA," I said. "Any idea how she did?"

"Coded from an aortic transection. It blew about ten minutes after you left the OR."

"I missed it," I said ruefully as we began undressing.

"No, you didn't!" Shelly said firmly. "If the aorta had been completely torn, she'd have been dead before EMS arrived at the scene. There were no signs, and she bled out in seconds. McKnight said it was a pseudoaneurysm, which means short of a CAT scan, you couldn't have seen it, and maybe not even then. Had you ordered a CAT scan, the aorta would have blown while she was in the machine. There was nothing you could have done, Mike, unless you have a direct line to God and He was in the mood to grant a miracle of the type YOU don't believe occurs!"

She was right, but that didn't make me feel any better.

"It still sucks."

"Yes, it does," Doctor Lindsay said, taking off her skirt. "But you know what really sucks? Drunk driving. In this case, it was the driver. You know what usually happens.

"Some innocent person dies and the driver survives," I said, having stripped down to my underwear.

We each put on red scrubs and left the locker room. She stayed on the surgical ward while I headed down to the ED.

"Morning, Mike!" Nate said when I walked up to the clerk's desk to check in.

"Morning Nate. I see the board is almost empty. Quiet night?"

"Mostly. You know the new EMS protocol started yesterday, right?"

"Yes."

In order to free up nursing resources, the ED clerks were going to answer EMS calls, and soon, we'd have an EMS radio, similar to the setup they had on Emergency, so that the paramedics could talk directly to us. That would allow them to get advice from doctors directly, rather than work through dispatch, and eventually, the EMS squads would radio directly when they were on their way, which would give us a few extra minutes' warning on their arrival.

"Morning, Mike!" Doctor Casper said.

"Hi, Ghost! Haunting the ED today?"

"Keep your day, night, and day job!"

"Morning, Doctor Mike!" Len Godwin said. "We have a seventy-two-year-old bowel obstruction waiting to go up. Otherwise, our board is clear. Surgery will take him at 8:00am."

"Last vitals?"

"EKG is clear; BP 130/80; pulse 80; PO₂ 99% on nasal canula. Surgery saw him at 0500."

"Orders on the chart?"

"Monitor vitals; IV Ringers; NPO."

"Did you and Bob have your breakfast?"

"Yes. Doctor Baxter sent us right after the surgical consult."

"OK. Where is she?"

"Sacked out in the on-call room. She said you should wake her when you arrived."

I went to the on-call room and saw only Kylie, so I simply called her name. She sat up almost immediately.

"What do we have?" she asked, pulling off her sleeping mask.

"A tired doctor in need of sleep! My prescription is to go home, sleep, and have a nice warm bath."

Kylie laughed softly, "Now, if only you could keep me warm and take that bath..."

"Time to go home, Doctor," I said. "Len gave me the scoop on the bowel obstruction."

"Sorry," Kylie said.

"It's OK," I replied. "I appreciate the sentiment."

"These shifts are WAY too long."

"I was basically dead on my feet on Tuesday evening."

"I believe it!"

We left the on-call room, and I went to Exam 3 to check on the bowel obstruction, then went to the lounge to get some coffee, where Len and Bob joined me.

"We're catching walk-ins," Bob said. "I'll be at the triage desk."

"OK," I said.

Bob left, and once I finished my coffee, Len and I went to the triage desk.

"LOL, weak and dizzy all over," Bob said, handing me a chart.

"Huh?" Len asked.

I kept my voice low to ensure I wasn't overheard, "Little Old Lady, near-syncope, with trouble standing."

I scanned the chart and had Len get a wheelchair before we went out to the waiting room to where the woman was sitting with an elderly man.

"Mrs. Valerio?" I said. "I'm Doctor Mike and this is Len, my student. Let us help you into the wheelchair, please. Mr. Valerio, you're welcome to come with us."

Len and I helped Mrs. Valerio into the wheelchair, and Len pushed her into the ED, where I directed him to Exam 3, then asked Ellie for a nurse. She sent Wendy, who had a nursing student with her, to help. Between the four of us, we helped Mrs. Valerio onto the exam table.

"What brought you to us today?" I asked, handing Len the chart to scribe for me.

"I got up early, as we always do, went downstairs to make breakfast, and I had just started the Mr. Coffee when I felt dizzy and could barely stand. Julius insisted I come here."

"Are you still feeling dizzy?" I asked.

"A little, yes."

"Anything else bothering you? Or anything else that's not normal for you?"

"My chest feels a bit heavy."

"Wendy, portable EKG, please," I said. "Mrs. Valerio, I'm going to examine you and put you on a heart monitor to see if we can figure out why you're feeling dizzy."

I got up to wash my hands and put on gloves, then returned to the exam table. I had a suspicion that Mrs. Valerio might have had a mild heart attack. The signs and symptoms for women were different, and often less pronounced than in men. For women, in many cases, only cardiac enzymes were definitive to rule out an MI as EKGs were not as reliable for women as they were for men. That meant I'd do the primary exam first, get blood drawn, and then do a history.

"Karen," I said to Wendy's student, "Chem-20, ABG, and cardiac enzymes, please."

"Right away, Doctor."

"Mrs. Valerio, I'm going to listen to your heart and lungs," I said. "Then Karen will draw some blood."

"What do you think is wrong?" Mr. Valerio asked.

"Right now, I don't know," I said.

I listened to Mrs. Valerio's heart and lungs, but didn't detect anything except minor crackles in her lower lungs, which might, or might not, be a sign of cardiac trouble. I had Len take her blood pressure, which was slightly elevated, then Karen drew the blood. For the EKG, Mrs. Valerio would need to take off her dress, so all of us except Wendy and Karen left the room. Normally, they would have left as well, but given Mrs. Valerio needed help, they stayed.

"All set, Doctor," Wendy said coming out the door about five minutes later. "Leads are attached, along with the monitor."

"OK. Please have your student take the blood to the lab. I want those cardiac enzymes stat."

"Right away, Doctor."

Len and I returned to the room, and I looked at the EKG, which was showing what appeared to be a normal sinus rhythm, though she was a bit tachy at 110, and her PO₂ was a bit lower than I preferred to see it at 95%.

"What's it show?" she asked.

"Your blood pressure is slightly elevated and your heart is beating a little fast," I said. "Your blood oxygen levels are a bit low, so out of caution, we're going to put you on oxygen via a nasal canula, which is a tube that sits right under your nose. Wendy?"

She hooked up the oxygen and a minute later, the monitor showed 98%.

"Are you taking any medication?" I asked.

"Naproxen for my arthritis," she said. "Plus a multivitamin with iron."

"Are you anemic?" I asked.

"Not since I started taking the vitamins about a year ago."

That could account for the low oxygen saturation I'd seen on room air, and might account for her other symptoms, if her anemia had worsened.

"Did you have another diagnosis?"

"What do you mean?"

"Sorry, did your doctor tell you what was causing your anemia?"

"No. He said it was mild, and I wasn't showing having any problems besides my arthritis."

"Have you had any health problems at all, besides your arthritis, in the past six months?"

"I have trouble falling asleep some nights, but otherwise, no."

Insomnia was a common problem that came with advanced age, and given Mrs. Valerio was seventy-eight, occasional insomnia wasn't a problem.

"Do you get any exercise?" I asked.

"Not since my arthritis started acting up about two years ago. The Naproxen lets me do my daily stuff around the house, but we don't take our walks at the mall the way we used to."

"What do you think is wrong?" Mr. Valerio asked.

"Everything your wife has said is consistent with her anemia worsening, but I want to wait for the blood test results before I say for sure that's it."

And I didn't want to worry them needlessly with my suspicion she might have had a heart attack, or even a mild stroke. Nothing I had seen so far called for a cardiac or neuro consult, though I could call for a gerontology consult without a specific reason for any patient over seventy-five, just as I could call for a pediatric consult without a specific reason for any patient under age fourteen.

"Mrs. Valerio, when was the last time you saw your physician?"

"February, just after my birthday. He said my anemia was under control and my arthritis was being controlled by the pills."

"How's your diet?" I asked.

"I don't eat as much as I used to, but I make sure I get plenty of fiber to keep things moving."

"Balanced?"

"Yes. I try to eat a good mix of meat, vegetables, and fruit. I take Metamucil for fiber every morning."

"I'd like to do a complete exam, if that's OK."

"Of course," she said with a sly smile. "I was a dancer in a cabaret when I met Julius almost sixty years ago, and I'm wearing more now than I was in front of an audience!"

"I was in the Navy," her husband said. "I went to a show, took one look at her, and said to myself I was going to marry her! Two months later, I did!"

I had a vague idea of what 'burlesque' had been like in the late 1920s, and her comment about her clothing strongly indicated she had been a striptease artist. And with her husband being in the Navy in the 1920s, I was sure they both had some very interesting stories to tell.

I performed the exam, noting nothing out of the ordinary, with her distal pulse and muscle tone being typical for someone who was nearly eighty and suffering from arthritis. I had just finished when the phone rang. Karen answered, then hung up.

"Lab results are ready," she said. "I'll go get them."

She left the room and returned about two minutes later and handed me the printout with the results. The results were basically what I'd expected, showing slight anemia, but also showing elevated cardiac enzymes.

"Mrs. Valerio," I said. "I believe you've had a mild heart attack."

XVI. Defeated

July 6, 1989, McKinley, Ohio

"A heart attack?" Mrs. Valerio gasped.

"Yes. Your cardiac enzymes show you had a mild heart attack."

"But you didn't see it on the machine!" her husband protested.

"Not every arrhythmia, that is an irregular heartbeat, shows on an EKG, and women often don't have the classic symptoms that men have. And the enzymes show that it was mild. I'm going to call for a cardiologist to see you. He or she and I will discuss what we do next, but for now, I'm going to give you some nitroglycerin, which will relieve the heavy feeling in your chest and bring down your blood pressure. Wendy, sub-lingual nitroglycerin tab, please. Len, call for a cardiology consult, please."

The nitroglycerin reduced Mrs. Valerio's chest pain, and brought down her blood pressure. About ten minutes later, Doctor Javadi came into the room with her student.

"Morning, Mike," Doctor Javadi said.

"Morning, Leila," I replied. "Mrs. Valerio, this is Doctor Leila Javadi, from Cardiology."

"Good morning, Mrs. Valerio," Doctor Javadi said.

"Good morning, Doctor."

"What do we have, Mike?" Doctor Javadi asked.

"Mary Valerio, seventy-eight, presented dizzy, weak, with mild chest pain, mild hypertension, and slight tachycardia. EKG showed no arrhythmia. Cardiac enzymes are slightly elevated. Nitroglycerin sublingual resolved the chest pain and hypertension. Len, the test results, please, for Doctor Javadi."

He handed them to her.

"Thanks, Mike," Doctor Javadi said. "Mrs. Valerio, I'd like to examine you, please."

Doctor Javadi reviewed the test results Len handed her, then performed her exam.

"Mrs. Valerio, I'm going to admit you to cardiology for an echocardiogram, which is an ultrasound of your heart. Mike, we'll need a portable EKG. Janelle, call for an orderly, please."

"Right away, Doctor," her student said.

"Len, you'll go with them. Cardiac patients are always accompanied by three."

"Will do," Len confirmed.

"Mrs. Valerio," I said, "Doctor Javadi will take good care of you."

"Thank you, Doctor."

I made notes on the chart, signed it, then left the room and went back to the admit desk.

"Who's next?" I asked Bob.

"Er, I thought you decided."

"Yes, but you tell me what you have and which patient you think I should take."

"Seventeen-year-old female with a sprained knee; twenty-nine-year-old male with a week-long productive cough; sixty-five-year-old with a minor forehead lac and contusion. I would take the cough, as the forehead contusion shows no neurological symptoms."

"Did you mask the cough?" I asked.

"Yes. That's on the standard procedure list."

"I agree that's who I should take first. Do a second neuro check on the contusion in ten minutes, please."

"Will do!"

He handed me the chart, and I went to the door and called out, "Mr. Kennedy?"

"Me!" came the muffled reply through the mask

He stood up and walked over to me.

"I'm Doctor Mike; follow me, please."

I led him to Exam 5, then asked Ellie for a nurse. She assigned Julie, who accompanied me to the exam room.

"How long have you had your cough, Mr. Kennedy?" I asked.

"About a week," he replied.

"OK, we'll get your vitals and I'd like to listen to your heart and lungs. Julie, we should mask."

"What do you think I have?" Mr. Kennedy asked.

"I don't know," I replied. "The mask is simply a precaution. I'll put one on because I'll need to have you remove your mask to check your breathing and look in your mouth and nose."

Julie and I both washed our hands, put on gloves and masks, and she took Mr. Kennedy's vitals. Once she'd done that, and written the results on the chart, I had Mr. Kennedy remove his mask and performed a basic exam. The only thing that stood out was that he had significant crackles in his lungs, along with slight tachycardia. I had him put his mask back on before I continued.

"Does your chest hurt?" I asked.

"Yeah," he replied.

"While you're coughing, after you cough, or all the time?"

"At first just when I was coughing, but now it feels tight and aches."

"Do you sweat at night?"

"Yes."

"Is that new or something that's been true for some time?"

"It started about the time the cough got bad."

"When, specifically, was that?"

"Let's see, it was after I came back from Mexico. I was coughing a bit after the flight, but figured I'd picked up a bug in Acapulco. So, maybe ten days."

"Have you been sick recently? Besides the cough?"

"No."

"Any other problems? Diarrhea? Fever?"

"No."

"Are you on any medication?"

"No."

"Any history of trouble with your immune system?"

"I don't think so. I don't get sick very often."

"OK. Julie, CBC and sputum sample. Mr. Kennedy, I'm going to order a chest x-ray."

"Chest x-ray?" he asked.

"You have fluid in your lungs," I said. "It's a standard test to rule out any number of respiratory diseases."

And would give me strong evidence that my preliminary diagnosis was correct. I wouldn't bet the farm on it, but my suspicion was that he had infectious tuberculosis. I wrote my orders on the chart, excused myself while Julie drew blood and obtained the sputum sample. I went to find Doctor Williams and made my report.

"Good precautions," he said once I'd reviewed the case with him. "Make sure he stays masked and come find me when you have the x-ray. If it shows what you think it will, we'll need Mark Hammond to examine him."

Doctor Mark Hammond was the hospital's infectious disease specialist.

"And report to the CDC and County Health Department," I added.

"What's the lab test for TB?" Doctor Williams asked.

"Initial test is for acid-fast bacilli, but definitive diagnosis requires sputum cultures, but that can take weeks as MTB is very slow growing."

"That's correct. Get the x-ray and lab tests and we'll take it from there. Chart?"

I handed him the chart, he made a few notes, then signed it and handed it back. I went to the nurses' station and called Radiology to set up the x-ray, then returned to the exam room.

"Someone from Radiology will come get you in about ten minutes," I said. "Just relax and I'll come see you when you're back."

"Thanks, Doc. What do you think it is?"

"Right now, all I can say definitively is either a viral or bacterial infection. The x-ray, blood tests, and sputum sample will point us in the right direction."

"Something I picked up in Mexico?"

"Possibly," I replied. "I'll see you in a few minutes."

I washed my hands, left the room, then disposed of the mask in the appropriate waste bin. As I went back to the admit desk, Len returned from Cardiology.

"Patient transferred," he said. "Nothing to report."

"Good. Bob, any change on the contusion?"

"No neurological signs."

"Then I'll take the sprained knee."

He handed me the chart, and I laughed, "First Kennedy, now Nixon!"

"I know, right?" he replied.

"Len, get a wheelchair, please."

He did, and we went out to the waiting room where a young woman with an ice pack on her knee was sitting. She looked vaguely familiar, and with her last name, I realized she might be related to Sheila, who I hadn't seen since my wedding.

"Cynthia Nixon? I'm Doctor Mike, and this is Len, my student. Let's get you into the wheelchair. Is this your mom?"

"My softball coach, Mrs. Paul," she said.

"Mrs. Paul, you can wait here while I examine Cynthia. We'll update you once we complete the exam."

She nodded and Len and I helped Cynthia into the wheelchair and pushed her into the ED, where I asked Ellie for a nurse and was assigned Becky, who followed us into Exam 3. We helped Cynthia onto the table and I began taking her history while Becky took her vitals.

"Any previous injuries to your leg?" I asked.

"I had a hamstring pull on my other leg last year, but that's it."

"How bad would you say the pain is?"

"It aches, but the ice helps."

"We're going to need to do an x-ray. Is there any chance you might be pregnant?"

"Only if my name were Mary and you're the Angel Gabriel!"

Len, Becky, and I all laughed.

"'Angel' is probably the last word anyone would use for me!" I said. "Len, call Radiology and arrange for a knee series."

"Right away!" he replied.

I filled out the chart, then handed it to Becky.

"Cynthia," I said, "I'll update your coach. Do you want her to come in? It might be as much as an hour before we get the x-ray results."

"Sure."

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

"Coach Paul? The sprain doesn't appear to be severe, but you can't always tell with an exam, so we're going to get an x-ray of Cynthia's knee before we decide how to proceed. She'd like you to come back and sit with her."

"Thanks, Doctor."

I escorted her to the exam room, then had Len come with me back to the admit desk where I asked for the chart for the forehead contusion.

"Mr. Abrams?" I said, walking up to him. "I'm Doctor Mike. Are you OK to walk?"

"Yeah, I just banged my head on the cabinet and my wife insisted I come have it checked out."

"Because you collapsed!" she said.

That was not noted on the chart, which concerned me.

"Mrs. Abrams, you can come back with us if it's OK with your husband."

"If I say 'no', I'll probably need a surgeon," he said.

The four of us went to Exam 1 where I washed my hands and put on gloves.

"When you collapsed, were you unconscious?"

"No. It hurt like a motherf...hell. I saw stars for a few seconds, but that's it."

"OK. Let me take a look, then we'll get your vitals, and I'll do an exam."

"The doc and nurse out front did three exams!"

"Which I asked them to do to ensure I could safely ask you to wait while I treated patients who had arrived before you."

I looked at his forehead and I felt it didn't even need a butterfly bandage, let alone sutures, and he showed no neurological deficits on exam.

"Len, clean the wound and apply a gauze dressing. 600mg ibuprofen PO. Monitor for an hour with neuro checks every fifteen minutes."

"Will do, Doctor!"

"Mr. Abrams, you don't appear to have suffered anything more than a minor abrasion and a headache, so we'll get you some ibuprofen, then monitor you for an hour. If there are no signs of concussion or other problems, we'll send you home."

"I told you, Mildred!" he said to his wife.

"Better safe than sorry, Max!" she countered.

I filled out the chart, signed it, and went to check on Mr. Kennedy, who hadn't returned from Radiology. I took the charts for Ms. Nixon and Mr. Abrams and went to see Doctor Williams. He reviewed both charts, made notes, and signed them.

"Kick the contusion as soon as you're happy. Let me know if you call an ortho consult on the knee."

"I'll want you to look at the film with me," I said.

He nodded, "Bring that to me when it's ready. Anything on the possible TB case?"

"He's not back from Radiology."

"We're keeping them busy this morning! This is four now. Varma had two and you've had two."

I left his office and almost ran into Ghost, who was moving quickly to the ambulance bay.

"Mike, I have a hot MI being transported in full arrest. Varma and Lincoln have traumas, and Nielson is on break. Can you assist?"

I was basically waiting, so I could.

"Yes."

I grabbed a gown and a fresh set of gloves and followed him, his Fourth Year, Jack, and Nurse Alice into the ambulance bay.

"Jack," Ghost said, "EKG and monitor, then Foley; Mike, intubation; Alice, trauma panel with stat cardiac enzymes."

A full arrest meant a fireman and paramedic performing CPR and a less than ten percent chance the patient would make it, and that was being optimistic. Two minutes later, the EMS squad pulled up, a paramedic jumped out and called out the vitals, which were basically non-existent, and moved to the back of the squad. There was a bit of shuffling as the gurney was moved out, and the fireman got on, straddling the patient, performing chest compressions as the second paramedic bagged.

"Trauma 1!" Ghost ordered.

The team performed the choreographed routine efficiently, and five minutes later the patient was on a respirator, but despite two amps of epi, an amp of bicarb, and continual chest compressions, we couldn't bring him back. With no heart sounds, no signs of electrical activity, and his pupils fixed and dilated, there was nothing left to do.

"Time of death, 08:19," Ghost said. "Alice, death kit, please."

We left the trauma room and stripped off our gowns and gloves.

"He was very likely dead when the paramedics got to him," I observed. "If you figure best-case response time, he was down ten minutes before they showed up."

"You know they prefer to bring everyone in because all it takes is my signature here, whereas it's a four-page triplicate form if he's declared dead on scene."

"Oh, I know," I replied. "I know this is going to sound crass, but that's a lot of resources expended to avoid paperwork."

"And if that were you? Would you want the paramedics to say 'fuck it'?"

"No, of course not! It was just an observation."

"You make some strange observations!"

"Maybe, but what is our number one problem here?"

"Besides people smoking, drinking to excess, and not seeing a doctor once a year?" Ghost asked.

I chuckled, "Yeah, other than those."

"Know-it-all Interns."

I chuckled, "Yes, yes! Besides that?"

"Lack of resources, of course, followed closely by ODs. I get your point, but your answer to my question points out the reality of the situation. Frankly, between you and me, if I had to conserve resources, I'd start with 'save my ninety-five-year-old grandma at all costs'."

I nodded, "And as crass as that sounds, as much as 80% of all healthcare expenditures are made in the last five years of life. I already have an agreement with Kris that if either of us is in a situation where there will be zero quality of life, we'll end any heroic measures. When we get older, that will apply in general. The last thing I want to do is spend the final years of my life confined to a hospital bed on a vent."

"You and me both," Ghost said.

"I need to check on my patients."

"Then hop to it! Thanks for the assist."

I nodded and went to check on Mr. Abrams, who was showing no neural deficits or signs of concussion, and Cynthia, who was being helped into a wheelchair for her x-rays. Ellie called out to let me know that Radiology had the films on Mr. Kennedy, so I sent Len to get them.

"What did you see?" I asked when he returned.

"I didn't know I was supposed to look," he replied.

"I was always curious and couldn't help but look. Go ahead."

We moved to a light board, and he put them up and I saw some dark areas that might well be indicative of TB.

"I have no idea what I'm looking for," Len said.

"I'm pretty sure this dark spot supports a diagnosis of TB," I said. "What does the wet read report say?"

He looked it over, "TB indicated and calls for further testing."

"Did we get the lab results?" I asked.

"Yes. Everything was normal except elevated white count. The sputum sample was positive for acid-fast bacilli."

"TB, almost certainly, but we have to wait for the culture to know for sure. And that takes weeks."

"So what do we do?"

"Call the infectious disease specialist," I replied. "He'll take Mr. Kennedy to Medicine, put him in isolation, and begin treatment, even before the results come back. It's a six-month course of an antibiotic cocktail. The CDC and County Health Department will be notified as well."

"Contact tracing?"

"Yes. Let's go see Doctor Williams."

We went to the Attendings' office, and I handed the chest film to him. He put them on the light board and looked them over.

"What do you see?" he asked.

"A dark area here," I said, pointing. "I'd say that's indicative of TB, and the Radiologist agrees. The sputum sample was positive for acid-fast bacilli."

"Let me call Mark Hammond," he said. "Keep everyone away from Mr. Kennedy except you two and the nurse. Just wait here while I make the call."

He picked up the phone, dialed, and then explained the situation.

"He'll be right down," Doctor Williams said.

Five minutes later, Doctor Hammond came into the office, looked at the film, looked at the chart and lab results, and nodded.

"I'll take him," he said, then turned to me, "Let's go see your patient, Doctor."

The three of us went to see Mr. Kennedy, putting on masks before we entered the room to which Julie had attached a 'quarantine' sign.

"Mr. Kennedy," Doctor Hammond said, "I'm Mark Hammond, an infectious disease specialist. I've reviewed your case, including the x-rays and lab test results, and discussed it with Doctor Loucks and his supervisor, and we all agree you most likely have active tuberculosis."

"TB?!" he exclaimed.

"You have all the classic signs, though a definitive diagnosis requires a culture, and that takes anywhere from two weeks to two months. We're going to admit you to our isolation ward, and we'll notify the County Health Department."

"Doctor," I said, "he was on a flight about two weeks ago."

"The County Health Department and CDC will deal with that. Mr. Kennedy, is there anyone you spend a lot of time with?"

"My girlfriend, my parents, and work, of course."

"Everyone will need to come in for a TB test," he said. "But the Health Officer will take care of that. Doctor Loucks, please arrange for transport. Mr. Kennedy, I'll see you upstairs momentarily."

He left, I had Len place the call for an orderly along with the instructions that they mask before they came into the room.

"How bad is it?" Mr. Kennedy asked.

"A course of antibiotics usually clears it up," I said.

About ten minutes later, he was on his way to the isolation ward, and after carefully washing my hands, I went to check on Mr. Abrams, who I felt was ready for discharge. I filled out the paperwork, signed the forms, and then directed him and his wife to Patient Services. A few minutes later, the films for Cynthia Nixon came back, and Len and I went to see Doctor Williams again.

"What do you see, Mike?"

"No tears or obvious damage," I said. "So a low-grade sprain."

"Athlete, right?" he asked.

"Yes."

"Refer her to a sports physiologist; there's no need for an ortho consult."

"Wrap the knee, ice, and ibuprofen?" I asked.

"That's the textbook treatment."

I acknowledged him, then Len and I went to see Cynthia and explain the diagnosis.

"How long do I have to stay off it?" she asked.

"At least until you see the sports physiologist," I replied. "We'll get you a set of crutches. We'll wrap it in an Ace bandage, and you should keep it wrapped except when you're in the shower, and use ice and ibuprofen for pain and swelling."

"I know someone you can see," her coach said. "And I think I can get him to see you today."

"Thanks, Coach."

"I'll write out the referral just in case," I said. "Len, an Ace bandage, please."

He retrieved one from the cabinet, and after getting permission, I wrapped Cynthia's knee. Len got her crutches, we showed her how to use them, and then, with discharge papers and the referral in hand, Len escorted them to Patient Services. I grabbed a quick cup of coffee, then Len and I went to see Bob.

"Nothing at the moment," he said.

"OK. I'll be in the lounge."

It was typical to have peaks and valleys, where things were utter chaos and I'd have to juggle multiple patients or they were very quiet. The quiet times rarely lasted long, so I took my coffee, went to the lounge, sat in a recliner, and sipped my coffee. The quiet lasted all of about two minutes before Alice opened the door to the lounge.

"Multi-victim MVA. All hands on deck!"

"Thanks, Alice. Let's go, Len!"

There were a total of seven victims, none of whom were serious, but that kept us busy for over an hour before I could check with Bob on walk-ins, of which there were four. I juggled those and managed to meet Clarissa for lunch in the Cafeteria.

"Crazy morning," I said. "Seven walk-ins, a fatal MI, and a seven-injury MVA."

"I saw on the chart that you sent us the TB case."

"He was on a plane less than two weeks ago. That should be fun for the CDC and County Health Department."

"A contact tracer was meeting with him when I came down for lunch. Any of the other cases interesting?"

"Seventeen-year-old softball player with a sprained knee."

"Who just needed Doctor Mike's magic touch to be healed?" Clarissa teased.

"No, but when I asked her if there was any chance she might be pregnant because she needed an x-ray, she said only if her name was Mary and I was the Angel Gabriel."

Clarissa laughed, "Cute. And?"

"And nothing. She didn't flirt. I just found it amusing. She did resemble Sheila and had the same last name?"

"Cousin? Niece?"

"No idea. You know we're not allowed to ask questions such as that, especially given Sheila was also a patient."

"Who you 'probed' extensively!"

"No comment! Did they start Mr. Kennedy on the antibiotic cocktail?"

"Yes. He's my patient, with Doctor Hammond as the Attending."

"Just palliative besides the cocktail, right?"

"Yes. And you know the culture can take over a month because MTB grows so slowly. What made you order the acid-fast test?"

"He had the classic symptoms -- productive cough, chest pain, and night sweats. And given it's a quick, inexpensive test with a staining agent, why not? If it had been negative, I'd have looked further for a diagnosis. What else do you have?"

"The usual collection of ailments; nothing exciting. How are things otherwise?"

"Rachel is unhappy she doesn't see me for long periods of time, but we're coping. She is happy to play with Abigail twice a week. And now that Viktoria Elizaveta is almost a year old, they're spending time together once a week."

"But avoiding little Viktor like the plague, right?"

"Yes. Both girls are very calm and he's hyper."

"Anything on the complaint about Angie's treatment?"

"Other than speaking to the attorney, no. I'm supposed to hear from him in the next few days to give a deposition. And to anticipate your next question, nothing on the citizenship application, but we don't expect that until next month, at the earliest. How are things with Tessa?"

"Great, except for not being able to see her during our long shifts."

"I'm having dinner with Kris and Rachel in the cafeteria again tonight. We're going to try to do that as often as possible during this first year."

"But cafeteria food..."

"Is irrelevant compared to seeing Kris and Rachel."

"Good point."

We finished our lunches, and both headed back to our respective services.

"Mike, can you take a patient so I can get lunch?" Paul Lincoln asked.

"What do you have?"

"Twenty-two-year-old presented with fever; abdominal pain; LMP six weeks; positive home pregnancy test; hCG levels consistent with reported LMP; white count normal; no distention or guarding. Waiting on OB to rule out an ectopic."

"Did you do an ultrasound?"

"No. I basically cowered in a corner during my OB rotation. Babies and I do not mix!"

"I'll take her. What room?"

"Exam 6."

He left, and I went to Exam 6 and checked the chart, then asked Becky to assist me, as Ellie wasn't at the desk.

"Let's get an ultrasound, please," I said.

"You're going to do the exam?" Becky asked.

"Yes. I know OB is coming down, but it'll be a bit because it's lunchtime. I'm trained to do the exam."

"Who'd you have for your OB rotation?"

"Doctor Leslie Cooper at Good Samaritan in Cincinnati. She's Chief of OB now."

"Catholic?"

"Russian Orthodox, but the same basic opinion on abortion, and before you get on your high horse, I believe it ought to be legal, I just won't participate in an elective one. Get the ultrasound, please."

Two minutes later, we went into the room.

"Good afternoon Ms. Blake," I said. "I'm Doctor Mike, and this is Nurse Becky. Doctor Lincoln asked me to check on you. I'm going to do an ultrasound."

"You're the OB?" she asked.

"Surgical Intern," I replied. "OK to examine you?"

"Yes, of course."

With Becky's help, I performed the ultrasound and saw what I hoped I'd see.

"There is a fetus in your womb," I said. "And a cyst on your ovary."

"The other doctor thought I had an ectopic pregnancy."

"He called OB to rule it out, but I can confidently say you have a cyst and, so far, a successful pregnancy."

"What's the treatment?"

"Your cyst isn't large enough to warrant treatment at this time. Cysts usually resolve on their own, so my recommendation is that you take Advil for the pain and follow up with your gynecologist. When the doctor from OB arrives, we'll get you on your way."

The door opened and Doctor Carmichael came in.

"Hi, Mike. I thought this was Doctor Lincoln's case."

"He's having lunch. Sorry to steal your thunder, but Ms. Blake has an ovarian cyst and, as far as I can see, a successful pregnancy."

"Mind if I confirm?"

"Not at all."

Doctor Carmichael examined Ms. Blake, then we stepped out.

"You did an OB Sub-Internship?" Doctor Carmichael asked.

"No, but I basically insisted on being taught during my Clerkship. I did internal exams, and was trained on rape kits."

"Who taught you?"

"Doctor Mary Kelly at Good Samaritan in Cincinnati, who's now an Attending. I had a case very similar to this, and as in that case, I suggested Advil and following up with her gynecologist."

"Exactly right. Want me to sign the chart?"

"The hospital runs on paperwork, and once Paul called you, somebody will look for an OB signature. Honestly, though, everyone here should be able to do what I did."

"I don't disagree, but those red scrubs give you a bit more freedom than most trauma PGY1s. Let's go speak to Ms. Blake."

We went back into the room, and after I reiterated my diagnosis, Doctor Carmichael signed the chart, and I went over the discharge instructions with Ms. Blake. Once I'd done that, I left her in Becky's care and went to the admit desk.

"What do you have, Phil?" I asked the Fourth year who was filling in for Bob so Bob could have lunch.

"Probable broken ankle on a fifty-year-old; possible strep on a thirteen-year-old; and hammer versus hand on a twenty-three-year-old."

"I'll take the possible strep case first."

The afternoon was busy, and I saw all of those patients, and four more. The possible strep case was actually a case of infectious mononucleosis; the ankle was broken, and actually needed surgical repair by orthopedics; the hammer versus hand also needed ortho, as the patient's distal phalange was shattered. The other patients were a case of poison ivy, food poisoning, and heat stroke. I finished with the last patient just in time to be able to meet Kris and Rachel for dinner.

I hugged and kissed them both, and carried Rachel into the cafeteria.

"How has your day been?" Kris asked.

"Busy. Just under twenty patients, including two I sent to Clarissa -- TB and mono."

"Tuberculosis? Here?"

"Tuberculosis. Here."

"All of your patients made it, then?"

"I assisted Ghost on an MI, but the patient was in full arrest when the paramedics got to him, so he was basically dead before we saw him."

"Then why bring him in?"

"If someone was with him and performed CPR, there would have been a remote chance of saving him, but the main reason is that Ghost or I could sign the death certificate, and it's a one-page form. For the paramedics, it would be a four-page form in triplicate. It would also require a Coroner's Inquest to decide why he died. In our case, it would just be an autopsy, and those aren't required if a patient dies in the presence of a doctor and there's no suspicion of foul play."

"How do they decide?"

"The rule is basically if there is so much blood that the patient has clearly exsanguinated or there is obvious brain matter or a decapitation, then they aren't brought in. It's a judgment call on everything else, and usually they default to transporting the person. As I said to Ghost, it consumes resources, but I think it's usually the right thing to do."

"You know my thinking on that!"

"I do, but there are not unlimited resources, and before you point to military spending, that's federal, and hospitals and doctors are state and local. There aren't enough, and I use this term advisedly, socialists in the US to change that."

"Why put it that way?"

"Because both Democrats and Republicans prefer to spend money on defense, funneling money to their districts, than they do on Medicaid or Medicare."

"That's disgusting!"

"I don't disagree, though you know I agree with my grandfather on having a sufficiently strong military to keep the Soviet Union in check. As President Reagan called it -- 'Peace through strength', which appears to be working. I pray that it ends relatively peacefully, but you know my fear."

Kris nodded, "A nuclear holocaust."

"Yes. How was your day?"

"Fine. My composition class is interesting, and you know my opinion of English! It's so silly!"

I chuckled, "You remember what I said about English, right?"

"Yes, of course! What you need is an authority like in France to designate the proper way to use it!"

"Good luck with that!" I chuckled. "We have significant regional variations, and there isn't actually an 'official' version. The English here, using Peter Jennings as a standard, is, as I'm sure you know, different from that spoken in England, India, and Australia."

"Why a news presenter?"

"Anchorman," I countered with a smile.

Kris rolled her eyes, "As I said!"

"The funny thing is, he's Canadian, but he speaks US English in a standard, flat, Midwestern way that's acceptable across the entire country, where a strong Boston, New York, Philadelphia, or Southern accent wouldn't be. Basically, all the three major network anchors sound as if they're from Ohio, Michigan, or Indiana, as do most of the reporters. Anyway, what are you writing?"

"A short story about two teenagers in love."

"So, for you, pure fiction?" I asked.

Kris smiled, "Teenage romance is almost always silly."

"Because," I asked with a sly smile, "teenagers are not mature enough to handle relationships?"

"Not most American ones, that's for sure! But you know my view on romantic love -- that it is more likely to interfere in a relationship than make it successful."

"I think it's more complicated," I said, "but I don't completely disagree with you. The divorce rate in a country where romantic love is the primary driver for marriage makes that point pretty well. What are your plans for this evening?"

"Put Rachel to bed, then work on my story with a glass of red wine! And tomorrow is Rachel's usual day with her cousin Viktoria. Did you want something special for dinner?"

"At the end of a thirty-six-hour shift, I'm not sure I'll care, so long as it's filling and nourishing."

"OK. There was a message from your mom asking when we could come to dinner. I'll arrange it, but when would be best?"

"Sunday after church, I think," I said. "That really is the only reasonable time."

"I'll ask if a week from Sunday will be good for them."

"Thanks."

We finished our meal, I walked Rachel and Kris to the car, and then headed back to the ED.

"Did you hear the great news?" Mary asked when I met her in the lounge, as Bob and Len had gone off shift just after I went for dinner.

"What's that?"

"Doctor Casper said that the Hospital Board approved the additional nursing staff to cover triage. The bad news is that it'll take until September 1st before the new nursing staff is hired and Fourth Years no longer have to do triage."

"I think that's good, obviously, but I also think triage is useful training. That said, if it's a choice between procedures and triage, I think procedures are overall better training."

"Out of curiosity, why do you think that?" Tom asked.

"Because at some point you may be called upon to do triage in a mass-casualty event and having done it when things are relatively calm helps you be ready for when they are chaotic. That happened with a school bus accident in my case."

"Doctor Mike?" Nurse Angela called out, "Paramedics three minutes out with a six-year-old choking victim. Use Trauma 2. Nancy will assist."

"Got it! Mary? Tom? Let's go!"

The three of us gowned, gloved, and hurried to the ambulance bay where Nurse Nancy joined us. I assigned tasks, and about a minute later the EMS squad pulled up. Tom jumped out of the cab and called out the vitals.

"Jeremy Lyons; age six; choked while eating; Heimlich maneuver performed when he began turning blue; airway clear; BP 120/70; pulse 88; resps strong; PO₂ 99% on nasal canula; GCS 15 and oriented times three."

"Trauma 2!" I ordered, and we began moving. "Nancy, ABG only."

"No trauma panel?" she asked to confirm.

"Correct."

"Jeremy, I'm doctor Mike and we're going to take good care of you," I said. "How do you feel?"

"OK. My brother squeezed me real hard, and the bread came out!"

"Tom, any LOC?" I asked.

"None reported. We elected to transport out of an abundance of caution."

"Smart. Parents?"

"Right behind us."

"Jeremy, how old is your brother?"

"Twelve."

That was impressive for a twelve-year-old, and that kid deserved some kind of recognition for saving his brother's life.

"Jeremy, do you think you can scoot from the rolling bed to the other bed?"

"Yes."

He did that with Tom ensuring the nasal canula stayed in place. Nancy switched the canula to the hospital system, though in my estimation it probably wasn't necessary. Once that was done, Tom and his partner left the trauma room.

"Jeremy, my friends Mary and Tom are going to put a monitor on you to let us see that your heart is OK, and I'm going to listen with my stethoscope. OK?"

"Yes."

"Tom, let's remove his t-shirt without cutting, please," I said. "It's OK to remove the nasal canula to do that."

Ten minutes later, with blood drawn, the EKG and pulse oximeter attached, and a primary exam performed, I was confident that Jeremy was OK, and instructed Tom to bring his parents in.

"What happened, Jeremy?" I asked.

"I was eating bread, and it got stuck in my throat. I couldn't talk and my brother Jimmy hugged me and squeezed hard and the bread popped out."

"How do you feel?"

"Good! Firemen carried me out of the house and I got to ride in the fire truck!"

"Does anything hurt?"

"Just my arm where the nurse took my blood."

"Mary, you can turn off the EKG and remove the pads," I said. "Leave the pulse oximeter in place for now."

"Yes, Doctor," she said.

"Doctor Mike, Mr. and Mrs. Lyons," Tom said.

"Hi, Mr. and Mrs. Lyons," I said. "Jeremy is fine and you should be able to take him home soon. We just need the results of his blood test, which we should have in the next few minutes."

"I'm OK, Mom!" Jeremy said.

"I hear his brother was the quick thinker," I said.

"Yes," Mr. Lyons said. "He learned that at school last year, along with other first aid."

The door opened and Deputy Leslie Cowan stuck her head in.

"OK to come in, Doc?"

"Yes," I agreed.

"Mr. and Mrs. Lyons," Deputy Cowan said, "I just need to speak to one of you to complete my report. There's nothing wrong, and you aren't in any trouble, I just need some details."

"I'll answer," Mr. Lyons said. "Terry, you stay with Jeremy."

They left and Jeremy's mom asked if it was OK to hug him. I nodded, and she did so, then stayed by the treatment table. The lab called to say the results were ready, and I sent Tom to get them. He was back two minutes later.

"Everything is in range," he said.

I looked over the results and concurred.

"Mrs. Lyons, Jeremy is just fine, and if you'll give me ten minutes to do the paperwork, we'll get you on your way."

I updated the chart, filled out the discharge form, then went to see Doctor Williams, who signed off.

"No followup?" he asked tapping his pen on the discharge form.

"Only if he shows any impairment," I said. "His EKG was textbook, his PO₂ was 99% on room air at the end, his blood gasses were also textbook, and he's awake, alert, and oriented times three. No signs of abuse, and his story fits all the facts."

Doctor Williams laughed, "A simple 'no' would have sufficed."

"Sorry."

"Don't be. I had to ask, or I wouldn't be doing my job, because you're an Intern. For the most part we treat you as if you weren't, but you still do have a lot to learn. And I didn't see your response as defensive, simply factual, which is your way. One thing to learn when reporting is that it's possible to give too much information. I know that sounds strange, but in this case, your med students could have handled it with their training. Save the details for important cases or when you're not sure."

"Yes, Doctor."

"Brent."

"Actually in this case, you're an instructor, not a colleague, so 'Doctor' seemed more appropriate."

"Formality from the guy who goes by 'Doctor Mike' to patients?"

"Totally awesome dude!" I said in a 'surfer voice'. "It's all casual!"

"OK, that might be going a bit TOO far! This isn't Malibu! Get out of here!"

"Right on, Brah!" I smirked.

Brent shook his head and pointed to the door and I left, returning to the trauma room. Mr. Lyons had returned, so I spoke to both parents, basically repeating what I'd said to Doctor Williams, and once Mrs. Lyons helped Jeremy put on his shirt, I did my usual thing.

"What's your favorite candy?" I asked Jeremy.

"Gummy bears!"

And with that, my perfect record was defeated.

"Second favorite?"

"Spree!"

I pulled a roll of Spree from my pack and handed it to him.

"For being a good patient," I said. "But you listen to your mom and dad about when you can have them, and you should probably share with your brother for helping you."

"Awww, do I have too?" he whined.

"No, you don't have to," I said. "But you should."

He gave me a look that said he'd reluctantly share, but that was between him and Jimmy.

"Thanks Doctor," Mrs. Lyons said. "Jeremy, you should say 'thank you'."

"Thank you, Doctor Mike!"

"You're welcome. Mr. and Mrs. Lyons, Tom will take you to Patient Services, and then you're free to take Jeremy home."

They both shook my hand, I said 'goodbye' to Jeremy, and Mary and I left the room.

"First time you didn't have what the kid wanted?" Mary asked.

"I only carry the ten most popular, and in the end, it had to happen. Was it that obvious?"

"You had a brief look on your face as if someone had killed your puppy, but you recovered quickly."

"I was lucky and his second choice was in the top ten. I might have been in real trouble after that!"

"Nah, just offer him a sucker from the jar at the nurses' station and pretend you aren't the 'Kid Whisperer'."

"I won't go down without a fight!" I declared.

"Doctor Mike?" Nurse Angela called out. "Ghost needs you in Trauma 2."

"Thanks! Mary, let's go!"

XVII. Air Ambulance

July 6, 1989, McKinley, Ohio

"What do you need, Doctor Casper?" I asked as Mary, Tom, and I entered Trauma 2.

"Doctor Wilson is in Trauma 3 for a chest tube and central line, so I need you to put those red scrubs to use and confirm my MVA needs an ex-lap for splenic rupture."

"Indications?"

"Abdominal pain, epigastric tenderness, Kehr's sign, tachy, hypotensive, strained respiration requiring intubation. The patient consented before intubation."

"Tom, ultrasound, please," I said.

"Be right back!"

"Mary, Kehr's sign?"

"Acute pain in the shoulder, usually resulting from blood in the peritoneal cavity in a supine patient with their legs elevated. Left shoulder referred pain is a sign of splenic injury."

"Differential?"

"Diaphragmatic injury, kidney stones, and, in a female patient, ruptured ectopic pregnancy."

"Very good. You perform the ultrasound."

"Uh..."

"You can do it," I said. "We'll all see the image."

Tom returned with the ultrasound unit and I walked Mary through the procedure.

"What do you see?" I asked.

"I have no idea what I'm looking at," she said.

"This," I said, pointing, "is his spleen, right below his left lung and to the left of his liver. And this," I pointed again, "is free fluid around the spleen, indicating bleeding. We could do a peritoneal lavage to prove it's blood, but I think that's wasting time. Mary, call up and say we have a surgical case -- ex-lap for probable splenic fracture. Tom, we need an orderly."

"Thanks, Mike," Ghost said, handing me the chart.

I made my notes, signed it, and handed it back.

"Somebody call for a surgeon?" Doctor Mary Wilson asked, coming into the room.

"Mike did the consult," Ghost said. "You were busy with the driver."

"Then I'm going up because they'll need two teams."

And if she was going up, that meant my students and I couldn't scrub in, as I'd be the only surgical Resident available.

Twenty minutes later, Mary, Tom, and I were back in the ED.

"I thought we might get to scrub in," Mary said.

"Once Doctor Wilson said there were two surgeries, and she was going to scrub in, I knew that couldn't happen."

"Doctor Mike?" Nurse Tiffany, who was at the triage desk, called out. "Walk in chest pain."

Which meant they had to be seen immediately, with only someone transported by EMS having priority. I looked at the board and saw Trauma 4 was free.

"Tom and Mary, wheelchair, and bring the patient to Trauma 4. GO!"

I went to the nurses' station and asked for a nurse, and Billie followed me to Trauma 4.

"What's your name, sir?" I asked, as my students brought him in.

"Mike Meyer," he grunted.

"Let's help him onto the table," I said. "Mary -- EKG, monitor; Tom -- IV saline and start a chart; Billie -- nasal canula, CBC, Chem-20, ABG, and stat cardiac enzymes."

We got Mr. Meyer onto the bed and I performed the primary exam while the others executed their tasks.

"How old are you, Mr. Meyer?" I asked after auscultating his heart and lungs.

"Forty-nine," he grunted.

"Do you smoke?"

"No."

"IV is in!" Tom announced.

"Do you consume alcohol?"

"A couple beers after work with the guys most days."

"When did the pain start?" I asked.

"About an hour ago, I guess."

"BP 190/120," Mary reported. "Tachy at 125; PO₂ 92%; EKG shows arrhythmia."

"What do you see?"

"The T-wave doesn't look right."

I looked up and saw she was correct.

"Inverted T-wave. Call for a cardiologist, please. Tom, get the blood to the lab."

"Right away!" Mary replied.

"On it!" Tom declared.

"What's that mean?" Mr. Meyer asked.

"That your heart has been damaged in some way. Just try to relax, please. We're calling for a cardiologist and we'll give you some medicine to help. Billie, 250mg ASA IV push and sub-lingual nitroglycerin tab."

"250mg AGA IV push; sub-lingual nitro," Billie repeated.

The nitroglycerin brought down his blood pressure slightly and helped with the pain. About four minutes later, Doctor Shore from Cardiology arrived with a Third Year I didn't know.

"Shore, Cardiology. What do we have?"

"Hi, Pat," I said. "Mike Meyer; forty-nine; presented with chest pains; hypertensive; tachy; inverted T-waves on the monitor; murmur on auscultation. Administered ASA and nitro. Recommend cardiac echo."

"Thanks, Mike. Mr. Meyer, I'm Doctor Shore from Cardiology."

He proceeded to listen to Mr. Meyer's heart and reviewed the EKG.

"I'll take him on my service," Doctor Shore said. "Mr. Meyer, we're going to take you upstairs and perform an echocardiogram -- an ultrasound of your heart -- to get a better idea of what's going on. Mike, enzymes?"

"Ordered stat. We should have them momentarily."

"Kyle," he said to his student, "call for an orderly. Mike, I'll need him on a portable monitor."

"Tom," I said. "Switch to a portable monitor and escort Mr. Meyer upstairs."

"Will do."

I updated and signed the chart, then said, "Mr. Meyer, you're in very good hands. Mary, with me, please."

We left Doctor Shore, Tom, Kyle, and Billie with the patient.

"Mike," Angela called out. "Arm lac in Exam 6. Doctor Varma asked if your student could suture."

"Absolutely," I said. "Mary, this is all yours. I'll watch. Remember, identify yourself as a Sub-Intern and me as your supervisor."

"Got it!"

The arm lac was clearly a simple repair, so once Mary had explained what she was going to do, I left the exam room and saw Tom walking down the corridor from the elevators.

"Trouble?" I asked.

"V-fib in the elevator, but he cardioverted immediately. How did you know?"

"You were gone too long for a simple transport," I said.

"Mike?" Nicki, the clerk called out, "EMS two minutes out with a burn victim. It's a bad one. Doctor Casper needs your help."

"OK. Tom, let's go. Mary is suturing."

We gowned and gloved and hurried to the ambulance bay. I looked across the driveway and saw the slowly rising building that would be our new trauma center, but the paramedics arrived just a few seconds later, and I cleared my mind to focus on the patient who was about to be unloaded.

"Mike, if this is as bad as it sounds," Ghost said, "we'll stabilize, then you'll take him to the burn center in Columbus."

"I haven't made all my flights," I said. "I'm one short."

"The number of flights is advisory only," he said. "Josh will sign off, I'm sure. The problem is that if one of the senior Residents or Attendings go, we'll have to call someone in and we're short-staffed because Loretta is on leave until tomorrow and Boyd and Fitzgerald are out sick."

"OK. I'll leave you Mary even though she'll have a fit. She can do suturing and other basic procedures for which Tom hasn't yet been trained."

"Helicopter?" Tom asked nervously.

"Yes."

"They come off the assembly line with the single mission of killing all their occupants!"

"I can take Doctor Varma's third year," I said.

"No, I'll go."

The EMS squad pulled up, and the paramedic jumped out.

"Bad one, Doc!" he said as he moved to the back of the squad and opened the door. "John Doe, mid-to-late twenties, with third-degree burns on his arms and most of his torso; smoke inhalation; BP 90 palp; tachy at 130; PO₂ 90% on ten liters by mask with no cyanosis; morphine administered; IV saline."

That amount of burn coverage meant, based on the rough calculations, about 50% and his chances of survival were around 60%, though with smoke inhalation, that number was likely generous.

"Mike, have them warm up the chopper. Tell Mary I need her, and the sutures will have to wait. Get ready to go, because as soon as I evaluate him and get another IV into him, he's going to Columbus."

"Right away, Doc! Tom, come with me."

My first stop was at the clerk's station, where I asked Nicki to call for the helicopter, which she did. Next, I went to Exam 6 and asked Mary to step out.

"Doctor Casper needs you in Trauma 3 to help with a burn victim. Tom and I are going to take him to Columbus by chopper as soon as he's stabilized. I'll let your patient know you'll be back in a few minutes.

"Not to be a bitch..."

"I know, but we're short-handed and no disrespect to Tom, but you can be much more useful here, rather than babysitting the patient on the helicopter. Go!"

"Yes, Doctor."

She left, and I went into the exam room and informed the patient that we had a serious emergency case and that Mary would be back shortly. We left the room and Nicki signaled me.

"Fifteen minutes," she said. "The crew is on their way to the pad."

"Thanks!"

I took Tom to the locker where I gave him the same basic instructions I'd once been given, and I put on a red flight surgeon jacket while Tom donned a blue trainee jacket. We grabbed our helmets, but didn't put them on, then headed to Trauma 3.

The patient had been intubated and now had two large-bore IVs for fluid replacement. The burns made an EKG impossible, and the pulse oximeter was on his ring finger, rather than index finger, due to burns. And the room smelled of charred flesh, which caused my stomach to turn.

"Chopper will be ready in about ten minutes," I said, fighting the nausea.

"Full-thickness burns over his arms and torso," Doctor Casper said. "Tom, get Doctor Taylor please. Drag him in here if you have to."

"Yes, Doctor," Tom replied.

He left and returned with Doctor Taylor about a minute later.

"What do we have, Ghost?"

"Male; late-twenties; 50% full-thickness burns; hypotensive and tachy; IV Ringers with dobutamine; intubated; minimal urine in the bag; he needs to go to the burn unit in Columbus as soon as surgery does an escharotomy. The chopper is warming up and I plan to send Mike and Tom. You'll need to formally sign off for Mike to fly solo. He's done three and has the signoffs for those in his book."

"Mike, let me have your procedure book, please," Doctor Taylor said.

I pulled it from my back pocket and handed it to him. He wrote on a blank page, signed it, and handed it back.

"You're cleared. I'll update the hospital records. Ghost, I think he should take a nurse as well. Kellie can go with them; she's a certified flight nurse from her Navy service. I'll let her know. She'll bring the drug box."

"What do we have?" Doctor Lindsay asked, coming into the room.

"Hi, Shelly," Ghost said. "50% full-thickness burns with pulmonary compromise. He needs an escharotomy."

"OK. Mike, put a gown over that flight jacket and assist, please."

Nurse Billie helped me into a gown, and put a mask on me, and I stepped up to the table with Doctor Lindsay, who had been helped into her gown and mask by Nurse Jenny.

"Have you seen one of these?" she asked.

"No."

"We incise the burn skin down to the subcutaneous fat and into healthy skin lengthwise, if possible. The goal is to relieve the constriction of his chest and allow for better respiration. When you cut, you need to take care to avoid nerves and veins. Watch and one of us will supervise you performing this in the future."

She made the necessary incisions, which only increased my nauseated feeling. I'd always heard severe burns were the worst, and now I was sure of it, and not just for the patient, but for the surgeon and other medical staff. The smell, combined with the sights and sounds of crackling flesh as she cut, was enough to induce nausea into anyone.

"Billie," Doctor Lindsay said, once she'd completed the procedure, "antimicrobial dressing, please. Vancomycin, 100mg IV push then drip at 10mg/min."

"Vancomycin, 100mg IV push, drip at 10mg/min; antimicrobial dressing," Nurse Billie repeated.

She and Jenny quickly and efficiently set up the IV and dressed the escharotomy.

"50%?" Mary asked quietly.

"It's a rough calculation -- 9% for each arm, 36% for the torso, 9% for head and neck, 18% for each legs, and 1% for genitalia."

"Thanks."

"PO₂ now 93%," Ghost said. "A slight improvement. Mike, your key number is his BP. Keep the fluids flowing, and keep the dobutamine drip going. The fluids and dobutamine should keep his pressure up. Increase the dobutamine if you see the pressure drop. If you need help, they'll patch you through the radio to us or the burn center."

"OK," I said. "Let's go."

Ten minutes later, Tom, Kellie, and I were buckled in and the patient was loaded on the helicopter.

"Hayes County Air Ambulance departing Moore Memorial Hospital for Ohio State University," I heard in my helmet as the helicopter lifted off.

"Relax, Tom," I said, seeing his knuckles whiten as he gripped the armrest to his left.

"First time on a helicopter?" Kellie asked him.

"Yeah," he said. "You were in the Navy?"

"I was a nurse aboard the carrier Nimitz for six years. I flew on dozens of SAR missions."

"Ever jump into the water?" I asked.

"No, we had divers who were trained as corpsmen for that. My job was to assist the flight surgeon, as I'm doing now."

"Fishing pilots out of the water?"

"Mostly, yes. Occasionally over land, but mostly at sea. Rescue choppers take off before air operations, and I flew those, too, but mostly that was simply sitting waiting for something that rarely happened -- a catapult problem or engine problem that dropped a Tomcat into the water."

"Get a BP for me, please," I said. "You'll need to use the ankle given the burns on his arms and the dressing."

She took the measurements and reported them as 110/80, which I adjusted, as ankle systolic pressure was anywhere from ten to twenty percent higher than brachial pressure. That meant his brachial pressure would be somewhere around 100/70, which was much better than when he'd first come in.

"No changes to the IV," I said. "Sats look as good as we could hope for."

It was 94%, and given his smoke inhalation combined with the circumferential burns, I doubted we could get it higher until his lungs recovered.

"Mike, can I ask why they didn't send an Attending?" Tom inquired.

"It's only required for cardiac cases," I replied. "And despite hypotension and tachycardia, the patient doesn't appear to have any compromise of heart function. In effect, we're acting as paramedics, and both Kellie and I have more training than they receive. Both pilots are paramedics as well, and you've had two years of med school. Given the limited ability to do procedures in the chopper, it doesn't make much difference. And I can radio in if something happens that concerns me."

"I wonder what happened?"

"One thing you'll learn in the Emergency Department is that you will likely never know much about what happened before or after you see a patient. Our job is assessment and then stabilization or treatment. After that, we admit or discharge them. Either way, what happens after they leave the ED is opaque in most cases. That was the most difficult thing for me to adapt to."

"Five minutes out," came over the headset.

I listened as the co-pilot spoke to the controllers and, as predicted, just under five minutes later, the helicopter touched down on the helipad. As usual, the rotors continued to turn as the local staff rushed out, ducking, and the co-pilot opened the door.

I carefully jumped out, took off my helmet, and moved directly to the doctor, who had arrived with two nurses, an orderly, and a medical student. I put my ear near his mouth and my mouth near his ear so we could converse over the noise of the helicopter engines and blades.

"Jones, burn specialist," he said loudly.

"Loucks, trauma surgeon; John Doe; late twenties; 50% full-thickness burns to arms and torso; escharotomy; IV Ringers; dobutamine and vancomycin; ankle BP 110/80; pulse 100; PO₂ 94% on vent; minimal urine production."

I handed him a copy of the chart, he signed my form for our chart, and they moved the patient from the helicopter. As soon as the patient was clear, I got back into the helicopter and the co-pilot shut the door. He climbed in, checked with the controller by radio, then announced our departure. As was my usual practice, as soon as the helicopter left the ground, I leaned back and closed my eyes.

I wasn't sure how long I slept, but I was jolted awake when a klaxon sounded and the helicopter shuddered. The nose of the helicopter dipped, and I felt my stomach move as it did on rollercoasters.

"Engine failure!" I heard over the headset. "Emergency landing! Hang on!"

"Oh, God!" Tom moaned in distress. "No!"

"We have two engines," Kellie said calmly. "They'll put us down on a road or other flat surface."

She was WAY too calm in my mind. Sure, I slept on the return flights, but this was different. I did the only thing I could -- prayed the Jesus Prayer. About thirty seconds later, we made a rough landing, and the co-pilot ordered us out of the chopper. Tom needed no encouragement, throwing open the door and bolting out. I quickly followed him, but Kellie simply calmly exited the passenger compartment.

I immediately surveyed where we were, and saw we'd landed on a baseball field, in the shallow outfield, just past second base. I turned and saw a bit of smoke coming from one of the two engine compartments, VERY happy the helicopter had two engines. The pilot and co-pilot both had extinguishers in hand, but weren't using them.

Tom, still moving, stumbled, and collapsed onto the ground. Kellie quickly moved to him. She checked his pulse, then had him lie down.

"180!" she announced.

My heart was racing, too, but probably around 130. Kellie, on the other hand, was cool as ice.

"Let's see if it resolves," I said. "Tom, just try to breathe normally."

"How are you, Doctor?" Kellie asked.

"Well, I managed to avoid soiling my underwear, so there's that."

After about a minute, Tom sat up and seemed to be doing better, with his pulse down to about 130. The pilot came over to us.

"I called it in. We're about six miles from the hospital. They'll send someone for you; we'll stay with the bird until the maintenance crew arrives."

"Will you fly it out?"

"No way. They'll put her on a flatbed and take her back to the barn."

About fifteen minutes later, a van arrived to take Tom, Kellie, and me back to the hospital. Kellie and I helped Tom into the van, we all buckled in, and the co-pilot closed the door of the van.

"Tom," I said when the van pulled away, "when we get back, take a thirty-minute break in the on-call room."

"Thanks," he said.

"Come see me after your rest period, and we'll evaluate."

"I will."

"How many mechanical failures did you experience, Kellie?"

"Four, but as with this, the pilot simply managed it and set the helicopter down on the deck. We had one really hard landing, worse than the one we just had, and that helicopter was salvaged for parts because it wasn't worth fixing. The others were back in the air within a day or two."

When we arrived back at the hospital, the news had spread, and Ghost came to talk to me while we took off our gear.

"Tom is going to take a break," I said. "His pulse skyrocketed."

"How are you?"

"Fine. My pulse went up from the adrenaline hit, but it resolved quickly. Kellie, on the other hand, has ice water in her veins!"

"Eight years in the Navy, six on a carrier will do that," Ghost observed.

"Kellie, when did you get out?" I asked.

"In May. I flew home, had my interview here the next day, and started a week later."

"Your work wife wants you to call her," Ghost said to me. "Then go see Josh."

I chuckled, "Thanks."

"Work wife?" Tom asked.

"Doctor Clarissa Saunders," I replied. "We did undergrad and medical school together, and now are doing our Residencies together. Eventually, we'll be Attendings in the same hospital."

"THIS hospital!" Ghost corrected.

"Who knows what will happen in seven or eight years?" I replied. "I have a long way to go."

I made sure Tom went to rest, then went to the lounge to get some juice and call Clarissa.

"I can't leave you alone for two seconds, Petrovich!" she said.

"It's been hours since I've seen you, Lissa! And, as Nurse Kellie said, the helicopter has two engines."

"What happened?"

"Flying machine break; alarm sound; land hard; Ogg not know more!"

Clarissa laughed, "The crew didn't say?"

"No. Just 'engine failure' and I saw some black smoke from one engine compartment after we'd landed."

"You might want to call Kris, because it'll probably hit the news."

"No reporters showed up, and I doubt my name will be attached to it. Not to mention no blood or gore and nobody died, and the chopper isn't obviously damaged, so the Press won't care too much. Tom had a bit of an anxiety attack, and I had the expected adrenaline rush, but our nurse, who is ex-Navy, was cool as a cucumber. I don't think her heart rate went up a point! She served on the Nimitz as a flight nurse."

"Let me guess -- you were sleeping."

"That is what I do on the flights back. The engine alarm woke me up."

"Call Kris. If she finds out some other way, it won't go well."

"You're right."

"I usually am!"

"Uh-huh," I replied flatly. "Snacks at 11:00pm if I'm free?"

"Call me when you are."

We ended the call, and I dialed the house, surprised when Lyudmila answered.

"You're not my wife!" I declared.

"Is that a good thing or a bad thing?" she teased.

"Oh, no you don't! You French girls are troublemakers!"

"Yes, we are! Kris is putting Rachel to bed. Is there a message, or do you need to speak to her?"

"I should probably speak to her," I said.

"Let me take over for her. Rachel won't mind her «tante préférée» stepping in!"

She set the phone down, and about a minute later, Kris was on the line.

"Mike? Is something wrong?"

"No, but I didn't want you to worry. I was on an air ambulance flight that made an emergency landing on a baseball field on the way back from Columbus. Everyone is safe, but I know TV can blow things out of proportion, so I wanted to call."

"What happened?"

"All I know is what the co-pilot said -- one of the two engines failed. My mechanical abilities are near zero, and I don't know anything more than the basics about engines."

"How did you get back?"

"They sent a van to pick us up."

"Why were you on the flight?"

"A patient with third-degree burns over more than fifty percent of his body. We're not equipped to treat a patient with those kinds of injuries, so we stabilized him, performed emergency life-saving procedures, and then loaded him onto the air ambulance to take him to the burn center in Columbus."

"What happened to him?"

"I have no idea. The paramedics didn't say, and he obviously couldn't talk because he was unconscious and intubated. I'm sure it'll be on the 11:00pm news."

"And I'll be in bed. Lyudmila is staying, so I don't have to take her home, and that's why Rachel was up late. I'll read about it in the Columbus Dispatch or McKinley Times in the morning."

"OK. I need to go."

"What's the answer?"

"To?"

"If it's a good thing or a bad thing that Lyudmila isn't your wife!"

"There is no way I am answering that question! In the immortal words of Admiral Ackbar -- It's a trap!"

Kris laughed, "A very wise man! See you tomorrow evening. Remember, Rachel won't be in daycare."

"I remember. See you!"

We said 'goodbye' and I hung up, then went to see Doctor Taylor.

"Are you OK?" he asked. "You can take some time if you need it."

"What? And get no end of grief from Kellie Martin?"

Doctor Taylor nodded, "I spoke to her. She's one cool customer."

"The alarm went off, the co-pilot called out 'Engine failure' and she just calmly said the helicopter had two engines."

"The Navy trains them right. She said Tom had an anxiety attack."

"Me, too! I nearly soiled my underwear, but Kellie was so calm that I didn't freak out. I sent Tom to rest for thirty minutes."

"Wise. Other than that, Doctor Loucks, how was the flight?"

I chuckled, "Nice play on Mrs. Lincoln and the play! No troubles at all. The patient's vitals were constant the whole way and an entire team was waiting for us on the pad when we arrived. I slept from the time we lifted off until I was rudely awakened by the klaxon. Where's my student?"

"Helping Naveen with walk-ins, but I don't know which room she's in. You OK with another trip when necessary?"

"If Kellie can do it, I can do it!" declared.

"Can't let a girl beat you?" Doctor Taylor asked with a grin.

"You don't know Russian women, do you?" I asked. "Or French women. Or Doctor Saunders."

He laughed, "No, but I have two daughters, eight and six, and I am not looking forward to the next ten years!"

"I think my dad would commiserate with you about my little sister."

"You'll get yours in about fifteen years!"

"I can wait, thanks!"

Nurse Angela came to the door of the Attending's office.

"No rest for the weary! Multiple MVA coming in. Trauma 2 and 4 are open. Four minutes out."

"Let's go, Mike!" Doctor Taylor said. "Angela, send us three nurses and see if Mary is free."

"Will do!" she said.

Fortunately, the accident wasn't serious, and both patients were transported as a precaution. After exams, both were discharged with what a news report would call 'bumps and bruises', with instructions to see their personal physicians. It was a testimony to the effectiveness of seatbelts that they had no serious injuries.

"Don't sit down," Nicki said as I left the trauma room. "EMS two minutes out with motorcycle accident. Doctor Casper is in the ambulance bay and wants your help."

"OK. Mary, let's go."

"Doctor Mike?" Tom called out, coming from the on-call room.

"How are you, Tom?"

"OK, I think. My hands a shaking a bit, but I feel better."

"Go home. I'll clear it with Doctor Taylor. Get a good night's sleep, and take tomorrow off. I promise this won't count against you in any way."

"Thank you."

He left and Mary and I hurried to the ambulance bay, arriving just as the EMS squad pulled in. As soon as the paramedic reported the vitals, I was sure it was a hopeless cause, but that didn't mean we wouldn't try.

"Traci, call for a neuro consult!" Ghost ordered as we rushed the patient to Trauma 1.

My assignment was intubation, and I considered allowing Mary to do it, but decided I needed to do at least some procedures. I did that, then did a neuro check while Ghost examined other injuries.

"CSF in the right ear," I announced. "Right pupil blown, left sluggish. He's going to need mannitol. Mary, check his pockets for his license, and see if he's an organ donor."

"Mind if I finish my exam?" Ghost asked.

"Sorry."

Given the patient wasn't breathing on his own, had cerebrospinal fluid in his ear, had a blown pupil, and had no response to the Babinski, and arrhythmia, the odds of him recovering were almost infinitesimal.

"Cohen, Neuro," Doctor Rebekah Cohen said, coming into the room, with her Fourth Year student Al Temple.

"Mike?" Ghost prompted.

I gave the report, and she nodded, then repeated the tests I'd done, and reached the same conclusion.

"Skull series, then an EEG," she said. "Mannitol, stabilize, then send him to Radiology."

"He's an organ donor," Mary announced.

"OK." Doctor Cohen said. "Is there a family member here?"

"We don't know," Ghost said. "Mike, see if someone is here. Mary, call Radiology for an emergency skull series."

I left the room and went to the admit desk and asked if Mr. Jackson had anyone waiting for him, and was directed to a young woman who was about my age.

"Ms. Jackson?" I asked.

"Yes! How is Mark?"

"We're evaluating him now," I said. "There are two doctors besides me with him and I came out to let you know we're going to take x-rays and run some tests, but his injuries are quite severe."

"Will he die?" she asked, a hitch in her breath.

"It's too early to say anything just yet. Someone will come speak with you, soon. I just wanted to make sure you knew we were taking care of him."

"Thank you, Doctor."

I returned to the Trauma room and let Doctor Cohen know.

"OK. Once the skull series is done and he's upstairs, have your student bring her up to Neuro and we'll take it from there."

"Will do."

"He's not stable enough to move yet," Ghost announced. "And I'm not sure we can do anything about that arrhythmia."

"ICP," Doctor Cohen said. "Mike, could you assist with an emergency craniectomy?"

"I could," I replied. "Here?"

"If we don't relieve that pressure, he's going to herniate and we'll lose him. We might anyway. Al, call Neuro for a nurse and a craniectomy tray, stat. Let's prep."

We washed our hands and put on fresh gloves while the nurses draped the patient. When the nurse arrived from neuro, the tray was opened and set up.

"I'll make the incision in the scalp," Doctor Cohen said. "I'll have you retract the scalp and clip it, and control any bleeders. I'll cut the skull with the saw, separate the dura, then make an incision to allow fluid to drain. We're going to remove a six centimeter section of skull."

"OK," I replied.

My part of the procedure was simple, as it basically involved pulling back the section of scalp she'd loosened, clipping it back with a surgical instrument, then using two hemostats to stop bleeding, while the neuro nurse carefully applied suction. Doctor Cohen, an experienced surgeon, but new to Neuro, cut out the section of bone, and put it in a basin.

"Herniation, Doctor!" the neuro nurse declared as the brain visibly swelled through the skull flap.

"Mannitol, IV push!" Doctor Cohen ordered and her nurse picked up a pre-loaded syringe and injected it into the IV.

"V-fib!" Ghost announced. "Paddles to me!"

Two rounds of shocks and a dose of epinephrine resolved the V-fib, but the patient still had arrhythmia.

"Al, call upstairs and ask for Doctor Baker to come down immediately, please."

He went to make the call and five minutes later, Doctor Baker came into the room. Doctor Cohen reviewed the case with him and he performed his exam, shaking his head.

"I don't think we're going to save this one," he said. "You can't move him and it wouldn't matter if you could. At this point, if the swelling resolves, he might make it. If not...is a next of kin here?"

"His wife is in the waiting room," I said.

"Rebekah, let's go talk to her," Doctor Baker said. "Ghost, with us. Mike stay here and monitor the patient."

"Yes, Doctor," I replied.

They left, along with Al, leaving Mary, me, and two nurses in the room.

"Is there anything more we can do?" Mary asked.

I shook my head, "I already said a prayer, and at this point, that's all that was left to do. The brain swelling isn't reducing after two doses of mannitol, and he's likely to suffer cardiac arrest at any moment. That V-fib before was the harbinger. Some time in the next ten minutes, most likely, he'll have another bout of V-fib which will lead to asystole, if not immediately, then shortly after. There is nothing we can do to stop that."

"You were sure when you did the neuro exam."

I nodded, "So was Doctor Casper, but he was correct to ask me to wait until he'd finished his full exam. A blown pupil, CSF in the ear, and no response to a Babinski all indicate serious neurological compromise. And then when the brain flap was created, the brain swelled significantly. A helmet might have saved his life."

"Why would anyone ride a motorcycle without a helmet?"

I shrugged, "It's a free country, which means we're free to do foolish things like smoke, drink to excess, ride motorcycles without helmets, and get on helicopters!"

"I was pissed right up until they called in that you'd made an emergency landing. After that, not so much."

"If we weren't short-handed, I'd have taken you, but they needed you here."

"I heard Tom was freaked out."

"He was. I sent him home to get a good night's sleep."

The monitor blared, and I reached over and pressed the silence button.

"V-tach," I said. "Run of eight."

"I thought you said V-fib," Mary observed.

"I did. V-tach in short runs isn't life-threatening, but it's an indication of trouble. Any drugs I could give him at this point would likely be counterproductive. Is there any urine in the bag?"

She checked and held it up, "Pink."

"Internal bleeding, too," I said. "Too many things wrong and not much we can do about it."

"I feel helpless," Mary said.

I nodded, "Me, too. But in the end, we're not gods, the red scrubs I'm wearing notwithstanding."

She laughed softly, "You aren't a..."

"Prick?" I prompted.

"I was going to say 'a-hole' like most surgeons."

"Because I'm not a surgeon and don't have the right mentality for it. I'll be a competent general surgeon, but my main role will be emergency procedures. I live for the adrenaline rush."

"Including helicopter accidents?"

"That one was over the top even for me."

The monitor blared again, and I hit the silence button.

"Run of ten," I said. "It won't be long now."

The three doctors came back into the room.

"Two runs of V-tach," I said. "Runs of eight and ten. I expect he'll go into V-fib soon, then arrest."

"I'd say that's right," Doctor Baker said. "We did get consent, so I had Al call for the transplant team to stand by."

"Do we try to shock him?" Mary asked.

"Yes," Doctor Casper said. "With no advance directive, we have to try."

Just under ten minutes later, the expected scenario played out, and after five shocks and two doses of epi, the monitor showed asystole.

"Call it, Mike," Ghost said.

"Time of death, 23:51," I said.

"Let's get him up to surgery," Doctor Baker said. "No time to wait for an orderly. Al, grab the gurney."

I filled out the chart while they moved the patient to a gurney, connecting a portable ventilator to keep his lungs perfused with oxygen. Doctor Beker, Doctor Cohen, and Al left with the gurney and Doctor Casper sent Mary to bring his wife to the consultation room.

"Ms. Jackson," I said when she came into the consultation room. "Please have a seat."

"He died, didn't he?" she asked, tears welling up in her eyes.

I nodded, "Yes. We used every skill and every procedure we could, but his injuries were too severe, and he died. With the consent you provided, he's being taken to surgery for organ donation, and you'll be able to see him afterwards. Would you like us to call someone for you? There's a chaplain on call, if you want."

"Our priest at Saint Augustine," she sniffed. "Father Clifton."

"I'll see that he's called," I said. "Mary will take you upstairs and sit with you until your priest comes."

"Thank you," she said.

Ghost and I left the room, and I went to the clerk's desk and asked Nicki to call Father Clifton and ask him to come to the hospital, then Ghost and I went to the lounge to get bottles of juice.

"You jumped the gun a bit," he said. "You were right, but it's important to always finish the exam, no matter how obvious the situation is. It's too easy to start taking shortcuts and making assumptions. And that is the way to kill your first patient."

"Message received loud and clear," I said.

"Just remember, Mike, ninety-five percent of the time the obvious answer is the answer. It's those other five percent that will burn you."

"Doctor Casper?" Nicki said from the door to the lounge, "There's a Sheriff's Deputy here who wants to speak to the pronouncing doctor."

"That's Mike," Ghost said.

"Send him in," I said. "I really do not feel like standing up at the moment."

She left and about fifteen seconds later, Deputy Schmidt came into the lounge.

"Hi, Doc," he said to me.

"Hi, Deputy. You're here about the donorcycle?"

"Yes. I just need a time of death and a summary of his injuries for my report."

"Mind if I ask what happened?"

"He was in the left lane and a car changed lanes without signaling or looking for him. The driver is at the sub-station being questioned. We have two witnesses in a car behind them."

"Reckless operation and negligent homicide?" Doctor Casper asked.

"Most likely, because they can make that stick based on what I've seen."

"Time of death was 23:51. Severe head injuries, which resulted in an irregular heartbeat that we couldn't resolve. He was paralyzed at least from the waist down, and wasn't breathing on his own. He also had internal injuries, but we won't know the extent until we see the surgical report from the transplant team."

"Can you give me a cause of death?"

"Not wearing a helmet," I said. "Beyond that, you'll need to wait for the surgical report or hear from Doctor McKnight."

"What do you think?"

"That I'm not a forensic pathologist or medical examiner," I replied. "All I can say is that we saw his heart stop, which is, in the end, the cause of every death. Which specific injury caused that, I'm not equipped nor prepared to say."

"OK. That's all I need. I heard his wife is here."

"Upstairs with my student, Mary, waiting for a priest. They're in the surgical waiting room."

"Thanks, Doc."

He left, and I leaned back again, the effects of multiple adrenaline rushes making me feel ready to collapse, despite being only halfway through my shift.

"Go take a nap," Doctor Casper said. "Barring the outbreak of World War III or giant grasshoppers attacking, we won't wake you for two hours."

"If World War III starts, let me sleep. I'd rather the nuke went off and I didn't know about it."

"I hear you on that one. Nice work deflecting Deputy Schmidt."

"It was drummed into my head by Doctor McKnight that he's the only one who can say definitively what happened except in cases of decapitation, which is routinely fatal and obvious."

"You think?" Doctor Casper said, shaking his head. "Go get some sleep."

"Thanks," I said.

I got up, made my way to the on-call room, put on the sleep mask I carried, got into bed, and fell asleep almost instantly.

XVIII. 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.

XIX. The Sleep of the Dead

July 7, 1989, Circleville, Ohio

"Dada!" Rachel exclaimed happily when I walked into the house.

I picked her up and kissed her forehead.

"I'm going to shower, eat, then fall into bed," I said to Kris.

"You don't look good at all, Mike," Kris observed.

"I need about two days of uninterrupted sleep."

"You have your shift tomorrow, plus band practice."

"I called Kim this afternoon and let her know I wasn't going to make it. I'll be back down in less than ten minutes."

I put down a protesting Rachel, then went upstairs, took a quick shower, put on shorts and a t-shirt, then went back down to the kitchen where Kris was putting dinner on the table.

"You're going to get sick if you aren't careful," she said.

"It's the after-effects of the adrenaline from the helicopter incident. Let's pray so I can eat, please."

I sat down and Kris put Rachel in her high chair. Once Kris had sat down, I gave the blessing and put food on my plate and began eating.

"I'm worried about you," Kris said. "It's only the first week and already you're so tired you can barely keep your eyes open when you come home."

"I know," I replied. "This is just something I'm going to have to find a way to get through. I'm not sure what the impact of the law that went into effect this week in New York will be here. It eliminates shifts longer than twenty-four hours and no more than eighty-hour work-weeks, averaged over four weeks. But there's no requirement that Ohio hospitals follow that, and the Accreditation Council for Graduate Medical Education hasn't adopted those new rules. That's going to create a conflict for Residents at New York Hospitals who seek Attending roles elsewhere."

"How so?"

"They won't have the number of hours or procedures that other Residents will without extending their Residencies. The other challenge is coverage on the services. If our hours are reduced, they'll need more Residents to do the same work. The problem, as always, is money. Hiring three additional Residents means money has to come from something else, and the County Board just approved hiring six nurses to help cover triage."

"You know my answer!"

"Yes, and that would require completely restructuring our tax system, our healthcare system, and basically the entire federal system. So until then, we're stuck with current funding methods and systems."

"America is such a mess!"

I smiled, "As President Bush has said, that's the 'price of freedom'. And I'm in no mental state to debate that right now. Can we save it for Sunday?"

"Yes."

I ate quickly, and with Kris' blessing, went right up to bed. I closed the blackout curtains, stripped off my clothes, put on my sleeping mask, and collapsed into bed.

July 8, 1989, Circleville and McKinley, Ohio

I slept the sleep of the dead, only waking when Kris shook my shoulder at 10:00am.

"Your shift starts in two hours," she said. "Rachel and I will do the shopping after you go to work."

"OK."

"How do you feel?"

"Better, but not fully human."

"With you being male, I can understand that!" Kris teased.

"Climb into bed and I'll show you the animal!" I teased.

"Rachel is in the living room."

"So put her in her playpen and come play with me! Unless you're not interested..."

"I suppose..." Kris said with a smirk.

She left and was back a minute later. She quickly stripped off her clothing and climbed into bed with me, and rather than our usual, slow, sensual lovemaking, we fucked for twelve headboard-banging minutes, then went to the shower.

"You certainly had plenty of energy!" Kris observed as we stepped into the spray.

"You're the one who accused me of being sub-human, so I decided to demonstrate!"

Kris laughed, "Very energetically! And that's fine on occasion, but I really do prefer our usual way."

"Me, too," I agreed. "Tomorrow evening after Rachel goes to bed?"

"It's a date!"

I managed to spend about thirty minutes playing with Rachel before lunch, and then I had to say 'goodbye' and head to the hospital. As I drove, I wondered how Doctor Mastriano would respond to my arrival. If I were in her position, and there was no way I'd ever be, I'd have done my best to make nice to try to gain enough camaraderie so as not to be thrown under the bus at the M & M.

With me, though, that wasn't going to work because I was simply going to relate the facts which included her writing her order on the chart. Doing anything else would call attention to me, and that was the last thing I wanted to happen in an M & M. My goal was to present, then find a foxhole to hide in to avoid the shrapnel from the fire she was going to take.

That said, I had to work with her, and that meant finding a way to get along, much of which would be on me as a PGY1. The problem was, there was open warfare between Doctor Cutter and Doctor Northrup, which was only exacerbated by the red scrubs. That said, those red scrubs and the 'S' on my badge meant I could do more procedures than any other PGY1 in the entire hospital.

"Morning, Luisa!" I said when I walked into the ED. "Is Doctor Mastriano in her office?"

"Yes. She said she wanted to see you as soon as you arrived."

"OK. I'm a bit early, so I'll see Doctor Billings before she leaves. If I end up stuck in Doctor Mastriano's office, have Doctor Billings come there so she can hand over any patients."

"Good luck."

"Thanks."

I walked to the door of the Attendings' office.

"You wanted to see me?" I asked.

"Come in and sit down. Close the door."

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

"I can't even begin to count the ways this is wrong, but you appear to be untouchable."

"I don't believe that's true," I said. "The same rules apply to me as apply to everyone. Residents perform procedures for which they are cleared by the Chief of their service. If you want to review my procedure book, I have it with me. If you have a problem with that, please take it up with Doctor Gibbs or Doctor Northrup, and they can take it up with Doctor Cutter. I'd prefer you didn't, and that we find a way to work together."

"Unfortunately, I don't have a choice. Your fairy godmother made that clear."

"There is literally no need to fight, Doctor Mastriano. How do you want me to handle things today?"

"What I want and what I think is correct both appear to be irrelevant. Do what you want, but it's your ass if things go wrong."

"That means I will check with you, even if it means waking you up, if I think it's necessary. That's the best way to help ensure things don't go wrong."

"You have walk-ins today," Doctor Mastriano said.

"Then let me speak with Kayla about the handover and get to it."

She nodded, and I left the Attendings' office. I found Kayla Billings at the nurses' station updating a chart and asked about her patient load.

"Cooking burn in Exam 6 waiting on discharge, which I'm filling out now and you'll handle one waiting on surgery for a badly broken ankle. Ortho said about 1:30pm. He's had Demerol IM with their approval, and is resting comfortably in Exam 2."

"OK. Where are the med students?"

"Lounge. Gabby just came back from dropping off pre-op labs for the ankle."

"Thanks. Have a good day."

"Ten hours of sleep! See you!"

I left the nurses' station and went to the lounge to see Callie and Gabby.

"Doctor Mike, can I have a moment in private?" Callie asked.

"Sure. Let's see if the consultation room is free."

We left the lounge, and I was happy to find the room free, as it doubled as an office, though most Residents had resorted to using the lounge for paperwork. We went in and I shut the door about halfway.

"What can I do for you?"

"I'm friends with Heather Pratt, well, Doctor Pratt, now, at Northwestern in Chicago. She had good things to say about you when I asked before you started. Anyway, I heard some scuttlebutt, and called Heather to ask about it because I wasn't sure what to do. She said I should just tell you one thing -- Doctor Mastriano is having an affair with Doctor Rosenbaum."

Which would explain literally everything about Doctor Mastriano's attitude, and would suggest the well was so poisoned that there would be no recovery. The consideration I'd given to finding a way to try to mitigate the results of the M & M went right out the window, though I'd been inclined against it.

"How sure are you?" I asked.

"Someone I trust implicitly has seen them together, including in the Pedes on-call room on multiple occasions. And another person I trust said you had a serious run-in with Doctor Mastriano and a patient died as a result of her orders."

"I can't really discuss this with you, but I very much appreciate the heads up. You should come to the M & M on Friday. If you're off, come in special; if you're on, ask permission. It's usually granted, though in the ED a lot depends on patient load, and both Doctor Mastriano and I have to be there. Let's go see our broken ankle, then see what we have waiting for us in triage."

We left the consultation room, collected Gabby from the lounge, and then went to see Mr. Miller, who had a shattered ankle.

"Hi, Mr. Miller," I said. "I'm Doctor Mike and I'll be taking care of you until you go up for surgery. How are you feeling?"

"My ankle is throbbing, but the shot they gave me took the edge off."

I checked the chart and said, "I can safely give you ibuprofen, which will help, in combination with the Demerol. I don't want to give you more Demerol because you'll be going up for surgery in just over an hour. The anesthesiologist will see you before then, and they'll give you the pre-op meds."

"Which ones?"

"An anti-anxiety drug, usually Versed or lorazepam. The actual anesthetic depends on the preferences of the surgeon and anesthesiologist, but is often a cocktail of propofol, fentanyl, and more of the anti-anxiety drug. The anesthesiologist will explain all of this to you when the time comes. Is there anything we can get you?"

"They said they called my wife, so she should be here."

"Callie," I said, "please check to see if Mrs. Miller is in the waiting room, and if so, escort her back."

"Right away, Doctor!"

She left and returned about a minute later with the patient's wife. Callie, Gabby, and I then left and went to the triage desk to get the next patient.

We handled a steady stream of mild injuries and illnesses, none of which technically needed an emergency room, but most GPs didn't work on Saturday, and despite the free clinic offering a complete range of services, most people associated it with gynecological services and therefore came to the hospital which had longer wait times and was more expensive.

I mostly avoided Doctor Mastriano, as the cases we handled were all so simple that I could have allowed Callie to run them unsupervised. On the plus side, it allowed me to give both Callie and Gabby opportunities to take the lead, which they very much appreciated. Things finally slowed just before 6:00pm, which let me take my dinner break with Clarissa.

"I think I might know what Mastriano's problem is," I said when we sat down at a table by ourselves. "She's having an affair with Rosenbaum in Pedes."

"Holy shit!" Clarissa exclaimed, though she kept her voice low. "No wonder she had such a bad attitude with you."

I nodded, "It started off OK, at least as I saw it, but quickly devolved. I wonder if they had a convo after my Saturday shift. That would explain the apparent change in attitude."

"Now what?"

"Nothing, though I had considered trying to find a way to mitigate the damage from the M & M, but she's made her bed..."

"Cute, Petrovich! Cute! He's married and has a couple of kids."

"His adultery is not my concern," I replied. "Nor who he's having sex with. What concerns me, obviously, is him poisoning the well."

"What are you going to do?"

"Nothing. As I said to Doctor Gibbs yesterday morning, I'll let the Attendings at the M & M deal with Doctor Mastriano. There's no need to bring her personal life into it."

"What do you think will happen?"

"I suspect it will end with a written note in her file, and the usual opprobrium of her colleagues. It'll put her on notice that she's being watched, and her contract is in danger of not being renewed. This is another case where a doctor is able to rely on 'standard of care' to avoid the repercussions of their actions, even though their actions are arguably negligent."

"You mean because she insisted on waiting until the patient had EtOH?"

"Yes. That is the standard, but in my opinion, the CAT scanner has changed the standard of care. Before it, I would have to admit waiting was the right course of action, as without a CAT scan we'd have to rely on x-rays, which are iffy at best. If asked, my argument will be to change the standard of care to not require the patient to be sober and obtain a CAT scan."

"It sounds as if you're blaming the system."

"In a sense, I am, but remember, I wrote I recommended a neuro consult so I could get a CAT scan, and wrote that on the chart. Doctor Mastriano specifically ordered me not to get a neuro consult and put that order in writing as 'monitor until EtOH is below 0.05'."

"I know you well enough, and so do others, to ask why you didn't override her order."

"Because you know exactly what the neuro Resident would have said given the patients EtOH was 0.19. They'd have refused, per policy. And I can't order a CAT scan without an Attending's signature. With no neurological signs that couldn't be attributed to being inebriated, Doctor Mastriano wasn't going to sign off, and she refused my request for a neuro consult, so I had nobody to side with me until it was too late."

"I think you're right about the note in her file because she did follow the approved standard of care, especially given the CAT scanner is new here."

"I know it's expensive to use," I said, "but I think any doctor in the ED should be able to order a CAT scan if there's an indicated risk of brain trauma."

"I think you're right, but the bean counters probably won't. Changing topics, how were you at the end of the shift yesterday?"

"Tired enough that I skipped band practice this morning. I slept about fifteen hours."

"I slept twelve, but I also wasn't on that helicopter!"

"Honestly, it was really no big deal. Two ex-Navy pilots resolved a minor mechanical problem by safely landing on a baseball field. Imagine similar trouble on a passenger aircraft which has to make it to an airfield. And from what I read, most people flying commercial never know about mechanical problems."

"Back to medicine, how has your day been?"

"Mastriano has me on walk-ins. That's positive for Callie and Gabby, because it allows them procedures they might not otherwise have a chance to do. We've been light on traumas today, anyway. How has your day been?"

"Routine, really, except for one mystery case. I've been doing research, but so far, nothing. I sent samples to Mayo yesterday, and I'll have a call with them on Monday."

"What do you suspect?"

"Mayo will test for Lyme disease antibodies, but the patient had no rash and claims not to have had a tick bite. That's what made us look for other things. If it's not that, we'll look at some of the rare autoimmune diseases. I honestly don't think it's Lyme, but I have to rule it out. Otherwise, we have a couple of pre-op patients, one waiting on a liver transplant, a pair recovering from surgery, one with COPD, and the TB patient."

We finished eating, and both headed back to our respective services. Callie, Gabby, and I continued to handle walk-ins, not fielding a trauma until just after 11:00pm, when there was a multiple-injury MVA. Doctor Casper took the first patient, and we took the second, and I had given advance orders to Callie, Gabby, and Billie.

"Joy Podesta, twenty-two; unbelted passenger; BP 110/80; pulse 110; PO₂ 98% on nasal canula; forehead laceration; right lower leg and right lower arm fractures; GCS 9; IV saline TKO."

"Trauma 3!" I commanded.

We quickly moved the patient to the trauma room, lifted her to the treatment table, and began our choreographed motions to implement my treatment plan.

"Normal sinus rhythm," Callie called out once the EKG was hooked up. "BP 110/70; tachy at 110; PO₂ 98%."

"Foley, please," I said. "Pupils are sluggish, but lungs are clear and heartbeat is strong. No rebound or guarding."

"Urine in the bag," Callie said, having inserted the Foley. "No evidence of blood."

The patient appeared to be in no immediate danger, but with the head injury, I was going to play it safe.

"Neuro and ortho consults," I said to Gabby. "And portable x-ray."

"Calling now!" she confirmed.

"Ultrasound?" Callie asked.

"No indication for that," I replied. "She has a moderate concussion and a pair of fractures, but I didn't appreciate any abdominal injuries. You can throw a pair of sutures in that forehead lac."

"Nurse, suture tray, please!" Callie requested. "Irrigation kit and lidocaine times two."

Just before midnight, we transferred the patient to neurology and did the handover with Kallie before heading to the surgical locker room for a shower.

July 9, 1989, Circleville, Ohio

After Church on Sunday, Kris, Rachel, and I headed home to spend some time together as a family.

"It dawned on me this morning that Sundays are the only day we have significant time together," Kris said as we relaxed on the couch. "You spend most of your time at home sleeping."

"There isn't really anything I can do about that," I replied. "We knew that going in."

"Yes, of course," Kris replied. "I was simply saying I hadn't thought of how it would work in practice."

"It's only going to be this bad for a year," I replied. "Once I complete my PGY1, I'll most likely have five fourteen-hour days, given one goal of the program is to free surgical Residents to do elective surgeries."

"Will the law in New York have any effect?"

"Directly? No. Indirectly, probably, though it will take some time for Ohio to consider adopting that rule, and I have no idea how that process works. Ultimately, though, it'll be up to the Accreditation Council, and I'd wager that will take a decade, possibly more, before it happens, if it does."

"Why?"

"A consensus has to be achieved, and that takes time. As we discussed, the biggest impediment is hiring new Residents."

"It always comes down to money, doesn't it?"

"One way or the other, in the end, we're constrained. If they don't hire more Residents, then waiting times will increase. There is always some limit, even in France. I know more about the Canadian and British systems, and in both of those, which procedures and which medications are permitted are restricted, and waiting times are longer.

"In the end, there are tradeoffs in every system. Here we have access to more technology, a higher ratio of doctors to population, and other significant advantages, at the cost of care being expensive and not universal. I wish that weren't the case, and I wish our training systems weren't so brutal, and I hope those things change. In fact, I'll advocate for them! But that doesn't change the reality of the next year."

"No, I suppose it doesn't."

"I guess I have to ask how much it bothers you."

"I was more concerned about Rachel," Kris said. "I understand the logic and the tradeoffs, but Rachel obviously misses you."

"And I miss both of you."

"I miss you when you're working, Mike," Kris replied.

"I didn't mean to imply that you didn't. And I'm actually happy you said something rather than letting something that concerns you go unsaid, which can lead to serious problems."

"Dada sing?" Rachel requested.

"I'll get your guitar," Kris offered. "That way, you don't have to put her down."

"I can't play with her in my lap, so I will have to put her next to me."

"Just stay with Rachel."

Kris got up, went to the study, and returned with my guitar. I played six songs that I knew Rachel liked, and when I finished, we put her down for her afternoon nap. I'd considered skipping it, but I didn't want her to be cranky, which happened when she didn't get enough sleep. Fortunately, Rachel didn't protest when I put her down, and once she was settled, I went back downstairs to sit with Kris, who cuddled close.

"Are you unhappy?" I asked.

"No, and I didn't mean it to sound as if I was complaining. I think it's the difference between knowing something and experiencing it. Our wedding night was a perfect example of that!"

"What?" I asked with a smirk. "It's more fun to do it than talk about it?"

"Obviously! But you understand my point, right?"

"I do," I replied. "I knew how bad these shifts would be, but until I actually experienced two of them this past week, I didn't actually understand just how bad that was."

"So bad that you skipped evening prayers on Friday."

"I wasn't thinking clearly at all," I replied. "I'm sorry."

"I think God will understand. I'm curious how you'll see Father Roman."

"That is a challenge," I replied. "I think the only way that can work would be to drive up on a Wednesday morning and back that evening, and I'd have to go alone because you have class. But I'll call him in a few weeks and see what he thinks. It's possible we could handle it by telephone at least some of the time. One way would be for me to confess to him, and for him to call Father Luke to perform the absolution."

"There's another practical matter," Kris said.

"What's that?"

"Finding time to get pregnant. If I understand conception, it's a fairly narrow range of days in the middle of my periods."

"Roughly, though it's possible about two-thirds of the days of the cycle, but the chance of success diminishes significantly with time before or after ovulation. We'll just have to try our best and see what happens."

"I'll stop taking my pills when I have my period in August, which should be in about six weeks. Will we use condoms then?"

"Either that or you need to get a diaphragm, which requires a prescription, as dumb as that sounds."

"It seems as if the entire point of the system is to prevent women from easily obtaining contraception!"

"There's some truth to that," I replied. "The concerns about side effects of the Pill could be addressed by having pharmacists dispense it without a prescription, but after having checked blood pressure and asked a few basic questions about medical history. That said, doing that creates a possible break in continuity of care, which is the big problem we see with people using the emergency room instead of seeing their own physician. That said, one reason to always visit the same pharmacist is for him to be able to catch drug interactions."

"Wouldn't the doctors speak to each other?"

"Not necessarily. And that assumes the patient actually tells his or her doctors the truth. That is not a given."

"Crazy!"

"Human nature, which might well be the same thing! What did you want to do?"

"Is it dangerous to get pregnant the month following when you stop taking the Pill?"

"No. As I think I've mentioned, about three women in a thousand will get pregnant at some point while using the Pill, even with perfect use. And there's no evidence of an increase in birth defects related to the use of birth control pills."

"Then why wait?"

"An OB/GYN suggested it, mainly from a point of allowing the woman's hormone levels to return to normal, but it was only a suggestion, not a command."

"I don't prefer using condoms, and it seems silly to get a diaphragm when I would only use it for perhaps four weeks."

"What about time between children?"

"I think we discuss that when the time is appropriate. Out of curiosity, how long does one wait after having a baby?"

"That depends on the individual, and how the labor and delivery progressed, but two or three months is considered typical. But that's just for intercourse, of course."

"Of course!" Kris replied with a soft laugh. "Is there any truth to what they say about not becoming pregnant while nursing?"

"There is no medical evidence of which I'm aware, but nursing does affect hormone levels, so it might affect it, but it certainly doesn't prevent it. Do you know the phrase 'Irish Twins'?"

"No."

"It means two children born less than a year apart, and is an implied criticism of Roman Catholic proscriptions on using birth control, whether chemical or physical barrier. Given that phrase, I'd say the experience, at least of English-speaking peoples, is that nursing does not inhibit conception.

"That said, I suspect that statistics DO show that nursing women don't get pregnant as often as those who aren't nursing, but mainly because they either don't try, or don't try as often, because of the challenge of caring for an infant. That causes 'confirmation bias' because we don't see too many women who are nursing and pregnant.

"In terms of relying on it, I wouldn't, any more than I'd rely on the oft-told misinformation that it's not possible to get pregnant your first time. That's absolutely false, to which I'm positive any number of teenage girls can attest. As Doctor Ruth Westheimer likes to say in response to her rhetorical question about how many sperm it takes to get pregnant -- 'Vun qvick vun'."

"She's the Jewish doctor on the radio, right?"

"Yes. I think she's doing the country a great service, but as you can imagine, there is serious pushback against her open and frank talk about teenage and young adult sexuality."

"You Americans!" Kris declared, shaking her head.

"Last I checked, you applied to become an American!"

"I will have American citizenship and carry American identity papers, but I will NOT succumb to the foolish American prudishness nor become a capitalist!"

"I'd be shocked if you did!"

"So we agree then that I'll simply stop taking my pills and we'll allow nature to take its course?"

"That's fine."

"You know, I never asked, but when do you receive your pay?"

"The last day of each month," I replied. "The money will be deposited directly into our joint checking account."

"And it's a fixed amount?"

"Yes. There is no overtime pay for doctors who are full-time hospital employees."

"What about nurses?"

"They receive overtime pay. They also have work rules very different from those of physicians. You won't see a nurse on a thirty-six-hour shift! Generally, they work about forty-five hours per week, though it varies. Right now, most of them are earning overtime, as we're short-staffed. That's changing as of September 1st, but we'll still be short-staffed in terms of nurses and physicians. It'll be better when the new facility opens in just under two years, but that won't last long as demand growth outstrips the planned increases."

"Do you realize how dumb that is?"

"Barring setting up a printing press in the basement of the new trauma center, I'm not sure there is anything any of us can do. The County Board hasn't been stingy, but there are limits to the amount of taxes they are able to collect, and those taxes are limited to property and sales taxes, both of which I'm sure you consider regressive."

"Of course! But you only have objections; do you have a solution?"

"Not really," I replied. "Because as I've repeatedly maintained, every system has resource constraints. It's a question of how you use the resources, and who decides. And I hate to tell you, but it appears things are going to get worse, rather than better."

"What makes you say that?"

"Some medical schools are beginning to raise tuition, which is going to lead to higher medical bills because more people will borrow more money to go to medical school and have to repay the loans. All of that money, and I mean one hundred percent, comes from patients, either directly or indirectly, or from the taxpayers. A similar problem is occurring with college tuition, but fortunately, state schools are still affordable, and it's possible to work your way through."

"You know how to solve THAT!" Kris replied.

I nodded, "Taxpayer funded tertiary education. And I'm not opposed to that idea, but federal money always comes with restrictions and mandates, and that could interfere with academic freedom and with religious freedom. The social and political environment is fundamentally different from Sweden or France, and we'd be in an endless tug-of-war between the progressive left and religious right, with wild swings depending on elections. But did you want to spend our limited time while Rachel is napping discussing political theory?"

"You had another desire?" Kris asked with a smile.

"An appetizer for later, perhaps?"

"Shall we go to bed?"

"Yes!"

July 10, 1989, McKinley, Ohio

"I was reviewing charts from Saturday," Doctor Gibbs said when I stopped in her office before my shift began on Monday morning. "You were on walk-ins the entire shift?"

"Yes."

"You know, I liked Mike the medical student better, as he was never reluctant to speak his mind, which is odd, given most medical students fear for their grades and their ability to Match."

"What do you want me to say?" I asked.

"That you think Doctor Mastriano is punishing you."

"I think Doctor Mastriano found a way to achieve her goal of limiting the procedures I can do. It does allow me to teach more, because in most of those cases, I can allow my students to do procedures. Speaking of students, assigning me all four Second Years is not working. Two would work, but four is unwieldy. Fortunately, I didn't have any procedures that involved intimate regions, because that size audience would present a real problem. Assign two to Naveen."

Doctor Gibbs nodded, "Will do. But going back to your assignment -- it doesn't upset you?"

"I asked Doctor Mastriano if we could find a way to work together. I'd say that's her solution, and, frankly, I'd rather not fight with her on the two shifts we share. I also daresay she's not going to be sleeping overnight after the M & M."

"No, she's not. You know we tolerate that for twenty-four-hour shifts, but sleeping is secondary to working."

"May I raise a concern privately?"

"You mean as in tell me, but I can't act on it?"

"Or reveal it to anyone. Well, you might know, but you might not know what flows from it."

"Just say it, Mike. You'll have to trust me to not misuse whatever you say."

"Doctor Mastriano is having an affair with Doctor Rosenbaum in Pedes. Normally, I don't give a fig about that, and any problems are between him and his wife. That said, I believe he's the source of Doctor Mastriano's attitude towards me. Remember how it was fine the first day? Well, I surmise she spoke to Doctor Rosenbaum after that, and he attempted to poison the well."

"Why would he do that? Your Pedes evaluation was as perfect and full of praise as every other evaluation."

"What you don't know, and most people don't know, is that he called my church to find out when services were held and purposefully and intentionally scheduled my shifts to prevent me from going to church."

"You're joking!"

"No, I'm not. I can't say how I found out, but I trust the person who told me. Not to mention my shifts didn't change from the first month to the second, while everyone else's did. I ended up doing an end-run courtesy of Kylie Baxter, when she asked to trade schedules because of an obligation to care for her mom post-chemo and post-radiation therapy. He made the comment that he felt I was smart to ditch my clerical garb, though that was after I'd chosen to resign."

"Why didn't you say anything?"

I laughed, "Come on, Loretta! You know me better than that!"

"You smiled and took the abuse because you knew it would annoy the fuck out of him."

"Yes. There's another incident you probably don't know about from Internal Medicine."

"What's that?"

"According to an Attending who shall remain nameless, I was assigned to work with Melissa Bush on my Medicine rotation in the hopes that it would lead to both of us failing that rotation."

"Oh, for the love of God!" Doctor Gibbs exclaimed. "Who told you that?"

"An Attending," I replied. "Honestly, I can't say more. That said, the view from the doctors who mattered was that if I could handle that, I could handle pretty much anything. They didn't know about the BS from Rosenbaum."

"I can see that, I suppose."

"The point I was trying to make is that there are Attendings who do not like me. There are Residents who don't like me. But the only one who actually did anything to me was Rosenbaum."

"There are NO nurses who don't like you," Doctor Gibbs smirked.

"That kind of 'like' I can do without!" I chuckled. "The same is true of certain McKinley PD detectives."

"Oh?"

"Detective Kleist's first question to me was whether I was married."

"She was just being thorough!" Doctor Gibbs said with a smirk. "She's the cute blonde, right?"

"As I said to Clarissa, I didn't notice. A combination of being tired and married, and at that point barely having the energy to stand, let alone think about anything other than medicine."

"What do you want me to do about Mastriano?"

"Let her suffer the withering fire at the M & M. I don't intend to offer anything that might mitigate her actions, and, frankly, nobody should. Once she's taken to task for her decision, then raise the issue of medicine being the priority over sleeping. If you're referring to her relationship with Rosenbaum, nothing. That doesn't violate my hospital ethics, though I find it morally objectionable for obvious reasons."

"I have half a mind to tell his wife."

"Do that, and you'll have to rat out half the married staff," I said. "It's none of our business. Even my strictest rules wouldn't bar a relationship between two Attendings on different services, and the last thing I want is for the Medical Director and the Hospital Board to become morality police. That cannot end well."

"No, it can't, and as reprehensible as I find cheating to be, it is, as you say, none of our business, so long as it doesn't affect patient care."

"I was reluctant to mention it, but I felt I needed to so that you know from where her attitude springs."

"I'm going to keep you off walk-ins today, at least as your primary responsibility."

"Does that include my medical students?"

"Unfortunately for them, no. Mary and Bob will still need to take their turns in triage. You heard about the new nurses, right?"

"I did. I'd say that's a good thing. May I suggest shorter shifts at the triage desk? Perhaps four hours at most?"

"That was my plan. I'm just waiting for agreement from the nursing supervisor and Doctor Northrup."

There was a knock at the door, and Doctor Gibbs called out for whomever was knocking to come in.

"Paramedics are about five minutes out with an OD," Ellie said.

"Mike, you take it. There's nothing on the board from Kylie as I just signed off on her last discharge. Grab your students. Call me if you need help."

"Will do!" I declared.

I got up and left her office and went to find Bob and Len.

XX. Popcorn?

July 14, 1989, McKinley, Ohio

By Friday afternoon, I was once again the walking dead, though it wasn't quite as bad as the previous week. Just before 3:00pm, Doctor Gibbs, Mary, Tom, and I left the ED to attend the M & M conference. Because of the timing, that meant several ED docs couldn't attend, as someone had to cover the ED, and it was possible that Doctor Gibbs might be paged, though that would only occur if a disaster protocol was activated.

When we reached the hallway outside the auditorium, I saw Clarissa waiting for us and started laughing.

"Seriously, Lissa?" I asked.

She smirked and asked with faux innocence, "What?"

"Popcorn?"

"It seemed appropriate! Other people bring snacks."

"Mike," Doctor Gibbs said. "One piece of advice -- keep it completely clinical."

I nodded, "That was my plan. And while I didn't bring popcorn, I'll sit back and watch once Doctor Mastriano is in the dock."

We went into the auditorium, and while everyone else sat towards the back, I sat down in the front row, as I'd be presenting. I opened the chart and skimmed, doing one last check that I had the sequence of events correct in my mind.

"Good Afternoon," Doctor Jerry Rhodes said. "Our first case will be presented by Mike Loucks, surgical Intern. Doctor Loucks?"

I rose and went to the podium, took a deep breath, let it out, then began.

"Good afternoon. Just after midnight, on July 4th, an African American patient was brought to the Emergency Department in private transportation, and left in the waiting room. Upon exam, his breath smelled of alcohol, and it was obvious he had been in a fight. The triage team reported he was semi-coherent upon arrival, but then appeared to have fallen asleep. At intake, his vitals were typical of an individual under the influence of alcohol.

"The patient was transported to Exam 2, and my Third Year, a nurse, and I evaluated him. A banana bag was hung immediately. The primary exam was unremarkable save obvious contusions and lacerations to the patient's face, and his vitals were stable and consistent with inebriation. Blood was drawn for a trauma panel, as well as EtOH levels. The nurse recommended soft restraints, but I did not feel they were necessary.

"About ten minutes after the blood was drawn, which was about twenty minutes after intake, the lab reported EtOH at 0.19, confirming that the patient was, indeed, inebriated. At that point, a Sheriff's Deputy arrived and gave us the patient's name, and confirmed that he had been severely beaten by other patrons of a bar. The patient's injuries were all consistent with the reported beating. The Deputy asked if he could question the patient, but I reported that the patient was incoherent.

"While I was discussing the situation with the Deputy, I heard a crash from the exam room, and went in to find the patient on the floor, with his IV out, and a small amount of blood leaking from the IV site. The nurse reported that the patient had come to, pulled out his IV, and tried to get out of the exam bed, but fell and lapsed back into his unconscious state.

"The patient was moved from the exam room to a trauma room. Soft restraints were applied, and the IV was reinserted. On exam, the patient had minor bleeding from his nose, though it's unclear if he broke it during the fall or it had been broken during the fight. I instructed the nurse to pack the patient's right nostril with gauze to control the minor bleeding. I also apologized to the nurse for not listening to her recommendation of soft restraints.

"At that point, I determined that the patient needed at least a skull series, and noted that on the chart, along with the need to rule out a concussion, though the patient's inebriation would interfere with that determination. The nurse and I both conferred with the Deputy, who took brief statements about the injuries from us, and then left.

"About that time, the patient came to again, but was incoherent. I was concerned about that, as well as his lapsing in and out of consciousness, as his EtOH levels were not high enough to cause unconsciousness nor complete incoherence. The standard practice in such cases is to wait for EtOH levels to drop below 0.1, but given the blows the patient had taken to the face, and his fall, I felt an immediate neuro consult and CAT scan were indicated, and noted those on the chart.

"After consulting with the nurse, I went to present the case to my Attending, Doctor Mastriano, with my recommendations. I found her in the Attending's office and asked to present the case. I did so and made my recommendations. Doctor Mastriano countermanded my written plan based on the patient's EtOH levels. I repeated my concern that the patient would suffer neural deficits and possibly herniate. Doctor Mastriano stated clearly and firmly that I was to monitor until the patient's EtOH levels were below 0.05, so I asked her to write her order on the chart.

"I returned to the room and performed another set of neuro checks, finding no appreciable signs that were inconsistent with inebriation. Because of my concerns, I ordered oxygen by canula, as well as a glucose stick test, which showed 96. I instructed the nurse to perform another stick test, an ABG, and obtain EtOH levels every thirty minutes, and wrote that order on the chart.

"At that point, I was called for another patient who'd been brought in by his wife for a syncopal episode. While I was examining that patient, a nurse reported that the initial patient was seizing, so I ordered my medical student to wake Doctor Mastriano, and hurried to the trauma room where the nurse who I'd left with him had inserted a bite guard. I ordered 4 megs of lorazepam, IV push, which resolved the seizures.

"Postictal exam showed a blown left pupil and a sluggish right pupil. I ordered an immediate neuro consult. At that point, Doctor Mastriano entered the trauma room and asked what had happened. I presented, then ordered my medical student to hook up an EKG and monitor. Doctor Mastriano examined the patient and observed the same condition. She instructed me to call her after the neuro consult, but I asked her to stay as I was at the limits of my skills and abilities. She refused and left the room.

"I ordered new blood work, then went to check on my other patient. I returned when the neuro Resident arrived and presented the case. The most recent EtOH level at that point was 0.15. She performed an exam, including a Babinski, which showed normal flexor response. She proposed a diagnosis of a subdural hematoma and suggested a CAT scan, and I concurred.

"In order to take the patient with EtOH levels above the standard, she called and spoke to her Attending, who approved both the CAT scan and the admission. At that point, the patient was transferred to her care, and I went to handle an EMS transport of a car versus bicycle accident."

"Thank you, Doctor," Doctor Rhodes said. "Questions?"

"Mike," Doctor Strong said, standing up. "Why did you not want soft restraints?"

"Lack of experience," I replied. "The nurse was more than happy to point out that I should have listened to her, and I've learned my lesson."

There was laughter from quite a few attendees.

Doctor Javadi stood up and asked, "What made you think the patient had neurological problems?"

"He had been subject to a severe beating, and I was concerned about broken facial bones, though I didn't appreciate any. The autopsy report showed a non-displaced orbital fracture, which Doctor McKnight ruled was from a blow by a fist, not from contact with the floor. The contradiction, of course, were the high EtOH levels, but, as I noted, not high enough to cause unconsciousness in a typical adult male in their twenties."

She sat down and Doctor Roth stood.

"Why not just call neuro?" he inquired.

"Because absent some kind of significant neurological sign, they won't consult on a patient with EtOH levels above 0.1 unless the ED Attending on duty certifies the need and places the call to her counterpart. I had no signs or indications other than my gut feeling, so all I could do was recommend to Doctor Mastriano that the call be made."

He sat down and Doctor Taylor, the surgeon, stood up.

"Is it true that Doctor Mastriano was sleeping each time you approached her?"

"Yes."

"Is it also true she had given orders not to be disturbed?"

"Yes."

"How did she respond when you approached her about this patient?"

"She was annoyed."

He sat down and nobody else stood.

"Thank you, Doctor," Doctor Rhodes said. "Doctor Cohen?"

I returned to my seat and Doctor Cohen went to the lectern. She repeated her version of our interactions, which basically matched mine.

"Once he was transferred to our service, we took him immediately for a CAT scan, but he seized during the procedure. Neuro exam showed signs of significant brain injury, and despite administering mannitol, the brain swelling could not be controlled and the patient expired. I have very little more to say, as we didn't complete the CAT scan."

Nobody had any questions for her, as she really did have very little more to add.

"Doctor McKnight?"

He replaced Doctor Cohen at the lectern and began his presentation.

"An African American male, age twenty-three, presented with facial injuries consistent with being struck repeatedly with fists. Upon autopsy, I appreciated a non-displaced fracture of his left orbital socket, as well as a hairline fracture of his left parietal bone, both consistent with being struck with a fist. In addition, he had a fracture of his nasal bone, consistent with either being struck with a fist or impact with the floor. It's my opinion that the injury was initially from a fist, but exacerbated by striking his face on the floor. He had no remarkable injuries to any part of his body other than his face, though there were some defensive bruises on his forearms.

"Upon examination of his cranium, I found three large subdural hematomas, and the patient's brain had herniated. A thorough examination led to the conclusion that the injuries sustained from the fists were sufficient to cause significant bleeding in the brain, which led to herniation, resulting in the patient's death. I filed that report with law enforcement. Questions?"

"Would an immediate CAT scan have resulted in a different outcome?" Doctor Subramani asked, standing up.

"I'd have to be clairvoyant to answer that question," Doctor McKnight replied. "That said, the CAT scan would certainly have detected the hematomas."

Doctor Subramani sat down and Doctor Rosenbaum stood up.

"Did the fall in the ED contribute to his death?"

"I don't believe so," Doctor McKnight said. "The fall certainly didn't do him any good, but there was no indication of injuries except to his nose. As I said, it's my opinion that injury was initially sustained when he was beaten."

"But the fall could have contributed to the outcome, right?"

"You know as well as I do," Doctor McKnight said, "that a minor bump on the head can cause a severe hematoma under the right circumstances. That said, there is zero indication that the fall had any significant impact on the patient's condition. In any event, such a fall could not cause hematomas in the regions where I found them. The laws of physics and what we know about the brain show that all three were the result of direct blows with fists."

Doctor Rosenbaum sat down and Doctor Gómez stood up.

"Did you confer with law enforcement?" he asked.

"Yes. The Sheriff's department confirmed that four men had set upon the patient and had beaten him up. Everything I saw was consistent with that, as was everything reported on the charts. I am absolutely sure the cause of death was the beating."

There were no further questions, and Doctor Rhodes called Doctor Mastriano to the lectern.

"Doctor, please explain your decision not to permit a neuro consult," Doctor Rhodes instructed.

"The standard of care," Doctor Mastriano said, "is that inebriated patients with no appreciable neurological signs, who are not in cardiac or respiratory distress, and who show no signs of internal injuries, are to receive IV fluids until their EtOH levels drop below 0.1, and if there are no indications of distress at that point, no further treatment until levels are below 0.05."

"Your Resident felt there was sufficient cause to discuss it with you and recommend a neuro consult and CAT scan."

"Interns don't have the experience to make those decisions, and I followed the standard of care."

"Does that include sleeping and demanding not to be woken up?" Doctor Taylor asked, standing up.

"On twenty-four-hour shifts, doctors are allowed to sleep," she countered.

"But isn't it true you gave express orders to both your Residents, and the nurses, to not wake you unless a patient was dying?"

"That's an exaggeration," she countered. "I left orders not to be disturbed unless necessary."

"How did you respond to Doctor Loucks' request to present?"

"I listened to what he had to say, and made a medical judgement based on the standard of care."

"Mike," Doctor Taylor said, "would you tell us exactly what transpired?"

I stood up and relayed exactly how Doctor Mastriano had responded each time I'd tried to speak to her.

"One more question, Mike," he said. "Did Doctor Mastriano attempt to put a formal reprimand in your file because she disagreed with the standing orders from Doctor Cutter and Doctor Northrup for your training?"

"I cannot speak to her motives, only her actions. She did state she was going to place a letter in my file because I obtained permission from Doctor Roth to do a surgical consult against her wishes, and then because I was asked to scrub in on an emergency surgery and didn't obtain permission from her."

"Thanks. Doctor Mastriano, who determines the training protocol for Interns and Residents?"

"The departmental Chiefs," she said.

"Do you believe you can substitute your judgment for theirs?"

"Doctor Taylor!" Doctor Rhodes said sharply. "Focus on facts, please."

"Sorry, Doctor. Doctor Mastriano, did you place a reprimand in Doctor Loucks' file?"

"Yes."

"And what happened?"

"It was removed and overturned by Doctor Cutter."

He sat down and Doctor Subramani stood up.

"In hindsight, do you agree that the neuro consult should have been ordered for this patient?"

"That's not the standard of care," Doctor Mastriano replied.

"With all due respect, Doctor, that wasn't my question. Your Resident felt the standard of care was insufficient in this case, and reported that to you, and wrote it on the chart."

"CAT scans are expensive, and I saw no indication that one should be ordered. I couldn't justify it, based on the standard of care."

"Then why not allow your Resident to call for a neuro consult?"

"Because with an EtOH of 0.19, they wouldn't have accepted him on their service."

"But that doesn't preclude a consult."

"Which would have shown nothing and achieved the same result."

"Mike, why did you think a consult and CAT scan were appropriate?" Doctor Subramani asked.

"The patient's neurological state did not conform to his EtOH levels."

"Thank you. Doctor Mastriano, isn't that a sign?"

"Everyone has a different response to alcohol, and a few hundredths of a percent difference is within the normal deviation."

Doctor Subramani sat down and Doctor Rafiq stood up.

"Doesn't it make sense to bring in someone experienced when there is a disagreement?"

"He's an Intern, and it was his first week in the ED. He doesn't have the experience to make that judgment call."

"Which is why he came to you, but you appeared to be more interested in sleeping."

"Doctor Rafiq!" Doctor Rhodes said sharply.

"I apologize," Doctor Rafiq said, sitting down.

Doctor Cutter stood up.

"Doctor Mastriano, did you tell a surgical Intern that they had neither the experience nor skills to make the judgments they were making?"

"Yes, of course, because it's true."

"Doctor Northrup and I obviously disagree, because we cleared Doctor Loucks for the procedures he's performing and set his training program. Are we wrong?"

"He's a PGY1 and has no business doing what he's doing."

"That's your judgment, Doctor. Are you perfect? Because if not, I find it odd that you do not care to listen to the opinions and judgments of others, whether they are junior to you or senior to you."

I was a bit surprised that Doctor Rhodes didn't intervene, but Doctor Cutter was the Chief of Surgery, and the most senior doctor in the hospital besides Doctor Rhodes, which I suspected gave him more leeway.

"That is not true," Doctor Mastriano protested.

"Did you tell Doctor Loucks that he was to obtain your direct approval before performing any procedures, including ones I personally approved for him to do?"

"That's the prerogative of the Attending who is supervising the Intern."

"And your comment to him that he was not allowed to touch a patient in the OR?"

"That's the norm."

"And your judgment overrides mine?" Doctor Cutter asked.

"As I said, decisions about what procedures an Intern is permitted to do are the prerogative of the Attending who is supervising him or her."

"No, Doctor, it's not," Doctor Northrup said, standing up. "Jerry, I'll handle this internally. I believe we've established that we failed this patient."

"Then this case is closed," Doctor Rhodes said. "Our next case will be presented by Doctor Bielski."

I listened to the case of an angioplasty gone wrong due to a severely weakened aorta, where the conclusion was that there was no negligence, and that not only had the standard of care been followed, but there had also been no indications of the problem prior to the insertion of the balloon catheter. The patient, under just about any imaginable circumstances, would have died with or without the attempted procedure, and the main lesson was that our imaging technology was not yet good enough to detect the problem encountered. A request was made for an MRI machine, and, as was nearly always the case with those kinds of requests, it was 'taken under advisement'.

There were no further cases, so the meeting was adjourned and Clarissa and I went to the cafeteria to get Cokes, a rare thing for me, but I wanted the caffeine and sugar to make it through the final ninety minutes of my shift.

"Let's see if we can summarize," Clarissa said with a silly smile. "Something along the following lines..."

'You see, this bitch of an adulterous doctor apparently was so tired from screwing her lover in an on-call room, that she just wanted to sleep all night, and dismissed all the life-saving, logical suggestions I presented to her. And while it's true that neuro would have rejected my suggestion of a CAT scan, it would have been on them, not on non-specialists in the ED. She 'followed orders' like a good soldier and the patient still gorked and died. How about actually listening to people who know what they're talking about instead of sleeping, and also try looking at the pretty pictures so we know what the fuck is wrong with the patient?!"

"That's a bit harsh, Lissa."

"Is anything I said inaccurate?"

"No. But she won't get in any trouble for that. Not even a reprimand."

"Because she said the magic words 'standard of care'," Clarissa replied disgustedly. "Except the standard of care is a guideline, and there are exceptions."

"I agree, but they're going to nail her for substituting her judgment for that of Cutter and Northrup. And while it's cold comfort to the patient and his family, that's actually going to cause her more trouble than questioning her medical judgment on a case where nobody can say she didn't follow the standard of care."

"You'd never hide behind that!"

"You do realize that if anyone ever sues the hospital over a case in which either of us is involved, we will have no choice but to invoke that phrase, and that would be true in this case. In fact, I'd almost have to take the other side from what I've said about it so far."

"Do you know how fucked up that is? What about Angie?"

"I know. But the difference is that in her case, the psychiatrist ignored behavior that demonstrated marked improvement and was an indication that Angie could be one of the people who actually recover. In this case, what did we have? An inebriated patient who was in and out of consciousness. No clear indications, just my gut. With Angie, there were clear indications.

"Now you're defending Mastriano?"

"It's a fine line, Lissa. Think about the DUI MVA who had the pseudoaneurysm. I didn't order a CAT scan, which might have detected it. According to Doctor Lindsay, had I ordered it, the patient probably would have coded during the scan. So should I have ordered it? Maybe she doesn't code in the scanner and we save her life. A judgment call, and if push comes to shove, we followed the standard of care by rushing her to surgery and resolving the tamponade. I'm sure some smart lawyer could make us look like bad guys, but were we?"

"I see your point, but there's a difference between critical trauma and a case like the one that was reviewed today."

"Which is what makes it all a judgment call, but that judgment has to be based on what we observe. That's why Mastriano won't be reprimanded for refusing the CAT scan. That said, I bet she changes her overnight instructions."

"And will have her attitude adjusted in a 'come to Jesus' meeting with Northrup?"

"Yes. His statement that it's an internal matter means it's a disciplinary question, not a medical question."

"She and Rosenbaum are going to be gunning for you."

"Well, so far, it's Operation Foot-Bullet on their part. And with Doctor Gibbs back in the hospital, I think I'll be OK. Anyway, I need to get back."

"Dinner tomorrow during our shifts?"

"It's a plan!"

We left the cafeteria, and I headed back to the ED.

"Doctor Gibbs would like to see you," Ellie said.

I acknowledged her and went to the Attendings' office, where I shut the door and sat down.

"I assume you fed Vince Taylor all of those tidbits?"

"As my mentor," I replied. "I went to him for advice."

"He doesn't know about Mastriano and Rosenbaum?"

"Not to my knowledge. Other than you and Clarissa, nobody knows about my trouble with Rosenbaum except for the person who told me about it. Well, Elizaveta knew, but..."

I allowed my voice to trail off without completing the sentence.

"I just want to make sure, because I'll be asked, but did you coordinate with any of those doctors except Vince?"

"No, and I didn't 'coordinate' with Vince, I simply provided him the necessary information to advise me."

"Which is not how it will be spun by a cornered Attending."

"I'm not concerned," I replied. "My only error was not using the soft restrains."

"And admitting you should have listened to your nurse was a deft way to deflect fingers being pointed at that."

"I had no idea if that was a contributing factor or not until I saw Doctor McKnight's report on Tuesday. It did concern me."

"In your position, I'd have been concerned as well."

"How do we change the standard of care?" I asked.

"Time," Doctor Gibbs replied. "As with everything else. Empirical evidence that we should do more CAT scans, for example. You provided one piece of evidence. The thing is, it's just one, and not to diminish what happened, but it's tough to make a case for a new standard from this case."

"Because he was just a drunk," I said disgustedly. "And drunks, like addicts, are treated as second- or third-class citizens. Add in the fact that he was African American, and it only gets worse."

"Doctors are human begins, Mike."

"And yet, we've taken an oath or made a vow to treat every patient with dignity and not allow our biases to influence medical decisions."

"Are you perfect, Mike?"

"No, of course not."

"Neither is anyone else. You have your biases as well, and they influence your behavior. I'm sure you know you have a reputation as a 'bleeding heart' and an idealist, and I'd wager you know that influences how people respond to you."

"Right," I growled, "loving my fellow man is a bad thing."

"That's not what I said and you know it! My point is that there is a middle ground and you deviate far enough from it that people notice and that affects how they see you and how they receive what you say. Remember the discussions about your clerical garb? Same thing. You know that's the source of Rosenbaum's opinion of you. You had permission to wear anything you felt necessary, and chose to wear your cassock. Yes, it was your right, but that doesn't mean there would be no consequences."

"You're blaming me?!"

"You're too tired to have the conversation now," Doctor Gibbs observed. "You're reacting emotionally instead of logically. That's my fault. I should have simply asked you about Vince, and left it at that. Finish out your shift."

"Medical training is totally fucked up when you say I'm too tired to have this conversation, then tell me to finish out my shift."

"As strange as it sounds, I'm confident in your ability to treat patients. That said, if you aren't confident, then we have a problem."

"I can do it," I said.

"Then go do it."

I got up and left the office and found Mary and Tom in the lounge.

"Everything OK?" Mary asked.

I nodded, "Yes."

"I had a call from Doctor Worth who confirmed the change to my electives. I'll be back in the ED in April."

"And Pathology?"

"Confirmed as well. The only potential sticking point is that nobody can make any commitments about the Match."

I nodded, "All you can do there is Match for surgery or trauma, and discuss it with the Chief once you Match. I'll add my two cents, but I can't make any promises, either, without getting in trouble with the National Match."

"Mike?" Kellie called from the door to the lounge. "Can you see a walk-in patient?"

"Sure. What do you have?"

"Nine-year-old male playing kickball head-to-head collision with another player. Significant forehead lac over the right eyebrow with significant bleeding. Vitals are otherwise stable and compression bandage in place."

"Put him in an exam room, please, and we'll be right there. I need to take a leak."

"Exam 3 when you're ready," she said.

I used the facilities, then Mary, Tom, and I went to Exam 3 to see the patient, who was lying on the exam bed with a compression bandage on his forehead.

"Eddie Connor, nine," Kellie said. "This is his mom."

"Hi, Eddie; Hi Mrs. Connor," I said. "I'm Doctor Mike. What seems to be the problem?"

"He ran smack dab into another kid," his mom said.

"Did you pass out, Eddie?" I asked.

"I, uhm, don't remember for sure what happened."

"Neuro consult," I said to Tom. "Eddie, I'm going to take a look at your forehead, OK?"

"Yes."

I washed my hands, put on gloves, and with Kellie's assistance, removed the bandage and examined the wound.

"That's going to require sutures," I said to Kellie. "Probably a dozen."

"Plastics?" she asked.

"No, there are good margins and I can approximate the edges. Let's prep him for suturing, please."

"Right away, Doctor."

"Mrs. Connor, Eddie needs stitches to close the wound. There will be some minor scarring over his eye, but given his age and the way he'll develop, it'll mostly be hidden by his eyebrow and will also fade. Did you see it happen?"

"No. The park is close to our house and one of his friends ran to the house to get me. I scooped him up and brought him in because we're only about five minutes from here."

"Is Eddie allergic to anything?"

"Baths!" she declared.

I smiled, "Normal for a diagnosis of a condition known as pre-teen boy! Has he had any local anesthetics?"

"No. No cavities, so not even that."

"What about family members?"

"Not that I'm aware of."

"Mary, lidocaine sensitivity test sub-cu on his forearm. Tom, let's get him on a monitor, please."

They both acknowledged my orders.

"We're going to do a quick test to ensure Eddie doesn't have a bad reaction to the anesthetic we use," I said.

"What could happen?" Mrs. Connors asked.

"The most common side effects are low blood pressure, headache, or dizziness. None of those are life-threatening. Truly adverse reactions are exceedingly rare, and what we're using is the same thing your dentist would use when filling a cavity, though they may call it by its trade name, Xylocaine."

"BP 110/80; pulse 90; PO₂ 98%," Tom announced.

"Eddie, I'm going to give you a small shot in your arm," Mary said. "You'll feel a small prick, and then it might tingle or feel warm."

"OK," he said.

Mary administered the quarter-dose of lidocaine, and while we waited to see if Eddie had a reaction, I performed my primary exam. I detected a slight delay in his response to the finger movement test, which indicated he might have a mild concussion, but it could also be a result of the splitting headache he certainly had.

"Hi, Mike," Doctor Cohen said, coming into the room.

"Hi, Rebekah. This is Eddie Connor, and that's his mom. Eddie had a head-to-head collision with another kid and has a five centimeter lac just above his right eyebrow. Admits confusion immediately following and loss of memory, so suspect brief LOC. Slight delay in eye response for the finger move test, indicating a possible mild concussion. Sub-cu lidocaine sensitivity test in progress."

"Hi, Mrs. Connor, I'm Doctor Cohen," Rebekah said. "I'm going to examine Eddie and make sure he doesn't have a serious head injury beyond the obvious cut."

"OK."

She began her exam, repeating much of what I did.

"BP 100/60," Tom reported.

"That reaction is mild enough that it's not a problem," I said to Tom. "Keep an eye on it, please."

Doctor Cohen completed her exam.

"I concur that it's likely a mild concussion," she said. "Monitor for symptoms for two hours after you complete your procedure, then release. If anything changes, call me."

"Thanks, Rebekah."

"Mrs. Connor," Doctor Cohen said, "I believe Eddie has a mild concussion. He'll need to rest for a couple of days, but that will coincide with Doctor Mike's instructions following the sutures. We'll keep Eddie for a few hours for observation, but then you'll be able to take him home."

"Thank you, Doctor."

Doctor Cohen left, and once a total of ten minutes had passed, I began to repair Eddie's laceration. The laceration required thirteen sutures, and once I finished, I ordered liquid ibuprofen for the headache and other pain, and had Kellie dress the wound.

"He'll need to keep the wound dry," I said to his mom. "Follow up with your family physician in a week, or bring Eddie back here for a wound check. If you see any redness, puffiness, or discharge that isn't clear, bring him in immediately."

"Why?"

"That would indicate an infection. You also want to watch for signs of nausea, confusion, dizziness, blurred vision, tinnitus, or abnormal drowsiness. If you see any of those signs, bring Eddie in immediately or call 9-1-1, as they would indicate that the concussion was more severe than we believe."

"Thanks, Doctor."

"You're welcome," I said, then turned to Eddie, who was sitting up. "How are you feeling, Champ?"

"My head hurts! But the stitches are COOL!"

"Boys!" Mrs. Connor said, exasperated. "He'd be happy to look like Frankenstein!"

Technically, it was Frankenstein's monster, but I wasn't sure how she'd respond to that correction.

"We men do have a different take on the world," I admitted.

"Now there is an understatement if there ever was one!" Kellie said brightly.

"Thank you, Nurse," I said curtly. "That will be all!"

She laughed, "I'll get Eddie a small smock to wear because I cut off his shirt."

"Can I keep my shirt?" he asked. "It's cool with all the blood!"

"Oh, for heaven's sake!" Mrs. Connor exclaimed.

"That's up to your mom, Eddie," I said. "But maybe I can make a trade. What's your favorite candy?"

"Skittles!"

I produced a small package and held it up for him to see.

"Only when Mom says it's OK, but you have to listen to what she says about the shirt."

"Awww, do I have to?"

"That depends; do you want the Skittles?"

"Fine," he said, rolling his eyes. "Moms!"

I couldn't help but laugh, "I have one, too, so I know what you mean!"

I handed him the package of candy, and after Kellie returned with a scrub smock for him. Mary and I left, leaving Tom to monitor Eddie.

"Hi, Mike!" Kylie exclaimed. "I was in the back for the M & M! I think somebody is in deep doo doo, and it's not you."

"Better if I don't comment right now. I only have one patient, so let me fill you in.

I gave her the rundown on Eddie Connor, and then she and I went into the exam room.

"Mrs. Connor, this is my colleague, Doctor Baxter. It's time for me to go home, so she's going to take over. You'll be in very good hands with her."

"How long are your shifts? If you don't mind my saying, you look beat."

"Thirty-six hours," I replied.

"And you don't sleep?!"

"I managed to take two twenty-minute naps last night," I replied. "Which is about the norm."

"Do all doctors do that?"

"For their first year, yes."

"Wait! You're a brand new doctor?"

"Yes. I graduated from medical school in May."

"I would have sworn you were very experienced!"

I smiled, "I am. Mary and Tom are both medical students I'm training. I was trained the same way, so that by the time I graduated, I had hundreds of hours of clinical experience -- that means treating patients."

"How old are you?"

"We're both twenty-six," I replied. "Mary is twenty-five, and Tom is twenty-four. To complete the picture, Doctor Cohen is twenty-seven, and my supervisor, Doctor Gibbs, is thirty-one."

"So young!"

"Most doctors in trauma are young," I replied. "It's grueling, but it's also the case that it's a very new specialty, only really existing for about fifteen years. Our most senior doctors are in their forties. Our Chief is in his fifties, and started as a surgeon."

"What are your normal hours? I mean, after your first year?"

"Twenty-four-hour shifts three times a week, and eventually twelve- or eighteen-hour shifts, depending. A normal work week is about ninety hours to start, going down to about sixty as a senior physician."

"Thanks for answering my questions."

"You're welcome. Have a good evening."

I left, and Mary and Tom followed me out, as Kylie would have her student monitor Eddie.

"Time for a hot shower, dinner, and bed!" Mary declared.

"Exactly!" I agreed. "I'm heading upstairs once I check out."

"See you on Monday," Mary said.

"See you then."

I checked out with Marjorie at the nurses' station, then headed up to the surgical locker room for a shower.

"Good job today," Doctor Lindsay said when I walked in.

"Thanks. Will there be an M & M for the DUI MVA?"

"No. McKnight confirmed to Rhodes that nothing could have saved her short of divine intervention."

"OK," I replied, stripping down to my briefs.

"How do you stay in shape?" Shelly asked, having stripped down to her briefs and sports bra.

"Before this rotation started, I ran and lifted weights. I haven't done either of those because, to be blunt, I'm dead tired and when I get home, I'm going to eat then fall into bed."

We both headed for shower stalls, where I removed my briefs, quickly showered, then wrapped a towel around myself. Shelly did the same, emerging just after I'd begun dressing. She turned her back to me, and I turned my back to her so she could put on her panties and bra without worry, and when we were both dressed, we left the locker room.

"See you Monday," she said.

"Monday," I replied.

I left the hospital, got into my car, and drove home where I greeted Kris and Rachel, ate dinner, then once again collapsed into bed.

XXI. A Hot Appy

July 15, 1989, McKinley, Ohio

On Saturday morning, I'd actually gone to band practice, and afterwards, Kris, Rachel, and I had done our weekly grocery shopping, and then I'd headed to the hospital for my Saturday shift.

"Mastriano is gunning for you," Doctor Billings said when we met for the turnover. "Watch your back or you might end up with a scalpel in it."

"Wonderful. What do you have?"

"Rule-out MI, which turned out to be gastrointestinal going up to Medicine as we speak. OD from last night waiting on a psych consult for rehab referral."

"Drug of choice?"

"Speedball."

"Because mixing a stimulant and a depressant is a wonderful idea," I replied, shaking my head. "Not that using IV drugs is a great idea to start with. Condition?"

"Coming down. Tachy, diaphoretic, and irritable."

"Male or female?"

"Male in Trauma 1. Callie and Gabby are up to speed."

"Perfect, thanks."

Doctor Billings left, and I went to find my medical students, who I discovered were in the lounge.

"The M & M was interesting," Callie observed. "Can I ask you about it?"

"Yes, though I probably don't have much more to add than I said."

"I was more interested in what 'internal matter' means."

"It's when the facts don't show a violation of the standard of care but do indicate bad judgment, poor reasoning, improper behavior, or policy violations."

"So what will happen?"

"That's up to the Chief," I replied. "And not something about which we should concern ourselves."

"I'm actually curious about what could happen."

"Anything from counseling to a disciplinary letter to suspension to dismissal. That's up to the Chief and depends on the totality of the circumstances."

"Is following the standard of care a 'Get Out of Jail Free' card?" Callie asked.

"There is no such thing. Following the standard of care will protect your rotation evaluation and medical license, assuming there aren't extenuating factors. It won't prevent malpractice claims, nor prevent the malpractice claims being paid, because it's up to the insurance carrier and they almost always pay because it's more cost effective."

"But then you'd have a claim against you!" Gabby protested.

"In most of the settlements, the hospital doesn't admit liability. The other thing to remember is that medical students and Residents are working on the license of their Attending, who is ultimately responsible. For you as students, and me as a Resident, so long as we follow the instructions of our Attending, and those instructions conform to the standard of care, we're mostly safe. It's the Attending who is left holding the bag, so to speak. Anyway, let's go see the OD in Trauma 1."

We made our way to Trauma 1, and I handed the chart to Gabby.

"Present, please."

"William Bisch, twenty-six. Transported by EMS after being found unconscious by his girlfriend. Naloxone administered prophylactically upon arrival. Tox screen showed high levels of cocaine and heroin. This morning, patient admitted injecting himself with a 'speedball' last night. Tachy at 110, with no arrhythmia. All other vitals normal. Waiting on rehab consult."

I nodded to acknowledge her.

"Mr. Bisch, I'm Doctor Mike. How are you feeling?"

"OK," he replied.

"Hi, Mike," Doctor Silver said, coming into the room with a Third Year medical student.

"Hi, Leah. Gabby, please present to Doctor Silver.

Gabby repeated the details, and once Doctor Silver had introduced herself, Callie, Gabby, and I left the room.

"Good job on the presentation," I said to Gabby. "I know most doctors accept 'normal' for vitals, but I prefer the actual numbers."

"Yes, Doctor. Sorry."

"No need to apologize, I do some things differently. Remember, you can't spell 'details' without dotting the i's and crossing the t's."

"Got it!"

"Mike?" Doctor Varma said, coming up to us. "Can I get a surgical consult? The on-call Resident just took up a traumatic amputation."

"What do you have, Naveen?"

"Suspected hot appy; bounceback abdominal pain discharged last night. Exam 3."

"I'll take a look. Gabby, get the ultrasound, please. Callie, what are we looking for?"

"Male or female patient?" she asked.

"Female, twenty-five," Doctor Varma replied. "Negative pregnancy test last night."

"Then we're looking for pain in the lower right quadrant on palpation. Lack of appetite is indicative, as is nausea. Doctor Varma, did the CBC show elevated white count?"

"No."

"Temperature?"

"38.8°C."

"Also indicative, but not definitive," Callie observed.

Gabby brought the ultrasound and the four of us went into the exam room where Doctor Varma's medical students were waiting.

"Ms. Brundle, this is Doctor Mike Loucks, a surgical Intern."

"Good afternoon, Ms. Brundle," I said. "May I examine you?"

"Yes."

"Cough please," I requested as I palpated her abdomen.

She did and winced in pain, exhibiting Dunphy's sign.

"Have you eaten anything since last night?" I inquired.

"No. I haven't been hungry."

"Have you felt nauseated?"

"Yes."

"I'd like to do an ultrasound," I said. "Gabby?"

She wheeled the cart over, turned it on, and handed me the transducer. She squirted gel on Ms. Brundle's abdomen and I placed the transducer at the approximate location of the appendix. I moved it around to locate her appendix and quickly found it.

"No obvious enlargement," I said. "But there is free fluid in the right iliac fossa. Callie?"

"Not determinative, but the combined signs suggest it's an appy."

"I agree. Call upstairs and let them know we have a hot appy. Ms. Brundle, it appears you have acute appendicitis and you'll need to have your appendix removed immediately."

"I knew that last night, but they sent me home!"

"Appendicitis is difficult to diagnose," I said.

"Mike," Callie called out three minutes later. "The nurse wants to speak to you."

I excused myself and went to the phone.

"Mike Loucks."

"Doctor Mike, Doctor Aniston is taking the other case that just arrived with Doctor Rafiq and Doctor Burke, and we're shorthanded today. He said to bring up the patient and scrub in. You'll assist Doctor Blake on the appendectomy. Bring your students. He said you should ask Doctor Mastriano to call in someone from Medicine to cover for an hour."

That meant all the Attendings were either tied up or unavailable, because it was rare that a Resident, even a PGY6 such as Doctor Blake, took the lead on a surgery without an Attending in the OR to supervise.

"We'll bring her up right away," I said.

I hung up, asked Gabby to call for an orderly, excused myself, and went to speak to Doctor Mastriano.

"What?" she asked.

"Doctor Anniston instructed me to bring up a hot appy and scrub in."

"You can't leave us short-handed!" Doctor Mastriano protested.

"Doctor Anniston suggested following the protocol to call someone down from Medicine."

"This experiment gets worse every day," she groused. "Just go."

I left the office and went back to the exam room.

"You two get to scrub in," I said. "Naveen, the OD in Trauma 1 is having a rehab consult with Psych. You'll need to take him."

"Got it," he replied.

The orderly arrived, and we helped Ms. Brundle move to the gurney, then we accompanied her up to the surgical ward.

"OR 2," Nurse Penny said.

"Follow me," I said to Callie and Gabby.

"Callie, you had your surgical rotation, so start scrubbing in. Gabby, do you recall the scrub procedure from your Preceptorships?"

"No," she replied.

"OK. Step up to the sink and I'll talk you through it."

I began scrubbing and explained each step along the way. The scrub nurse, Jean, came in about halfway through and assisted us with masks, hats, gowns, and gloves. Once we were scrubbed, we went into the OR where Doctor Blake, two nurses, and an anesthesiologist were preparing Ms. Brundle for surgery.

"First solo, Bill?" I asked.

"Second. First was an appy as well."

"Open procedure?"

"Yes. I'm not certified on laparoscopy yet."

"Under and stable," Doctor Peter Larson, the anesthesiologist, announced. "You may cut when ready."

"Mike, take the assisting surgeon's position, please. Who are your students standing in the corner?"

"Callie Newsom and Gabriella Martin."

"Step up, ladies, but ensure you leave room for Mike to move his arms."

They moved to stand just behind me on my right and left.

"OK, here we go!" Bill said. "Mike, I'll cut, you retract, Annie will suction."

He began with a transverse incision parallel to McBurney's point, incising the epidermis and dermis. I retracted, and he used a Bovie to dissect down to the external oblique aponeurosis. Following that, he opened the aponeurosis, exposing the internal oblique muscle, and I added a second retractor. After dividing the muscle, he divided the transverse abdominal muscle, and I shifted the retractors. He then grasped the peritoneum with forceps and made an incision, then located the appendix.

"There's that little bugger," He said. "Babcocks, please."

Nurse Felicity handed him the forceps, and he grasped the taeniae coli and advanced until the appendix was externalized.

"Good call, Mike," he said. "Inflamed and enlarged."

He dissected the mesoappendix, then applied two clamps to the appendiceal vessels, divided them, and ligated with silk sutures. Finally, the appendiceal stump was inverted into the cecum.

"And that's it," he said. "No rupture, no involvement of any surrounding tissue. Nice and clear. Mike, Doctor Aniston said you could close if I felt comfortable. What would you do?"

"Begin with an antiseptic lavage, then each of the three muscle layers are closed separately with running absorbable sutures. With no rupture, no drain is necessary, so close the dermis with 3-0 subcuticular absorbable sutures, then close the epidermis with basic mattress sutures.

"Correct. Felicity, surgical closure tray to Doctor Mike."

"Bill, could you see your way clear to allow Callie to close the epidermis? She's signed off for unsupervised laceration sutures, and this is an extremely simple procedure."

"Are you sure?"

"Positive," I said firmly.

"If you complete everything else with no complications, then, yes."

I could tell from her body language that Callie was about to burst, but she didn't say anything, which was the appropriate response. I worked slowly and methodically, ensuring I made no mistakes, and when I had closed the dermis, Doctor Blake gave Callie permission to close the epidermis, which she did flawlessly.

"Good work, Ms. Newsom. Mike, you may now resume your regularly scheduled duties!" he said. "Peter, You can bring her out from under."

"What happened that you're shorthanded?" I asked.

Doctor Blake laughed, "Department golf outing. Didn't you get the memo?"

"No. When was it sent out?"

"End of June. Ah, before you started. But it's on the bulletin board, which you should check on a daily basis."

"Will do."

"Scrub out and we'll get her to recovery. Stop by on break and I'll sign your procedure book. I'm here until midnight."

"Thanks, Bill," I said.

We left the room and scrubbed out, and the three of us went to the locker room to change scrubs.

"Holy shit!" Callie gasped when the three of us were alone in the locker room.

"You may be the first Fourth Year to ever suture in surgery," I said. "May I suggest you put it in your book, but keep it to yourself?"

"Mastriano?" she asked.

"Let's just say you don't want to put a target on your back. With two weeks to go on this rotation, there's no point in riling her up. Let me take all the flak from her."

Five minutes later, dressed in fresh scrubs -- red for me and blue for my students -- we returned to the ED where, unsurprisingly, I found Clarissa covering for me.

"One patient," she said. "Finger fracture. Splinted and discharged. Meet for dinner?"

"I'll call you when I take my meal break."

She left, and I went to Doctor Mastriano's office to let her know I was back.

"Let me guess, you performed the appendectomy," she said, disgustedly.

"Of course not," I replied. "I've only seen a few and I've never used a scalpel on a live patient except for chest tubes. Doctor Cutter may be changing the norms a bit, but nobody is going to let a PGY1 perform even something as simple as an appendectomy."

"Walk-ins."

"Yes, Doctor," I replied.

I left her office and after the 'high' of surgery, we now had the 'low' of walk-ins with complaints that mostly should have been handled in a physician's office or at the free clinic. The afternoon was entirely routine, and I managed to meet Clarissa for dinner at 6:15pm.

"I take it from the lack of details earlier you stood and watched?"

"I closed," I replied with a grin. "Well, everything but the epidermis. I asked, and Callie was allowed to put in the final sutures."

"Holy shit, Petrovich! You're an Intern! She's a Fourth Year!"

"Surgery was short-handed," I replied. "Yesterday was the departmental golf tournament."

"You're joking!"

"You know how serious they are about golf! The problem really was a traumatic amputation, which required three surgeons, leaving Doctor Blake to take a bounceback hot appy. Protocol is they call in a surgeon, but neither case could wait, and Bill Blake had done a solo appy before. I held retractors, then closed."

"What did Mastriano say? She must have totally lost her shit!"

"She asked if they let me do the appy, and I said that Doctor Cutter would never allow an Intern to perform surgery, even something as simple as an appendectomy. That's only the third or fourth one I've seen, and despite knowing the procedure, I've never used the Bovie electrocautery before, nor made any incisions in living tissue except for chest tubes."

"You didn't tell her you closed?"

"Why create more animosity?"

"She's going to find out."

"Probably. I did tell Callie to simply write it in her procedure book and not talk about it."

"Riiiigggghhht! Because a Fourth Year who sutured in the OR isn't going to tell every single person she knows? I don't know a single female med student who wouldn't offer to have your baby for the chance to do that!"

"You know my take on that, Lissa."

"And you know I was exaggerating for effect! Besides, you'd prefer the seventeen-year-old who offered!"

"I prefer my wife," I replied. "Period."

Clarissa smiled, "With one exception."

"Yes, but you know that will never happen, no matter how much we might prefer to conceive that way."

"Speaking of that, how are things at home?"

"I sleep. Rachel is very unhappy. I'm gone for long stretches, then eat and sleep when I get home. Kris is handling it OK, and we're on track for trying for our first starting in September. You?"

"I feel as if I never see Tessa, but she seems to be handling it OK."

"The lot of Interns everywhere," I replied. "And even if changes are made, they couldn't be implemented before we're PGY2s, because the ED would need five more Residents to have the same coverage; more if hours are reduced across the board."

"Think it'll happen?"

"I suspect, eventually, the pressure will be so great that the Accreditation Council will make changes to fend off legislation in other states. For the entire medical industry, the nightmare scenario is states having different, incompatible standards. That plays havoc with licensing and the ability of doctors to move from one state to another. It's the same with medical school, though adding Preceptorships doesn't create the same problem, though it does disadvantage students who don't have them."

"I can't imagine you closing an appendectomy without having had that extra experience."

"Me, either. I think, importantly, it also allows students to form important relationships early on. That was certainly a major plus for me."

"Playing golf?"

"Yes, but the relationships were far more important than the golf. Another important thing to consider with regard to hours is whether there are actually enough qualified Residents and enough slots in medical schools to train them. I'm not sure there are, given that Residency slots go unfilled every year."

We finished eating and after a quick hug, returned to our services.

"I was just about to page you," Becky said. "Doctor Gabriel said you should handle the incoming EMS run."

"What do we have?"

"Sexual assault," she said. "They're two minutes out. Trauma 2 is open."

"I'll need an OB/GYN and a nurse trained on rape kits, please."

"I'm trained, so I'll assist. Let me call for the consult. Female, right?"

"Preferably, in case the victim refuses a male doctor. Get a kit once you've done that, please."

She acknowledged my orders, and I went to the lounge to get Callie and Gabby.

"Sorry, I can't let you have your dinner now. We have a sexual assault victim two minutes out."

"Oh, God," Gabby moaned. "I hate these."

"I understand, and if you can't stay in the room without exhibiting emotion, you can swap with Kim, Doctor Varma's student. These can be tough."

"No, I can handle it," she said.

"Then let's go."

We hurried out of the lounge, put on gowns and gloves, and went to the ambulance bay, stepping outside just as the EMS squad turned into the driveway. It pulled up, stopped, and Mark Klein, a new paramedic, jumped out of the cab.

"Hi, Doc. We got a bad one. Julie Rafferty, nineteen, beaten and sexually assaulted. GCS 7; pulse thready at 120; BP 80 palp; PO₂ 96% on five liters; facial and abdominal contusions; blood around the vagina."

"Oh, God," Gabby gasped again.

"Keep it together, Miss Martin!" I said firmly. "Trauma 2!"

The three of us and the two paramedics rushed Ms. Rafferty to Trauma 2, where Becky and Kellie were waiting for us. The seven of us quickly moved Ms. Rafferty to the trauma table. She was so badly injured that the rape kit took a back seat to stabilizing her.

"Callie, EKG and monitor; Kellie, CBC, Chem-20, pregnancy test, ABG. Becky, IV Ringer's. Gabby, ultrasound."

"What about the kit?" Callie asked.

"Cut away her t-shirt and bra, and put them in the bags. The protocol is different for a badly injured victim. She'll need a Foley, but that can wait. Becky, modesty cloth, please."

"Mike?" Nurse Angie said, coming into the room. "Detective Kleist is here."

"She can come in," I said.

I began a careful primary exam as the others sprang into action, following my orders.

"Are you preserving evidence?" Detective Kleist asked.

"As best we can with an unstable, unconscious patient. I'll forego the Foley until OB performs an exam."

"What do we have, Mike?" Doctor Alice Carmichael asked, coming into the trauma room with her student.

"Apparent sexual assault. Primary exam not yet complete, but patient is unstable. Would you perform the pelvic exam and kit, please?"

"Right away. Jacqui, assist me, please."

She and her medical student began the pelvic exam while I completed my exam, calling out my findings.

"Belly is rigid," I announced. "Possible surgical case. Gabby, I need the ultrasound. Becky, type and crossmatch; Kellie, hang a unit of plasma."

"Blood around the vagina and anus," Doctor Carmichael announced. "Suspect internal injuries; collecting swab samples before the internal exam."

"Free fluid in Morrison's," I announced. "With the contusions to her stomach, she may have multiple internal injuries. Gabby, call upstairs. Let them know the patient has multiple injuries, which may include vaginal and anal tears."

About two minutes later, Doctor Carmichael confirmed the tears I'd suspected.

"Foley?" she asked.

"I'm concerned about a ruptured bladder," I said, looking intently at the ultrasound. Let's leave that for the surgical team. She may also have uterine damage."

The phone range and Gabby answered it then hung up.

"Positive pregnancy test," Gabby announced.

"I'll go up with her," Doctor Carmichael said.

"Let me take a quick look," I said, moving the transducer.

"That doesn't look good," Doctor Carmichael said, looking at the screen with me.

"This?" I asked, moving the trackball to shift the pointer to a location.

"That looks like a uterine rupture," she said. "What monster did this?"

"Her husband," Detective Kleist said. "The dirtbag is next door. He fell down a flight of steps, trying to evade us."

I wondered about that, as there had been a few instances of suspects sustaining improbable injuries, but nothing had been proven against the McKinley PD.

"Callie," I said, "portable monitor, and you go up with Doctor Carmichael and her student. Gabby, grab a gurney."

The team worked quickly, and two minutes later, Ms. Rafferty was on her way up to surgery.

"Can I get a statement?" Detective Kleist asked.

"Doctor Carmichael did the most important part," I said.

"Understood, but you evaluated the other injuries."

We spent ten minutes with me describing the injuries I'd seen, as well as the ones I suspected, with Detective Kleist taking copious notes.

"Thanks, Doc," she said. "Buy you a beer at the end of your shift?"

"I don't get off until midnight, and then I'm going home to sleep so I can go to church tomorrow morning."

"Rain check, then!"

"With my work schedule and my family, I really don't have time."

She smiled, "We can always make time if we want."

She didn't wait for an answer, turning to head to the elevators that would take her up to the surgical ward.

"Let's not be too obvious," Callie said quietly.

"She's recently divorced," Becky said, equally quietly. "Don't go there, Mike."

"No chance," I replied. "I'm a happily married man, and contrary to the stereotype, I do not play around."

"Good."

"Thanks, Mom," I chuckled.

"I'm not THAT old, you twit!" she protested.

"Older sister?"

"That works!"

"Callie, let's see what we have in the way of walk-ins."

"How do you do it, Doctor Mike?" Gabby asked.

"What?"

"Go from that," she nodded to the now empty trauma room, "to flirting and laughing."

"I wasn't flirting, she was," I corrected.

"Sorry, but you know what I meant."

"It's a primary trait for the best trauma docs and surgeons," Becky interjected before I could answer. "They compartmentalize, and leave the horror of trauma in the trauma room or the OR. If you have to make yourself do that, think about a different specialty."

"What my older sister said!" I added with a grin.

"Watch it, Doc, or I'll hand you a scalpel blade first!"

I winked, then turned to Callie, "Let's see what's waiting for us at the triage desk."

The next five hours were filled with routine cases, and I allowed both Callie and Gabby opportunities to handle cases, and just before midnight, handed things over to Doctor Lincoln before heading upstairs to shower and dress. I arrived home about 12:30am and found Kris asleep, so I undressed and quietly slipped into bed.

July 16, 1989, Rutherford, Ohio

"How have you been, Mike?" my grandfather asked after we sat down at his house on Sunday afternoon.

"Tired," I replied. "But I love my work."

"And you're attending services?"

"Wednesday Vespers and Sunday morning Matins and Divine Liturgy," I replied. "Kris and Rachel also attend Saturday Vespers, but I'm working, and don't get home until after midnight."

"And you start again tomorrow morning at 6:00am?" Stefan asked.

"Yes."

"And I thought new lawyers worked long hours!"

"Two weeks down, fifty to go before it lightens up a bit. As of next July, it'll only be about seventy-two hours a week."

"'Only'," he says," Paul said, shaking his head. "And I thought running my own business had long hours."

"Just tell my sister to take her feet off the coffee table, put down the bonbons, and turn off Days of Our Lives!"

"If you say that to her, you're a braver man than I am!" Paul replied.

"Brothers can get away with more than husbands," I replied.

"But not more than wives!" Stefan said with a wry smile.

"YOU married a Russian woman," I chuckled. "In fact, you married a Borodin! You have only yourself to blame!"

"Marry in haste; repent at leisure!"

I laughed, "That might be apropos for me! Where did you hear that one?"

"From another attorney who has a client with a very, very interesting past -- former Navy Chief, former OSS and CIA officer, now a very successful businessman in Cincinnati. He has a son your age, despite being your grandfather's age."

"His youngest?" Paul asked.

"No, his oldest. I don't know the whole story, so I can't say what else happened in his life, though I do know his wife is twenty years younger."

"Paul, how is business?"

"Occupancy rates are good and we're turning a nice profit. We've worked out the deal for the restaurant and ownership will transfer on January 1st, 1991."

"That's great news. Why so long?"

"That's when the owners intend to retire, and we're in no rush. They'll take the note, similar to how Mr. Zhuravlyov handled the sale of the motel to us. That gives them income and we don't have to borrow from a bank."

"I'm happy for you. Have you heard from Emmy?"

"She stops by on every patrol," he said. "She's the kind of cop we need -- laid back most of the time, serious when necessary. She cuts most people slack for minor stuff and doesn't write many tickets."

"I'm not surprised. Tell her I said 'hello'."

"When's the last time you spoke with her?"

"At her wedding a year ago. Why?"

"She's due at the end of January."

"Well, tell her congratulations for me. And Liz and I are going to have words about her not telling me!"

"You enjoy putting your head in the lion's mouth, don't you, Mike?" Stefan asked.

I chuckled, "Being her brother gives me certain advantages and immunities that Paul could only dream of! The same is true of the man married to my mother!"

Stefan laughed, "You Borodins are an interesting lot."

"You can say THAT again!" Paul chuckled.

"Dinner is ready," my grandmother announced.

My grandfather, Stefan, Paul, and I joined my grandmother, my mom, my wife, my sister, Elaine, and the three kids -- Michael, April, and Rachel at the table.

"Would you give the blessing, Michael?" my grandfather requested.

I gave the usual Orthodox blessing, and we all began to eat.

"You seem to have failed to call me with important information," I said to Liz. "I had to learn from Paul that Emmy is pregnant!"

"You're never home even if I called!" Liz protested.

"There are these cool inventions called answering machines," I replied. "Not to mention an even older invention -- the wife!"

Everyone laughed, including Kris, who also rolled her eyes.

"Emmy is the Sheriff's deputy, right?" Kris asked.

"Yes. Liz's best friend growing up, and she and I dated briefly before she decided my college roommate was more interesting."

"Because she's smart!" Liz said, sticking her tongue out at me.

"That's exactly the response I'd expect from Lizard Breath!" I chuckled.

"Did we somehow step into a time warp and go back ten years?" Mom asked.

"Because you and Alexi don't treat each other the same way even now that you're both grandparents?"

"Mom!" my mom protested.

"She speaks the truth, Rahil Mikhailovna!" my grandfather said with a twinkle in his eye.

"This is all YOUR fault, doctor!" my mom said to me.

I laughed, "Yes, because I somehow went back in time to when you were little and taught you and Uncle Alex to tease each other!"

"Your mother didn't need any help misbehaving," my grandmother said with a wink.

"So Mike comes by it honestly, then?" Kris asked.

"As does my great-granddaughter!" grandma said.

"She was certainly named correctly!" I said with a grin.

"You are all so silly!" Elaine observed. "My parents would never talk that way to each other! And certainly not in front of me!"

"How are you and April doing?" I asked.

"Great! She's almost two, which you know, and she and Rachel were playing really nice. I had all A's on my last report card, and I have a boyfriend."

"What's his name?" I asked.

"Tommy," she said. "He's going to be a Senior."

"What grade are you in?" Kris asked.

"I'll be a Junior," Elaine replied.

"He's a nice kid," Mom said. "And really dotes on April."

"A teenage boy doting on a baby? What's next? Cats and dogs living together?"

"You doted on April Nash's baby when he was born!" Liz said.

"So sue me! I like babies!"

"Dada love Rachel!" my daughter declared.

"I do," I said. "And I'll love any brothers or sisters you have."

"NO BROTHER!" Rachel said firmly causing everyone to laugh.

"Her Highness has spoken," Mom declared.

"Is that soon?" my grandmother asked.

"If all goes according to plan, a sibling will arrive next summer."

"Lord have mercy if it's a boy!" my grandmother said with a sly smile.

"She'll just have to deal with it! She and her friend Abigail are building a clique of little girls that in about fourteen years are going to terrorize the county!"

"Or at least their fathers," my grandfather said. "I know how that goes!"

"DAD!" my mom warned.

"Where do you think the white hair came from, Rahil?"

"Alexi!" my mom declared.

Grandpa laughed, "He got in his fair share of trouble, but you had no use for the 1950s view of women!"

"What is that supposed to mean?" my mom asked.

"I'm positive your outrage is because your son is here," Grandma said, "but I think he knows!"

"I give up!" Mom said, shaking her head.

"Wise," Stefan said.

"You have only yourself to blame, Mom," I said slyly. "Everything I know outside of medicine, I learned from you!"

"I should have given you to the Gypsies!" Mom said.

"They'd have returned him as being too much trouble!" Kris said.

"You go, girl!" Liz said.

"I am very happy we all love each other enough that no feelings are hurt by teasing such as this," my grandfather said. "I'm very happy to have all of you here."

July 17, 1989, McKinley, Ohio

"I heard a rumor," Doctor Gibbs said when I checked in with her early on Monday morning.

"What's that?"

"You did an appendectomy."

"Do you know REO Speedwagon's Take It On The Run?"

"The part about the tales growing taller down the line?"

"That's it. My students and I scrubbed in, and I assisted Doctor Blake with the appendectomy because there were only four surgeons on duty and both Attendings and the on-call Resident were busy trying to reattach a traumatically amputated arm."

"Why not call in another surgeon?"

"I'm not sure how long it would have taken or what state they would have been in. They had the department golf outing yesterday."

"Say no more!" Doctor Gibbs said. "Surgeons take golf more seriously than anything except surgery! Retractors?"

"Yes. I might also have been permitted to close. I also might have talked Bill Blake into allowing Callie Newsom to make the final closure of the epidermis."

"I'd say the rumor wasn't too far off, given you're an Intern. What year is Blake?"

"PGY6," I replied. "But Residents who have passed their Boards are permitted to perform complete procedures without direct supervision. This was Blake's second solo appy."

"I have a written complaint from Mastriano about you being pulled out of the ED."

"Send it to Doctor Northrup without your endorsement," I said. "She won't like the results."

"I was simply going to reject it as Chief Attending, but you might have a point."

"Never interrupt your opponent when he is making a mistake," I said.

"Napoleon, right?"

"Yes. I say that based on two key points -- first, both the reattachment surgery and the appendectomy had successful outcomes; second, Clarissa saw exactly one patient when she covered for me for about ninety minutes. It was one of those lulls that happen from time to time. Sure, it was chance, but in the end, the resources were applied properly. And you and I both know we're not going to get a larger headcount before the new ED opens, and even then, we won't keep up with the demand."

Doctor Gibbs nodded, "The Chief Attendings meet every other Friday and the biggest gripe is how often we have to shift doctors from Medicine or Surgery to the ED. And it's never the other way around."

"Oh, really?" I asked.

"OK, present company being the lone exception, but he's actually wearing the red scrubs of a surgical intern, so not included in that stat!"

"Did Doctor Mastriano say anything else?"

"Just her usual gripes about what she considers favoritism."

"May I make an honest observation?"

"Yes."

"I'd rather have Callie Newsom run a trauma that involved me than Mastriano. Callie at least cares, and that is important. The same is true for Mary Anderson."

"I heard Mary changed her schedule around."

I nodded, "She's interested in trauma surgery, but you know there won't be a Residency slot next year. She'll go the route of either ED or surgery and then apply for the open Residency slot after her Intern year."

"I take it you'd recommend we take her?"

"I have to see the entire candidate pool, but I'd certainly put Mary near the top of any list I was making."

"You, Bob and Len catch traumas today; Naveen and his students will cover walk-ins."

"No shifts at triage?"

"No. Naveen's students will cover."

"That'll make Mary very happy! Let me go speak to Kylie so she can get out of here."

I left Doctor Gibbs office and spoke to Kylie, who handed over three patients, all of whom were waiting on discharge labs or completing observation, and Doctor Nielson had signed the charts. Once we finished, I checked on each of them, then went to the lounge and sat down on the couch next to Ghost.

"Assisted on an appy, I hear," he said.

"At least you got it right," I chuckled. "Someone told Loretta I'd actually done the procedure!"

Ghost laughed, "The day this hospital allows an Intern to do an appy is the day the state revokes our credentials! You were with Bill Blake, right?"

"Yes. Changing subjects, ready for Sunday?"

"As ready as any man is to get married!"

"I was ready," I replied. "Though the first time was basically at the command of my bishop, not that I objected in any way, shape, or form."

"Well, let's just say that marriage has some very specific benefits!"

I chuckled, "Indeed it does. I guess you'll be my cousin by marriage."

"Is that even a thing?"

"Who knows? But we will have one set of grandparents-in-law in common, which means any kids you have will be blood related to any kids Kris and I have."

"I hadn't considered that," Ghost said. "I mean, obviously I knew Oksana and Kris were cousins."

"Timing?" I asked.

"Well, given Oksana has her Associates in accounting, she's ready to start right away."

"And Kris and I are hoping to have our first next summer. The second cousins might be born around the same time."

"I'm not sure I'm ready for kids," Ghost said.

"If I could do it in med school, you can do it in your final year as a Resident!"

"Yes, but you're certifiably crazy!"

"I won't dispute that!"

"Because you can't!"

"Ghost, Mike?" Ellie said from the door. "Time to earn your pay! EMS transporting two MVA victims. Four minutes out. Not critical. Trauma 2 and 3."

"Time to go to work, kids!" Ghost declared.

Bob, Len, and I, along with Ghost and his students Jack and Stephanie, all left the lounge and headed for the ambulance bay, grabbing gowns and gloves along the way.

"First or second patient?" Ghost asked.

"You're senior, so it's up to you."

"I'll take the second one. You take Trauma 2 and I'll take Trauma 3."

"OK. Bob, Len, we'll assess what we need when we hear the bullet, but Len, for sure we'll need a basic monitor and vitals."

They acknowledged my instructions and about a minute later the EMS squad pulled up.

"Morning, Docs!" Bobby said jumping out. "Two victims of a low-speed MVA. Both complaining of neck and back pain. Patient one is a forty-two-year-old male; Patient two is a forty-five-year-old male. Both restrained. Both fitted with cervical collars. No other treatment except transport. Patient one pulse 90; BP 110/70; resps normal. Patient tow pulse 92; BP 120/80; resps normal."

"I'll take patient one," I said. "Name?"

"Karl Gross. Patient two is Randy Monroe."

He and his partner unloaded the gurneys, and we escorted the patients into the trauma rooms where nurses were waiting.

"Bob, would you handle the three patients waiting on discharge? Just bring me the forms to sign when you're ready."

"Sure thing, Doctor."

"Mr. Gross, I'm Doctor Mike. How are you feeling?"

"My neck hurts! I'm going to sue that bastard for every cent he has!"

"They were arguing in the squad," Bobby reported.

"Thanks," I said.

He left and Becky, Len, and I helped Mr. Gross move to the trauma table.

"What kind of pain are you having? Is it dull and throbbing? Shooting? Stabbing?"

"Dull and throbbing."

"On the sides or in the back?"

"Sides."

"Do you have a headache?"

"Yes."

"You were driving?"

"Yes, and that bastard just slammed into me! He wasn't paying attention!"

"Did you hit your head at all? Or did your chest impact the steering wheel?"

"No, I had my seatbelt on."

"Then let me examine you, please."

"Need any help in here?" Doctor Williams asked from the door.

"We're all set, Brent," I said. "Just possible whiplash from a low speed, restrained MVA."

"Holler if you need me," he said, then stepped away.

"Who was that?" Mr. Gross asked.

"One of the senior doctors on duty," I said. "He'd have heard there were accident victims and because I'm relatively new, he's checking on me."

"How new?"

"I graduated medical school at the end of May."

"God help me! Do you know what you're doing?"

"He's the best doctor here," Becky said. "I'd put my life in his hands."

"Thank you, Nurse! Mr. Gross, I'm going to examine you and see if we can remove that collar."

"Kids!" he said, shaking his head, giving lie to what I'd suspected -- he was faking his injury.

XXII. I Didn't Call to Fight

July 17, 1989, McKinley, Ohio

"I can remove the cervical collar," I said after examining Mr. Gross' neck.

"It really hurts, Doc."

"Nothing is broken, and I don't feel any swelling," I said. "We'll give you some Tylenol 3, which will take care of the pain."

"Tylenol?"

"This actually is a combination of acetaminophen and codeine, not the same thing you buy at the drugstore," I replied. "Let me speak with Doctor Williams and we'll get it for you."

I removed the cervical collar, updated the chart, then Len and I went to find Doctor Williams, who was at the nurses' station.

"OK to present?" I asked.

"I thought it was minor, but go ahead."

"It is minor. No appreciable injuries; BP 120/70; pulse 72; PO₂ 99% on room air. Complains about 'extremely sore neck', but no appreciated tenderness or swelling."

"What are you not saying? Your tone of voice says there's something.

"When you came in, he asked about you and I explained you were a senior physician, and he asked how long I'd been a doctor. When I explained I'd just graduated, he said 'kids' and freely shook his head. The paramedics reported he was arguing with the other driver on the way in."

"Ah. So why the codeine?"

"Because it is entirely possible he has a mild case of whiplash, and pain can't be proved one way or the other. He might actually be in pain, and given I see no indication he's drug seeking, the standard of care is to provide pain relief. I'll discharge him with instructions to see his personal physician for a follow-up, but his chart will reflect my findings."

"So when he files his insurance claim, he comes up dry?"

"That'll be between him and his physician."

"Approved. Chart?"

He signed off and made notes, and I went to Ellie and asked for the drugs, showing her the signed chart. She retrieved two tablets for me from the Schedule Drug locker, and I took them to Mr. Gross.

"Len, a cup of water, please," I said when I returned to the room.

Len got the water and handed it to Mr. Gross, and I handed him the small paper cup with the two tablets.

"These will be very effective for pain relief," I said. "After six hours, you can take three regular Advil every six hours, and you should follow-up with your personal physician within forty-eight hours. He'll manage any pain or whiplash symptoms."

Mr. Gross swallowed the tablets and handed the cup back to Len.

"I'm going to fill out your discharge papers. Is there someone we can call for you?"

"My wife," he said.

"Len, get the number and call Mrs. Gross, please. I'll be back in a few minutes.

Ten minutes later, Mr. Gross was shown to Patient Services.

"He was faking," Becky said.

I nodded and showed her the chart.

"WAIT!" Len protested. "He was faking?!"

Becky smiled, "I was pretty sure Doctor Mike caught it. I saw it in his eyes when the patient shook his head."

"Which you don't do if you have whiplash," Len said.

"Exactly," I replied. "Take a look at what I wrote on the chart."

Becky handed it to him.

He nodded, then read aloud, "'Patient claims neck pain but has no appreciable injuries or signs. Paramedics report patient combative during transport. Tylenol 3 PO, but no script. Follow up with PP'. Then why the pain meds?"

"What is the one thing we have no way of independently verifying under any circumstances?"

"Pain."

"And the standard of care?"

"Appropriate analgesia unless the patient appears to be drug-seeking."

"Correct. And if they appear to be drug-seeking?"

"Psych consult or social worker."

"Doctor Mike," Bob said, approaching with a chart. "Rule-out MI with heartburn ready for discharge."

"Did you perform an exam?"

"Yes, and I have an EKG strip for you. Cardiac enzymes negative on repeat test."

He handed me the chart, and I looked at the EKG strip which showed textbook sinus rhythm, and cardiac enzymes that were in the lower middle of the acceptable range. Nothing else was amiss, so I signed the chart and discharge form.

"Street him," I said, handing back the chart. "OTC heartburn medication and follow-up with his personal physician."

Bob took the chart and left.

"Thanks for stroking my ego," I said to Becky.

She smiled, "I actually meant it!"

"I believe I need more experience before that would apply."

Becky shook her head, "I didn't say you were the most experienced; I said you were the best."

"And you can tell that after two weeks?"

"Would I lie to my little brother?"

I laughed, "Well, given how my little sister and I treat each other..."

"Good point! I have an older brother, and, yeah. Even now!"

"My mom and her older brother are the same way. My grandparents even commented on it at dinner yesterday."

"And my sister and me," Len said. "I think it's universal."

"Mike?" Ellie called out. "Walk-in teen with breathing difficulties. Bringing them to Trauma 4."

Len, Becky, and I saw Jamie bringing a teenage male from the waiting room in a wheel chair and we followed them into Trauma 4. It was a fairly straightforward asthma case, resolved with a nebulizer of albuterol, and I turned him over to Bob to discharge after two hours of observation.

We had a bit of a lull, then a series of routine walk-in cases, with no EMS transports. I sent Len and Bob to lunch at staggered times and then took mine at 12:30pm so I could meet Antonne in the cafeteria.

"How are things going?" I asked Antonne as we joined the line.

"Great, actually. My mom loves her job working for...how should I refer to him?"

"It's OK to call him my father-in-law," I replied. "The law may not see it that way, but he's Rachel's grandfather. Go on."

"Anyway, mom loves her job, as I said, and the housing here is far better than what she had in Cleveland, and it won't be long before she can get out of the subsidized housing. My brother and sister are both happy, though they miss their friends. That said, they're both glad to be out from the gangs. I'm working at Kroger stocking shelves. How about you?"

"The hours are brutal, but I love what I'm doing."

"I won't ask about interesting cases, because I'm positive the others will want to hear about them. Will you have time starting in August?"

"I'll make time," I replied. "I don't know what my schedule will be beyond the end of August. Until then, I'm on two thirty-six-hour shifts, one starting at 0600 on Mondays and the other 0600 on Thursdays, and then a twelve-hour shift on Saturdays, starting at noon."

"Military time?"

"All our schedules use military time, as do our charts, time of death announcements, and so on. It prevents any confusion. One major point is noon and midnight, which would both be twelve, where so many people mix up am and pm because you go from 11:59pm to 12:00am and 11:59am to 12:00pm. Both of those are by convention, too. With the twenty-four-hour clock, what you called 'military time' has no possible confusion because 2400 is never used in the hospital."

"I don't look forward to those shifts."

"There's a good chance you won't have to do them. New York passed legislation to limit shifts to twenty-four hours, with a maximum of eighty hours per week, and with a minimum of eighteen hours between shifts. That was in response to the Libby Zion case we discussed. That will likely spread, though it could take some time. That said, it's seven years before you're a doctor, so I'd wager you won't have thirty-six-hour shifts."

"Have you heard from any of the others?"

"No. I figured that would be the case, given a mix of how busy I am and the fact that none of them live in McKinley. Just remember, your break between graduation and med school is the last one you'll have until you've served your Internship."

"Are there any black doctors at this hospital?"

"Five, I think. Only one in the ED -- Paul Lincoln. He's a PGY1 like me. For a brief period, Doctor Gibbs was the only female, but there are more now. Surgery is the true boys' club with just two female surgical Residents. Fortunately, McKinley Medical School's ratio of male to females is shrinking, but they're still lacking in minority applicants. I'm hoping all six of you apply there."

"You know Danika is going to go to Stanford, right?"

"I strongly suspect that's the case, but we'll see what happens two years from now. Maybe she'll meet the right guy and decide to stay in the area."

"YOU were her right guy!" Antonne declared. "And from what I understand, you felt she should go to Stanford."

"I didn't realize that was public knowledge."

"I wouldn't call it public, but everyone in the group knew it, just as they knew Conchita would have married you just to be Rachel's mom!"

I chuckled, "I got that impression, but I needed an Orthodox wife."

"How do you have time for church?"

"As with everything else that's important, I make time. It's when there are important things which conflict that tough choices have to be made."

"But medicine always comes first, right?"

I nodded, "Yes, and even if I wasn't predisposed to that, it would be forced on me. As I've said, medicine is a harsh, demanding, jealous mistress, and she does not brook anyone or anything interfering with her demands."

"How does your wife handle it?"

"You'd have to ask her! But I made absolutely sure she knew what she was walking into before we married. Over the years, quite a few girls who might otherwise have been very interested took a look at the demands of medical training and Residency and chose not to pursue a relationship with me. Is there anyone special in your life?"

"There was a girl back in Cleveland, but she'll only be a Senior, and I don't think she's mature enough to handle the kind of life I'm going to have."

"My advice is when you find someone who can, you marry them. That's going to be FAR more important than being in love with them."

"Crazy."

"We are! It's the only way to stay sane!"

Antonne laughed, "That's so Zen!"

"I know you were raised Pentecostal, but I think you'll find a lot of wisdom in Eastern philosophy."

"You mean Buddhist?"

"Among other things. I'd recommend taking World Religions along with a philosophy class in your electives. It'll pay off."

"What about Latin?"

"It helped, but you can memorize the words by using flashcards. What language did you take in High School?"

"German, of course. This is Ohio, after all!"

"Given who I married, I probably should have taken French, but there was no way to know this is where I'd end up."

"Is Kris teaching Rachel French?"

"No, but my troublemaker sister-in-law is!" I chuckled. "I know Rachel's grandparents use Russian with her, and so do my grandfather and grandmother, but it's mostly English."

"Sisters are always troublemakers!"

I laughed, "I agree, and I just had that conversation earlier."

When we finished our lunch, Antonne left for a shift at Kroger and I headed back to the ED. The afternoon was busy with a mix of walk-ins and EMS transports, but nothing out of the ordinary. I admitted an MI and a diabetic, and streeted eight patients before Kris and Rachel arrived so we could have dinner together.

When I returned from dinner, Mary and Tom had taken over for Bob and Len. Almost immediately we had an EMS transport for an MI. I checked the board for an open trauma room, then we gowned and gloved.

"What are we doing?" I asked Mary as she, Tom, and Nurse Kellie waited in the ambulance bay.

"High-flow oxygen, EKG, and monitor. CBC, Chem-20, ABG, and cardiac enzymes."

"You have your cardiology rotation next, right?"

"Yes."

"Make sure you ask to be taught to read EKGs, and I don't mean just the basics. Doctor Strong is a good choice to ask, as he's an excellent teacher, as is Doctor Javadi."

"Already on my list of things to learn before this time next year."

The EMS squad turned into the driveway and, a few seconds later, pulled up in front of us.

"Art Nesmith, fifty-three; collapsed while dining; complaining of severe chest pain; diaphoretic; BP 180/120; tachy at 120; PO₂ 98% on nasal canula; history of hypertension according to his wife; taking Capoten; no IV due to hypertension."

Which was the right move, as adding fluids was the last thing a hypertensive patient needed.

"Trauma 3!" I ordered.

Three minutes later, after performing an auscultation and hearing no irregular heart sounds, I looked at the EKG and saw sinus tach, but no indication of an MI.

"What do you see, Mary?"

"Sinus tachycardia, but otherwise, no deviations."

"Differential?"

"With systolic of 180, hypertensive crisis."

"Mr. Nesmith, have you taken your medication today?"

"Yes," he replied, clearly in pain.

"First thing we need to do is get your blood pressure down. Have you been diagnosed with any liver problems?"

"No."

"Have you had a heart attack?"

"Just this one."

"I don't believe you're having a heart attack," I said. "Have you seen a cardiologist?"

"No. My doctor is treating my high blood pressure."

"Billie, sublingual nitro tab, then chlorpromazine, 50 megs IM, please."

"Right away, Mike!"

"Mr. Nesmith, the nitroglycerin will reduce the pain and help lower your blood pressure. The nurse will put a tablet under your tongue. She'll then inject you with chlorpromazine, which is an anti-hypertensive, that is, combats high blood pressure."

"OK," he said with a grimace.

"I'm going to complete the exam," I said.

I went through the usual exam steps, asking the usual questions. I wasn't surprised that Mr. Nesmith drank several cans of beer a day and smoked, and ate plenty of fried foods.

"Did your doctor discuss the effects of diet, alcohol, and smoking on your hypertension?" I asked.

"He's a pain in the ass!" Mr. Nesmith declared.

I decided I'd let Medicine deal with that, and simply let it go.

"We're probably going to need to admit you to get your blood pressure under control. Would you like your wife to come in?"

"Sure."

"Tom, would you see if his wife is in the waiting room and bring her in? Mary, call for a Medicine consult for hypertensive crisis, please."

Everyone followed my instructions and five minutes later my consult from Medicine arrived.

"Hi, Petrovich! What do you have?"

"Hi, Lissa!" I replied, then gave her the information.

"Mr. Nesmith, I'm Doctor Saunders from Internal Medicine. I'd like to examine you, please."

He agreed, and she performed her exam.

"No arrhythmia and stable, so I'll take him," Clarissa said, then turned to her student, "Jay, call for an orderly, please. When we get upstairs, you'll need to do the admission paperwork."

"Yes, Doctor," he agreed.

Ten minutes later, Mr. Nesmith, his wife, Clarissa, and Jay left the room to head up to medicine.

"Petrovich?" Mary asked.

"Mikhail Petrovich Loucks," I replied. "Or in English, Michael Peter Loucks. My dad's name is Peter, so that became my middle name, because Russians use patronymics instead of middle names. The 'vich' part means 'son of'."

"So, you're a son of a vich?" Billie asked with a silly smile, causing Tom, Mary, and me to laugh.

"ANYWAY," I said when I could after laughing so hard, "close friends call each other by the patronymic. Clarissa and I have been partners in crime since Freshman year at Taft."

"You're Russian?" Tom asked.

"«Да, товарищ»," I replied.

"I don't speak Ruski!" Tom declared.

"'Yes, Comrade'. Half, anyway. My dad is Dutch, from the time when Manhattan belonged to the Dutch. My mom's side of the family is Russian."

We left the room and Nicki waved me over.

"You had a call from a Doctor Fran Mercer in Milford. She left a number."

She handed me the message slip, I thanked her, then contemplated what to do. I decided I should return the call and went to the consultation room that served as an office for the Residents. I shut the door, sat down, and said forty repetitions of the Jesus Prayer before picking up the handset and dialing the number.

"Fran Mercer."

"Doctor Loucks returning your call. I'm on shift. What can I do for you?"

"I didn't call to fight, Mike," Doctor Mercer said. "I called to apologize."

"For?"

"How much time do you have?"

"I can't guarantee I won't be called for a trauma, so I can't really say."

"When would you have time to talk?"

"Wednesday during the day," I replied. "I'm on until 1800 tomorrow, sorry, 6:00pm, then I'll go home, eat, and collapse."

"Could you call on Wednesday morning at 9:00am?"

"I could. Your office or this number?"

"My office please."

"I'll call you on Wednesday."

"Thanks. Have a good evening."

"You, too."

I hung up and left the consultation room, wondering how far her apology might go. The fact that she had called at all was a good sign, given everything I'd said to her in the past. I was extremely curious about what she would say, but my duties in the ED had to take priority over my curiosity. I pushed those thoughts into the back of my mind and refocused on the ED.

"I heard Callie got to close an appendectomy," Mary said when I joined her and Tom in the lounge.

"Right place, right time, right circumstances," I replied. "Basically, all the planets aligned, and I did most of the suturing while she closed the epidermis. And that only happened because both Attendings and the on-call Resident were handling a traumatic amputation and the remainder of the staff was on the golf course for the annual golf outing."

"I'd...sorry, never mind."

I chuckled, "Give your eye teeth?"

"Yes, that is what I was going to say because I'm my grandma!" Mary replied with a smile.

"Trust me, I know the feeling, and making deals with the Devil is not uncommon, but also not wise. The Devil always gets the best of you."

"Well, I want to know which god I offended so I can atone and get into the OR!"

"Unfortunately, I think Loki is in charge of the hospital!"

"The Norse trickster god?" Tom asked.

"Yes. Either him or Shiva."

"Which one is that?"

"The Hindu god of creation and transformation, but also known as 'the Destroyer'. Interestingly, both Loki and Shiva are associated with serpents, along with Moses, and we have a serpent on our badges on the Staff of Asclepius."

"So it's snakes all the way down?" Tom asked.

"Quoting Stephen Hawking in A Brief History of Time quoting, supposedly, an anecdote by Bertrand Russell?"

"Yes! I laughed hard when I read that."

"It's related to the critique Russel made of the 'First Cause' argument for the existence of God, though in his words, the Indian guru asked to change the subject."

"What do you think of the argument?"

"I'm Russian Orthodox, so I don't. Given it is impossible to prove the existence of something which is outside the universe, and given no philosophical argument will ever satisfy someone who is convinced God does not exist, why waste time or energy? To rephrase something one of our bishops said -- let the philosophers fight over proofs of God's existence, and let us worship the undivided Trinity who has saved us.

"As with so many conflicts between faith and science or faith and philosophy, we have no dog in that fight. From our perspective, the Scholastics did grave harm to the faith by trying to tie it all neatly up in a rigorous philosophical package, something we would maintain is impossible. Experience has borne us out on that belief. And this is where I stop talking theology on duty."

The timing was perfect because we were called for a walk-in hand lac, which I assigned to Tom, with Mary guiding him, and me standing aside and supervising.

"Is this like the government road crews?" Mr. Metcalf, the patient, asked.

I chuckled, "It might seem so, but this is how medical training is conducted. Tom is suturing and Mary is acting as his supervisor. I'm here to ensure everything goes well and to evaluate both of them."

"How long have you been a doctor?"

"I received my MD on May 25th," I replied. "But I have around 8000 hours of clinical experience, most of that from before my MD was conferred. Those clinical hours were exactly like what Tom and Mary are doing right now."

"But if you just graduated..."

"The same thing happens in complex traumas -- I'll be assigned to work with a more senior doctor. There's an adage that, while not literally true, captures how medical training works -- watch one, do one, teach one. I still need a senior physician, called an Attending, to sign off on some procedures, and to prescribe all Schedule II and Schedule III drugs, which is basically anything addictive. But for sutures and a tetanus shot, I have a notation in my procedure book," I held it up, "that authorizes me to do it without needing to be checked. Mary has a signature from me in her book for that, but until she's actually an MD, I'd have to check her work."

"Interesting. It almost sounds like my situation as a Master plumber."

"You're not as far off as some might think. We have Interns, Residents, and Attendings. I'd compare medical students to your apprentices or entry-level jobs. An Intern or Resident is akin to a Journeyman, and an Attending is akin to a Master. Training is partly classroom and partly hands-on. A friend of mine is an electrician, and that's how he's trained."

"Same for plumbers."

"I've had people compare an angioplasty to a roto-rooter job."

Mr. Metcalf laughed, "A snake through a blood vessel to open a blockage?"

"Exactly! And an arterial graft could be compared to fixing a broken or leaky pipe."

"Sign me up, Doc! I bet it pays better!"

I chuckled, "You'd lose that bet. My friend the electrician makes more as a Journeyman than I do. He'll make more than I do until I'm an Attending, which is about eight years from now. Mary and Tom are paying for the privilege of working."

"Get out of here!" he protested.

"I pay tuition," Mary said, "and don't get paid for working, so Doctor Mike is technically correct."

"I thought docs made big bucks!" Mr. Metcalf countered.

"Surgeons, especially plastic surgeons, do," I replied. "Also, Attending physicians at large hospitals or at research hospitals tend to be paid much higher salaries. Residents work for a relative pittance."

"You're an ER doc, right?"

"I'm actually training to be a trauma surgeon," I replied. "That's why I'm in red while Mary and Tom are in blue. Surgeons here wear red."

"What's the difference between you and a regular ER doc?"

"I'll be able to do minor surgical procedures during a trauma, including inserting chest tubes, central line IVs, and tracheostomies. Right now, a surgeon has to be called to do that. In the future, there will be trained surgeons assigned to the Emergency Department. I'm the first one at this hospital."

"Finished," Tom announced.

"Mary?" I prompted.

"Nice, even sutures, wound edges properly approximated. OK to administer the tetanus booster?"

"Yes."

She handed Tom the package and walked him through the process. Once that was complete, Mary filled out the chart and handed it to me to sign, which I did. Tom provided the discharge instructions and then directed Mr. Metcalf to Patient Services.

"Excellent work, Tom," I said once we were sitting in the lounge.

"Thanks. This Clerkship is the only one where I'll actually get to do procedures, right?"

"Generally speaking, yes. You'll monitor patients, take vitals, do wound checks, and so on, on the other services, but actually doing procedures is pretty much limited to the ED until you've graduated. There are some exceptions, such as Pathology or if you do a rotation at the Free Clinic."

"What was the coolest procedure you did as a med student?"

"Retrieving a lost condom with a speculum and forceps."

"Lost cond...wait! Inside?"

"If you don't hold on to them, they can slip off," I said. "And worse is allowing yourself to go soft before withdrawing."

"I bet that ruined their day!" Mary exclaimed. "Leaked?"

"Yes."

"How old?" Tom asked.

"Freshmen at Taft."

"Not quite as bad as being sixteen, but bad enough. How could you do that as a med student?"

"Because during my OB/GYN rotation, I participated in exams."

"And I thought you were going to say something along the lines of knowing your way around a pu...vagina!"

I chuckled, "That would be exactly what Doctor Saunders would say to tease me! But she'd use the non-medical term you self-corrected away from, which I appreciate."

"If you two are so close, I'd have thought you two might..." Tom stared.

"She has a girlfriend, you idiot!" Mary interrupted, laughing.

"Oops," Tom said. "Sorry."

"No need to apologize," I said. "Clarissa doesn't hide it, but she also doesn't make a big deal about it."

"Mike?" Billie called out from the door to the lounge. "EMS four minutes out with a possible stroke. Doctor Taylor asked you to join him."

"Thanks. Let's go!"

We gowned and gloved and joined Doctor Taylor and Jamie, the male nurse, in the ambulance bay.

"Mary, how do you feel about intubation?"

"I can do it, Doctor Taylor," she said firmly.

"Do that. Tom, EKG, and monitor. Mike, supervise Mary, then peripheral muscle tone and reflex checks."

"Will do," I confirmed.

"Jamie, trauma panel; Billie, Foley. We'll decide on thrombolytics once we assess the patient. Mike, which drug would we use?"

"Off-label t-PA would be my choice," I said. "It's normally given for STEMIs, but has shown better success with strokes than streptokinase. Alternatively, streptokinase and heparin followed by ASA."

"Interesting," Doctor Taylor said. "Based on?"

"A recent article in Journal of the American College of Cardiology," I replied.

"We'd need approval from Doctor Getty and Doctor Northrup before we could do that. Neither of them are in the hospital."

"Then streptokinase, boosted by heparin, followed by ASA," I said.

The EMS squad pulled into the driveway.

"You're not wrong, Mike," Doctor Taylor said, "just a few years ahead of the game. We only started using t-PA with STEMIs in June."

The EMS squad rolled to a stop, and the paramedic jumped out.

"Bill White, sixty-seven; BP 170/90; pulse 110 and thready; PO₂ 99% on ten liters; vomited, then passed out; GCS 6; pupils sluggish; drooping left eyelid and facial palsy."

"Trauma 1" Doctor Taylor ordered.

"We're going to need a CAT scan as soon as we stabilize him," I said as we rushed Mr. White to the trauma room.

"Agreed."

The team quickly moved Mr. White to the trauma table, and Mary did a good job intubating the patient. As soon as I'd verified the breath sounds, I began checking Mr. White's extremities.

"Tobacco stains on his fingers," I said. "Consistent with the discoloration of his teeth."

"Did you notice a gag reflex on intubation?"

"Mary?" I inquired.

"Minimal," she said.

"Poor peripheral pulse, both lower extremities," I said. "Both flaccid and with some edema."

"Preliminary diagnosis is subarachnoid hemorrhage," Doctor Taylor said.

"Indicates no thrombolytics," I said.

"Agreed," Doctor Taylor said. "Let's get neuro down and see what they want to do. Tom, make the call, please. Mike, what do you see on the EKG?"

"PVCs and SVTs," I replied. "We want to try to bring down his systolic pressure, but we don't want to give him anything that's going to cause bleeding. And we want to address the arrhythmia."

"IV labetalol," Doctor Taylor said. "The contraindications are hypotension, bradycardia, and cardiogenic shock."

He gave the order to Billie, and she went to get the drug from the drug locker.

"More PVCs," I said. "He's decompensating. Recommend digoxin."

"Agreed."

When Billie returned, she administered the labetalol and Doctor Taylor ordered digoxin.

"Cohen, Neuro," Rebekah Cohen said when she came into the room with her student Joy.

Doctor Taylor explained the case, and she performed an exam.

"CAT scan," she said. "We'll take over."

"All yours, Rebekah," Doctor Taylor said. "Tom, stay and assist."

Josh, Mary, and I left the room. Over the next four hours, Mary and I, and eventually Tom, handled a steady stream of walk-in patients, none of which actually needed a trauma doctor.

"As useless as the idea likely is," I said to Mary just before midnight, "I'm going to try to take a nap. Naveen will handle anything that comes in for the next two hours, so you and Tom should try to get some rest if you can."

July 18, 1989, McKinley, Ohio

I actually managed thirty minutes of uninterrupted sleep before Billie woke me.

"Doctor Williams asked me to wake you," she said. "House fire with multiple victims. First transport is five minutes out."

"OK," I said.

I pulled myself from the bunk, took off my eye mask, and went to the locker room to empty my bladder. Once that was accomplished, I washed my hands, splashed a bit of cold water on my face, and headed to the ambulance bay where basically the entire medical staff was assembled.

"How many and how bad?" I asked Doctor Williams.

"Five, and pretty bad. Three of them are kids. Pedes was notified."

"Smoke or burns?"

"Both."

"Did anyone notify the air ambulance crew?"

"They're on stand-by."

The next ten minutes were pure chaos as the patients arrived -- a family of five, with the father being the most severely injured as he'd rescued his kids before collapsing trying to rescue his wife, with both of them suffering significant smoke inhalation and moderate burns. Fortunately, none of them were burned badly enough to need to go to the burn center in Columbus, but three of the five -- the dad, mom, and seven-year-old son were admitted to the ICU, while the five-year-old daughter and two-year-old son were admitted to Pediatrics.

"That could have been a lot worse," I said to Doctor Taylor about ninety minutes later when the last patient had been transported.

"Gutsy move going back into the house four times," Tom observed.

"There's a fine line between gutsy and foolish," Doctor Bill Schmidt, a PGY2, added. "He came damned close to crossing it."

"And if they were your kids?" I asked.

"That's why I said 'damned close'. I'd have done the same thing."

"Think they'll all make it?" Naveen asked.

"I'm worried about the dad," he said. "The pulmonary compromise was pretty severe, and CO levels high enough that the pulse oximetry was useless."

"Why?" Tom asked.

"Mike?"

"Carbon monoxide attaches to hemoglobin and the pulse oximeter cannot distinguish between it and oxygen. So with an ABG showing 10% carbon monoxide and 80% oxygen, you'd see a PO₂ of 90%, but that's a false number."

"How do you know?"

"Cyanosis is the key," I replied. "If you see it in a smoke inhalation victim, you don't trust the oximetry numbers and get a stat ABG."

"Oxygen is the only treatment, right?" he asked.

"Yes," Doctor Williams replied, "with hyperbaric O₂ being the current gold standard."

"One more piece of equipment we don't have," I observed.

"It's been on medicine's 'wish list' for about five years, but there's no space for it even if we could get the funding. That should change in about five years when the new ED and surgical wings are completed. Remember, ten years ago this wasn't even a Level II trauma center. Most patients were transported to Columbus. Anyway, Naveen, you and your students grab a nap. Mike will cover walk-ins."

"Tom, go relieve Norm at the desk and we'll be right there."

Mary smiled at that, as that meant she'd get a chance to do procedures, rather than be stuck in triage. I went to get some coffee from the lounge, and Mary followed me.

"Thanks," she said.

"You're welcome. You take the lead and I'll kibitz as needed."

"Norm was complaining earlier about being assigned to Naveen and not getting nearly as many opportunities."

"All I can do is train my students and set an example. It's also the case that I don't know Norm well enough to judge if he should be given the same opportunities as you've been given. You have the personality and mindset for trauma. Without it, you wouldn't be given the opportunities."

"Can I ask something you might not be able to answer?"

"You can always ask."

"How does someone as high-strung as Doctor Lewis get a Residency slot?"

"I can only theorize that he interviewed very well. "He graduated in the top ten in his class in medical school. Let me ask you a question -- should I reference Tom's panic attack following the helicopter incident in his evaluation?"

"I don't think that would be fair," she replied.

"There's at least part of your answer."

"You mean being cut slack for being inexperienced?"

"More or less. And, honestly, until you're actually baptized in fire, you don't know how you'll respond."

"You're cool as ice."

I chuckled, "And yet, I have nothing on Nurse Kellie who's only response to the incident was to say 'we have two engines'. I'd say my pulse was in the 150 range from all the adrenaline. I'd bet hers never hit 120, if it even broke 100."

"One more question, if I may."

"Sure."

"Is it wrong to be disappointed we didn't have to fly someone to Columbus?"

"I once observed that I wanted more procedures, but the only way that could happen is if someone was sick or injured, which bothered me tremendously. The way I balanced that in my mind was that the universe would provide patients whether I was here or not, and someone would have to treat them. I wasn't asking for more people to be sick or injured, just the opportunity to treat a higher percentage of them.

"To answer your question directly, every medical student in the history of the world has wanted more procedures and been disappointed when they missed out on something they truly wanted to do. That includes me, Doctor Gibbs, Doctor Javadi, Doctor Subramani, Doctor Saunders, and on and on. I could list the entire medical staff. So, no, don't feel guilty about wanting procedures.

"Before we go see Tom, I'll remind you what Sir William Osler, a co-founder of John's Hopkins and the creator of the first Residency program said -- 'Medicine is learned by the bedside and not in the classroom. Let not your conceptions of disease come from words in the lecture room or read from the book. See, and then reason and compare and control. But see first.' Have you been in Doctor Getty's office?"

"No."

"He has a photo of Doctor Osler and that quote on his wall. It should be on the wall in every Attending's office. And every doctor in a teaching hospital should memorize it and internalize it. For the next ten months, you need to push hard for training and procedures. Don't take 'no' for an answer. Be proactive and make it happen. Let's go see what Tom has for us."

We went to the triage desk and Tom handed a chart to me, which I scanned, then passed to Mary.

"What do you want to do?" I asked once she had read it.

"Crying toddler pulling on his ear is a pretty good indication of otitis media," she said. "And Tom's exam confirms red, bulging tympanic membranes and a slight fever. So confirm, administer analgesics, and fend off the demand for antibiotics."

"What do you need to watch out for?"

Mary considered for a moment, "Confirmation bias. I know what I'm looking for so I'm likely to find it."

"And the antidote to that?"

"A complete exam and history, looking for any signs that I'm mistaken."

"Very good. Let's go get your patient."

XXIII. A Nerf Bat and an Olive Branch

July 18, 1989, McKinley, Ohio

"Get any sleep?" Clarissa asked when we met for breakfast very early on Tuesday morning.

"About thirty minutes before the smoke inhalation victims you accepted, and about thirty minutes after. You?"

"About an hour before you called. After that I was caring for those two. I also spent some time in the ICU because all three of those patients are Medicine patients."

"How's the dad?"

"So far, so good. Jacobs from Pulmonology will evaluate him in about an hour. His monoxide levels have come down, and his PO₂ is at 92%. He inhaled a lot of particulate matter and probably some toxic fumes. The other four are in much better shape, and the mom and eldest son will be out of the ICU this afternoon."

"Good."

"Anything else interesting?" Clarissa asked.

"A subarachnoid hemorrhage that Neuro took. That one didn't look good at all."

"Gorked?"

"I'd say that's the odds-on bet," I replied. "I don't know what the CAT scan showed, but the physical signs were indicative of a major bleed. How is the hypertensive crisis?"

"One foot in the grave. Both feet if he doesn't quit smoking, limit his drinking, change his diet, and exercise. We got his BP out of the stratosphere, but it's still too high."

"And it'll stay there, as you say."

"I just don't get it!" Clarissa said, shaking her head. "If you know it's going to kill you..."

"Because if that's what you've done for your entire adult life, change is hard."

"You'd think staring death in the face would be sufficient."

"You would, but we know it's not. Let's be honest, my behavior during the interregnum was irresponsible and dangerous, given the prevalence of HIV and other 'gifts that keep on giving'."

"I wonder what the incidence of STDs is at Taft."

"That would be a question for Trina at the Free Clinic," I replied. "I bet she could tell us. But I was extremely lucky."

"I never did know the exact body count..."

"Somewhere around fifteen, I think, not counting you or Lara. I was a bit out of control."

"Given what you went through, you were far more in control than out of control. Sure, you had a lot of sex, but you cared for Rachel, graduated first in our class, passed your exams, Matched, and found the perfect partner in crime for the rest of your life."

"Which doesn't excuse my behavior."

Clarissa rolled her eyes, "Did any of those girls feel used? Heck, did any of them feel anything other than expertly fucked? It might be different if you had lied to them or abused them, but name ONE girl you went after. Just one!"

"You."

"Very special circumstances, and we'd been together before. Besides me? Heck, you lusted for Tasha, and she had to basically drag you to bed! You couldn't even get up the courage to ask her for a date in High School despite the fact you both wanted to fuck each other half to death!"

"Angie."

"Again, special circumstances, but she was already after you when you spoke to her. The guys pointed out she was interested."

"By the way, speaking of Angie, Doctor Mercer called last night."

"Uh-oh."

"She said she wanted to apologize. We're supposed to speak tomorrow."

"Interesting. I assume you'll accept her apology?"

"Assuming it's sincere, of course I will. But I also have to be careful because of the complaint that was filed against Doctor Greenberg."

"What are your plans for tomorrow?"

"A day with Rachel," I replied. "It's basically the only time I have with her when it's just the two of us. I'm not sure what we'll do, well, once I speak to Doctor Mercer in the morning."

"Is Rachel here?"

"No, she's with Anna today so she can play with her girl cousin and hide from her boy cousin. I'll stop by and get her on my way home."

We finished our breakfast and Clarissa returned to Medicine while I headed back to the ED.

"You two should grab your breakfast before the morning rush," I said to Mary and Tom.

They left, and I sat down in the lounge with Doctor Varma.

"Mind if I ask where you're from?"

"Sunnyvale, California," Naveen replied. "My dad works for Apple Computer. You're from around here, right?"

"One county over. I went to Taft and McKinley Medical school. You?"

"UC Berkeley, then OHSU School of Medicine in Portland."

"How'd you end up here?"

"My fiancée is working on her PhD in biochemistry at OSU. I interviewed at six hospitals and Moore Memorial was my second choice, but I have no complaints."

"Doctor Varma?" Nurse Alice called from the door to the lounge. "EMS four minutes out car versus pedestrian. Doctor Nielson needs your assistance."

"Coming," he replied. "Sorry, Mike."

"Duty calls," I replied.

He left and about two minutes later, Tami McCarty came into the lounge.

"I came down to take a woman in labor up to Labor and Delivery and wanted to say 'hi'."

"Hi. How have you been?"

"Good. I started in OB full time on June 1st. How is Rachel?"

"Growing like the proverbial weed! Walking, talking, and generally acting like a toddler."

"I heard you married in January."

I nodded, "I did. A girl from the Russian Cathedral in Columbus. She's majoring in Political Science at OSU."

"Mike?" Nurse Jenny said, coming into the lounge. "Walk-in with near-syncope and nausea."

"My students are at breakfast, so I'll need a nurse, please."

"I'm all yours!" Jenny declared. "We brought the patient into Exam 2."

I excused myself, then got up and followed Jenny to the exam room, taking the chart from the rack and scanning it. The name was uncommon enough that I made an assumption which was proved correct when I walked into the exam room.

"Good morning, Detective Tremaine," I said. "Doctor Mike Loucks."

"I remember you from a case about six years ago. A missing student."

I nodded, "You interviewed me in the disappearance of Angie Stephens. What brings you here this morning?"

He smiled wryly, "I was at the coffee shop having doughnuts with my partner, felt light headed, and felt as if I was going to throw up. The nauseous feeling passed but not the light-headedness, and my partner insisted on bringing me in."

Correctly speaking, it was 'nauseated' but I didn't feel it was the time or place to correct him.

"I'll dispense with the cop and doughnut jokes," I said with a smile. "Are you armed?"

"Yes."

"Would you please remove your firearm so we can do the exam? I don't need to take it, but I don't want to take any risks, even with the safety on. Well, a safety assuming it's semi-auto, not a revolver."

"I carry a Glock 9mm," he said, removing the shoulder holster. "Where should I put it?"

"The nurse can put it on the counter for you."

He handed it to Jenny, and she set it on the counter.

"No vest, right?"

"No."

"Then if you'd take off your jacket, loosen your tie and unbutton your shirt, I'll examine you."

I did the basic exam and found nothing remarkable, so my first impression was likely some kind of viral infection or inner ear disorder, but I had nothing on which to hang my hat.

"Have you had any medical procedures? Even minor ones?"

"A colonoscopy about three years ago, but that's it other than my annual physicals."

"Have you recently had a head injury of any kind or been in a fender bender?"

"No."

"Do you smoke?"

"I quit about five years ago using the Kojak method. My dentist hates it, but it worked."

"I'd trade cavities from lollipops against lung cancer or emphysema any day. Do you drink?"

"A beer after work most days, but just one. An occasional glass of whisky."

"Exercise?"

"The gym three times a week, mostly for cardio, recommended by my doctor. Something about sitting on my ass six or more hours a day."

"Any headaches?" I asked.

"Off and on for years, and aspirin always worked. My doctor advised cutting back on caffeine, so I drink decaf half the time and that's helped."

"How much coffee do you drink?"

"All of it!" he chuckled. "I always have a cup."

"How's your diet, besides the police breakfast?"

He laughed, "Believe it or not, we only get doughnuts once a week. Usually it's a sit-down breakfast. Eggs, bacon, and either toast or waffles."

"And otherwise?"

"Too many burgers and fries," he said. "My doc got on my case about that, but the exercise has taken off some of the weight I put on."

"How much?"

"Gained ten, took off five."

"Over what period did you lose that weight?"

"About two months."

"Any changes in frequency of urination or significant changes in bowel movements?"

"No. Thank God I'm not getting up every two hours to take a leak like my dad."

"Any trouble performing in the bedroom?"

"According to me? No."

Jenny laughed, and I chuckled.

"Have you ever had dizzy spells before?"

"No. First time."

"Any vision changes?"

"A new prescription in May."

"And before that?"

"At least five years."

"Presbyopia?" I asked.

"Sorry, I don't know that word."

"Literally it means 'elder eyes'. Did your prescription change in general, or is it for reading?"

"These are progressive bifocals and I needed them for reading."

"Fairly common for men over fifty," I observed. "Any problems with your hearing?"

"According to whom? My wife? My captain?"

I chuckled, "I was thinking more about doctors."

"No."

"Tinnitus or 'ringing' in your ears?"

"Twice, when I've had to fire a gun without ear protection."

"When was that?"

"Once as a patrol officer about thirty years ago, once eight years ago."

"How long did the tinnitus last?"

"Less than a day both times."

"Any changes in how you feel during your workouts? Changes in your breathing? Or trouble walking or standing?"

"No. None of those."

"OK. The next thing we'll do is draw blood. Are you still feeling light-headed?"

"It's not as bad when I'm lying down, but yes."

"Jenny, nasal canula, please, then draw blood for a CBC, Chem-20, ABG, cardiac enzymes, and metabolic and glucose panels."

"Right away, Mike."

"Detective, I'm also going to get an EKG."

"OK. Mind telling me what all those other tests are?"

"A CBC is Complete Blood Chemistry and looks at the number and types of cells in your blood; Chem-20 measures twenty different components of blood, including calcium, sodium, and electrolytes; ABG is arterial blood gas and tells us about oxygen and other gasses in your blood; cardiac enzymes are markers for heart attacks, though I don't think you're having one; the metabolic and glucose panels tell us how your body is processing glucose and eliminating waste, as well as your cholesterol. The nasal canula is oxygen, and that's simply out of an abundance of caution."

"What do you think is wrong?"

"This is the shotgun approach to non-specific syncope -- fainting or lightheadedness -- and nausea. The most common diagnosis with those symptoms is a virus or a mild inner ear disorder. The challenge is that neither of those can be directly diagnosed in most cases, so we run all the tests to rule out the other things."

"So, like eliminating suspects?"

"Something like that, yes."

"You understand why we liked you for that disappearance, right?"

"For the same reason," I replied. "With the basic information, you look for reasons why it's not the boyfriend with whom the young woman had a fight before you'll stop thinking it's the boyfriend. And the reason is, that more often than not, it actually is the boyfriend. So, in that sense, it's the same way we deal with differential diagnosis. Let me get the EKG pads on you and Jenny will draw the blood."

Ten minutes later, the blood was drawn, and I had five minutes of EKG strip which showed no specific anomalies, his pulse was 75, his BP was 120/70, and his PO₂ was 99%.

"Everything looks good so far," I said. "Would you sit up and tell me how you feel?"

He did, and I could tell he was still suffering from lightheadedness.

"My head spun a bit, and I felt queasy," he reported.

"OK. At this point, just relax and we'll wait for the blood work to come back. Jenny, I, or one of my students, will check on you while we're waiting, and if you need anything, just press the purple button on the wall there."

"Thanks, Doc."

Nurse Jenny and I left the room, and she touched my arm.

"Care to explain?" she asked.

"A young woman with whom I was close disappeared after we went jogging. It turned out, when all was said and done, she was diagnosed with schizophrenia, but nobody knew it at that point. It was no fun at the time, but Detective Tremaine was doing his job."

"How is she?"

"Medicated, but able to work a data entry job, go to church, and practice Aikido."

"That's better than many."

And it should have been even better, but I didn't want to get into a lengthy discussion about Angie with anyone not directly involved.

"It is."

"What do you think? I mean, about the detective?"

"Exactly what I said -- the probable cause is a virus or inner-ear disorder."

"And if it's not that?"

"Any other diagnosis is pure speculation," I replied. "Let's wait and see if we find any clues in his blood work. Get that blood to the lab and we'll see what they say. Actually, here come Mary and Tom, so you can have Tom take the tubes to the lab."

She handed Tom the tray, and I filled Mary in on the case and asked her to check on Detective Tremaine every fifteen minutes until the blood came back.

"If there are no clues in the blood," I asked as we went to the lounge, "what would you do next?"

"Well, from what I've been taught, there's no reliable way to prove it's a virus or inner ear disorder, so with normal blood chemistry, you have to be thinking about the possibility that it's a tumor or some kind of neurological problem, including an aneurism, stroke, or some other problem."

"Yes. And?"

"EEG, CAT scan, or lumbar puncture would be the next diagnostic steps, so a Neuro consult."

"What about monitoring and if it resolves, streeting him with a referral to his family physician?"

"You're worried about the cost of the tests if it's simply viral?"

"I don't give a fig about the cost of the tests, but a CAT scan induces significant ionizing radiation and a lumbar puncture is very uncomfortable at best."

"We were warned in practice of medicine about the cost to the hospital of advanced tests."

"Well, I know the cops have good insurance, so it's not the hospital that would be on the hook, but even then, I don't care. That's for the bean counters. If I think a test is warranted, and it's not against standard hospital practice, I'm going to run it. If it is against standard hospital practice, then I'm going to be..."

I paused to see how they would respond.

"A forceful advocate for your patient," Mary said, completing the thought.

"Yes," I confirmed. "What do we do if the blood tests are all negative diagnostically?"

"Did you do reflex and muscle tone tests?" Mary asked.

"No. That would be the next step before a consult."

"He had good distal pulses, right?" she asked.

"Yes, and he's about twenty pounds over his ideal weight, but he's in good shape for fifty-three. And if the reflex and muscle tone tests are diagnostically negative?"

"EEG, because it's non-invasive and doesn't use ionizing radiation."

"And if that shows nothing?"

"Then one of the invasive tests."

"Or street him," I said.

"That seems counter to your usual thinking," Mary protested.

"Now, why might I do that?" I asked.

Mary laughed softly, "Devil's Advocate, right?"

"The question is whether or not you can defend your decision. You haven't seen me have a strong disagreement with an Attending over a diagnosis, but they do happen, and you have to be able to defend your position and support your conclusions. Think about the M & M."

"Have you had those disagreements?"

"Not specifically adversarial, but differences of approach and opinion. In the end, the Attendings make the decision on how to proceed, and you have to consider how hard you want to push and how certain you are that you're correct. And that was why it was legitimate for Mastriano to question me and override me."

"But she was wrong."

"Yes, but at the time, I couldn't prove I was right. That said, I was concerned enough about her decision that I had her write the order on the chart."

"So she couldn't deny it later, right?"

"If you are ever told by anyone, including me, to do something you believe is wrong, make sure it's in writing."

"You would listen."

"That's true, but that doesn't mean I'd agree with you, nor does it mean I'm going to be right every time. Don't put me on too high a pedestal, because I won't survive the inevitable fall."

"So, what will you do?"

"Neuro consult," I replied. "It's the ED equivalent of dropping back ten yards and punting. I don't have the experience to diagnose the kind of thing we're discussing, and neither does Doctor Gibbs. We'll punt it to Neuro and let the experts decide the next steps. And don't be surprised if Doctor Gibbs suggests streeting him with orders to take it easy for a few days and follow up with his physician."

"She seems more like you than like Mastriano."

"Yes, but the difference is Attendings do have to care about allocation of resources, and also have a lot more experience than we do. Yes, Doctor Gibbs has only been out of medical school for six years, but those six years are huge. Think about what you've learned in the last six weeks, then multiply that out."

"Got it. Let me go check on the detective."

I nodded, and she left, returning about five minutes later, along with Tom.

"No change," she said. "EKG still shows sinus rhythm, vitals are good...sorry, pulse 72, BP 120/70; PO₂ 99% on nasal canula."

"Then we wait for the blood work."

"Mike?" Ellie said from the door to the lounge. "Doctor Gibbs needs you. EMS three minutes out with car versus pedestrian."

"Another one?" I asked.

"Bad day to walk the streets of McKinley, I guess."

"Thanks. Mary, Tom, let's go."

The pedestrian's injuries were serious, but not life-threatening, and he was admitted to Ortho with a badly broken leg. I'd sent Mary to check on Detective Tremaine twice, and the lab results had come back just before we transferred the accident patient.

"Nada," Tom said. "Everything is completely in range across the board."

"Anything close to the limits?" I asked.

"No. All mid-range. Basically textbook readings."

"Mary?"

"Neuro consult for sure."

"I agree. Let's present to Doctor Gibbs and see what she says."

We went to the Attendings' office where Doctor Gibbs and Doctor Mastriano were speaking, and I waited until Doctor Mastriano was finished. She gave me a hard look as she left, but I simply ignored it.

"What do you have, Mike?" she asked.

I presented the case and gave my recommendation.

"Why?" Doctor Gibbs asked.

"Otherwise generally healthy male with no obvious indications of the source of the problem. If this were May, I'd attribute it to the new glasses. If this were immediately after he quit smoking, I'd attribute it to nicotine withdrawal and changes in hemoglobin and pulmonary function associated with inhaled carbon monoxide, tar, and nicotine. If he'd eaten something out of the ordinary, I'd attribute it to that. That leaves us with 'probably a virus' or a generic Ménière disease diagnosis."

"Neuro is going to push back."

"Entirely possible," I replied. "But I don't feel comfortable streeting a patient who has sudden-onset symptoms with no discernable cause."

"Why not wait and see?"

"Krissy Sumner," I said.

"You've lost me," Doctor Gibbs said.

I smiled, "Burnt toast."

She cocked her head, then nodded, "Your very first day here when you were a First Year."

"How many times was she sent away?" I asked.

"Enough. I'm sure you remember the exact numbers."

"We diagnosed her brain tumor on visit nineteen and she'd seen eleven different doctors over three years."

"Call for your consult," Doctor Gibbs said.

I handed her the chart, she made a notation and signed it.

"So, did I?" I asked when she handed me the chart.

"Did you what?" Doctor Gibbs asked.

"Make a decent doctor?"

"Get the hell out of my office!" Doctor Gibbs said, laughing. "Shoo!"

Tom, Mary, and I left, and as soon as we walked into the corridor, Mary put her hand on my arm.

"What did I miss?"

"I'll explain after we speak to Detective Tremaine and call for the consult."

We went to Exam 2 and after a quick check of the monitoring equipment, I explained the situation.

"So, with nothing we can point to, I'm going to call in a neurologist," I said.

"To look for what?"

"The cause of your symptoms. If you had any hearing trouble, I'd start with an ENT, but without that, a neurologist is the best choice."

"What will they do?"

"Decide what additional tests to run. I could order them, but I'd need them to sign off, so it's easier just to call for a consultation."

"Fess up, Doc. What are you looking for? Give it to me straight."

"I could be a smart ass and say 'the cause of your symptoms', but I know that's not what you mean. There are any number of things that could cause this, besides the ones I mentioned. Anything from having hit your head on one end to a tumor on the other. But please don't jump to any conclusions."

"I said I hadn't hit my head."

"Believe it or not, even a minor bump, something you don't even think about, could cause a hematoma, that is, bleeding in your brain. Small ones generally resolve on their own. The same is true with a very mild concussion, which could happen even if you don't fall, if your head snaps quickly one way or the other, again, perhaps without you even realizing."

"Huh. I was rough-housing with my grandson yesterday. He's three, and he hit me with a Nerf bat."

"That may well be it," I said.

"You're joking!"

"Not at all. Any kind of blow to the head, including from a three-year-old terrorist with a Nerf bat, could do it."

He laughed, "Terrorist?"

"You do know the difference between terrorists and toddlers, right?"

"Yeah, I've heard that one! And he is fearless."

"Let me call for the neuro consult, but I think we have an idea as to what caused your symptoms."

"I am going to get SO much shit at work, if that's the case."

"Consider the alternative," I said with a smile.

"Yeah, I suppose being beaned by a toddler with a Nerf bat beats a tumor or stroke or whatever!"

I had Tom place the call, and Rebekah Cohen came for the consult, concurring that it was most likely the blow from the Nerf bat, and prescribed forty-eight-hours of rest and follow-up with his physician. I went over the discharge notes with him, reminding him to come back to the hospital immediately if the symptoms worsened. Once he was discharged, Mary, Tom, and I reported to Doctor Gibbs.

"What Lesson did you learn, Mary?" Doctor Gibbs asked.

"That patients don't always volunteer relevant information. Doctor Mike asked about injuries, including head injuries, but the patient denied them."

"What should I have asked," I prompted.

"If he'd suffered any blow to the head of any kind."

"Very good," Doctor Gibbs said. "Tom, what should you do if you think Doctor Mike has missed something?"

"Ask him, privately, about it."

"Correct. Dismissed."

The three of us left the office and went to the lounge.

"What was I just saying?" I asked.

"But the patient didn't answer correctly!" Tom protested.

"Mary?"

"He answered the question Doctor Mike asked, not what Doctor Mike actually wanted to know."

"Bingo," I said. "How you ask the question is important, and I should have asked about even a slight blow to the head. The patient should have told us; why didn't he?"

"Because it was a Nerf bat and nobody thinks those can harm you."

"Especially wielded by a toddler," I replied.

"So what was the 'burnt toast' thing?" Mary asked.

"On my very first day of my first Preceptorship, when Doctor Gibbs was a PGY2, we had a Frequent Flier who had previously come to the hospital eighteen times over the course of three years, always with varying complaints. Each time she was given an analgesic or released without treatment.

"Eleven different doctors saw her over that period of time, and none of them sat down with all her charts and put all the pieces together. I asked Doctor Gibbs to ask the patient a single question, based on something I'd read when I was researching my friend's illness. The answer 'burnt toast' was the diagnostic symptom that pointed to a brain tumor."

"WHOA!" Tom gasped. "It was missed?"

"Mary?"

"No continuity of care. They stressed that in Practice of Medicine. She wasn't seeing her own doctor, was she?"

"No. And with all records on paper except billing, there was no easy way to find and compare all those charts. I sat down with all of them after the fact and found the pattern, but it took significant time. The new computerized system will help, but that's coming with the new ED so it's still a couple of years away before it's populated with enough data."

"But why did nobody else figure it out?" Tom asked.

"Confirmation bias," I replied. "With nothing provable, and repeat visits, they classified her as a 'Gomer' and treated her as such."

"'Gomer'?" he asked.

"'Get out of my ER'. I use 'frequent flier' because it's not as derogatory, but it's the same idea. You will see patients who present simply because they want attention or have some imagined illness or are mentally ill. They thought that patient, Krissy Sumner, was mentally ill, but she refused psych consults and they had no plausible reason to put her on a psych hold."

"You remember her name?"

"She was my very first diagnosis! I know a few other names, but they were special cases. You heard what triggered Doctor Gibbs' memory -- the smell of burnt toast. That phantom smell, together with that of burning rubber, are signs of a brain tumor. And to complete the story, it was after that diagnosis that Doctor Gibbs said that if I continued along those lines, I might make decent doctor."

"And she ran you out of her office because your ego doesn't need a boost!" Mary said mirthfully.

"Your evaluation is still pending, Missy!" I said with a grin.

"Says the doctor in surgeon's colors!"

I chuckled, "As you've noted, I'm not a big enough prick to be a surgeon, but I do have the ego necessary to do it."

"Why do you say that?" Tom asked.

"It takes a strong, confident person, with a very positive self-image, to cut into bodies to fix them. But that doesn't make me into some kind of god as some surgeons think of themselves. I put my pants on one leg at a time like everyone else, and I nearly soiled my underwear when the helicopter had the mechanical malfunction."

"I can't believe Kellie's response was to calmly say 'we have two engines'!" he said.

"The Navy will do that to you," I replied. "Do you know the most dangerous workplace in the world?"

"Coal mine?"

"Deck of an aircraft carrier. It's only because they are so highly trained and skilled that there aren't more injuries or fatalities. I mean, would you go stand on a runway at Port Columbus while a plane was taking off or landing?"

"Hell no!"

"Those sailors do that every day, with multiple launches per day. Personally, I'll stick to medicine."

"What about the helicopter?"

"I'll get on the next one without even thinking about it. And as much as I know Mary won't like to hear this, if we have another run in the next ten days, you'll go with me."

"I'm not sure I can do that," he said."

"Your call, but I think you should."

"Mike," Nate said from the door to the lounge, "several walk-ins in the waiting room. Doctor Gibbs said to ask you to see them."

"Thanks, Nate."

I used the facilities, washed my hands, then Mary, Tom, and I went to see the patients. A steady stream kept both Naveen and me busy until lunch, which I ate with Ghost and Doctor Gibbs, then returned to the ED to find my two Second Years waiting. They shadowed us for the afternoon, with a mix of EMS transports and walk-ins, but nothing life threatening or all that interesting. At 6:00pm, I signed out and left the hospital.

"How are you, Mike? Viktor asked when I arrived at the house to pick up Rachel.

"Tired," I replied. "But I'm getting used to it, so it's not as bad as the first week. How are things with you?"

"I'm enjoying my three grandchildren and Geno is handling most of the day-to-day at the family businesses. I know this is probably a foolish question, but any chance you could play a round of golf?"

I shook my head, "I have so little time, so no. Between my shifts and sleeping, I only really get to see Rachel on Wednesdays, Saturday mornings, and Sundays. I see Kris less, because she's at school on Wednesdays."

"I heard you were on the helicopter that had engine failure last week."

"I was, but we all came out unscathed, and it was on the return flight, so no risk to a patient."

"I'll let you get Rachel, but we'd like you to come to dinner in the next few weeks."

"Let me speak with Kris and I'll get back to you."

We went to the living room and Rachel squealed and hurried over to me to be picked up.

"How's my little girl?"

"Playing!" She exclaimed. "Viktor loud!"

I laughed, "Little boys are like that.'

"Big boys, too!" Anna said with a smile.

"Shall we go home to Mama?" I asked.

"Yes! And «tante» L'dmila!"

"She's probably not there," I said, causing my daughter to pout.

We left the house and headed home.

July 18, 1989, Circleville, Ohio

"Hello!" I called out when I carried Rachel into the house.

"Hi!" Kris said, coming out of the kitchen.

I put Rachel down so Kris and I could hug and exchange a quick kiss. I went upstairs and changed into shorts and a t-shirt and then went back downstairs. Rachel demanded to be picked up, so I scooped her into my arms and carried her to the kitchen.

"Did Doctor Mercer get in touch with you?" Kris asked as she put the finishing touches on dinner.

"Yes. I couldn't speak too long because I was on shift, so I'm going to call her tomorrow morning."

"Do you know what she wanted?"

"She said she wanted to apologize, so we'll see."

"Did she tell you what Lyudmila said?"

"No. She didn't mention anything."

"I was putting Rachel in her crib and Lyudmila answered the phone. Doctor Mercer asked if Lyudmila was your wife and my little sister said you only wished you'd married the better sister!"

I chuckled, "She was only fourteen back in January, so that wasn't even an option!"

"And the 'better sister' comment?"

"What is it with you and Lyudmila suddenly in competition?" I asked.

"Love «tante» L'dmila!" Rachel declared.

"So?" Kris asked with her hands on her hips. "Better sister?"

"You, of course!"

"Well said!" Kris declared and turned back to the counter.

"In all seriousness, it feels as if something has changed."

"Not really," Kris said. "It's just that Lyudmila feels comfortable around you. She's always liked to tease, but at first she wasn't sure how you'd react so she was careful about it. She said things privately to me. And you know that's how Chloé and I were with each other. Does it bother you?"

"Not if it doesn't bother you. Rachel certainly loves her."

"How were things at the Kozlovs'?"

"Fine. Viktor invited us to dinner, but I put him off saying I needed to discuss it with you. I think no sooner than a few weeks from now."

"I think that's wise. How tired are you today?"

"It's not as bad as the past two weeks, and I did catch a few very short naps overnight."

"Oh, before I forget, Jocelyn and Gene will be here a week from Sunday, along with Tasha and Chris, and Sophia and Robby. We'll be at the wedding this Sunday, so I rescheduled."

"Great! I miss the Sunday dinners that we used to have before...everything changed."

"That was with different couples, though, right?"

"Subdeacon Mark and Alyssa and Elias and Serafima. And we do need to have them over at some point."

"Why not alternate Sundays?" Kris suggested.

"If that works for you, it works for me, though we'll need to take into account seeing our parents, too."

"Maybe one dinner a month with each group?"

"That sounds reasonable."

"Dinner is ready. Please get Rachel in her high chair."

We had a nice meal, and as I wasn't feeling completely dead on my feet, I helped Kris clean up, played my guitar for about twenty minutes, we said evening prayers, and I turned in as soon as we put Rachel to bed.

July 19, 1989, Circleville, Ohio

On Wednesday morning, I was awake before Kris needed to leave for OSU, so we said morning prayers and had breakfast together. Once she had left, I played my guitar for Rachel until just before 9:00am.

"Daddy needs to make a phone call, so I hope you'll play quietly."

I put Rachel on the floor with some toys, then picked up the receiver on the new cordless phone Kris had purchased and dialed Doctor Mercer's office number. I had to wait a minute before she came on the line and used that time to say the Jesus Prayer to keep myself in the right frame of mind.

"Hi, Mike."

"Good morning, Doctor Mercer," I replied evenly.

"How are you?"

"Other than being generally exhausted from my shifts, fine. Rachel is doing well, and Kris and I are happy, minus the fact we can't spend as much time together as a family as we would like."

"How does it feel to be a doctor?"

"Satisfying, I suppose, is the best answer. I was provided with so many opportunities during my clinical rotations that the change wasn't night and day as it is for some."

"That makes sense. As I said on Monday evening, I want to apologize."

"Is this apology about Angie?" I interrupted.

"Yes..."

"And is it unequivocal, unqualified, and with no caveats?"

"Will you at least let me say what I want to say?"

"You're the one who said, quite clearly, that we had nothing to speak about if I insisted on those conditions. My position has not changed. The ball is in your court."

"Still as inflexible as always."

"On this topic? Yes. And you know why."

"I do," Doctor Mercer confirmed. "Mike, you were absolutely right with regard to Angie. She showed clear signs of improvement and the correct course of treatment was the one you were following. I was wrong to try to defend Doctor Greenberg with statistics and the literature. What he did was indefensible, and I'll say that in a letter to the Medical Licensing Board."

"I accept your apology," I replied. "Let me supply you with Tom Kirkland's number. He's the attorney handling the complaint to the Board."

"I have it. I was sent a copy of the complaint because I was named in it, though no formal accusation was leveled against me."

"I never thought you should be brought before the Board," I said. "My beef with you was your defense of Doctor Greenberg despite all evidence pointing to clear malpractice on his part, and the way you defended him."

"I really am sorry, Mike, and I hope you can see that I had no real choice but to report Angie's statement to Doctor Greenberg."

"I understand that, as I understand that Father Stephen had to tell you, because Angie said something outside of confession. My only question to you is how hard you pushed Doctor Greenberg to not tell Angie that what she wanted was impossible?"

"Not hard enough, obviously."

"What will your letter say?"

"In effect, what you said -- that allowing Angie to continue with her efforts, while potentially fruitless, could not have led to a worse situation than the one created by Doctor Greenberg when he told her it could never happen, thus depriving her of some amount of time where she didn't need drugs, though knowing how long that might have been is impossible."

"Will you call it for what it is?"

"You mean use the term 'malpractice'?"

"Yes."

"No, but I will say that he discounted clinically significant behavior."

Which, in the end, was the same thing, but couched in words that he'd made a bad judgment call. I felt it was more than that, but having Angie's counselor, a licensed clinical psychologist, say it was bad judgment was a huge win, and would put Doctor Greenberg in an untenable position.

"That's sufficient for my purposes," I replied.

"I'll call Mr. Kirkland this afternoon. I'd like to have lunch with you, if you're open to the idea."

She'd extended the olive branch, and I couldn't, in good conscience, slap it away.

"I am, though it would have to be a Wednesday, but not next week, as I already have plans."

"That's fine. What about two weeks from today? We could meet in Rutherford, if that works for you."

"That would be more convenient than coming to Milford."

"Shall we say Lou's in Rutherford at noon on August 2nd?" Doctor Mercer asked.

"That sounds good. I'll see you then."

XXIV. Wonderful!

July 19, 1989, Circleville, Ohio

"What did you do today?" Kris asked when she arrived home on Wednesday afternoon.

"Rachel and I hung out. I played my guitar, read to her, and we took a walk."

"How did your call with Doctor Mercer go this morning?"

"She capitulated," I replied. "And she agreed to support Angie's claims with the state licensing board, though as an error of judgment, not malpractice. But, with all the other facts, I believe that will be sufficient to cook Doctor Greenberg's goose."

"You mean he'll lose his right to practice?"

"I still think that's a longshot, but a formal reprimand is certain, and a suspension for a year is probable. And that information is public, so he won't ever escape it."

"And that would satisfy you?"

"Nothing will satisfy me because the situation can't actually be fixed, but it's the appropriate action by the State of Ohio. Call it a 'warning shot' to others not to make the same mistake. Sadly, I doubt it will be heeded."

"So, what can be done?"

"By me, very little except to try to encourage the psychiatrists I encounter to stop reflexively prescribing psychoactive drugs to create docile patients, rather than doing the hard work of trying to help patients overcome their illnesses. Fundamentally, it's a product of Western civilization, and I'm not sure how to address it."

"Western civilization? How?"

"In a hunter-gatherer tribe, what triggers would Angie have had? And if she was quirky and celibate, she might well have been a seer or a medicine woman. The so-called barbarians would have treated her with respect, and possibly even awe. Think also of the Russian tradition of 'Fools for Christ'. We so-called 'modern' and 'civilized' people treat her, and people like her, terribly.

"It's also the case for those tribes that nearly everyone engaged in some sort of labor that didn't require specialized knowledge, except that which was imparted from father to son or mother to daughter, and all of that revolved around food, shelter, clothing, and what passed for medical practice. If Angie is able to do data entry and practice Aikido, she could certainly have been a productive member of the tribe. More so if she was a medicine woman or seer, things which were valued."

"Are you saying we should go back to that kind of existence?"

"I'm no Luddite!" I chuckled. "And I prefer my creature comforts. What I'm trying to point out is that progress isn't always positive, and there is much to learn from the ancients. Were you aware that there was reliable herbal birth control in Roman times?"

"No!"

"A plant called silphium was a very effective contraceptive. It's thought to be extinct, mainly because the demand for it was so high, because it also had other medicinal qualities. It was reported to be an abortifacient, because it would induce menstruation whether the woman was pregnant or not. A single monthly dose was as effective as the pills you take every single day."

"Why not plant more of it?"

"From what I've read, it would only grow in a very limited region around the ancient city of Cyrene, in what's now Libya. They tried to manage the harvest, but as you can imagine, the demand was simply too great. That's not the only ancient herb or medicinal plant that was effective. Modern aspirin is synthesized, but it's based on an extract of willow bark, which was used as an analgesic.

"Coca leaves, which are chemically processed to make cocaine, act as a mild stimulant and analgesic, and also suppress hunger, and are not addictive, nor do users suffer from withdrawal if they stop using it. Of course, we moderns have developed a process to extract it, concentrate it, and make it addictive, to the point where we no longer have what amounts to a natural remedy.

"And yes, Coca Cola did originally use coca leaf in Coke, but they stopped doing that just after the start of the twentieth century, when they substituted 'spent' leaves that had no cocaine. A bottle of Coke made with the original formula had around ten milligrams of cocaine, compared to a typical line of coke which has around sixty milligrams, give or take."

"And that was legal?"

"Absolutely. Until the passage of the Pure Food and Drug Act in 1906, there were no effective limitations of what drugs could be sold or used. And that act only required proper labeling. Modern drug laws came about in 1938 with the Federal Food, Drug, and Cosmetic Act, and prescriptions became mandatory for listed drugs in 1951 with the Durham-Humphrey Amendment, which created two groups of drugs -- prescription, also called 'legend', and over-the-counter. Interestingly, Senator Hubert Humphrey was a pharmacist by trade. He later on became Vice President under Lyndon Johnson."

"So before that, anyone could take anything?"

"Yes, so long as they could find someone to provide it, and I don't mean just doctors or pharmacists. One of the reasons for the passage of the Pure Food and Drug Act was the availability of so-called 'patent medicines' which where, as the term goes, 'snake oil'. Coke, Pepsi, and Dr Pepper had their start as 'patent medicines'. Coke was sold as a cure-all for, among other things, morphine addiction, indigestion, nerve disorders, headaches, and impotence.

"Pepsi Cola was first marketed as a cure for dyspepsia, that is, an upset stomach. The name refers to the digestive enzyme pepsin, but the drink never included that enzyme, despite some people thinking it did. Dr Pepper was sold as a digestive aid, and was claimed to restore 'vim, vigor, and vitality'. It, like Coke and Pepsi, was developed by a pharmacist and sold in drug stores, which, as you might guess, is the origin of the soda counter and soda 'jerks'."

"That's not a French thing at all, and I only know about it from things I've read or movies I've seen. Anyway, what's the plan for this evening?"

"Dinner, Vespers, and making love to my wife, if she's interested."

"She's interested! Shall we make dinner?"

"Yes!"

July 20, 1989, McKinley, Ohio

"Hi, Stranger," Lara said when I met her in the cafeteria for lunch on Thursday.

"We saw you and Nathan about a month ago!" I replied.

"And you and I saw each other nearly every day for the past seven years!"

"True, minus somebody's jet-setting during Summer breaks and my honeymoon with Elizaveta."

"How are you holding up?" Lara asked.

"Good, actually, despite being very tired. You won't believe what happened yesterday."

"What?"

"Doctor Mercer capitulated and agreed to write a letter stating that Doctor Greenberg had made an error in judgment by discounting clinically significant behavior."

"It was malpractice, and you know it!" Lara declared.

"It was," I replied. "But Doctor Mercer has to work within her community, so she couched it in terms that would help us, but also protect herself. Saying that he discounted clinically significant behavior is sufficient to have him receive a disciplinary letter and will likely result in suspension. He'll have a permanent black mark on his record at that point. That is the best we can do and is better than what I'd expected."

"You know the attorney was instructed to push for revocation of his license, right?"

"Yes, and knowing how this works, he'll work out the equivalent of a plea deal and accept the reprimand and suspension in lieu of losing his license permanently, and the licensing board will agree. That said, if there were other incidents, things might be different. As far as I'm aware, there aren't, and revocation usually requires a pattern, or some egregious act like performing surgery under the influence of alcohol or drugs, or committing an illegal act."

"Sadly, that makes sense."

"Let's change subjects! How are things with Nathan?"

"I invited him to church, and he hasn't run away screaming!"

I chuckled, "He was at my wedding!"

"Which isn't three or four hours on Sunday morning!"

"True. And?"

"I think, with your blessing, I'll say 'yes' when he asks me to marry him."

"As much as I object to that entire idea of you needing it, you have my blessing."

"And you know I don't mean it in a patriarchal way, just that if you had anything negative to say, I'd listen carefully. I trust your judgment, Mike. It's been proven to be damned good for the past seven years."

"Minus a few significant mistakes."

"I think you've made fewer mistakes than you think, but that's bound up in your rigorist view of sin."

"As if there is any other option! I mean, for me, not how I apply it to others."

"You always did take the pre-Eucharist prayer literally."

"Yes and no," I replied. "It says I believe, O Lord, and I confess, that thou art truly the Christ, who camest into the world to save sinners, of whom I am chief. That's quoting the Holy Apostle Paul's First Letter to Timothy. And the point is to never, ever, look down on another person because of their sin. It may disqualify them from ministry, but it is never to be lorded over them. It is not just to be forgiven, but forgotten. That is, it should have no meaningful effect on how I perceive the person."

"Frank Bush," Lara said.

"As one example. I'm no better than he is, in terms of sinfulness. He's paying an earthly penalty for his sin, but you know my take, right?"

"That he should live a long life so he has a chance to repent of his sin and ask God to forgive him. And you've made him your personal mission in life. What do you gain by that?"

"Personally? Nothing. And that's the point. I don't want anything for me out of that, though I would obviously feel good if he were to acknowledge God's saving grace even while serving a life sentence without parole. But, in the end, I'll never know, at least in this life, if that happens. In the end, only God can see into Frank Bush's heart, and I'm certainly no «staretz» with the gift of insight into another person's interior life. My calling is to heal the body."

"So, is it just Frank Bush?"

"Long term? No. I hope to start a prison ministry that will also provide medical consultation. I'm sure I can find enough nurses to help."

"When you need funding, you know where to come."

"I appreciate it. Any idea when Nathan will ask?"

"I'd say before the end of the year."

"I'm happy for you," I said.

"I take it everything is OK with you, Kris, and Rachel?"

"Yes, minus not being able to see them as much as I'd like, but Kris and I knew that beforehand. Rachel is unhappy at times, but she enjoys our Wednesdays together."

"More soon?"

"Yes, Mom!" I chuckled. "We'll start trying in September."

"Did you receive your invitation to Maryam's wedding?"

"Yesterday. Kris and I plan to fly up on that Saturday and fly back late on Sunday."

"That's going to be very tight. What do you think about flying in a private plane? We wouldn't be bound to a specific flight schedule, and split four ways won't be ridiculously expensive. I know someone with a Twin Beech who could fly us up and back. That means we could stay for the reception and still make it back so we could go to work on Monday morning."

"That would help," I replied. "I'd only have to trade a Saturday shift. Would you check into it and let me know how much it will cost? I think we'll likely leave Rachel with Lyudmila rather than try to take her along, because I'm not sure how well she'd tolerate the trip."

"I'll check into it and get back to you."

"Thanks! Invite Clarissa, because I'm sure she and Tessa received invitations."

"That will work. Six passengers will be fine."

"Great!"

We finished our lunch, hugged, and Lara left the hospital while I returned to the Emergency Department.

"Doctor Mike," Ellie called out as I walked towards the nurses' station, "Doctor Gibbs would like to see you."

I acknowledged her and went to the Attendings' office.

"You wanted to see me?" I asked.

"Come in, shut the door, and grab a seat."

I did as she asked and waited for what she had to say.

"Doctor Mastriano was placed on probation this morning," Doctor Gibbs said. "All her orders will need to be confirmed by another Attending until her probationary period has ended. There will be a memo published tomorrow, but Doctor Northrup asked me to tell you in advance. Doctor Mastriano claimed you set her up."

"And Doctor Northrup's evaluation of that claim?" I asked.

"That it is unfounded. She claimed you insisted on a written order for the express purpose of undermining her authority and that you failed to provide relevant details about the patient. The facts are not in dispute, and the charts from that night are definitive."

"I decline to respond to that accusation, and I'll stand on the facts and the orders on the charts."

"Which Doctor Northrup, Ghost, and I all knew would be the case, and why we didn't need to speak to you before Doctor Northrup concluded his investigation and determined the proper course of action. This will require a bit of juggling of schedules, as we'll need a second Attending on overnight. Doctor Northrup does have an Attending slot open that he hopes to fill this week."

"What do you want me to do?" I asked.

"Keep on keeping on. You did exactly the right thing that night, and in your position, I'd have asked for the order to be written. That should have been her clue she might have misjudged the situation with the patient. And that's something to remember. If your Resident feels strongly enough to insist you write your orders, in your own hand, that's the time to reconsider."

"Understood. On another topic, I may need to trade a shift in October; Maryam is getting married on October 15th and Kris and I will fly to Chicago on a Saturday and fly home late Sunday evening."

"OK. Let's discuss it when the schedule for September and October is published in August."

"Is there anything else? I saw patients in the waiting room when I walked past."

"That's all. Go heal the sick!"

I nodded, got up, and went to find Bob and Len so we could handle some of the walk-ins.

July 21, 1989, McKinley, Ohio

"Mike, Doctor Lawson would like to see you," Ellie said just before noon on Friday.

"Did he say what he wanted?" I asked, despite having a strong suspicion what it was he wanted.

"No, just that you should stop by his office between noon and three."

"I'll take my lunch now, then go upstairs."

I went to the cafeteria, ate my lunch quickly, then headed up to Psych to see Doctor Lawson. He was in his office and waved me in, indicating I should close the door.

"I had a call from Doctor Jules Greenberg. Your name appears on a witness list in a complaint against him filed by the parents of a patient. I believe we discussed this."

"We did," I replied. "And her family chose to proceed. I heard from their attorney, and if they do call me as a witness, I'll answer truthfully and forthrightly."

"You are unqualified to make any diagnostic comments."

"I have no intention of doing so, and no need to do so. I will simply state my observations, which, by themselves, are damning."

"A doctor supporting a claim that revolves around diagnostic decisions and treatment choices will forever tarnish his own reputation. You can decline to testify."

I stood up.

"I reject your advice, Doctor, and I will not remain silent in the face of clear medical errors. I'm needed in the ED, so if you'll excuse me."

"You're throwing away your career, Loucks."

I left without another word because there was nothing I could say to him. The only decision I had to make was whether or not to make a complaint about Doctor Lawson. My initial inclination was to simply let it go, but my second thought was better -- to wait for the outcome of Doctor Greenberg's hearing. And before I did anything, I'd need to speak to Clarissa, and, more importantly, Kris.

When I returned to the ED, I found Mary and Tom, and as there wasn't an active trauma, we went to the triage desk to take a patient. Before we could take a patient, Nate let us know that EMS was eight minutes out with an MVA with severe trauma. That ETA meant some distant part of the county, and a long response and transport. The three of us gowned and gloved, and went to the ambulance bay and a minute later, were joined by Ghost and Kellie.

"You run it, Mike," he said. "I'll only step in if you ask me to."

"OK. Who's covering for you next week while you're on your honeymoon?"

"Gómez from Medicine. A locum tenens is covering for him."

"Why not have the locum directly in the ED?"

"Doctor Northrup's policy. Only PGY3s from Medicine or PGY2s or higher from Surgery, as they're known quantities."

"Makes sense."

"Let's chat privately after this trauma."

"OK," I agreed.

About six minutes later, the EMS squad arrived and pulled up.

"Ian Barnes, twenty-two, MVA versus telephone pole; BP 80 palp; pulse 110 and thready; resps labored and shallow; PO₂ 93% on ten liters; absent breath sounds on the left; crush injuries to both legs; severe head trauma; GCS 3."

"Trauma 1! Ghost, intubate," I said as we quickly moved with the gurney. "Mary, EKG and monitor; Kellie, trauma panel. Tom, call the surgical Resident. The patient will need a chest tube and I can only do it with an Attending present."

"Tom, get Doctor Gibbs," Ghost countermanded. "This guy can't wait!"

"Also get the ultrasound," I said.

In the room, Ghost, the two paramedics, Mary, Kellie, and I moved the patient from the gurney to the table and began our work. As I assessed, Ghost intubated the patient.

"Tube is in!" he exclaimed.

I quickly auscultated the patient's lungs and announced, "Absent sounds on the left, but all signs point to a collapsed lung, not a misplaced tube."

"What do you have, Mike?" Doctor Gibbs asked as she came into the room.

I quickly repeated the vitals, taking the PO₂ and pulse from the monitor Mary had hooked up, and asked for permission to insert a chest tube.

"Do it," she declared. "I'll complete the assessment."

"Kellie, chest tube tray!" I ordered.

Four minutes later, the patient's lung was re-inflated, and I supervised Mary putting in several sutures to hold the tube in place.

"That didn't resolve the thready pulse," I said. "Ultrasound, please!"

I did a quick assessment and determined the patient needed a pericardiocentesis, and with Doctor Gibbs' assistance, performed it, which improved the patients' heartbeat. Next up was an ultrasound of the abdomen, which detected fluid in Morrison's pouch.

"Tom, call upstairs to surgery. He's going to need an ex-lap. We'll splint the legs. They'll have to wait. Mary, Foley; Ghost and Kellie, splint the legs, please."

"Abrams, Ortho!" Doctor Kelly Abrams announced as she came in with her student. "What do we have?"

I ran through the vitals and injuries, and she concurred that despite the crush injuries to the patient's lower legs, his internal bleeding was a priority. Five minutes later, Mary, Tom, and I escorted the patient upstairs and turned him over to a surgical team.

"We don't get to scrub in?" Mary asked as we walked towards the stairs.

"No, because he's going to need at least three surgeons, including Ortho, and the room will be crowded at that point."

"What are his chances?" Tom asked.

"Given we re-inflated his lung and resolved the pericardial effusion, pretty good. A lot will depend on the extent of his internal injuries, obviously, and his legs are pretty badly crushed, but he should live. Of course, I wouldn't say that to his family or friends."

"What would you say?"

"That he was severely injured and that we're doing everything in our power to repair the extensive damage to his body. Anything more than that is speculative, and you risk giving the family false hope, though you also don't want to completely crush their spirits. It's a tough balance. Even saying something like we stabilized him is a double-edged sword because 'stable' means out of danger to most people. Think about how we use that word internally."

"It's a point-in-time observation of the patient's vitals, and not specifically predictive, because, for example, the patient could arrest or suffer arrhythmia despite having stable vitals."

"Exactly," I said as we reached the ground floor. "You could say the patient was in critical condition, as that term is commonly understood by the general public to mean in severe danger of dying, which is true about our MVA, even though we resolved the weak pulse and collapsed lung, and brought his PO₂ up to 97%."

"Do you think he'll lose the legs?"

"I'm not qualified to answer that question even speculatively. What I'd tell his family or friends is that his legs were severely injured and we'd assess the extent of the damage once we'd dealt with his potentially life-threatening internal injuries. And who knows about the head injuries? At least his pupils weren't blown, so odds are that it's a severe concussion."

We reached the ED, and after removing our gowns and gloves, we went to the triage desk to get a patient.

"Got a full house," Jack, a Fourth Year assigned to Ghost, said. "Three with some form of stomach ailment and two with injured ankles."

"Did the three come in together?"

"Yes. They were all at a picnic yesterday."

"Food poisoning," I said. "Tom, Mary, you handle those three, and I'll take the worst ankle injury. Assess, then come to me with your reports."

"I'll take the girl," Mary said to Jack.

He handed her a chart, and one of the charts for the two guys to Tom, then handed me a chart for one of the ankle injuries. While Tom and Mary called their patients, I asked Kellie for assistance, and we took a wheelchair to the waiting room to retrieve the teenage guy with what I strongly suspected was a broken ankle from the discoloration and swelling.

Tom and Mary did a good job assessing the food poisoning patients, and I authorized IV Ringer's for each of them to counter dehydration along with anti-emetics to control their vomiting. Of the two ankles, one was broken and one was badly sprained, and Kelly Abrams assessed the broken ankle for me, declaring it was surgical and likely needed pins. I finally had a chance to see Doctor Casper after all those patients were treated and either admitted or released.

"Loretta said she spoke to you about Mastriano."

"She did," I confirmed.

"Anything you need to get off your chest?"

I smiled, "I have no problem speaking my mind to Loretta," I replied. "Or anyone else, for that matter!"

Ghost laughed, "So true, but sometimes we determine the politics of the situation require us to be circumspect, and that's where mentors come in."

"I'm not concerned about Mastriano," I said.

I thought about saying something about Doctor Lawson, but decided I was better off discussing that with Kris and Clarissa first before making it in any way 'official', even though I could speak to Ghost 'off the record', if necessary.

"Then we'll leave it. Good job on the MVA. You did everything in the correct order and we saved a good ten minutes by you doing the chest tube and pericardiocentesis."

"Every trauma doctor should be able to do both those procedures," I said.

"I don't disagree, but that's between Northrup, Cutter, and Getty, and you know that's political. Your red scrubs are Cutter marking his territory, and he's not about to cede anything he thinks is his domain."

"You know my take on that," I replied. "But I also know the rules about supervision of surgical procedures."

"Eventually, some of those procedures will be reclassified, and as there are more doctors trained similar to how you're being trained, the rules will change. But, as with everything, it's going to take time."

"Any rumors about Resident hours?"

"No, but obviously that can only change if we have a larger allocation of Residents or hire more Attendings. Your former father-in-law would have more information than any of us, except the Medical Director."

"I try to avoid discussing those things with him. I want to keep that relationship solely as Rachel's grandparents, and not seem as if I'm trying to gain any advantages. I already have doctors gunning for me."

"Besides Mastriano and Rosenbaum?"

"Those are the main ones, but there are others who aren't happy with how things have played out. I'm sure you know Doctor Rafiq had his nose out of joint because I was permitted to do things as a Fourth Year."

"I've always felt the idea that because I didn't have a chance to do something, that nobody should is stupid."

"I agree, obviously."

"Also, good choice in having Tom and Mary handle the food poisoning cases. It helps build confidence."

I nodded, "Those were my favorite opportunities during medical school. Sure, I loved learning new procedures and doing 'cool' stuff, but those few times I was assigned a patient and made responsible for them -- under supervision, of course -- were the true highlights."

"I do have one question for you -- would you be willing to take an eight-hour shift at the Free Clinic during September and October?"

"Sure. Is this a new program?"

"Yes. Something they're trying out, rather than direct hires."

"I have to ask how we're going to cover the extra hours when we're already stretched thin."

"Believe it or not, the Free Clinic has funding to make it happen. We'll give them five eight-hour days and they'll fund a good portion of the salary for an Attending who'll work forty hours, Monday through Friday, 0800 to 1700."

"Interesting."

"It's a doctor who lives in Columbus and needs a regular schedule. He's worked in what they're calling an 'urgent care' facility that is closing. It's similar to the Free Clinic, but they provided more services. They lost their funding, and it wasn't a profitable venture, so it closed. He was a trauma Attending in Toledo before moving to Columbus for family reasons."

"Is this in addition to the Attending Doctor Northrup is hiring?"

"Yes."

"Thanks for explaining. I'll take a shift, obviously."

"Thanks."

There was a knock at the door of the consultation room, which served as the temporary Resident's office, and Ellie opened the door.

"Ghost, paramedics three minutes out with an MI."

"Thanks, Ellie."

We left the room, and I went to find Tom and Mary. We handled walk-ins for the rest of the afternoon, and just before 6:00pm I turned things over to Kylie, then headed up to the surgical locker room.

"How did the MVA do?" I asked Shelly Lindsay, who, as usual, was in the locker room at the end of the day.

"Splenectomy, liver lac, and bladder tear were all repaired. Flail chest being monitored overnight in the ICU and Ortho will work on his legs tomorrow. Neuro status is a severe concussion, but with no skull compromise. He'll have a CAT scan tomorrow as well. Good job on the chest tube and the pericardiocentesis -- perfect placement for both."

"Thanks."

We both showered and dressed and left the hospital together.

"See you next week," she said as we got into our cars, which happened to be parked side-by-side.

I got into my car and headed home, where I planned to eat dinner and collapse into bed.

July 22, 1989, McKinley, Ohio

"Mike, when will you know your schedule for September and October?" Kim asked when I arrived at Taft for band practice early on Saturday morning.

"It'll be published in about three weeks," I replied. "Why?"

"Goshen's Harvest Ball and a gig at the club in Newtown."

"Take the gigs," I said. "One way or another, I'll work it out. But those two, plus Taft and Stirred not Shaken, are probably it for the next three months. Obviously, if you four want to play without me, I won't stand in your way."

"Nah," José said. "We're doing this for fun, not for cash, and I'm cool with limited gigs."

"Same here," Sticks said. "We'd starve to death trying to make money as a band!"

José, Kim, Sticks, Kari, and I completed our practice session, I headed home for a few hours, then drove to Moore Memorial for my Saturday shift. I'd be seeing Doctor Mastriano for the first time since the discipline had been handed down, so as I drove, I reminded myself to stay professional. It was imperative to not allow her to bait me or trap me, and I seriously hoped she wouldn't put her disagreement with me ahead of patient care. The saving grace was that Doctor Williams would have to sign off on any orders, and I could, for the most part, ignore her.

At the hospital, I went to the surgical locker room, changed into my red scrubs, then headed to the ED, where Callie and Gabby were waiting with Kayla Billings. She handed over three patients, all of whom were being admitted to Medicine. My students and I spent the next twenty minutes with Clarissa and her students transferring those patients to Medicine.

The afternoon was busy, but not crazy, with half-a-dozen walk-ins and three EMS runs, none of which resulted in admissions. Just before 6:00pm I took my dinner break and met Clarissa in the cafeteria.

"Complete secrecy?" I asked.

"Yes. Mastriano?"

"No, Lawson. He asked me not to testify at the hearing for Doctor Greenberg. He was careful not to threaten me, but he did say that a doctor supporting a claim that revolves around diagnostic decisions and treatment choices would forever tarnish his reputation, and when I rejected his advice, he said I was throwing away my career."

"Carefully worded to sound as if it was a warning and advice, but based on what he's said to you before, I'd say you're right to call it a threat. What are you going to do?"

"Nothing, though I did write down a summary of the conversation in my personal notebook, so the date can be verified."

"Not your procedure book, right?"

"Right. The other one I carry to make personal notes and to keep track of the types of cases I've handled. Nobody sees that except me, though I'd show it to you, if you asked."

"True about anything you have!" Clarissa teased.

"Before I asked Kris to marry me, yes. Now, no."

"You're just no fun, Petrovich!"

"Sure I am! Ask Kris!"

"Maybe I will! Do you plan to ever say anything to anyone about this?"

"Not unless he tries to mess with me. If he does, my notebook and your testimony will sink him."

"Mutual Assured Destruction?"

"No, because he literally can't hurt me, no matter what he thinks. Honestly, if he does anything, how do you think Doctor Cutter would react? Or Doctor Gibbs?"

"Badly. And you think Mastriano is defanged, but what about her boyfriend?"

"What can Rosenbaum do as a Resident on another service?"

"Not much, I suppose."

"And he has to consider what the revelation of his affair to his wife might cost him."

"You'd do that?"

"Only to show the link between him and Mastriano, not expressly to reveal it. I've told you all of this, and it's all in my notes or on charts, just in case."

"What do you plan to say at the hearing?"

"All I need to do is present observed behavior. Doctor Mercer will confirm it, and that will be enough to sink Doctor Greenberg's ship. Changing subjects, did you receive your invitation to Maryam's wedding?"

"Yes. It's going to be tough to go."

"Lara is arranging with a family friend to fly us to Chicago and back in a light airplane. It would be you, Tessa, Lara, Nathan, Kris, and me. We'd pay for the trip, of course, but we wouldn't be on a fixed airline schedule. We would fly up on Saturday and we could fly back late on Sunday."

"That would make things easier, but it has to be expensive."

"Lara indicated it wouldn't cost much more than airline tickets, and she'll let me know in the next few days."

"We're in," Clarissa said. "The problem will be getting coverage."

"We have enough time to sort it out, though obviously we can't do anything until the schedules are published in August."

We finished our meal, and I headed back to the ED while Clarissa went up to Medicine.

"Mike," Nurse Wendy said when I walked up to the nurses' station, "can you take a Sheriff's Deputy with a hand injury?"

"Sure. Which room?"

"Exam 3."

Because it would likely be simple, I sent Callie and Gabby to have their dinner, then went into Exam 3.

"No holes, Doc," Deputy Kenseth said as I walked in.

"That's good! What happened this time?"

"Serving a warrant and had my hand slammed in a car door."

"Let's take a look," I said.

I washed my hands and put on gloves, then sat on the stool near the exam table, and examined Deputy Kenseth's hand.

"That's going to need an x-ray," I said. "How much pain are you in?"

"I popped a pair of aspirin before I drove here, it hurts, but I can handle it."

"Let me call radiology and see if they can take you right away."

I went to the phone and made the call, and once I mentioned it was a Deputy, the radiology tech said we should come right down. I walked with Deputy Kenseth to radiology, and the tech quickly took four shots of his hand.

"Wet read, right?" the tech asked.

"Yes," I replied.

We left and went back to the exam room. I got a chemical cold pack from the supply cabinet, squeezed it, and handed it to Deputy Kenseth.

"Just hold that on it and relax. The radiologist will call in a few minutes."

"What are the possibilities?"

"Cast, most likely," I replied. "I don't think it's surgical, but there's no way to know for sure until we see how bad the break is. If it's bad enough, I'll call for an Orthopedic consult. I meant to ask, is this your shooting hand?"

"No."

"OK. Then there's less of a concern, unless you're a concert pianist or do other work that requires significant dexterity."

"Like surgery?"

"That would be one, or a watchmaker, jeweler, or anything like that."

"The only thing I ever did like that was build model planes when I was a kid. The model sets just aren't the same now."

"I only ever built one model, and it was the Apollo Saturn V spacecraft with the lunar module."

"Still have it?"

"It's at my mom's house," I replied. "I didn't have room for it when I first moved out, and hadn't even thought about it until just now."

The phone rang, and I went to answer it.

"Mike Loucks."

"Neil Stephens. Your deputy needs an orthopedic surgeon."

"OK. I'll call for the consult. Would you have the x-rays sent over?"

"Will do," he agreed, and hung up.

I turned to Deputy Kenseth and said, "Well, I might have been mistaken about surgery. The radiologist recommended an orthopedic consult. I'll call up for that now."

"Well, shit," he groused. "I get shot and you throw in a couple of stitches, but get my hand shut in a door and it needs surgery?"

"Maybe. The point of the consult is that neither the radiologist nor I are qualified to make a final determination. He's sending the x-rays over so I'll show you, but my specialty is trauma, not orthopedics."

I placed the call for the Ortho consult then chatted with the deputy until the x-rays arrived. I put them up on the screen and saw immediately saw why Doctor Stephens had recommended a consult.

"There are three breaks," I said pointing to each one in turn. "One scaphoid fracture, here, and a pair of boxer's fractures, here and here. The scaphoid fracture is the problematic one, as that bone is very slow to heal and needs either external or surgical fixation."

"Wonderful," he sighed as the door opened.

"Hi, Mike," Doctor Val Jackson said, coming into the room with her student, Karl.

"Hi, Val. Deputy Sam Kenseth. Broken left hand. X-rays are on the viewer. Left scaphoid fracture and a pair of boxer's fractures as a result of the hand being slammed in a car door. Good vitals."

"Hi, Deputy, I'm Doctor Jackson from Orthopedics. Let me take a look at the x-rays and we'll let you know what we recommend."

Doctor Jackson, Karl, and I went to the viewer and Doctor Jackson confirmed what I now suspected -- he'd need surgery.

"Deputy, we're going to need to surgically repair this break," she said. "This part of your hand is very slow to heal and if it doesn't heal properly, you're at risk for serious osteoarthritis. We need to do the procedure right away, as blood flow is often compromised. Karl will bring you up, and Doctor Cole and I will repair your hand."

"Wonderful."

"Mike, can you get your Attending to sign the chart please, and then I'll take the Deputy."

I took the chart and went to find Doctor Williams who quickly signed off. I returned to the room and handed the chart to Doctor Jackson.

"You're in good hands, Deputy," I said. "Good luck and let's stop meeting this way!"

"Thanks again, Doc. See you next time!"

"Wonderful," I chuckled.

I left the room and went to see if there were any walk-ins I could take.

XXV. Mama Bear

July 23, 1989, Circleville and McKinley, Ohio

On Sunday morning, we attended Matins and the Divine Liturgy at the Cathedral, but skipped lunch so we could take Rachel home for a nap before Ghost and Oksana's wedding, which was being celebrated at Saint Michael the Archangel. Once Rachel was in her bed, Kris and I decided to take a bubble bath together.

"How are you feeling, Mike?" Kris asked as we lounged together in the tub with her reclined back against me.

"Better," I replied. "I enjoy my work and I've adjusted to the hours, though obviously I wish I had more time for you and Rachel."

"You chose this course in fourth grade."

"I did," I agreed. "That doesn't make it easier."

"Is everything OK at the hospital?"

"You mean with Doctor Mastriano? Yes. She's on probation and all the facts and records support me. Even if she's upset with me, there isn't really anything she can do."

"You're sure?"

"Yes. Anything she says or does will be heavily scrutinized, so there's no risk. That said, the Chief of Psychiatry all but ordered me not to testify on Angie's behalf against Doctor Greenberg."

"Can he do that?"

"No. He stopped just short of a threat, saying I was 'throwing away my career' by testifying against a fellow doctor on what was, in the Chief's mind, a judgment call."

"Did you report him?"

"No. That wouldn't be smart, given it would back him into a corner. I'm only going to testify to things I personally observed and will refrain from making any diagnostic comments. Doctor Mercer will corroborate what I say, and that will be enough for Angie to prevail, and at least have Doctor Greenberg reprimanded, and possibly to have his license suspended."

"You're not worried?"

"No, but even if I was, I have an obligation to tell the truth, and Angie really has nobody except me to forcefully advocate for her."

"Her parents?"

"Without my support for Angie, they wouldn't have pressed the malpractice claims or the complaint to the Medical Licensing Board because they didn't have enough information. And that was because Doctor Greenberg and Doctor Mercer were telling them the same thing, and, to be honest, nobody without a personal stake would step into a case such as this."

"Why?"

"Sadly, doctors cover for each other, even in cases of negligence and malpractice. It's wrong, but it's similar to cops covering for each other or politicians covering up their own malfeasance."

"You're on good terms with the police, though, right?"

"Yes, of course, but that doesn't mean I wouldn't call out corruption if I saw it. Isn't that a socialist principle?"

"You know it is!"

"And government corruption was the objection both Jefferson and Trotsky made about bureaucracies!"

Kris laughed, "You do enjoy tweaking me!"

"Yes," I agreed, then gently pinched her nipple.

"Not like that!" Kris declared mirthfully.

"I enjoy both!"

"I think we have enough time..."

We did, and after very enjoyable lovemaking, we showered, then dressed for the wedding. I woke Rachel from her nap, changed her diaper, dressed her, and then the three of us left for Saint Michael the Archangel.

"Are you going to arrange a meeting with Father Nicholas as Father Roman suggested?"

"I think I have to," I replied. "Father Roman advised it, and I'm positive Vladyka would advise the same thing. I'll speak to Father Nicholas after the ceremony, and make the arrangements for sometime next month."

"You're going to see the doctor in prison on Wednesday, right?"

"Yes. Clarissa and I will have lunch that day, so she's riding along. She'll take Rachel to a park while I'm visiting Frank Bush."

"I'm having lunch with a group of girls from the Cathedral tomorrow. Believe it or not, Danijela Dimitrijevic is joining us."

"I think that's a good thing. I still get evil looks from her grandmother."

"Me, too! She feels I cut in line, so to speak."

"Well, I gave Danijela every opportunity, and had she been a bit more patient, Oksana would not have had the opportunity to introduce you to me."

"And?" Kris asked impishly.

"And nothing. I have no regrets and I do not wish anything different had happened after the day after Rachel was born. I'm very happy to be married to you and I am looking forward to giving Rachel a brother or sister or two."

"NO BROTHERS!" Rachel said adamantly.

"You, young lady, have no say in the matter!" I said lightly.

"Viktor is loud! Ben is loud!"

Ben was a little boy at daycare who Marcie had said seemed sweet on Rachel, but was as rambunctious as any other male toddler.

"Daddy is a boy. Is he loud?"

"Rachel loves daddy!"

"I love you too! Will you dance with me?"

"Yes!" Rachel giggled. "Like dancing!"

"She's going to be dangerous as a teenager!" Kris said, sotto voce.

"And our job is to guide her to make good decisions," I replied. "But above everything, the most important thing we can do is love her and teach her how to think for herself."

"What about God?"

"All we can do is live our lives as Christians. Preaching doesn't work."

"Then why visit the doctor in prison?"

"Doing exactly what I just said -- showing Christian love. How well do you think it would work if I went in there and beat him over the head with the Gospel? Or the Creed?"

"It wouldn't."

"And it won't work with our kids, either. At one point, when I was speaking to Doctor Mercer, I reminded her of what Saint Seraphim of Sarov said -- 'Acquire the Spirit of Peace and a thousand souls around you will be saved'. His advice for how to achieve that was succinct --

'You cannot be too gentle, too kind. Shun even to appear harsh in your treatment of each other. Joy, radiant joy, streams from the face of him, who gives and kindles joy in the heart of him who receives.

All condemnation is from the devil. Never condemn each other, instead of condemning others, strive to reach inner peace.

Keep silent, refrain from judgment. This will raise you above the deadly arrows of slander, insult, and outrage and will shield your glowing hearts against all evil.'

"That sounds like you."

"I try."

"You do more than try, Mike."

"When I achieve inner peace, I'll let you know."

When we arrived at church, Serafima met us in the narthex.

"May I borrow my goddaughter?" she asked.

"OK to go to Serafima?" I asked Rachel.

"Yes!"

I handed Rachel to Serafima, then chatted briefly with Elias and Subdeacon Mark before the combined betrothal and crowning services. We all gathered for the services, which were identical to every other betrothal and crowning service, save the names of the couple and their sponsors. Just under an hour later, Ghost and Oksana were married, and we all gathered in the parish hall for the traditional reception. When that reception ended, I asked Father Nicholas if we could get together, and after a bit of back and forth, agreed to have lunch on August 16th, the soonest our schedules aligned.

"We have about an hour before the reception at the banquet hall," I said to Kris. "Should we take Rachel to the park? I could use more time outside."

"That sounds good," Kris said. "What about her dress?"

"We'll change her at the park, then put it back on before the reception."

I briefly considered inviting others to join us, but decided I wanted time with my family, as we had so few opportunities to be together. The three of us got into the car and drove to Milton Lake, where Rachel, Kris, and I found a shady spot under a tree. We played with a ball. Rachel, being nearly two, was just becoming coordinated enough to learn to catch and throw, but she clearly enjoyed her time with me.

I did wonder how she'd respond to a baby brother or sister, and suspected she'd get her nose out of joint either way, as she'd no longer be the sole center of attention. That was something to think about, and fortunately would be after I finished my Intern year. I was looking forward to having more kids, and that brought to mind Clarissa, and how a baby we had together would integrate into the family.

But that was for later, and as it was time to leave the park, we changed Rachel, then headed to the reception hall. The food was decent, and I did, as promised, dance with Rachel. Kris had her dances as well, and with her permission, I danced with Clarissa, though Clarissa and I were careful not to dance too close.

Kris, Rachel, and I left as soon as Ghost and Oksana departed, as I had to be at the hospital before 6:00am, and because Rachel was very tired. At home, we said evening prayers, and after putting Rachel in her bed, Kris and I went to bed.

July 24, 1989, McKinley, Ohio

"Morning, Kayla," I said to Doctor Billings when I arrived in the ED about five minutes before my shift began on Monday morning.

"Morning, Mike. Quiet overnight. One patient waiting for admission to Medicine for gallstones. Probably surgical, but they'll assess upstairs. They said they'd take her about 6:30am."

"OK."

"How was Ghost's wedding?" she asked.

"Literally, if you've seen one Russian Orthodox wedding, you've seen them all! There's no variation permitted."

"So you have to use traditional vows?"

"Orthodox don't use vows the way other Christians do. The prayers are always the same, and have been for the best part of sixteen hundred years, with minor differences in translations depending on if they came from Greek, Russian, or Arabic. We basically follow the practices of the Hagia Sophia in Constantinople, and much of what they did was handed to them by even earlier traditions."

"Istanbul?"

"That's a recent name, and literally derives from the Greek phrase 'to the city' or, colloquially, 'the big city'. Orthodox nearly always refer to it as Constantinople. But even that is a new name, as the city was originally Byzantium, from which we derive the terms 'Byzantine Empire' and 'Byzantine Rite', though 'Byzantine Empire' a misnomer, as it was the Roman Empire and never ceased to be. The capital was moved from Rome long before Rome fell. To complete the short history lesson, it was known as 'New Rome' and later the 'Second Rome', with Moscow being the 'Third Rome', reflecting the seat of the most important bishops in Christianity."

"Not the Pope?"

"Not from our perspective, but that's an even LONGER history and theology lesson!"

"Pass!" Doctor Billings said. "I find it fascinating, but I need some sleep!"

She left, and I went to find Bob and Len, who were in the lounge with Doctor Nielson and a woman I didn't recognize.

"Mike, this is my wife, Shelly," he said. "Shelly, Doctor Mike Loucks."

"Nice to meet you," I said to the pretty strawberry blonde who I estimated was about five months pregnant.

"Shelly's here for a pre-natal check with Alice Carmichael."

"Isn't it a bit early in the day for that?" I asked.

"Shelly teaches English at the High School, and she's teaching summer school, so Alice did us a favor by setting up a 6:15am appointment here."

"Speaking of which," Shelly said to Perry, "I should go upstairs. I'll let you know before the ultrasound starts."

They exchanged a kiss, and she left.

"When did you guys meet?" I asked.

"About a month before I Matched at Cook County. We hit it off right away and were married that summer. She finished her degree just as I finished my Residency and did her student teaching in Columbus. She was hired at the High School the following year."

That made her six or seven years younger than him, which seemed fairly common with doctors. Ghost was about eight years older than Oksana, and I was about eight years older than Kris.

"Cool. Excuse me, if you would."

"Sure."

I went over to Bob and Len and asked if they'd had breakfast. They hadn't, so I had them take turns, and both were back before 6:45am. We handed the gall bladder patient to Clarissa and then began taking walk-ins. The first one was a second-degree burn and was routine. When we returned, there was a hand lac, which upon evaluation, I decided Bob could handle, so I had him and Len take the young man to Exam 6 for sutures.

"What else do you have?" I asked Jack, the Fourth Year at the desk.

"Fourteen-year-old with severe nausea."

"Sudden onset?" I asked.

"Last couple of days. Her mom was concerned, so brought her in."

"Only in the mornings?" I inquired.

"I, uhm, didn't ask. You think it's morning sickness?"

"Fidgety fourteen-year-old presenting with nausea this early? It's a thought. How is the mom?"

"Mama bear," he replied.

"Wonderful," I replied. "Let me get a nurse and we'll take her."

I went to the nurses' station and asked Ellie for a nurse, and was assigned Kellie, which made me happy, as I was sure she and I could cooperate to find out if my suspicions were true without provoking 'mama bear'.

"Mary Josephson?" I called out.

"Here," a woman of about forty with a pretty girl with long blonde hair next to her said.

"If you'll come with us, please, we'll get Mary checked out."

Mrs. Josephson and Mary followed Kellie and me to Exam 4, where I had Mary get onto the table.

"What's bothering you, Mary?" I asked.

"She's been sick to her stomach the last few days," Mrs. Josephson said before Mary could answer.

I smiled and turned to Mrs. Josephson, "Thanks. I've found that this works better if the patient answers. Would that be OK with you?"

Mrs. Josephson eyed me suspiciously, but nodded and said, "Yes."

"Mary?"

"I've been throwing up the last three days," she said.

"Before you eat, after you eat, or both?"

"Mostly before, but I feel kind of sick all day."

"Is it as bad in the evening? You know, around bedtime?" I asked, trying to avoid using 'morning' or 'breakfast' as I didn't feel things would turn out well if Mary was pregnant.

"No."

"Have you had a fever, cough, or runny nose?"

"No."

"What about hitting your head or being in an accident?"

"No."

"Any trouble hearing? Or do you have ringing in your ears?"

"No."

"Do you wear glasses or contacts?"

"No."

"Are you seeing double or is anything blurry?"

"No."

The one-word staccato answers gave me the strong impression that Mary suspected the same thing I did, and the question was how I could ask the key questions without setting off 'mama bear', as I felt even asking the question would cause a severely negative response.

"Are you on any medication or taking any drugs, vitamins, or supplements?"

"Just a vitamin every morning," Mary replied.

"A multi-vitamin with iron," Mrs. Josephson interjected. "Her doctor recommended it."

"Is she anemic?"

"The doctor didn't say."

"OK," I replied, then turned back to Mary, "Let me examine you, please. If you could untuck your blouse and open the top two buttons, that'll be enough for me to listen to your heart and lungs."

While she did that, I washed my hands and put on exam gloves.

I ran through the usual set of exams -- auscultation, ears, eyes, nose, throat, glands, palpation, and checking distal pulses, then had Kellie take Mary's blood pressure and temperature.

"I don't see anything obviously wrong," I said. "Mrs. Josephson, I'd like to draw some blood and get a urine sample and run some tests, please."

"What do you think is wrong?" she asked,

"At this point, I don't have any indications of the obvious things, such as a virus or appendicitis or food poisoning, so the next step is either 'wait and see' or blood tests. It's your choice, of course, though I'd recommended the tests."

"What would they show?"

"Any abnormalities in her blood chemistry, with the main thing I'd look for is an increased white cell count, which would indicate some kind of infection."

"Go ahead."

"Kellie, CBC, Chem-20, hCG, and urinalysis."

I hoped that using 'hCG' rather than saying 'pregnancy test' would work, and it appeared to, as Mrs. Josephson didn't react. Kellie wrote it on the chart and handed it to me to sign, which I did. While Kellie drew the blood and obtained a urine sample, I went to check on Bob and Len. There were no concerns, and I asked Len to come back to Exam 4 so he could take the blood and urine to the lab.

"How long will this take?" Mrs. Josephson asked.

"We should have the results in about an hour," I replied. "If you'd like to get coffee, the cafeteria is straight down the corridor. Kellie will stay with Mary while you go."

"You won't treat her without my permission, will you?" Mrs. Josephson asked.

"Only in the event of an immediate, critical illness which would put her life at risk. I don't see any indication of that necessity. Otherwise, as she's a minor, we'd need your express permission, which is why I asked you about the blood and urine tests, not her."

"Maybe I will get some coffee," she said.

"Turn right out of the room, follow the corridor to the other end of the hospital, and it'll lead you straight into the cafeteria."

She left, and I looked to Kellie and said, "NVP."

That was 'nausea and vomiting of pregnancy' and was the medical term for 'morning sickness'. Kellie and I made eye contact and she gave a slight nod.

"Mary, have you started having your periods?" Kellie asked.

Mary bit her lip and nodded, and I knew right then what the tests would show.

"When was your last period?"

"The end of May."

Which was exactly the right timing, as NVP typically began in the fourth week of pregnancy, and if I was right, Mary would have conceived mid-June, either on or just after her fourteenth birthday.

"Is there any chance you could be pregnant?" Kellie asked.

Mary didn't answer, but the tears streaming down her face told the story. Kellie and I exchanged a look, and I nodded, got up, and left the exam room. I went to check on Bob and signed off on the sutures, and he streeted the patient. I asked him and Len, who had returned from the lab, to wait in the lounge, and seeing Mrs. Josephson coming back, I went into the exam room where Mary had stopped crying. When Mrs. Josephson came in, Kellie and I excused ourselves, saying we'd check on Mary in about twenty minutes, and then went to the consultation room.

"She doesn't want us to tell her mom," Kellie said.

"I'm not sure we have a choice," I replied. "Hospital policy is fifteen and up, and it's going to be tough to get a social worker to speak to her without her mom in the room. Do we know anything about the guy?"

"A classmate. They were playing 'Spin the Bottle' and 'Truth or Dare' at her birthday party and hormones took over."

"So they're close in age?"

"Yes. They'll both be Freshmen in the Fall."

"No indications of abuse or force?" I asked.

"No," Kellie replied. "It was pure hormones. I know how that is! I had a scare at fifteen which taught me to be VERY careful. She said it happened again a few days later."

"I know about hormones in High School," I replied. "But I was frustrated until after graduation! Anyway, if the tests come back the way we think they will, I don't see that we have much choice."

Kellie frowned, "No, we don't. Do you want to ask Doctor Nielson or Doctor Gibbs?"

"Even if we get an exception, then what? She needs either pre-natal care or the services of the Free Clinic."

"I had you pegged as solidly 'Pro Life'."

"Because I am," I replied. "But I'm also a physician with a duty to my patients and with an admission that as evil as I think abortion is, it's not up to me. I won't impose my morals on anyone, though I would counsel for adoption if I was asked."

"You don't want it banned?"

"Did the fact that it was illegal stop it before Roe?"

"No, of course not. It just made it extremely dangerous. What do we do?"

"Get the blood test results and present them," I said. "Then refer them to Family Services or the Free Clinic."

"What about having the social worker in the room?"

"We'd have to wait until 9:00am for that, and we'll have the blood tests back by 7:30am. I think you and I have to do it, and do our best to calm both of them down. I take it Mary is not in denial?"

"No," Kellie said. "She knew, even if she didn't have proof beyond having had sex and having missed her period. On the bright side, we don't have to involve the law even though she's under the age of consent because the boy is fourteen."

We walked out of the consultation room and we saw Mrs. Josephson and Mary, leaving the exam room.

"Mrs. Josephson?" I called out.

"We're leaving!" she declared. "Cancel those tests!"

"I'm not allowed to do that once they're on the chart," I replied.

"Then tear up that chart!" she demanded.

"I can't do that, either," I replied. "It's a legal document."

"My husband is an attorney, so we'll just see about that! I want to see whoever is in charge!"

"That would be Doctor Gibbs," I said, then turned to Kellie, "Would you ask Doctor Gibbs to come to the consultation room, please?"

I felt that was better than trying to convince Mrs. Josephson to return to the exam room.

"Right away, Doctor," Kellie said, becoming formal.

"Mrs. Josephson, let's go to a small meeting room so you can have the conversation with my supervisor in private."

Thankfully, she acquiesced to the request, and I escorted her and Mary to the consultation room. Kellie returned with Doctor Gibbs and we huddled in the corridor before going into the room.

"Mary Josephson, fourteen, with morning nausea, a missed period, and recent unprotected sex. I ordered a pregnancy test, along with CBC and Chem-20, and the patient's mother is trying to take her AMA. She also demanded I stop the tests and tear up the chart. When I said I couldn't do those things because the chart was a legal document, she threatened legal action, stating her husband is an attorney."

"No positive pregnancy test as yet?" Doctor Gibbs asked.

"No. Kellie?"

"She admitted two instances of unprotected sexual intercourse," Kellie said. "The timing is consistent with her missed period and nausea."

"Does Mom know?" Doctor Gibbs asked.

"No. I used a bit of subterfuge by asking Kelle for hCG and then suggested Mrs. Josephson get coffee while we waited for the blood and urine results. When she left, I asked about possible pregnancy, and when the patient began crying, I left and allowed Kellie to handle it. No signs of abuse, no other symptoms, generally healthy, and the patient reports her partner was the same age."

"Technically not AMA," Loretta observed. "But the same result. I'm going to surmise the mom guessed and wants no records."

"I'd say that's a safe bet, Doctor," Kellie interjected.

"What was your plan, Mike?" Doctor Gibbs asked.

"Referral to the Free Clinic and Family Services. Reporting to law enforcement is discretionary, and I suggest not reporting this given the ages and circumstances."

"No alcohol or drugs?" Doctor Gibbs asked.

"Just hormones," Kellie said.

"OK. Let's go speak with them. Kellie, you join us."

The three of us went into the consultation room and I shut the door behind us.

"Mrs. Josephson," I said, "this is Doctor Loretta Gibbs, Chief Attending. She's in charge of the Emergency Department today."

"This doctor is running tests without my permission!" Mrs. Josephson said before Doctor Gibbs could speak. "I want it stopped and all the records destroyed!"

"Mary," Doctor Gibbs said, "was your mom in the room when the nurse drew the blood?"

"DON'T ANSWER THAT!" Mrs. Josephson ordered. "JUST BE QUIET!"

"Yes," Mary said anyway.

"MARY! I SAID BE QUIET!"

"Did Doctor Mike ask your mom's permission?"

Mary nodded and began sobbing, and Kellie handed her some tissues.

"Mrs. Josephson," Doctor Gibbs said, "hospital charts are legal records and we're forbidden from destroying them. They are not public, and nobody has access to them without a court order except medical staff, the patient, or their parents, if they're a minor."

"My husband is an attorney, so we'll just see about that! We're leaving!"

"That is your right," Doctor Gibbs said. "That said, if you leave before the test results come back, and they show what Doctor Mike and Kellie suspect, we're required to report it to Family Services."

"Don't you dare!" Mrs. Josephson said.

"The only way to avoid that is to wait for the test results and have a consultation about them, at which point we'll provide you with information and options."

"This is none of your business! If you report this, I'll sue!"

"Which," Doctor Gibbs replied, "is your prerogative. Kellie, get an AMA form, please."

"What's that?" Mrs. Josephson demanded as Kellie left the room.

"It's a form we fill out when a patient leaves 'Against Medical Advice'. You'll need to sign it."

"I'll do no such thing! And you can't keep us here! That's kidnapping!"

Technically, it was illegal restraint or something similar, as I'd been taught how to respond to possible kidnappings in our practice of medicine, and they involved taking someone from one place to another, which we hadn't done, as Mrs. Josephson had brought Mary to the hospital and had walked to the exam room with her.

"You can, of course, refuse to sign, but the three of us will sign it and file it with the hospital administration."

"I SAID NO RECORDS!" Mrs. Josephson insisted.

"I understand, but we have legal requirements," Doctor Gibbs said. "We could all lose our licenses, or worse, if we don't follow them."

"I'll get your licenses revoked!"

"I can see we're not going to make any progress here," Doctor Gibbs said. "I'm informing you that you are taking your minor daughter from the hospital against medical advice, and I encourage you to reconsider."

"We're leaving!" Mrs. Josephson declared. "Mary, let's go!"

She basically dragged her sobbing daughter from the consultation room and out the doors to the waiting room as Kellie returned with the AMA form.

"Well, that went well," I sighed.

"And exactly how do you think you'd react if Rachel were to become pregnant at fourteen?" Doctor Gibbs asked with a slight smile.

"Don't ask," I replied flatly.

"Exactly. As loving and kind and caring as you are, you'd still react badly. Your personality and demeanor are such that you might not show it outside, but inside you'd be looking for your shotgun."

"Perhaps," I replied. "But that would also be hypocritical."

"Dads are like that," Kellie said. "I had one! It's normal."

"Me, too!" Doctor Gibbs said. "Unfortunately, in this case, Mrs. Josephson made her predicament worse. Had she simply stayed for the confirmation test, we'd have referred her to a social worker and the Free Clinic. Now we'll have to report it because we'll have a positive pregnancy test for a fourteen-year-old and can't bypass reporting by discussing it with the girl's parents. If she were fifteen, it would be a judgment call, but not at fourteen without parental notification."

"That's likely to end very badly," I observed.

"Maybe so, but you know the law expressly says sixteen and we're given leeway with fifteen-year-olds who are mature, and who, in our medical judgment, are capable of making a decision. With girls under fifteen, we really have no alternative except parental notification and referral. As much as I hate to say it, we have to cover our butts."

"You think the mom would claim we hid the pregnancy?" Kellie asked.

"In a heartbeat," Doctor Gibbs said. "When I was doing my OB/GYN rotation during Third Year, we had a mom similar to this one who lost her mind and claimed we never told her that her fourteen-year-old daughter was pregnant. The girl had suffered a ruptured ectopic and died."

"Lord have mercy."

"Denial is not just a river in Egypt," Doctor Gibbs said. "Fill out the AMA form, you and Kellie sign it, then bring it to me. I'll make sure it's filed with legal. When the tests come back, fill out the contact report for Family Services and take it to Jeanne Wilders. She'll make the report to the McKinley PD or Sheriff's Department if it's warranted."

"Wonderful."

"I agree, Mike, but we don't have a choice."

She left and Kellie and I filled out the AMA form and contact form. Kellie and I both signed the AMA form, and she took it to Doctor Gibbs' office. The lab results came back a few minutes later, and confirmed that Mary was pregnant, so I signed the contact form and then walked down the corridor to Jeanne Wilders' office.

"Hi, Mike!" she said. "Oh, sorry. Doctor Loucks!"

"Doctor Mike, if you have to use the title, but just 'Mike' is fine."

"How are you?"

"Good."

"And your daughter?"

"Growing like the proverbial weed! I don't get to see her enough."

"The lament of every Intern who has children. Is there something you need?"

"Me, no? I have a contact form for a pregnant fourteen-year-old whose mother dragged her away AMA before we had the test results."

"Consensual? And I don't mean that in a legal sense."

"As far as we can tell, yes. She told Kellie Martin that she had been playing 'Spin the Bottle' and 'Truth or Dare' at her birthday party and hormones took over. She had another consensual encounter a few days later."

"Happy birthday," Jeanne said sarcastically.

"Yeah. Mom was out of the room when the girl admitted her encounters to Kellie, but deduced the problem and demanded we cancel the tests and destroy any record we'd seen the girl. She then refused to sign the AMA form and basically threatened to sic her husband, who is an attorney, on us."

"She made her problem infinitely worse," Jeanne observed.

"We tried to explain that, but Mrs. Josephson, the mom, wasn't thinking clearly."

"I'm not sure I'd think clearly if my teenage daughter were pregnant, and I'm trained to handle things like that!"

"As Doctor Gibbs pointed out, it's different when it's your own kid."

"Let me have the form and I'll put the wheels in motion. How old was the partner?"

"Same age. Mary said they'll both be Freshmen in the Fall."

"Then I'm not required to involve law enforcement. You know the guidelines there, right?"

"Close in age, and over thirteen, and it's at your discretion."

"And medical findings except the pregnancy?"

"No. She's perfectly healthy, properly developed, well-nourished, and there were no signs of injury or abuse. I did not do a gynecological exam."

"You wouldn't normally, right?"

"Correct. Only in the case of some kind of trauma or an abnormal indication, and even then, I'd call for an OB consult if it wasn't life-threatening."

"That guideline hasn't changed, then."

"No. And I did have Kellie Martin in the room with me at all times."

"Good. OK. If I need anything, I'll let you know."

I left her office and returned to the ED and let Doctor Gibbs know I'd handed in the form.

"I'm sure I don't have to remind you not to discuss this with anyone except me or Jeanne Wilders."

"You don't, but I also know you have to say it when there's a threat of legal action, even if it's obviously BS. I strongly suspect that right about now, Mrs. Josephson is regretting not taking Mary to see her gynecologist."

"I'd say that's a safe bet."

"Mike?" Kellie said from the door. "Nate just let me know there's an MI three minutes out."

"OK," I said. "Let Bob and Len know, please."

"Already did!" she replied.

I left Doctor Gibbs' office, gowned and gloved, and headed for the ambulance bay with Kellie. Bob and Len were there waiting, and I gave my preliminary orders. A minute later, the EMS squad rolled up and stopped.

"Patient arrested about a minute ago," Bobby exclaimed, hopping out and moving quickly to the back of the squad.

"Bob, chest compressions," I ordered. "Get on the gurney as soon as they get it out of the squad.

Thirty seconds later with Bob on the gurney doing chest compressions and Bobby's partner Sam bagging, we moved toward Trauma 2.

"Will Breckenridge, fifty-two, collapsed in his driveway," Bobby said. "BP 80 palp, pulse was thready at 80; diaphoretic; PO₂ was 91% by mask. Arrested one minute ago, chest compressions administered immediately."

We quickly transferred the patient to the trauma table, with Len taking over compressions while Bob hooked up the EKG and I intubated and hooked up the ventilator.

"Asystole," Bob called out.

"Kellie, epi down the tube!" I ordered.

She quickly complied and there was no change on the monitor.

"Len, stop compressions," I instructed.

He did, and I listened and shook my head, "Nothing. Kellie, another dose of epi, IV push."

She did that and there was still no change. I asked Len to stop and once again auscultated and heard no heart sounds. I checked the patients pupils and once again shook my head. The EKG showed a flatline, so defibrillation would be ineffective.

"He's been down six minutes," I said. "Kellie, would you get an Attending, please?"

She left and returned with Doctor Nielson.

"Arrested during transport," I said. "Two doses of epi in; no heart sounds; no pulse; no shockable rhythm; pupils fixed and dilated."

He checked for heart sounds, checked the patient's pupils, then looked at the EKG.

"Call it."

"Time of death, 08:42," I said.

"I'll get the death kit," Kellie said.

"Thanks," I replied.

I made notations on the chart then left the room with Bob and Len following.

"My dad is fifty-two," Len observed quietly.

"So is mine," I replied.

"That guy looked pretty healthy."

I nodded, "Not overweight, and he appeared to be in decent shape, but as you know there are no external signs of arteriosclerosis and a host of other cardiac problems. And we won't know what did him in until Doctor McKnight does an autopsy.

"Mike?" Ellie said. "The MI's wife is in the waiting room."

"OK. Name?"

"Evelyn Breckenridge."

"Thanks. Call for the chaplain, please."

"One moment."

She placed the call and three minutes later, the chaplain for the day, Robert Hamilton, a Lutheran pastor, arrived.

"Bob," I said to my student, "we'll be in the consultation room. Please bring in Mrs. Breckenridge. You know how to answer, right?"

"That I'm not a doctor and you'll explain everything."

"Exactly."

"Len, let Kellie know we might bring in his wife, then come to the consultation room.

"Will do," he replied.

Bob went to the waiting room and Len did as I asked before joining Robert and me in the consultation room.

"Fifty-two-year-old male collapsed in his driveway," I said quietly to Robert. "Arrested during transport and arrived with no vitals. We were unable to revive him."

"OK," he replied.

"Doctor Mike," Bob said coming into the room with a woman of around fifty. "This is Mrs. Breckenridge."

"Hi, Mrs. Breckenridge," I said.

"How is my husband?" she asked nervously.

"Have a seat, please," I suggested.

She sat down and Robert and I followed suit while my students stood along the wall.

"Mrs. Breckenridge," I said. "When the paramedics arrived at the hospital with your husband, he was receiving CPR. We immediately took him to a treatment room and began life-saving procedures. We used all our skills and abilities, including drugs and equipment, but we could not restart his heart and he died. I'm sorry."

She put her head in her hands and began crying.

"I'm sorry to ask, Mrs. Breckenridge, but is your husband an organ donor?"

"No," she answered through her sobs.

I contemplated pressing the issue, but decided against it.

"This is Robert Hamilton," I said. "He's the hospital chaplain and will help you. If you'd like to see your husband, we can arrange that."

She took some tissues Robert offered her and blew her nose, then asked, "Can you take me to him?"

I nodded and Robert assisted her, allowing her to lean on him, and we went to the trauma room, stopping just outside the door.

"You're going to see a tube in his mouth," I said. "Along with wires and other equipment."

"OK," she said.

We went into the room where Kellie was going through the death kit, but had covered the patient with a clean, white sheet. Mrs. Breckenridge wailed loudly and quickly moved to her husband's body, and laid across his chest.

"I've got this, Mike," Robert said quietly.

"Thanks."

I motioned to Bob and Len, and we left the room.

XXVI. Let's Take a Walk

July 24, 1989, McKinley, Ohio

"That just seems so...cold," Len observed after we had moved away. "I mean the way you told her."

I nodded, "That's the standard, developed through years of experience. Our job in such cases is to clearly state that the patient has died. Emotional support, and everything else, comes from the chaplain, the social worker, or Doctor McKnight. I can't tell you why the patient died, and, generally speaking, doctors are not qualified grief counselors or spiritual counselors."

"You are, though, right?" Bob asked. "You were clergy."

I nodded, "I was a deacon, and I'm actually an appointed chaplain, though I can't do that here because it's literally not my job. That was one of the hardest lessons for me to learn during my clinical rotations, and I was reminded of that time and time again. Let's just say, I had my nose whacked with the rolled-up newspaper sufficiently often to convince me to stop peeing on the carpet, as it were."

"Doesn't it bother you?" Bob asked.

"Of course it does, which is why it took so many applications of the rolled-up newspaper. But it doesn't bother me enough to go into private practice or pediatrics or internal medicine where there is more personal interaction and the lines are a bit fuzzier. Don't work in the ED if you can't handle that. Think about all the shorthand we use, and how at times it's like an assembly line. We simply don't have the time to get involved.

"Going back to the monologue, that is something you need to memorize, and it's what you'll say each and every time a patient dies. You absolutely have to say 'he died' or 'she died' unequivocally, without euphemisms. And you don't give any diagnosis. It's almost always safe to say that the patient's heart stopped and we could not revive them, as that is, from our perspective, the sign of death. No heart sounds and nothing on the monitor is, for our purposes, definitive.

"With this patient, he was down for at least six minutes, and we don't know what his heart rhythm looked like before went asystole in the EMS squad. Two doses of epi, chest compressions, and a vent, with his pupils fixed and dilated, were sufficient to stop trying. At that point, there was literally nothing left in our toolkit, as it were, so we called it. It's up to Doctor McKnight to say what the cause was, assuming Mrs. Breckenridge agrees to an autopsy."

"It's not automatic?" Len inquired.

"No. When a patient dies in the presence of a physician, the death certificate can be signed at that point and it's up to the family to decide if they want an autopsy. When the patient dies outside the presence of the physician, the County Coroner holds an inquest, which always includes an autopsy. We also try to do them for patients who die unexpectedly, for our own purposes, but the family doesn't have to agree."

"Do you sign it?"

"No, because it needs to be signed by someone with a license. Attendings all have their licenses, but only some Residents do. Most get them during their second or third year of Residency, though surgeons sometimes wait, given it takes roughly eight years to be an Attending."

"How does that work for you?" Bob asked.

"I plan to take the licensing test late next year. I'll take my trauma boards around the same time, and then in about six years, my surgical boards as a general surgeon. While I'll be fully qualified, and be able to put FACS behind my MD, the vast majority of procedures I'll do will be chest tubes, pericardiocenteses, central lines, tracheotomies, and similar life-saving procedures. I will, at times, take a patient up to perform emergency surgery, but that won't be the main part of my job."

"Mike?" Nate called out. "EMS four minutes out with an electrocution. Use Trauma 3."

"Got it!" I replied, then turned to Len and Bob and said, "Let's go!"

We gowned, gloved, and went to the ambulance bay to meet the squad, which pulled up about four minutes later.

"Jerry Maclean, twenty-six; electrocution on a construction site. CPR performed by co-workers; tachy at 110; resps shallow at 16; BP 90/60; PO₂ 95% on five liters by mask; GCS 9; IV saline TKO; burns on both palms."

That indicated that the charge had gone across his chest.

"Voltage?"

"240."

"Trauma 3!" I ordered. "Bob, EKG and monitor; Len, CBC, Chem-20, ABG, and cardiac enzymes."

We began moving, and I called out to Ellie that I would need a nurse, and she sent Jenny with us.

"Jenny, switch the IV to Ringer's," I said. "Len, Foley; Jamie will draw the trauma and cardiac panels."

Everyone acknowledged my orders and, with the help of the paramedics, we transferred Mr. Maclean from the gurney to the trauma table. I did a quick assessment and determined he was breathing OK and had a strong pulse, so immediate intervention wasn't needed. I began a more thorough workup while the others performed the tasks I'd assigned them.

"Foley is in!" Len declared. "Urine in the bag, and yellow."

"Take the blood to the lab; trauma stat."

"Right away, Doctor!"

"Arrhythmia," Bob announced.

"What do you see?"

"I'm not sure; I just know it doesn't look right!"

I looked up and nodded, "A-fib and irregular ST, both consistent with electrical shock. Put the unit in continuous print mode and call for a cardiology consult, please."

He did as I asked while I checked reflexes, all of which were nominal.

"What would you do next?" I asked Bob.

"Control the A-fib."

"Yes. Jenny, 1 meg digoxin IV push; 2 megs warfarin in the IV bag."

"1 meg digoxin, IV push," she repeated. "And 2 megs warfarin in the IV bag."

"Why those?" I asked Bob.

"Digoxin to control arrhythmia and warfarin to prevent thrombosis."

"Good. Now what?"

"Monitor; he'll need to have his INR checked daily to dose the warfarin."

"Correct. What about the burns?"

He moved to examine the patient's hands.

"Irrigate, debride, dress," he said.

"Yes. We'll wait for cardiology before we do anything else. What can you deduce from the burns?"

"He was holding wires?"

"Yes, but what stopped his heart? 240 will usually knock you on your ass, but not stop your heart."

"I'm not sure."

"The charge went across his chest. Think about that."

"Ah," Bob said, the answer obviously dawning on him, "similar to defib, only in reverse."

"Yes. What will we look for in the blood tests?"

"Elevated cardiac enzymes, which indicate damage to the heart muscle."

I nodded, "Specifically, the MB component of creatine kinase and troponin."

"Javadi, Cardiology," Leila Javadi said as she entered with a Third Year.

"Hi, Leila," I said.

"Morning, Mike. What do you have?"

I ran through the patient's vitals, my exam results, and the treatment so far.

"I don't like the fact that he's still out," I concluded.

"Let me do an exam, but we may want a neuro consult as well. We can do that upstairs, though, because he needs continuous monitoring."

"The EKG is on continuous."

"Thanks," she said, beginning her exam.

She asked similar questions of her Third Year as I'd asked Bob, and concluded by accepting Mr. Maclean on her service. In keeping with policy, she, Bob, and her student escorted the patient to Cardiology, and when I left the room, Nate indicated that there were walk-ins waiting.

"What do you have?" I asked at the triage desk.

"Take your pick -- sprained ankle; abdominal pain, but without elevated temp; arm lac; alien infestation."

"Psych consult?"

"Either that or a Scientologist who failed to blow off his body Thetans with his e-meter!"

"Nice," I chuckled. "Who's been here the longest?"

"Psych consult."

"Let me take him and get him his psych consult and I'll come back for another. Bob can take the arm lac."

"Sold!" he said, handing me two charts.

I handed the arm lac chart to Bob, instructed him to evaluate and come see me, then we each called out to our patients. I escorted Nelson Thomas, who had aluminum foil on his head, to Exam 6, asking Kellie to join us.

"What brings you here today?" I asked.

"Aliens inserted tracking probes into my brain!" he said.

"When did this happen?"

"Last night. I put the foil on to block the signals!"

"How did they insert the probes?" I asked.

"Up my nose!"

"I'm going to do an exam," I said. "I'll leave the foil in place, and once we've run our tests, we'll call our alien expert to check you out."

He looked at me strangely, "You believe me?"

"I need to take your report seriously to treat you," I said.

"The alien expert is secret, right? You guys are government, so you don't admit it like they don't admit the alien bodies and ship they have at the Air Force Base in Dayton, right?"

"Right," I agreed.

Hangar 18 in Area B of Wright-Patterson Air Force Base purportedly had the wreck of a crashed UFO from Roswell, New Mexico, along with the bodies of the crew.

"Jenny, let's draw CBC, Chem-20, liver and metabolic panels, and tox screen."

"I'm not on drugs!" Mr. Thomas protested.

"Are you sure the aliens didn't inject you with something?" I asked.

"Good thinking, Doc!" he said.

Once we'd completed the exam and the blood draws, I asked Mr. Thomas to lie down and wait. He complied without argument, and we left the room.

"You are strange!" Kellie declared.

"And what would have happened if I hadn't gone along with his delusion?"

"He'd have freaked out and wouldn't have cooperated, saying you were part of the conspiracy."

"Bingo. Now I just have to convince someone from psych to play along with my charade long enough to get him upstairs."

"Why the blood tests?"

"Because it's possible his delusions are based on metabolic or other problems. You know psych will only run those as a last resort in a case such as this one, or if he develops other symptoms."

"So wait for the results before we call Psych?"

"Yes."

"Unconventional, but likely effective."

"Thanks. I see Len coming, have him run the blood to the lab. I'll meet you in Exam 2 with the young woman with abdominal pain after I inform Doctor Gibbs. Bring her in, please."

She acknowledged my orders, and I went to see Doctor Gibbs, who was at the nurses' station.

"OK to present?" I asked.

"That goofy grin says you're up to something."

I laughed, "Busted, but I think you'll agree. I have a male patient, late twenties, who believes aliens inserted probes into his head last night. I humored him, ordered blood tests and once they come back, I'll get a psych consult."

"Humored him?"

"I didn't make him remove his aluminum foil hat, and said once we'd run the tests, I'd bring in our alien specialist to examine him."

She started laughing, as did Ellie.

"I also allowed that I knew about the alien spacecraft they have at Wright-Patterson."

"Psych is going to love you! And by 'love' I mean 'hate'!"

"The patient is calm, relaxed, and feels safe. Did I do any harm in accepting his delusions?"

"No."

"There you go. I did order complete blood work, including a tox screen, to rule out metabolic or other causes. I don't think he's on drugs, but there are things which manifest only as paranoid delusions or hallucinations. It's also the case that electrolyte imbalance, meningitis, and other ailments can cause mental confusion, including hallucinations and paranoia."

"And later when he tells people we believe in UFOs?"

"He won't be wrong," I replied.

"Don't tell me YOU believe in UFOs?!"

"We all do," I chuckled. "There are absolutely, provably, Unidentified Flying Objects. There's no proof they're alien spacecraft or any such thing, but the UFOs are actually real!"

"Give me your chart to sign, you clown!" Doctor Gibbs said rolling her eyes and shaking her head.

I handed it to her, and she scribbled a note and signed it. I winked, left, and put the chart in the holder outside Mr. Thomas' room, then went to Exam 2.

"Peggy Gibson, nineteen," Kellie said.

"Good morning. I'm Doctor Mike. What brings you here this morning?"

"My side hurts."

"More towards the front or the back?"

"The back."

"When did this begin?" I asked.

"Last night. I took two Tylenol, and that helped, but when I woke up this morning it hurt worse, and Tylenol didn't do anything."

"Did you do anything in the last few days which might have strained a muscle?"

"Not that I can think of. I went to class, studied, then hung out in the dorm common area."

"Taft student?"

"Yes."

"Did you pick up anything heavy?"

"Nothing heavier than my chemistry book."

"Did you eat anything out of the ordinary?"

"No."

"Any nausea, vomiting, dizziness, or imbalance?"

"No."

"Blurred vision, ringing in your ears, or strange smells or tastes?"

"No."

"Are you taking any medication or using any drugs?"

"Just the Tylenol."

"OK. I'd like to perform a basic exam. Just unbutton one more button on your blouse and untuck it, please."

She complied while I washed my hands and put on gloves. I auscultated her heart and lungs and found nothing remarkable, then checked her eyes, ears, mouth, and nose with similar results, and found nothing amiss with the glands in her neck.

"If you'd lie back, I'm going to examine your abdomen," I said.

She complied, and I palpated her abdomen and listened for bowel sounds, once again not finding anything remarkable.

I had her turn on her side and did a manual exam of her back, finding two spots where pressure caused her to wince, but which didn't indicate any masses.

"Any trouble urinating or any burning sensation when you urinate?"

"No."

"You can sit up," I said. "There are a few possibilities, the most likely of which is an ovarian cyst. Is there any chance you're pregnant?"

"Not unless two girls can get each other pregnant."

"So, no relations of any kind with a guy?"

"Never. Not even a kiss."

"Then you aren't pregnant, which narrows down the possibilities. I'd like to do an ultrasound to confirm."

"What else could it be?"

"Kidney stones would be a possibility, but you're awfully young to have those unless you've been diagnosed with some kind of renal disease. Any kidney problems?"

"No. What's the treatment for a cyst?"

"It depends on the size," I replied. "Small ones usually resolve on their own. Larger ones need evaluation by on OB/GYN and could be surgical. But let's check it out first before we speculate. Kellie will give you a gown to put on. You can leave on your bra and jeans, but you'll need to take off your blouse.

"I'm not modest. I can just take off my blouse."

"OK. We'll step out to get the equipment we need. Just take off your blouse and then lie on your left side with your back towards this side."

She acknowledged me, and Kellie and I stepped out. I stood outside the door while Kellie retrieved the ultrasound. Bob came to me to report he'd irrigated the arm lac, and felt it needed six sutures. I checked, confirmed that, then went back into the exam room with Miss Gibson. I performed the ultrasound and confirmed Peggy had a four centimeter cyst on her right ovary.

"You have a cyst," I said. "It's small, so for now, take three Advil every six hours, which should help, along with warm compresses. Make an appointment with your OB/GYN for followup."

"That's it?"

"That's it. If the pain persists beyond three days or gets significantly worse, and you haven't seen your OB, come back and we'll have an OB/GYN check you out and recommend treatment. Kellie will get you some Advil now, and I'll fill out the paperwork to discharge you."

"Thanks, Doctor."

"You can put on your blouse," I said. "We'll be right back."

Kellie and I left the room, and she touched my arm.

"You aren't going to ask for an OB/GYN consult or an Attending?"

"No. I've seen a number of these and she has no symptoms which warrant anything more than 'wait and see'. Her OB/GYN is best suited to care for her. I've also done other gynecological procedures, so I know Doctor Gibbs will sign off without an exam."

We went to the Attendings' office, and I asked Doctor Gibbs if I could present. She nodded, so I ran through my exam and diagnosis.

"No blood work?" Doctor Gibbs asked.

"No. There's no need to run extra tests at this point. All her symptoms line up."

"You're positive she's not pregnant?"

"Lesbian," I replied. "And I did confirm that she'd never had relations with a guy."

"Let me have the chart, please."

She made her notations, signed it, and handed it back.

"Street her, as you proposed."

"Thanks."

I filled out the necessary discharge information, completed the chart, then returned to the exam room to discharge Miss Gibson. Once that was completed, I took the sprained ankle, and finally received the results for Mr. Thompson's tests, all of which showed normal ranges, though with slight anemia, but that was insufficient to cause hallucinations or paranoid delusions. The tox screen was negative, though it didn't test for everything possible.

"The aliens are crafty!" Mr. Thomas said when I explained the nominal blood test results. "They don't use anything you can detect!"

I nodded, "That would make sense for an advance species of aliens! Let me place a call and have someone who specializes in this come see you."

"Thanks, Doc!"

I left the room, wondering which Psych Resident was on duty. I placed the call, and five minutes later, Leah Silver arrived with a Third Year in tow. I reviewed the patient's vitals, the exam results, and the blood test results.

"You seriously want me to pretend to be an alien expert?" she asked.

"My patient is calm and cooperative. I'd suggest maintaining the fiction until you get him upstairs, otherwise he's likely to fight you and have to be sedated."

"You know that's not protocol!"

"Hang the protocol!" I replied. "Our goal is to provide the best possible care, and if that means going along with his hallucination and delusion, at least in the short-term, so be it."

"Doctor Lawson will never agree to that."

I shrugged, "You have my advice, but you're the psychiatrist."

I handed her the chart.

"Oh, this is going to go over great," she said, shaking her head. "Your Attending signed off on this?"

"Again, we have a docile, cooperative patient who thinks we're going to help him, as opposed to one who thinks we're in league with his enemies."

She shook her head, "I have to follow protocol."

I almost said 'Of course you do', but bit my tongue.

"Kellie, prepare five of Haldol," I said. "We're going to need it."

"Right away, Doctor," Kellie agreed.

"Leah, can we at least just say you're a specialist, and NOT say you're from Psych? Can't you see your way clear to maintain that tiny fiction?"

"You shouldn't have fed his hallucinations or delusions."

"Fine," I said flatly. "Have it your way. Just wait so I can have Len and an orderly standing by."

I had them stand outside the room when Doctor Silver, Kellie, and I went back into the room. I made one last-ditch attempt to continue the charade.

"Mr. Thomas, this is the specialist I was telling you about," I said. "She needs to talk to you about what happened last night."

The gambit paid off, and she simply introduced herself.

"Hi, Mr. Thomas. I'm Doctor Silver," she said. "Can you tell me what happened last night?"

She listened and asked questions, but it was clear from the tone of her voice and body language that she was skeptical, and Mr. Thomas picked up on that.

"You don't believe me!" he said accusingly to Doctor Silver.

"There are no such things as aliens, Mr. Thomas," she said.

"YOU'RE ONE OF THEM!" he screamed. "YOU'RE PART OF THE COVER-UP! HELP!"

He became more and more agitated, and I had no choice except to call in Len and the orderly to help me hold him down while Kellie injected him with the Haldol, which, thankfully, took effect quickly. I picked up the chart, wrote the Haldol on it, along with a note that the patient had become extremely agitated during the Psych exam, and signed it, then handed it to Doctor Silver, who rolled her eyes and shook her head.

"All yours," I said. "The orderly and Len will help you and your student take him upstairs."

"You'll hear from Doctor Lawson, I'm sure," Doctor Silver said.

"He can speak to Doctor Gibbs. She signed my chart and my orders."

Len, the orderly, and Doctor Silver's Third Year got Mr. Thomas onto a gurney, strapped him in with soft restraints and wheeled him out. I went straight to Doctor Gibbs to let her know what had happened.

"What is it Clarissa says?" Doctor Gibbs asked with a wry smile. "That she can't leave you alone for two minutes without you getting into some kind of mess?"

"She does say that," I confirmed. "But I still stand by the fact that Mr. Thomas was docile and cooperative until Doctor Silver stated flatly that there are no aliens. At that point, he accused her of being a collaborator and being involved in a cover-up. She made the point that she was going to tell Doctor Lawson that I hadn't followed protocol."

"And your defense?"

"Hang protocol when it's not in the best interest of the patient. This goes right back to the situation with Angie. That doctor followed protocol, too. I know I'm not a psychiatrist, and I wasn't trying to treat Mr. Thomas' illness, I simply afforded him the dignity and respect every patient deserves. I fail to see how requiring me to administer Haldol was a positive development, when a small bit of fiction could have had him walk upstairs and begin treatment. He wasn't a danger to himself or anyone else, so I could have streeted him. I guarantee that if I had suggested a Psych consult, he'd have left. I'm sorry if this will cause you problems with Doctor Lawson."

"Do I sense some problem there?"

"Nothing I'd want to discuss on the record," I replied.

"I'll surmise from that you two spoke about Angie and he defended her psychiatrist."

"I can neither confirm nor deny the accurate speculation," I replied with a grin.

"Got it. Was this you tweaking him through his Resident?"

I shrugged, "Who knows what my innermost subconscious motivations were? My conscious motivation was what was in the best interest of the patient, and in my mind, that was him cooperating with his treatment, rather than fighting it. You realize he'll be drugged into a stupor now, because ANY attempt to wean him from the drugs will result in him losing it because he's been captured by collaborators and cover-up artists?"

"I'd say you have the surgeon's mentality about drugs, but it's deeper than that."

"While the phrase 'better living through chemistry' is true, we're far too anxious to prescribe some drug, especially long-term maintenance drugs, rather than seek alternative treatments. Part of that is people preferring pharmaceuticals to changing their behavior, part of it is laziness of physicians, part of it is the system, and part of it is the 'drug them into submission' theory of psychiatry."

"I think I'll have the conversation with Doctor Lawson alone."

I nodded, "I understand."

"Don't worry, though. I signed your chart and I don't disagree with you in principle. May I give one piece of advice?"

"Of course."

"Creating adversarial relationships with other doctors in the hospital is not wise."

"I will point out that in each and every case, it's the other doctors who have taken exception to me doing what is right, or, in the case of Mastriano's paramour, simply being faithful. I can, and will, defend each and every response."

"I didn't say you were wrong, Mike," Doctor Gibbs replied with a smile. "Your usual style is disarming, but you rub some people the wrong way. They probably need it, but at some point, the volume of complaints is going to reach a level where somebody has to decide what's best overall for the hospital."

"So be it," I said. "I owe every patient the duty to provide the best possible care, and to be a forceful advocate for their treatment. The day I'm not allowed to do that is the day I can no longer be a physician."

"Please don't get dramatic."

"This is a private, confidential discussion, right?"

"Yes, of course."

"Then I stand by what I said. But I think you also know who my role models are."

"Men who refused to quit in the face of adversity, and who were wronged for doing the right thing."

"Exactly," I replied. "I'm no martyr, and I have no intention of giving up. That said, if I'm ordered to act in a way contrary to a patient's best interest, you know exactly what I'll do. And so did everyone who voted to hire me as a Resident. What do you want me to do?"

"What I said. I'll deal with Lawson. Go heal the sick."

"Thanks, Loretta."

I left her office and went to check on Bob, who had finished suturing and had been waiting on me to review and discharge the patient. I signed off, and after giving the patient discharge instructions, Bob, Len, and I handled the ankle sprain, then I sent them to have lunch. While they were gone, I dealt with a broken finger which simply needed a splint, then went to have my own lunch.

The afternoon was busy, but relatively routine, with three ambulance runs and six walk-ins. Just before 6:00pm, when Mary and Tom arrived, I went to the cafeteria to have dinner with Kris and Rachel.

"Good day?" she asked.

"Mostly OK. I had a situation where I did the right thing, but likely created more animosity with Doctor Lawson in Psych."

"What happened?"

I explained the 'alien encounter' patient and the discussion with Doctor Gibbs.

"I don't see that you did anything wrong," Kris said. "And I'm not saying that as your wife, but as someone who agrees with you about dignity and respect. May I say something?"

"If you can't, who could?"

"Clarissa!" Kris declared mirthfully.

"Lissa!" Rachel exclaimed.

"She's upstairs!" I replied.

"No, she's not!" Clarissa announced from behind me.

"Sit down with us, Clarissa," Kris invited.

"If I'm not intruding."

"I believe our daughter would be quite cross with us if we didn't agree!" Kris declared.

Clarissa sat down and began eating.

"What did you want to say?" I asked Kris.

Kris smiled, "That you wear your heart on your sleeve and are extremely sensitive to people with mental health concerns. I understand why, but perhaps you need to be more diplomatic."

"I was diplomatic," I replied. "As I said, I simply requested Doctor Silver to continue with the charade until they could take the patient upstairs. She's the one who insisted on going strictly by the book."

"What happened, Petrovich?" Clarissa asked.

I recapped the situation for her.

"I can't leave you alone for two minutes!" she said, shaking her head.

"Which is what Loretta said. But seriously, Lissa, all I did was treat the patient with dignity and respect. My approach was working, and he was docile and compliant. After Leah Silver did her thing, we had to physically subdue him and hit him with Haldol. Honestly, I'd have streeted him if I'd known that was going to happen because he was no danger to himself."

"You know you have to call for a Psych consult for something like that."

"I know no such thing!" I said firmly. "He was calm, responsive, and no danger to himself. Now, he's drugged and thinks the government is covering up and the doctors are part of the conspiracy. How does that help him? He was harmless. I should have checked him out and given him some kind of placebo."

"Oh, come on, Petrovich! You know darn well you could be dismissed if anything happened to him or he hurt anyone and you failed to call for a psych consult. I know you're sensitized to this subject because of Angie, but you can't continue your crusade or you'll ruin your career exactly the way Lawson said. And maybe that was what he was trying to tell you."

"I don't think so."

"Are you sure?" Clarissa asked. "I think you're blinded by your outrage about Angie's treatment, and you take everything Psych does as a personal affront."

"Maybe so, but that doesn't mean I was wrong in my handling of the case."

"And the Psych Resident decided otherwise, and she's the one responsible to the Psych Chief. This isn't the same as the Mastriano or Greenberg situations."

"Seriously, Lissa? A psychiatrist says something to a lucid, functioning patient that directly results in that patient being drugged into docility?"

"Mike," Kris said gently, "I haven't been to medical school, but I have listened to you and Clarissa, and I believe Clarissa is correct. What did Doctor Gibbs say?"

"Basically the same thing."

"End your crusade, Mike," Clarissa pleaded. "It will end in disaster if you don't."

"I can't let injustice go," I protested.

"So don't! But find a way to do it without antagonizing every psychiatrist on the planet and wrecking your career. You're going to hate me for saying this, but you can't bring Angie back, and she'd never accept you throwing away your career for her."

"You know what?" I said, standing up. "I'm going back to work."

"Mike, sit down and eat," Kris said.

"I'm not hungry. I'll see you at home tomorrow."

I kissed Rachel, then Kris, then left the cafeteria and walked down the corridor to the ED, and went to the triage desk because I needed to work to take my mind off the conversations.

"What do you have?" I asked.

"Twenty-eight-year-old male with abdominal pain."

"Any other symptoms?"

"Nausea, diaphoresis, and goose bumps."

"Any previous visits?" I asked.

"None in the current files."

"Any patients more in need?"

"No."

"OK. I'll take the chart."

He handed me the chart, and I quickly reviewed the vitals which showed a borderline tachycardia and borderline hypertension. I went to the door, opened it, and called for Mr. Nicholas Holt. He came to me and I escorted him to Exam 2, then remembered my students. I asked Mr. Holt to wait, then went to the lounge to get Mary and Tom, who returned to the exam room with me.

"What seems to be the problem, Mr. Holt?" I asked.

"I feel like shit," he replied.

"When did this start?"

"About four days ago and it's become worse every day."

"Tell me about that, please."

"It started with the shakes, then nausea and sweating, then my gut started hurting."

"OK, let me do an exam, and we'll draw some blood."

I completed the exam, and it matched the vitals which were on the intake form.

"Mr. Holt, the scar on your abdomen looks relatively recent. What surgery did you have?"

"I had my gall bladder removed."

"What did they give you for pain?"

"Dilaudid."

"How long did you take it?"

"Six weeks."

"It was refilled?" I asked.

"Twice."

"I strongly suspect you're suffering from hydromorphone withdrawal. You were on Dilaudid for a long time, and the symptoms you're experiencing are consistent with abrupt cessation. Is the pain different from the reason you were taking the medication?"

"Yeah. It's not the same place or the same feeling. How bad will this get?"

"It could get significantly worse, but I can give you a drug called clonidine that will alleviate the symptoms. It's not an opioid drug like Dilaudid, so it's not addictive. I'll give you a fast acting dose now, and then you'll take progressively lower extended release doses for the next two weeks. You'll need to follow-up with your personal physician, and he can adjust the dose, if necessary."

"That's it?"

"That's it. Let me get the paperwork done and have my boss sign off."

"Why?"

"I'm a Resident, so I don't have authority to write prescriptions just yet."

"But you're a doctor, right?"

"Yes. Give me five minutes on the first dose, which will take effect fairly quickly and relieve your symptoms. Once they resolve, which will be about an hour, we'll get you on your way with a prescription you can fill at the drug store down the street that's open until midnight."

Mary, Tom, and I left the exam room and went to find Doctor Nielson who had come on at 6:00pm. I presented the case, he signed the chart, and I asked Alice to get the first dose of clonidine. She administered it, and Mr. Holt relaxed in the exam room while it took effect. I assigned Mary to check on him, and Tom and I took a walk-in with a severe headache.

"Mike?" Doctor Shelly Lindsay said, sticking her head into the room. "Got a minute?"

"As soon as I finish the workup," I replied. "OK?"

"I'll be in the lounge."

Fifteen minutes later, after Doctor Cohen had come down for a consult, I went to the lounge.

"Let's take a walk," Doctor Lindsay said.

"Who called you?" I asked.

"That transparent?"

"Yes."

"Clarissa. She actually called Vince at home and he called me because I'm here."

"Let me tell Perry I need fifteen minutes."

I did that, then Doctor Lindsay and I walked out the doors of the ambulance bay and along the entrance road to the sidewalk.

"Clarissa was concerned, and she said your wife is concerned as well."

"How much do you know?"

"I called Loretta. Let me start by saying I sympathize, but you're allowing your visceral hatred for your friend's psychiatrist to affect every interaction you have with Psych. If you don't let it go, you're going to destroy yourself."

"How the heck can I let it go? Her life was ruined by that, that..."

"Doctor," Shelly said, completing my sentence with a word I wouldn't use. "Mike, nothing can fix that now, and wrecking your career won't help her. What possible good can you do with this Quixotic quest? You're tilting at a windmill. Is there a problem? Yes. Will your righteous anger fix it? No. How many patients are alive because you were there for them? How many thousands will be alive if you're there for them?"

"There are other doctors," I countered.

"And how did that work out for Krissy Sumner?"

I sighed, "Not well."

"And who would have advocated for Peter Firth?"

"A fat lot of good that did!"

"While the outcome was bad, what happens to the next Peter Firth? And what happens to your friend in the future if you don't have 'MD' behind your name? And the countless other patients who will have improved outcomes because Michael Loucks, MD, is there for them?"

"I just..."

"Have to let it go," Shelly said firmly. "Look, I know you're operating on minimal sleep, and there isn't anything anyone can do about that now, and it's affecting you in a number of ways -- emotionally, psychologically, and probably spiritually, given what I know about you."

"I'm handling my cases properly," I protested.

"That is what Loretta said, and I don't doubt it. But it's also caused you to walk away from your wife and daughter because Kris and Clarissa were telling you the truth and giving you good advice. For most doctors, I'd recommend going home and taking sick time, but not only would you not do that, I think it would be counterproductive. Worse would be Doctor Gibbs or Doctor Northrup questioning your judgment. If that happens, they'll send you home, and a note will go into your file. That is the last thing you want, Doctor."

"It's not fucking fair," I sighed.

"If you mean what happened to your friend, I agree with you, but you aren't helping by allowing your disgust with the psychiatrist to cause you to behave irrationally. You realize he wins if you do that, right? Rosenbaum and Mastriano win. You lose. Your family loses. And your future patients lose. Does that sound like a good outcome?"

"No."

"You're going to do two things. First thing tomorrow you're going to make an appointment with a counselor I know in Columbus. She specializes in doctors, and she's not a psychiatrist. You'll also find she agrees with you about mental healthcare. Second, you're going to discuss this with either Vince or Ghost, and keep them apprised. Do you drink?"

"Occasionally, but I abide by the rules, and when I do drink, it's a glass of wine with a meal."

"Never at other times?"

"Not since start of third year."

"Ever take or consider taking narcotics?"

"No."

"You're wound awfully tight, so you need to be accountable to Vince and Ghost about that. I'd mentioned the other typical self-medication, but given your faith, I don't think that's necessary."

I laughed, "Surely you jest! My primary means of self-medication after Elizaveta died was sex because both drugs and booze would have resulted in me being dismissed from the program. A lot of sex."

"You could knock me over with a feather on that! Your reputation is pristine!"

"I studiously avoided even a hint of that at the hospital and refused to even consider the usual hanky-panky that goes on. Weirdly, I'm also capable of completely controlling these desires. I simply chose not to."

"I'll leave it to your wife to hold you accountable on that one."

"Which she'll do."

"Are you going to call the counselor?"

"I'd ask if I had a choice, but I know I do."

"We all do. Mike, the entire point of this is to keep you from making a serious mistake, either with professional relationships, or worse, with a patient. Right now, as tight as you're wound, I'm not sure you'd survive that."

"I'll call the counselor in the morning."

"I'll give you her card when we go back inside. The hospital will cover the costs. You OK to keep working?"

"Yes."

XXVII. All I Can Do Is Try

July 25, 1989, Centerville, Ohio

"I need to apologize for dinner last night," I said to Kris after I greeted her and Rachel when I arrived home on Tuesday evening.

"You were upset and stressed," Kris replied. "But please don't walk away from Rachel and me that way again."

"I have an appointment tomorrow morning with Maryann Manning, a counselor in Columbus who specializes in doctors," I said. "Shelly Lindsay recommended her. Clarissa called Vince Taylor, and he asked Shelly to talk to me. Clarissa will watch Rachel."

"You're still going to the prison, right?"

"Yes. My appointment is at 9:00am, and I can be at the prison at any point between 10:00am and 5:00pm. Technically, as a chaplain, I can visit other times, but I don't want to use up any possible goodwill I might need at some point in the future."

"Go change," Kris said. "Dinner is in five minutes."

I went up to our room, put on shorts and a t-shirt, then returned downstairs where I picked up Rachel.

"How's my little girl?" I asked.

"Rachel, miss Daddy!" she declared.

"I know, little one, but Daddy has to take care of people at the hospital."

"'Daddy' needs to care for himself, too," Kris interjected.

Kris put the finishing touches on dinner and we sat down to eat, with Rachel sitting on my lap. It made eating a bit of a challenge, but I knew she needed my attention.

"Are you going right to bed?" Kris asked.

"I managed two forty-minute naps overnight, so I'm actually doing OK. I can spend some time with you and Rachel before bed. I think I'll go to bed when she does around 8:00pm so we can say evening prayers together."

"Daddy sing?" Rachel asked.

"If it's OK with Mama."

"Of course it's OK," Kris agreed. "And I can come to bed with you, if you have enough energy."

"I think I can find the energy for that."

After our meal, Kris and I cleaned up while Rachel played, then I retrieved my guitar and sang for Rachel for about thirty minutes before we said evening prayers. After prayers, I read The Bears Picnic to Rachel as part of her bedtime routine, and after we put her down, Kris and I went to bed and made love before falling asleep spooned together.

July 26, 1989, Columbus, Ohio

"Tell me why you're here," Maryann Manning, who was in her late thirties, said after I sat down in her office on Wednesday morning.

"The snarky answer is that I was ordered to," I replied.

"Let's accept that as true," she said with a smile. "Why were you ordered to?"

"I wasn't really ordered," I replied. "I was counseled because, actually, I can't give a specific reason, except to describe a fairly lengthy series of events."

"I blocked out a full hour, so tell me what you think I need to know that led to you sitting in my office today."

I decided to start with the first time I'd seen Angie and ended with the treatment of the patient who averred alien contact. That used nearly thirty minutes, and Maryann was mostly quiet, asking only four questions of a clarifying nature.

"Why, then, did Shelly send you to me?"

"Because I'm at a risk for burnout or depression, and those are the primary causes of alcohol abuse, drug abuse, domestic violence, and infidelity amongst physicians."

"And knowing that, you allowed your understandable anger about your friends' treatment to lead you to a place where burnout or depression are not only possible, but likely, at least in the eyes of your mentors. What does that tell you, Doctor?"

"Well," I said with a wry smile, "the phrase 'physician, heal thyself' advises a course of action that can lead to dismissal from the hospital staff. That tells me I need to speak to someone who can help me, because self-help by physicians almost always leads to one of the abuses I mentioned before."

"Who are you accountable to with regard to alcohol or drug use?"

"In addition to the Chief Attending in the Emergency Department, my mentors, one in the ED and one on the surgical staff."

"I'm going to assume you're accountable to your wife for fidelity?"

"Yes, of course, but also to my «staretz» at a monastery in Michigan, as well as my bishop at the Russian Orthodox Cathedral here in Columbus."

"What's a «staretz»?"

"A spiritual guide, who has the gift of insight into a person's interior life. Call it the religious equivalent of a combined trauma surgeon, GP, and life counselor."

"So why come to me rather than go to him?"

"Oh, I'll go to him, but his guidance tends to focus on spiritual topics and my interior life, not on externals, which, for Orthodox, are a product of interior life. Or, to put it in secular terms, the psyche is responsible for our actions. It's also the case that he's not well-versed in the trials and tribulations of physicians, and his guidance in that area would have to be somewhat generic and open to interpretation. And like most Orthodox, I'm a fairly expert rules lawyer."

"What do you mean?"

"With regard to just about everything, save a few clear dogmatic statements, most Orthodox rules are open to interpretation and can be applied with strictness or lenity. Thus, it's both easy to read them in either way, as well as to find opinions amongst the Church Fathers and teachers that interpret them either way. I'm a catechist, which authorizes me to teach at church, as well as a prison chaplain."

"Prison chaplain?"

"Starting this year, with exactly one person. And that's another story that involves tragedy."

"Besides your first wife and Angie?"

"There are several others, including the suicide of one of our medical school classmates who I'd been involved with; a close friend who was badly injured in an accident and later attempted suicide; and a friend who was murdered, which is what led to my appointment as a chaplain."

"There's a lot to unpack here, even compared to most doctors."

"Life has thrown me a ridiculous number of curveballs."

"If I may make an observation -- your reaction to your friend's treatment for her illness is stronger and more visceral than how you described your reaction to your wife's death in childbirth."

"I suppose that's at least partly because Elizaveta isn't suffering now, while Angie will suffer for decades. And while there's a hole in my heart that will never completely heal, that's different from spending every moment for the rest of my life aware of Angie's predicament, and knowing it didn't have to be this way."

"There's no need to get into a debate about the specifics, but you do understand the logical fallacy of 'hypothesis contrary to fact', right?"

I nodded, "The idea that changing something in the past would have guaranteed a different outcome when there is no way of knowing what else might have changed because of that change, or what other events might have occurred."

"But knowing that, you still believe an alternative outcome was guaranteed?"

"If I implied that, I'm sorry, because no, I don't know what the outcome would have been, only that it could not have been worse than the one that actually occurred."

"But you don't know that. Perhaps that chain of events would have led to her being permanently institutionalized?"

"And perhaps I'll sprout wings and fly to Europe," I countered. "If I've learned one thing, it's that there are no guarantees in life. That said, if Angie had gained even one more day without psychoactive drugs, that would have been a better outcome, which has been my point all along. I never once had the idea that she was cured, or that complete remission was in any way likely. That said, I won't dispute that I've obsessed about the situation and allowed my visceral reaction to that to color my responses in just about any instance where psychiatry is involved."

"I notice you make the point to say 'psychiatry' versus 'mental health' or even 'psychology'."

"Can you prescribe medication?"

"No."

"That's why. I have an aversion to pharmaceutical intervention unless strictly necessary."

"You have the typical surgeon's mentality that all other doctors are 'pill pushers'."

"Because they are," I chuckled. "But I had that even before I chose the dual path of trauma surgery. My goal since fourth grade was emergency medicine. The trauma surgery thing came along after I learned about a program started by a doctor at Indiana University Hospital."

"We only have about fifteen minutes left today, so I'd like to discuss the negative interactions you've had with doctors at Moore Memorial."

I nodded and described my experiences with Doctor Rosenbaum, Doctor Mastriano, Doctor Lawson, and, to a lesser extent, Doctor Rafiq.

"We're basically out of time," Maryann said. "I know you have a crazy schedule, so shall we say two weeks from today?"

"Yes."

"I'll leave you with this question, which I don't need you to answer today -- do you believe you can solve every single thing that ails medicine?"

July 26, 1989, McKinley, Ohio

"I'd say she asked exactly the right question," Clarissa said after she, Rachel, and I sat down in a booth at Frisch's.

"What can I get you?" the waitress asked.

"FRIES!" Rachel exclaimed happily.

"You need something other than fries," I said.

"More fries!" she giggled.

"Your mom, aunt, and I are going to have words!" I chuckled.

I ordered a chopped salad given it was Wednesday, Clarissa ordered a Big Boy platter, and we ordered a chicken strips and fries from the kids' menu for Rachel.

"She made a good point, you know," Clarissa said once the waitress had left.

"I don't want to cure every ailment, just the ones that affect me."

"So, as she said, every ailment. Come on, Petrovich! You know darn well it all affects you one way or the other because you care so deeply about both the practice of medicine and your patients. And you need to focus on your patients."

"You do realize that was what I was doing with Mr. Alien Encounter, right? Looking out for my patient."

"I know this is going to sound wrong, but you care too much."

"How is that even possible?"

"What is your job, Mike? I know you've been asked that question before, and I know you know the answer. I want to remind you that every single day you pray to the Savior of the World, and that is not you. Honestly, if you can't do your job the way it's meant to be done, you'll prove Lawson correct."

"What if the way it's meant to be done is wrong?"

"When it's YOUR department, you change it. Until then, and that will happen, you have to work by the policies that are set by the Chiefs. And guess what? Even when you're Chief of Emergency Medicine, you can't tell the other chiefs what to do. And unless you become medical director, a job you don't want, that's going to be the way it is."

"That's defeatist!"

"No, it's not, Petrovich! It's reality. And I'm not saying you have to be complacent, but you have to accept reality. I know it's not an Orthodox prayer, but it's one I know you could pray - 'God, grant me the serenity to accept the things I cannot change, courage to change the things I can, and wisdom to know the difference.'"

"Martin Luther King was influenced by Reinhold Niebuhr."

"Which is high praise in your book."

"He was also an avowed socialist in the 1930s."

"So high praise from your wife, too! You understand the key phrase, right?"

"The wisdom to know the difference."

"So do that. You won't do anyone any good if you burn out, or worse, have someone decide you aren't really qualified to be a doctor. We know that's not true, but you're giving idiots like Rosenbaum and Mastriano ammunition they don't deserve, and you KNOW they'll try to use it against you."

"I'm just trying to be the best doctor I know how to be," I protested.

"Remember the prayer, Petrovich! If you're lacking anything, it's what I think you call discernment, but which Niebuhr called 'wisdom'. Mike, you're regarded as the best young doctor in the hospital. Be that doctor. Don't throw it away in some Quixotic crusade to single-handedly save the world."

"The entire system is fu...messed up."

Clarissa laughed, "Don't want a certain little tape recorder to repeat what you say?"

"That would be bad," I chuckled. "She'll learn those words eventually, but why give her a head start?"

The waitress brought our food and after I prayed, we began eating, with Rachel greedily and happily eating her fries, which she finished before she ate her two small chicken tenders which she slathered in catsup.

"Are we OK, Petrovich?" Clarissa asked.

"If anyone can call me on the carpet, you can."

"But how many times before you actually listen? It's been three years, Petrovich. And it's the same story over and over again. Something offends your notions of right and wrong, and your response every time is 'damn the torpedoes; full speed ahead!' Well, this isn't the Navy, and it's not a suicide mission."

"Daddy! Poo!"

"You got that exactly right, Rachel!" Clarissa said through barely contained laughter.

I cleaned Rachel's face and hands with a pre-moistened towelette that came with her meal, then took her to the restroom where I changed her diaper. After washing my hands, we returned to the table so I could finish eating.

July 26, 1989, Southern Ohio Correctional Facility, Lucasville, Ohio

"Doctor Michael Loucks, chaplain, here to see prisoner Frank Bush," I said to the officer behind the plexiglass.

We went through the same basic motions as during my previous visit, and ten minutes after I'd arrived, Frank Bush, dressed in orange prison overalls, was escorted to the visitors' room and sat down across from me.

"How are you?" I asked.

"How do you think I am?"

"We had this conversation last time, so rather than repeat it, I'll simply assume your answer would be 'as well as can be expected, given the circumstances'. The book you asked me to order will be shipped directly here next month."

"Thank you."

"What else can I do for you?"

"Nobody can do anything for me."

"That's demonstrably false, because I arranged for you to get your book."

"Meaningless in the larger scheme of things, but if it makes you feel good..." he shrugged.

"I expect you'll obtain some amount of enjoyment from the book, even if the locale leaves something to be desired. If that weren't true, you wouldn't have asked me to get it for you."

"How do you find being a doctor?"

"Not all it's cracked up to be," I replied.

"You're an Intern, and that's tough in general, but toughest in trauma. What has you disillusioned?"

"Mostly things which are outside my control."

"That's the exact reason I went into private practice, instead of working in a hospital. I made my own rules, set my own hours, chose my patients, and practice medicine exactly the way I wanted. But I get the feeling that's not you. You're driven in a way I never was."

"I'm interested in how you became a doctor."

"The same way everyone does -- medical school and Residency."

"Obviously, but was it a family thing?"

"My dad was a physician, though a GP, not a pediatrician."

And that had been Melissa's goal as well, and in theory she could be a pediatrician or a GP, despite matching for internal medicine. The track to being a pediatrician was a bit complicated, but could be done by taking shifts in pediatrics during her Residency. I suspected that in her rural medical center, that would be easier than it would in a big city hospital, or even at Moore Memorial.

"I'm the only physician in my family. My dad's side were all businessmen or government employees; on my mom's side it was all trades of some kind in Russia and here. Would you like to play chess?"

"If you want."

I signaled the guard and asked for a chess set, which was brought from an adjoining room. Frank took the white pieces, and I took the black, and we began to play while we talked.

"I spoke to Melissa," I said.

"I'm going to guess she has no interest in speaking with me."

"Correct, but I'll keep in touch with her. At a minimum, I can let you know how she's doing."

"What is it you want?" Frank asked, moving his queen-side knight.

"Why do I have to want something?" I asked. "I'm sure you recall Matthew 25, starting at verse 31:"

When the Son of Man comes in His glory, and all the holy angels with Him, then He will sit on the throne of His glory. All the nations will be gathered before Him, and He will separate them one from another, as a shepherd divides his sheep from the goats. And He will set the sheep on His right hand, but the goats on the left. Then the King will say to those on His right hand, 'Come, you blessed of My Father, inherit the kingdom prepared for you from the foundation of the world: for I was hungry and you gave Me food; I was thirsty, and you gave Me drink; I was a stranger, and you took Me in; I was naked, and you clothed Me; I was sick, and you visited Me; I was in prison and you came to Me.'

"Then the righteous will answer Him, saying, 'Lord, when did we see You hungry and feed You, or thirsty and give You drink? When did we see You as a stranger and take You in, or naked and clothe You? Or when did we see You sick, or in prison, and come to You?' And the King will answer and say to them, 'Assuredly, I say to you, inasmuch as you did it to one of the least of these My brethren, you did it to Me.'

"Then He will also say to those on the left hand, 'Depart from Me, you cursed, into the everlasting fire prepared for the devil and his angels: for I was hungry and you gave Me no food; I was thirsty, and you gave Me no drink; I was a stranger, and you did not take Me in, naked and you did not clothe Me, sick and in prison and you did not visit Me.'

"Then they also will answer Him, saying, 'Lord, when did we see You hungry or thirsty or a stranger or naked or sick or in prison, and did not minister to You?' Then He will answer them, saying, 'Assuredly, I say to you, inasmuch as you did not do it to one of the least of these, you did not do it to Me.' And these will go away into everlasting punishment, but the righteous into eternal life."

"Memorized that for today, did you?"

"No. We use so much Scripture at church that I have about half the Psalms and a third of the New Testament memorized," I said as I castled king side. "Our monks generally have the entire Psalter memorized."

"Then I'm sure you know that the Scriptures say a pastor is to have a wife and kids."

"Which is, of course, why the vast majority of our pastors are married men," I replied. "But back to the verse, how could I, as a believing Christian, not obey that text?"

"The same way you don't obey the instruction to call no man 'father'."

I smiled as I moved my king's knight, "And yet, you and I both have fathers, and use that term. That verse is not intended to be taken any more literally than Paul's command to pluck out your eye or cut off your hand is to be taken literally. As my former bishop said, 'let the Protestants and their scholars fight over the literal truth of each word, while we worship the undivided Trinity who has saved us'."

"And you're here to save me, is that it?" Frank asked, moving his queen.

I shook my head, "Only God can save. All I can do is live my life as a Christian. As Saint Seraphim of Sarov said -- 'Acquire the Spirit of Peace and a thousand souls around you will be saved'. His advice for how to achieve that was succinct:"

"You cannot be too gentle, too kind. Shun even to appear harsh in your treatment of each other. Joy, radiant joy, streams from the face of him, who gives and kindles joy in the heart of him who receives.

All condemnation is from the devil. Never condemn each other, instead of condemning others, strive to reach inner peace.

Keep silent, refrain from judgment. This will raise you above the deadly arrows of slander, insult, and outrage and will shield your glowing hearts against all evil.'"

"So this is about you, then?"

"No, it's about God's love and mercy. But I'm actually interested in where you went to college and medical school, and when you decided to be a doctor."

"My dad and grandfather expected me to be a doctor, so I never really gave consideration to anything else. I attended University of Virginia, then Drexel for medical school, which is the same as both my father and grandfather. I did my Residency at the University of Virginia Hospital."

"You met your wife sometime around then, right?"

"When I was a Third Year. We married after I started my Residency."

"Your dad and grandfather practice in Virginia?"

"Yes. I moved here because Fred Newsome and I were friends in medical school and wanted to practice together, similar to what I've heard about you and the lesbian."

"The lesbian has a name," I said. "It's Clarissa Saunders. Where did Doctor Newsome serve his Residency?"

"The University of Cincinnati," Frank replied. "He's from Hamilton, Ohio, and we met at Drexel."

"Did you attend the same church as your dad?"

"My dad and grandfather were High Church Episcopal, but I read my bible, and joined Faith Bible Fellowship."

"Where did your wife attend before that?"

"She was basically unchurched. Her parents were Lutheran. What about your family?"

I delayed answering to consider my next move, shifting my knight.

"Check," I said. "My mom's side has been Orthodox since the tenth century; on my dad's side, Dutch Reformed, and they attended a Bible church in the Chicago suburbs. My parents met at the University of Illinois and dad converted. He's basically unchurched since the divorce."

Frank countered by moving his king, providing me with a slightly stronger line of attack, but as rusty as I was, I wasn't sure I'd be able to sufficiently press the advantage.

"Do you attend services here at all?" I asked.

"No. I know exactly what the Scriptures say."

"I'll happily debate that with you, though I'd rather simply talk."

"I expected you to start preaching at some point."

"James also says he'll show his faith by his works, and I'll take him at his word. Did you two found the practice?"

"We bought a practice from a doctor who was about to retire. His dad and my dad financed the purchase for us."

"What happened when you were arrested?"

"I actually retained an ownership interest in the partnership, so I receive a portion of the profits. A good chunk of that goes to Nadine, and she received everything else we had in the divorce. I didn't contest it because what was I going to do? But the money I get keeps me in commissary."

I shifted my rook, preparing for my next attack.

"How does that work?"

"Basically we can spend our own money to purchase additional items to what the state provides -- toiletries, food, stationery, stamps, and other sundries."

"I take it most of that money comes from families?"

"Yes. They can make deposits into the commissary account, though there are rules if you owe fines or restitution about how much can be in that account."

"What do you do all day?" I asked, advancing a pawn.

"So long as I behave, I can spend most of my free time in the day room, which is where the TV is, or the library. There are free weights and when the weather is nice, I can spend an hour a day in the yard. Lights out is 10:00pm, and lights come on at 7:00am, and I work for three hours in the laundry after breakfast."

"What about education?"

"Correspondence courses, mostly."

"Check," I said, capturing a pawn with my bishop and revealing a check.

Frank toppled his king, and we reset the board with me taking white and him black.

We played a second game, and I made a fairly large blunder mid-game, allowing Frank to win, and then my two hours were up. Most visits were an hour, but chaplains had up to two hours per person they visited. Given it was permitted, I shook hands with Frank before calling the guard over to collect the chess set. Once he'd counted the pieces, he put it away, then called for a guard to escort Frank to the day room and me to the entrance.

"How did it go?" Clarissa asked when I got into the car.

"We talked and played chess. He's doing about as well as anyone could expect, given his predicament."

"And he's ready to join the Orthodox Church?"

"That's not my goal, Lissa. My only goal with him is to give him some hope. At some point in the next year, I'll see if I can hold a weekly Vespers for anyone who might be interested. How was the park?"

"We met some moms and kids and Rachel had fun playing with the little girls while I chatted with the moms."

"That's you for real someday."

"I think I can wait a few years on having one of my own! You're going to work on siblings soon, right?"

"We're getting in occasional practice now, so we'll be ready."

Clarissa laughed, "You're the last person to need to practice! And you know the equipment works not just for pleasure but for procreation. Changing subjects, are you going to take the beatings to heart, or are you going to do what you usually do and require additional beatings?"

"All I can do is try, Lissa."

July 27, 1989, McKinley, Ohio

"Lawson called Northrup," Doctor Gibbs said when I checked in with her before my shift started on Thursday morning.

"Unhappy that I humored the patient."

"You could say that."

"And?"

"I understand Shelly Lindsay spoke with you."

"She did."

"Then that's the end of it. You're a surgical intern and were counseled by a senior Resident from your service."

"Did he say anything about you having signed the chart?"

"Between you and me, and off the record, he and I had a good laugh. Then he said you need to stop antagonizing Bill Lawson."

"I am going to testify on Angie's behalf, no matter what Doctor Lawson thinks."

"He did encourage Northrup to try to dissuade you, but Northrup declined, because you're not giving medical testimony and it's not about someone at this hospital."

"And if it was?"

"You'd have to ask Northrup for the answer to that question, because I don't know."

"Besides Shelly, Clarissa spoke to me, and I went to see a counselor Shelly recommended in Columbus."

"Maryann Manning?" Doctor Gibbs asked.

"Yes. You know her?"

"I had three sessions with her when I was a PGY1."

"Stress?"

"Caused by the intersection of idealism and reality, combined with lack of sleep. Sound familiar?"

"It does," I confirmed.

"It's a common ailment," Doctor Gibbs said. "Shelly was the one who sent me to see Maryann. She was my mentor because there were no female Residents in trauma when I arrived, and Doctor Simons was the only female Attending. Shelly was the first female on the surgical staff, and we still don't have any female Attendings."

"She's a PGY5, so three more years and she'll be the first female surgical Attending. That's a good thing, but delayed far too long."

"When she started college thirteen years ago, nobody in Surgery would have even considered selecting a woman in the Match. Cutter had to fight to get her five years ago."

"She's one of the best up there," I said.

"She is," Doctor Gibbs confirmed. "Play things at least in the neighborhood of the book today? Please?"

"I'll do my best."

"That's what I'm afraid of!" Doctor Gibbs said with a wry smile. "Go heal the sick."

I left the office and went to the lounge to get the handover from Kayla Billings. There were two patients waiting to go up to Medicine and one to discharge. Bob, Len, and I handled those three cases, catching an EMS run just after the last patient.

"Cody Nelson, twelve; go-kart accident; flipped and his head struck the pavement; no LOC; pulse 76; BP 110/70; PO₂ 98% on air; multiple scrapes and contusions; cervical collar and backboard."

"Trauma 2," I said. "Do you have the helmet?"

"Deputy Miller has it," the paramedic said, just as the Sheriff's Department cruiser pulled up.

"Len, monitor, but no EKG; Bob, primary assessment. I want to talk to the deputy."

"No IV or blood?" Bob asked.

"No. And be very careful moving him."

The two paramedics and my students went into the ED while I walked over to the cruiser.

"Hi, Doc," Deputy Miller said.

"Greg says you have the helmet."

"Yep," he said, retrieving it from the passenger seat.

I looked at it and saw a scrape, but it was intact otherwise.

"Thanks," I said. "Parents?"

"Deputy McCallum is on his way to inform the dad; he works construction and there's no phone on the site."

"OK. Have him find me when he arrives."

"I'll radio it in."

"Thanks."

I walked into the building and went to Trauma 2.

"Continue your primary exam," I said to Bob. "Cody, I'm Doctor Mike. How are you feeling?"

"Dizzy, and my head hurts."

"Can you tell me what happened?"

"I had my go-kart out and was on our street. The kid who lives next door rode his bike out in the street in front of me and I swerved, hit the curb, and flipped."

"Did you lose consciousness?"

"No, just dizzy and my head and leg hurts."

"No apparent internal injuries," Bob said. "No CSF. Pupils reactive. Leg is bruised, but no breaks or lacerations."

"Babinski," I said.

He performed the check, and the response was proper.

"Clear the neck," I said.

"I haven't done that before," Bob said.

"OK. Carefully feel under the cervical collar for any swelling or distension, or bulging vertebrae."

Bob did that, then said, "I think it feels normal."

"Cody, I'm going to double check your neck," I said.

I checked and confirmed Bob's findings.

"Now, I'll hold his head, and you remove the cervical collar," I said. "Then repeat the check."

Bob followed my directions and found nothing.

"Cody," I said. "I'm going to slowly rotate your head right and left. You tell me if your neck hurts, or if anything feels strange."

I did that and Cody reported no pain.

"You can unstrap him from the back board, remove it, then raise the bed so he can sit comfortably."

As Bob and Len were doing that, Deputy McCallum came into the room with Cody's father.

"Mr. Nelson, I'm Doctor Mike," I said. "Cody has no serious injuries, though I believe he has a concussion. Because there is a scrape on the helmet, I'm required to call for a neurology consultation."

"What happened, Cody?" Mr. Nelson asked.

"Joey purposefully drove his bike in front of me," Cody said.

"Deputy, I want that kid arrested!" Mr. Nelson said. "This has happened four times now. Every time my kid tries to drive his go-kart, the neighbor kid rides in front of him, or throws things at him."

"Deputy, the consultation room is free if you want to take a report. Len, call neurology, please."

Deputy McCallum escorted Mr. Nelson from the trauma room, and about five minutes later, Doctor Larry Flynn came in.

"Flynn, Neuro."

"Mike Loucks," I said. "Bob, present please."

He did, and Doctor Flynn walked over to Cody.

"Hi, Cody, I'm Doctor Flynn and I'm a neurologist, which is a brain doctor. Mike, the helmet?"

I reached over to the counter and handed it to Doctor Flynn. He looked it over, then handed it back.

"Did you lose consciousness?" Doctor Flynn asked.

"No, but I was dizzy and my head and leg hurt. Mrs. Jameson told me not to move and called the Fire Department."

Doctor Flynn repeated the neuro checks and cleared Cody. We conferred and agreed Cody could be discharged. I updated the chart, we both signed it, and I took it to Doctor Gibbs for her signature. Once that was complete, I returned to the room and explained to Cody and his dad that Cody needed three days of rest and should take Tylenol or Advil for pain. I went over the reasons they should return, gave Cody his choice of candy, then directed them to Patient Services.

We handled three walk-ins before Detective Kleist came into the ED with a young woman in handcuffs.

"Mike, can you take this one?" Ellie asked. "Exam 4."

"Sure. I'll need a nurse."

"Kellie will come in with you."

"Exam 4, Detective."

"Bob, Len, take your break, please."

Kellie joined me and we went into Exam 4 with Detective Kleist and her arrestee.

"What's your name, Miss?" I asked.

"Fuck you!"

"OK. Miss You, why are you here?"

She simply glared at me.

"Department policy is anyone under eighteen is brought here for a health check before we take them to holding."

"Name and age?" I asked Detective Kleist.

"Debbie Jones, sixteen."

"What are the charges?" I asked.

"Possession with intent to distribute."

Which was non-violent, and the girl didn't look dangerous, though she had a bad attitude.

"Can we remove the cuffs, please? I'll need to do an exam."

"Compromise on one cuff on the rail of the bed?" Detective Kleist asked.

"That will work," I agreed. "Debbie, do you consent to an exam?"

"What if I say 'no'?" Debbie asked defiantly.

"Then Detective Kleist will go see a judge in Juvenile Court who will order an exam. If you were over eighteen, they'd take you to the city jail where they'd examine you and you wouldn't have a choice. But I can't examine you without your permission or a court order. You'll only piss off Detective Kleist by requiring her to do extra work, and you'll still have to have the exam. I can get a female doctor if you prefer, too."

"Fine."

"OK to examine you?"

"I said 'fine'!"

"Detective?"

Detective Kleist removed the cuff from Debbie's left wrist and hooked it to the railing of the exam bed.

"First question," I said. "Are you on anything?"

"I'm not saying anything with the cop here."

I understood her lack of cooperation, but it was important to know if she was on anything.

"Then well do it the hard way," I said. "Kellie, CBC, Chem-20, tox screen, EtOH level, and hCG."

Kellie drew the blood and called a student nurse take it to the lab. I put a monitor on Debbie's finger, then checked her blood pressure and temperature.

"PO₂ 99% on room air," I announced so Kellie could record Debbie's vitals on the chart. "Pulse 72; BP 120/70; temp 36.9°C. Debbie, I need to check your heart and lungs."

Debbie didn't object so I auscultated her heart and lungs through her thin t-shirt.

"Lie back, please."

I palpated her abdomen, listened for bowel sounds, checked her peripheral pulses, then had her sit up so I could check her ears, eyes, nose, and throat, then checked the glands in her neck.

"Barring something in the blood work, she gets a clean bill of health," I said.

"How long on the blood work?" Detective Kleist asked.

"Anywhere from sixty to ninety minutes, because it's not stat."

"I have a form for you to sign once the blood work comes back," Detective Kleist said.

"You'll need Doctor Gibbs signature," I said. "But I'll take care of that."

"Buy you a drink at the end of your shift?"

"That's not until tomorrow at 6:00pm, and then I'm going home to my wife."

"Tough luck," Debbie said with a smirk.

"Keep your mouth shut!" Detective Kleist ordered.

"We'll come back when we have the blood test results."

"Thanks, Doc," Detective Kleist said.

Kellie and I left the exam room and went to inform Doctor Gibbs. Once that was done, we went to the lounge.

"She's cute," Kellie said.

"The detective? She is, and persistent. But she's barking up the wrong tree."

"I realized that from the first second I met you. Your wife is a lucky woman."

"Yes, she is. But I'm luckier."

XXVIII. 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 and 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 on 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 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.

"We had a guy on the 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, 'lytes, 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 never heard it called just 'dust'. And that would explain it. It can cause hallucinations, 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 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 knew, 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 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.

"The rest of the lab tests aren't back?" she asked.

"No. Len, call to check, please, and ask them to expedite."

"Will do!"

"Let me do an exam," Doctor Cohen said.

She repeated the same steps I'd gone through with my primary exam.

"And it's been how long since he was found?"

"Call it seventy-five minutes," I replied. "His clothes and the drugs were in his car, so I figure at least ninety minutes since he ingested or inhaled the drugs. He shouldn't be in what amounts to a postictal state."

"No medical history?"

"No. I'm not sure what the police are doing with regards to finding family."

"I'd say there's something neurological, though it could be psychiatric."

"I'd prefer to rule out medical causes," I replied. "CAT scan and EEG? Maybe he's actually an epileptic?"

"That's one thing we can't rule out, given his current state. Let's get the CAT scan first because if he did have a hemorrhagic stroke, he'll need some kind of procedure. Chart?"

Len handed her the chart, and she made the notations for a CAT scan.

"Al," she said to her student, "call radiology and tell them we need a stat CAT scan."

Al picked up the phone and dialed and had a brief conversation, then put his hand over the mouthpiece.

"They're backed up," he said. "It'll be close to two hours unless the Chief bumps."

"Book that," she ordered. "Mike, given he's not showing any other signs, we can't bump another patient. Keep a close eye on him and watch his BP and his pupils. Keep him on the EKG. If you see any blips, and I mean any, call me and I'll have Doctor Baker or Doctor Sandberg call Radiology to get priority."

"Thanks, Rebekah."

She and Al left, and I wrote the instructions onto the chart, leaving Len with the patient, and went to report to Doctor Gibbs.

"I'd say that was the right call," she said after listening to my report. "There are reports of severe psychological and physiological effects from high doses of PCP, beyond the exaggerated TV stuff."

"I have Len on permanent watch," I said. "I'll do a check every twenty-minutes, or send Kellie if I'm tied up. Where did Detective Tremaine go?"

"I'm not sure. Why?"

"We could really use a medical history."

"Have Nate call the PD and find out. He can chase the records, too."

"I actually had Bob check the recent charts, but there was nothing there."

"Nate's computer terminal could tell you if he's been here before that. Have him check in addition to chasing the cops."

"Will do."

"Doctor Varma needs help with walk-ins."

"OK."

Two hours later, after treating three walk-in patients with minor ailments, we finally got Mr. Russell to radiology for his CAT scan. I had my lunch while that was occurring, then went to speak with Doctor Cohen.

"Nothing," she said. "I'll admit him to my service for an EEG, and we'll take it from there."

"Len and Bob will bring him up."

I arranged that and had them take their lunch break once they'd escorted Mr. Russell to neurology. I called Clarissa to let her know, and then helped with walk-ins until I was called for an EMS run for a pair of smoke inhalation victims, which Doctor Gabriel and I handled. Neither patient was at any real risk, and basic oxygen therapy and monitoring were sufficient and we were able to street them before dinner.

"Did you have a better day today?" Kris asked when she and Rachel joined me in the cafeteria.

"No windmill tilting. I did find out my schedule for September and October. The major plus is that I'll only have to work eighty hours, and I'll be home every night. The downside is I'll work six days a week. That said, I'll be able to attend Vespers on both Wednesday and Saturday, and services on Sunday morning."

"That sounds much better!"

"Overall, yes, though I'll start at 5:00am and work until 9:00pm on Monday, Tuesday, and Thursday; 5:00am to 5:00pm on Friday and Saturday, and 8:00am to 5:00pm on Wednesday, with that day being at the Free Clinic. I'll only have eight hours off between some of those shifts, but that beats thirty-six straight, because it guarantees I'll be able to sleep five hours, which I haven't even come close to this month."

Which was, of course, the main point, as it had been sleep deprivation which had, in the end, led to the bad result for Libby Zion.

"We can arrange Rachel's schedule so she doesn't go to bed until after you arrive home," Kris suggested. "She'll just take longer naps in the afternoon. That way, we can say evening prayers as a family every day."

"That sounds good," I said.

"What are you going to do about Maryam's wedding?"

"Already covered with Doctor Gibbs. I'll get someone to cover the Saturday shift."

"What about band practice?"

"That was always going to be a problem for this year, and I asked Kim not to schedule any more gigs before the end of the year beyond the ones we have scheduled -- Stirred not Shaken, Taft, Goshen, and Newtown. And my schedule actually allows for all of those. We'll just need to find time to practice, but if we don't add any new songs, they can practice without me most times and I can run through my songs for you and Rachel."

"She'll love that!"

"Like when Daddy sings!" Rachel declared.

"Your adoring audience!"

"How adoring is she going to be with a sibling?"

Kris laughed, "I think she'll be fine, so long as the addition is female! She has zero use for males of her own age!"

"On that topic, is your sister dating?"

"She was asked to the Fall dance, and said 'yes', and that will be her first real date."

"I don't know if I should congratulate or pity the boy!"

"As long as he treats her like the princess she thinks she is, he'll be fine!"

I chuckled, "Empress, is more like it! Can you imagine when the Tsarina has her first date?"

"You're no longer clergy, so will you follow the redneck Ohio tradition of buying a shotgun?"

"I am NOT a redneck, despite being from a rural area of Ohio. I know that me being from a rural area offends your «Parisiens» sensibilities, but so be it!"

"You think I'm elitist?!"

"Is there anyone from Paris who is not?" I teased. "Tell me you don't believe it's the most important city in the world with unmatched cultural significance! And that it's a leader in cuisine, fashion, art, music, literature, theatre, and cinema!"

"You are very difficult, Michael Loucks!"

"Thank you," I said with a silly smile. "But in all seriousness, you do have a worldview that believes cities are better than rural areas. The US, until very recently, had decidedly the opposite opinion, but things are beginning to shift. For the US, the ideal has always been the small town, not the big city, and you know the Constitution is, to put it pejoratively, rigged against densely populated states because of the composition of the US Senate."

"I made that point in American Government and it was not well received."

"That's no surprise. You know why, right?"

"Yes, of course. I studied what your Founding Fathers have said! And you know they very much loved France!"

"Especially Franklin! How is your studying going for your citizenship test?"

"It's fine. I'm sure I will pass it. I spoke to the attorney, and he believes I'll hear from them about interviews soon."

"Let's hope it's in August, because September and October will be difficult. I'll arrange it, of course, but August would be easier."

"What about seeing Father Roman and the man in prison?"

"I'll speak to Father Roman by telephone. He was aware that my schedule might make visiting the monastery difficult if not impossible at times. I'll have to figure something out for Frank Bush, as I don't want to miss my monthly visits with him. But I'll worry about that in a month or so."

"OK to join you?" Clarissa asked coming up to the table.

"Clarissa!" Rachel exclaimed.

"I'd say that's all the approval you need," I observed.

Clarissa sat down and began eating.

"Any word on the altered patient?" she asked.

"His EEG showed depressed brain function consistent with a postictal state. Right before I came to dinner, I heard that they'd found his brother in Kenosha, Wisconsin, and Doctor Cohen was going to call to speak to him. The current thinking is that it's an adverse reaction to the PCP. In effect, a brain short circuit, to put it in layman's terms."

"What happened?" Kris asked.

"A patient was found walking naked down Main Street. He was disoriented, and by the time they got him to the hospital, he was basically non-responsive, though not unconscious or in a coma. We ran all manner of tests, but at this point all we know is he used PCP, also called 'Angel Dust'. It's a class of drug called dissociative anesthetics, and it's taken for its mind-altering effects. Well, in this case, it seems to have altered the patient into a condition from which we, so far, can't resolve, and isn't resolving on its own."

"So what do you do?"

"Run tests and try to find a cause that we can fix, otherwise, he ends up in some kind of long-term care facility which I wouldn't wish on my worst enemy."

"You don't have any enemies!" Clarissa countered.

"Fine," I said flatly. "I wouldn't wish it on anyone."

"Touchy, touchy!" Clarissa smirked.

"Don't you have drugs to push or pharma reps to hang out with?"

Clarissa stuck her tongue out at me.

"How adult," I chuckled.

"Well, I am dealing with a guy, and they're pretty much toddlers in bigger bodies and with larger...wallets."

Kris laughed, "Yes, 'wallet' is what you meant!"

"And you know that particular part of male anatomy holds NO interest for me! But I bet you agree on my assessment of Mike!"

"Mike is actually pretty good," Kris said with a wink.

"He's not too bad," Clarissa said.

"At least I can count on Rachel for support!" I declared.

"Until she's about fourteen and wants to go on a date!" Clarissa teased.

"So long as I approve of the boy, we won't have any problems!"

"And you know your daughter will be sure to find someone who you don't like just to tweak you!"

"Perhaps," I allowed. "But we'll worry about that in twelve years or so!"

I finished eating and had to return to the ED, so I hugged and kissed Kris and Rachel, and left them with Clarissa. When I arrived in the ED, Mary and Tom had arrived to relieve Bob and Len.

"Mike?" Nicki called out. "Paramedics three minutes out with a choking victim. Use Trauma 2."

"Mary, Tom, let's go!"

I stopped at the nurses' station and asked for a nurse, and Jenny joined Mary, Tom, and me in the ambulance bay.

"Jacob Schultz; thirty-eight; choking while eating, Heimlich maneuver performed by a fellow diner; brief LOC; regained consciousness on site; pulse 80; BP 120/70; PO₂ 99% on three liters; GCS 15."

"Trauma 2," I ordered.

We began rolling the gurney into the ED.

"Mr. Schultz, I'm Doctor Mike. Are you having trouble breathing at all?"

"No," he said, his answer muffled by the oxygen mask.

"Jenny, we'll just go with a nasal canula; draw for an ABG. Mary, EKG and monitor."

In the trauma room, we transferred Mr. Schultz to the treatment table and while I performed the basic exam, Jenny and Mary carried out my instructions.

"What happened, Mr. Shultz?" I asked when I finished the exam.

"I was eating and my buddy and I were telling jokes. He told one that made me laugh hard while I was chewing a piece of steak. It went down the wrong pipe and I passed out while he was trying the Heimlich maneuver."

Which meant his friend probably had not applied enough pressure initially to expel the piece of steak and eventually had used more force once his friend had passed out. That was not an uncommon occurrence, and was something that was highlighted in our brochure on choking.

"Do you have a headache?" I asked.

"Mild," he replied.

"Everything checks out," I said. "We'll get your blood gas levels back in a few minutes, but I expect the results to be OK given your physical condition. If they are, we'll keep you for a few hours for observation because you were briefly unconscious. Any questions?"

"Why do I have to stay for a few hours? Not that I won't, but I feel fine."

"Precaution," I replied. "Anyone who has been unconscious is monitored for a few hours, at least. Anytime you pass out, especially due to oxygen deprivation, you could have delayed heart or breathing problems. I don't expect that, but I prefer to take the cautious approach."

The phone rang and Jenny answered it, and received the verbal ABG numbers which she repeated to me. I sent Tom to get the printouts, and let Mr. Schultz know the numbers were all in range.

"We'll have you out of here around 8:15pm," I said. "I'll do the paperwork now so there are no delays."

"Thanks, Doc."

"Jenny will check on you every fifteen minutes or so, but if you need anything, just press the purple button on the box next to the treatment table."

"Thanks again, Doc."

I left the room with Mary and Tom, filled out all the paperwork, then reported to Doctor Taylor. He signed the chart and Nicki let me know there were several patients waiting in triage. We handled a broken arm, and a sprained ankle, then discharged Mr. Shultz. There was nobody in triage, so I decided to grab a nap, and actually managed to sleep ninety minutes before I was woken for an EMS run.

July 28, 1989, Circleville, Ohio

"How was your day?" Kris asked after I greeted her with a hug and scooped up Rachel when I arrived home on Friday evening.

"Busy, but not crazy. I managed to get two ninety-minute naps. How about yours?"

"There's are two letters from the INS with interview dates and times."

"Specific dates and times? Not requesting we schedule them?"

"The letters say we're directed to appear at their offices on Monday, August 21st, at 9:00am sharp."

"Let's ask John Burge if the interviews could be conducted at the hospital. Obviously I'll get someone to cover for me if they won't do that, but maybe the situation will move them to cut us some slack. And it doesn't hurt to ask."

"OK. I'll call him on Monday and ask. If they won't, then perhaps a Wednesday?"

"That would work as well."

"Dinner is in about ten minutes. Are you going to bed right after dinner?"

"No. I can stay up so we can say evening prayers, and I can participate in Rachel's bedtime routine. And then make love to my wife, if she's interested."

"She's interested! Go get changed and then we'll have dinner."

"Rachel, stay with Mommy," I said, putting her down. "Daddy will be right back."

She scowled at me but she didn't fuss. I went upstairs, changed out of the slacks, shirt, and tie I wore to and from the hospital into shorts and a t-shirt, then went back downstairs to have dinner with Kris and Rachel.

"What happened with the man who they found walking naked down the street?"

"As of this morning, no change, but that was the last I heard. I usually don't get updates, but Clarissa is consulting with Neurology and Psych, and she told me at breakfast. It's a tough case, and it may be that the drugs basically caused the equivalent of a short circuit in his brain. And that can actually happen with a single hit of some drugs, if you take a large dose. Or your heart could stop."

"Is that what happened to the comedian John Belushi?"

"He did die from something called a speedball, which is a combination of a stimulant and a depressant, in his case, cocaine and heroin. But that wasn't his first time; he had a serious drug problem. Did you know he was Albanian Orthodox and had an Orthodox funeral?"

"I had no idea!"

"Did you know that Jamie Farr, the actor from M✶A✶S✶H, is Antiochian and a member of a parish in Toledo."

"Have you met him?"

"No. I've never been to his parish, either."

"Changing topics, what are we serving on Sunday?"

"I think steaks on the grill, corn on the cob, and salad."

"OK. I'll pick those up tomorrow afternoon when I do the weekly grocery shopping. I know it's still a month away, but what did you want to do for someone's second birthday?"

"Mine!" Rachel giggled. "Rachel will be two!"

"Who told you that?" I asked with a smile.

"«Tante» L'dmila!"

"And the chief family troublemaker strikes again! I think a party on Sunday afternoon with her friends. That would be the day after her birthday."

"I'll arrange it. I'm sure Lyudmila will help!"

"Oh, I'm sure!" I said rolling my eyes.

"Is there a memorial service?"

"I'm sure Viktor has made arrangements with Father Nicholas; I'll ask them."

"Is it OK to ask you about that?"

"Yes, of course."

"You don't think the memorial service is important?"

"Which answer do you want?" I asked.

"The honest one," Kris replied with a smile.

"As much as I loved Elizaveta, my focus has to be you and Rachel. I grieved, in my own way, but I have to focus on the here and now, not the past. I haven't forgotten Elizaveta, and we pray for her in our family prayers, and she's remembered in the Eucharistic prayers at both Saint Michael and the Cathedral."

"You're concerned about the day right?"

I nodded, "Yes. I prefer to celebrate Rachel's life. That's the memory I want of that day, because the other one is too difficult."

"Do you need to see someone about that?"

"I don't think so. I believe I've come to proper terms with it. I have what's called strong psychological resilience."

"Internalizing the grief isn't what's driving your Quixotic behavior?"

"No, that behavior is because of Angie and it's simply something I have to deal with. Shelly Lindsay set me straight, and Maryann Manning will help. Speaking of Angie, I want to see her before the hearing. What would you say about attending services at Saint George in Loveland in two weeks? That will also let me see my godson Michael, whom I've been remiss in seeing."

"Yes, of course."

We finished eating, cleaned up the kitchen, then I read to Rachel, and at her request, played my guitar before we said evening prayers. I helped with Rachel's bedtime routine, and once we put her to bed, Kris and I went to our room.

"Bubble bath, then make love?" I suggested.

"You don't have to ask twice!"

XXIX. I Agree With Doctor Mastriano

July 31, 1989, McKinley, Ohio

"I may have to take off on the 21st of next month," I said to Doctor Gibbs on Monday morning. "The INS sent subpoenas for both Kris and me to appear for interviews. She's going to ask her attorney to request that INS conduct the interviews here at the hospital, but I suspect that will fall on deaf ears."

"An actual subpoena?"

"Yes. Both letters are entitled Subpoena ad testificandum, a command to appear and testify."

"Bring me a copy and you can have the time off. Finding coverage is our responsibility, not yours. That's hospital policy with regard to subpoenas. It's meant mostly for medical cases, but it doesn't say that in the policy manual."

"I'll probably only need about twelve hours," I replied. "The appointment is at 9:00am and I can't imagine it would go past 5:00pm, and I can be here by 6:00pm. We will see if the interview can be moved, but if not, then I'll take advantage of that policy."

"Any concerns?"

"No. The main thing they're looking for is evidence of a sham marriage. According to our attorney, the fact that Kris legally adopted Rachel is dispositive, though the government will go through the motions to ensure it's not a sham."

"Do they really ask questions about sex?"

"According to our immigration attorney, yes. That appears to be a key deciding factor, but it's silly because a bit of planning can defeat any questions they could ask, and I seriously doubt they'd get away with asking for a demonstration!"

Doctor Gibbs laughed, "'Please demonstrate how this is accomplished'?"

I chuckled, "My response would be identical to Pulaski's -- 'Not likely'. Though, had it been Crusher instead of Pulaski, I suspect she'd have happily demonstrated with Picard!"

Doctor Gibbs smirked, "'Wesley, the Prime Directive isn't the only thing I regularly violate on this ship!'"

I laughed hard, "A perfect line for the guy who goes to the planet where literally everyone gets laid and where they make love at the drop of a hat -- any hat -- and ends up with the death penalty for trampling flowers."

"Worf had the best straight line in that regard -- 'Go to her door. Beg like a human.'"

I chuckled, "And Worf's description of Klingon mating rituals sounds suspiciously like dating and marrying a Russian woman!"

"Did you warn Ghost?"

I chuckled, "No, because the benefits far outweigh the suffering! In that way, it's like surgery."

"Go heal the sick!"

I left the office and went to find Kylie so we could do shift turnover.

"Two waiting on beds in Medicine," she said. "Or, rather, waiting until the lazy Resident goes off shift. Clarissa will take them right away, I'm sure."

"Have you reported that?"

"I let Doctor Nielson know before he left this morning. This is the third time. The first time, OK, sure. The second, maybe? The third? No way. And I asked one of the nurses. There are eight open beds."

"Wonderful," I said, shaking my head. "Anyway, I may need coverage for concerts in September and October," I said.

"None this month?"

"At Taft, but it's a Friday night, so I'll gut it out. Once the new schedules hit on August 15th, I'll talk to you about September and October. Anything else?"

"No. It was a mostly quiet night."

"How's your mom?"

"Still alive and kicking, which wasn't a sure thing back when we traded shift schedules."

"That's good to hear."

"And your family?"

"Rachel will be two at the end of August, and she's asserting herself."

"Having more?"

"That's the plan!"

"You proved to my satisfaction you know how that's accomplished!"

I laughed, "Fortunately, only as practice!"

"Fortunately! I'm outta here!"

She left, and I went to the lounge to find Bob and Len.

"Up to speed on the two admissions?" I asked.

"Yes," Bob replied. "Now that it's 6:00am, I'll call upstairs and speak to Doctor Saunders and get them transferred."

"Good. Len, let's go see if there are any walk-ins."

There was actually nobody waiting, so I sent Len to have his breakfast, and I sent Bob for his once the two patients had been admitted. I picked up my first paycheck, or rather a receipt, as the money was direct deposited into my bank account, then went to the lounge.

"Morning!" I said to Ghost when he came into the lounge just before 7:00am. "How was your week off?"

"Enjoyable! Loretta said you had an interesting week."

"You could say that."

"You're going to clash with Psych for the rest of your career. I tend to agree with you, but I'm not nearly as passionate. Just be smart about it."

"Did Lor tell you I'm seeing a counselor recommended by Shelly Lindsay?"

"No. It's almost always off limits to reveal counseling, for reasons I suspect strongly you understand."

I nodded, "To avoid stigmatization, among other things. In my case, it really comes down to what happened with Angie, which sensitized me to mental health issues, something also reinforced by a friend's attempted suicide and another friend's successful suicide, along with my own battles with depression on more than one occasion."

"I've had my own struggles, though nothing compared to yours."

"Ghost? Mike?" Ellie called from the door of the lounge. "Nate says EMS is on scene of a high-speed MVA. Four victims, but no ETA due to potentially lengthy extrication. We're clearing all four trauma rooms."

"Any further details?" Ghost asked.

"No," Ellie replied. "Just Doctor Gibbs saying it's an all-hands-on-deck response."

"Thanks," Ghost said.

"This is where we need paramedics who can intubate," I observed. "Or doctors responding to the site."

"We're understaffed as it is," Ghost said. "The juggling I'm going to have to do with the schedule will be worthy of a circus!"

"Have you heard of Sergej Ignatov?" I asked.

"No."

"A Russian who's called 'The Poet of Juggling'. He often juggles seven balls and holds the world record for juggling eleven rings in the early 1970s."

"That's about what I need for the next ten months. Cutting PGY1s back to eighty hours didn't help, and means PGY2s will be on eighty hours and PGY3s on seventy-two. All Attendings are on sixty hours. And having to have a babysitter for one Attending doesn't help, either."

"For how long?"

"End of August, though ultimately it's up to Northrup. I really need those additional two Residents right now. We're busier than we've ever been, and it's only going to get worse. Patient loads are up nearly twenty percent since last year, and fifty percent over five years."

"EMTALA. I've treated more people who should have been seen by a GP or a 'doc-in-a-box' than I have severe traumas."

"And it's going to get worse," Ghost replied. "Shall we go slum by the ambulance bay doors?"

We got up, grabbed gowns and gloves, but didn't put them on, and went to stand with a gaggle of other ED staff by the door.

"I called for a surgical Intern and one from Medicine," Doctor Gibbs said. "The Medicine Intern will cover anything that comes in while we're on this trauma, and the surgical Intern will pitch in where we need them."

"Which one?" I asked.

"Mary Wilson. Concerns?"

"No, just curiosity."

"Somebody called for the best Intern in the hospital?" Clarissa asked, coming to join us.

"I'm already here," I chuckled.

"277, Petrovich!" she exclaimed.

"Double valedictorian!" I countered.

"And yet, I still had the highest MLE Step 2 score in the history of the medical school!"

"By one point!"

"Now, children..." Doctor Gibbs warned. "Clarissa, you'll need to cover walk-ins. Take the Third years -- Len, Kim, and John -- to assist. Ellie can fill you in on the patients in the exam rooms."

"What's coming in?" Clarissa asked.

"Four high-speed MVA victims."

"ETA?" Doctor Wilson asked, walking up to us with a male student in tow.

"Lengthy extrication," Doctor Gibbs said. "Send your student to help Clarissa."

"Let's go, little ducks," Clarissa said to the Third Years.

I laughed as the four students followed her towards the triage desk.

"First squad is three minutes out with two victims," Nate called out. "Other two are still being extracted."

"We'll double up," Doctor Gibbs said. "Mike, with me; Mary, with Ghost. We'll take the first two. Chuck and Naveen wait for the next squad. Send a nurse to me if you need surgical help."

Two minutes later, the first squad rolled up and Bobby jumped out.

"First patient male, about thirty, restrained passenger; Multiple crush injuries; possible collapsed lung; tachy at 120; BP 80 palp; PO₂ 92% on ten liters; GCS 6; IV saline TKO, backboard and cervical collar."

"Trauma 1 with me!" Doctor Gibbs ordered.

She, Bob, nurse Jamie, nurse Anne, Bobby, and I quickly moved the patient towards Trauma 1.

"Mike, verify the collapsed lung and get a chest tube in; Bob, EKG and monitor then Foley; Jamie, a unit of plasma; Anne, full trauma panel."

We reached the room and rolled the gurney next to the trauma table.

"Carefully, on my count!" Doctor Gibbs ordered. "One...two...three!"

We hoisted the backboard with the patient on it to the trauma table and, after disconnecting the oxygen bottle, Bobby left.

"Absent breath sounds on the left," I announced. "Chest tube tray to me!"

"Plasma running!" Jamie announced. "Chest tube tray to you, Mike!"

"Sinus tach!" Bob announced.

I glanced up at the monitor and confirmed his read.

"Agreed," I said.

Jamie brought the chest tube tray, and I began the procedure.

"Foley is in!" Bob announced. "Blood in the bag!"

"Flail chest, possible skull fracture, crushed right arm," Doctor Gibbs announced.

The patient was, in ED parlance, a 'train wreck'.

"Rigid abdomen," Doctor Gibbs announced. "Surgical belly."

"Let me finish the chest tube and I'll confirm," I replied. "Anne, I need the ultrasound cart."

"I'll get it and give the blood to a student to run to the lab."

I finished the tube and auscultated the patient's lungs.

"Weak bilateral breath sounds," I said. "PO₂ hasn't come up. He needs a vent before I confirm the belly. Intubation tray to Bob!"

I supervised Bob putting in the endotracheal tube, and once he'd hooked up the vent, I verified bilateral breath sounds.

"Good bilateral breath sounds," I said.

The monitor blared and Doctor Gibbs called out, "V-Fib! Charge to 200!"

"Paddles to you," Jamie said to Doctor Gibbs, moving the defibrillator to her.

I grabbed two pads and slapped them on the patient's chest just as the machine pinged.

"CLEAR!" Doctor Gibbs ordered.

We all raised our hands and Doctor Gibbs applied the shock as Anne returned to the room with the ultrasound.

"Sinus tach," I said, then auscultated. "Weak heart sounds. Suspect tamponade or effusion. I need a pericardiocentesis tray!"

Anne grabbed one, remove the cover and set it on the stand next to me, replacing the chest tube tray. Before I could begin, the monitor blared again.

"V-Fib!" Bob called out.

"Charge to 200!" Doctor Gibbs ordered.

Before the machine was ready, I heard the continuous monotone from the monitor and looked up.

"Asystole!" I announced. "Beginning compressions!"

"Anne, 1 meg of epi, IV push!" Doctor Gibbs ordered as I began performing CPR.

"Bob, take over compressions," Doctor Gibbs said. "Mike, resolve that tamponade!"

Bob took my place and as quickly as I could, I performed a blind pericardiocentesis.

"Blood in the syringe," I announced, knowing what that meant.

"Bob, stop compressions!" Doctor Gibbs ordered.

She listened for his heart and shook her head.

"Bob, resume compressions; Anne, another meg of epi!" she ordered.

Two minutes later, nothing had changed and after checking pulse, pupils, and cornea, Doctor Gibbs shook her head.

"Time of death, 07:13."

"I'll get the death kit," Jamie said.

"Mike, let's see if anyone needs help."

Ghost's patient hadn't made it, but the other two were still alive, so we pitched in to help, and sent one upstairs with Mary for emergency surgery while the other continued to be treated in the ED.

"Mike, see what Clarissa has and relieve her," Doctor Gibbs said.

"Right away!" I acknowledged.

I found her in Exam 3 and asked her to step out.

"How'd it go?" she asked.

"Two didn't make it, one emergency surgery, they're still working on the other one, but she should make it. What do you have?"

"Two needing sutures which Len and Kim are doing, and John is splinting a broken finger."

"Doctor Gibbs said to relieve you; Bob and I will take over."

"Then I'm off!"

"That's for sure!" I teased.

"277, Petrovich. 277."

"Go back to pushing pills, Lissa!"

She stuck her tongue out at me, winked, then headed for the stairs.

"I take it you two have extensive history?" Bob asked.

"Partners in crime since Freshman year at Taft. We agreed to go to medical school together, serve our Residencies together, and practice together."

"But you couldn't marry?"

"Clarissa's girlfriend might have something to say about that."

"Oops. Sorry."

"Nothing to apologize for. She doesn't advertise, but she also doesn't hide it. Check on our suturing ducklings, please."

"Can I have you sign my procedure book for the intubation?"

I took his book, signed, then added a notation he was cleared for unsupervised intubation.

"You think so?"

"I didn't have to guide you and you got it right, with time to spare. The chances you'll need to do one unsupervised are slim, but you can let any Resident or Attending know you're completely cleared. Good job on the EKG as well."

"I should have called out 'Asystole'."

"I beat you to it because it's basically a reflex for me from Fourth Year. I should have let you do it. Would you supervise Len and Kim, please? I'll check on John and his splint."

"Right away, Doc. Thanks for the faith."

"Keep doing what you're doing."

We cleared the three patients, along with two more walk-ins, before another EMS run for a rule-out MI, who we admitted to cardiology with uncontrolled A-fib. I had lunch, and we had a steady flow of patients during the afternoon, and I joined Kris, Rachel, and Clarissa for dinner in the cafeteria.

"Mr. Burge said it's very unlikely the government will agree to do the interviews at the hospital, but he'll ask. He strongly suggested not trying to change the date because the usual response is for the government to put it off for months and then to be difficult about it."

"OK," I replied. "Doctor Gibbs said if I bring a copy of the subpoena, I can have the time off and the hospital will find someone to cover the hours."

"Subpoena?" Clarissa asked.

"That's how INS summons you for a citizenship interview," I replied. "And they put you under oath, too."

"All to decide if the marriage is real?"

"Pretty much," I replied. "You remember the idiocy when we returned from Europe, right?"

"Of course."

"That was when they questioned your marriage to Elizaveta, right?"

"Yes, though that was because she was sixteen. They weren't the only ones who looked askance, but Ohio law permitted the marriage. The Federal law they might have tried to apply -- The Mann Act -- expressly does not apply to married couples, and marriage is a state function, not a Federal one, just as driver's licenses, medical licenses, and other licenses are."

"You know it makes no sense to me that you can be a doctor only in Ohio."

"I realize, but occupational licenses, with a few exceptions such as pilots and ship captains, are all issued by the states. That said, it would be simple and straightforward to obtain a medical license in another state, so long as my license in Ohio is in good standing. Of course, I have to get it first."

"What about now?"

"So long as a hospital hires me, the Chief Attending, or whoever is supervising me, needs a license. I don't."

"So you have more freedom now than when you're licensed?"

"In the sense of government control? Yes. But transferring Residency programs is not easy to do because slots are limited, especially the further on you go. There simply aren't that many that are open because someone would have to drop out, transfer, or die, and that just doesn't happen very often. So while I have the freedom to change, I don't really have the opportunity. Granted, I could switch to an unfilled PGY1 slot in another specialty, but that's not a real option."

"But don't you think everything should be consistent across the country?"

I shook my head, "No. In fact, the system was expressly designed to prevent that. People in Ohio do not want people in California or New York telling them what to do and how to live any more than people in New York or California want people in Ohio telling them how to live. That's the entire point of the US Senate, which is meant to represent the states, and ensure that simple majorities cobbled together from the largest states cannot overwhelm the small states. Without what was called the Connecticut Compromise, the Union wouldn't exist, which is why the Constitution forbids removing equal representation among the states by amendment, unless it's on a unanimous vote of every state legislature."

"I remember that," Kris said. "I just don't agree."

"And so long as you only disagree via rhetoric, we're fine. Heck, you can even wave your red and black banner! You just have to promise not to have ever advocated overthrow of the government!"

"But that's what your Founders did!" Kris replied.

I chuckled, "Do as I say, not as I do. But the second Civil War ended that."

"Second?" Kris asked.

"Petrovich is just being himself!" Clarissa interjected. "He's going to point out that the Revolutionary War was actually a civil war for independence from Great Britain. Well, either that, or that it was British subjects fighting for traditional British rights against a German king and his German mercenaries."

"You know me too well, Lissa!" I chuckled. "But both those statements are accurate."

"Mr. Black must have been a fun teacher."

"The best!"

"Who's that?" Kris asked.

"I've mentioned him before -- he taught English and Current Events, and was a font of all manner of interesting trivia, and he had a quirky take on history, including the comment about the German King."

"The Germans are always causing trouble!" Kris declared.

"Including founding France," I teased.

"How have you put up with him for so long, Clarissa?" Kris asked playfully.

"I ask myself that question almost every day!" Clarissa teased.

"At least ONE woman here appreciates me, right Rachel? Love Rachel!"

"Love Daddy!" she replied.

"She'll learn," Clarissa declared. "Just wait!"

"I figure about a year from now with a sibling, especially if they're of the opposite gender."

"If that happens, I'd say you're a dead man!"

"She'll just have to live with it!"

"Yes, but will YOU live?!" Clarissa teased.

We finished our meals, and I walked Kris and Rachel to the car, kissed and hugged them both, and after they'd driven off, I returned to the ED where Mary and Tom had relieved Bob and Len. The evening saw a steady flow of minor injuries and a few EMS runs, none of which were critical. Just before midnight, there was a complete lull, so I took the opportunity to take a nap.

August 1, 1989, McKinley, Ohio

I managed to sleep for seventy-five minutes before Nurse Alice woke me.

"Paramedics are bringing in an assault victim," she said. "About three minutes out."

"OK. Are Mary and Tom awake?"

"Yes."

I quickly went from the on-call room to the lounge, emptied my bladder, and joined Mary, Tom, and Alice in the ambulance bay just seconds before the EMS squad rolled to a stop, followed by a McKinley PD cruiser. The paramedic hopped out and gave the usual report.

"Johanna Stern, twenty-two; facial and abdominal contusions; pulse 76; BP 110/70; PO₂ 99% on air."

When they unloaded the patient, I immediately recognized her as one of the four 'pact' girls I'd met at Stirred Not Shaken.

"Hi, Jo," I said.

"Mike?"

"Doctor Mike now," I replied. "But it's OK to call me Mike. What happened?"

"I was...raped."

"Trauma 2," I ordered.

"Got the scumbag here," a uniformed McKinley PD officer called out, getting out of his car. "He claims he needs medical assistance."

"Tom, wake Doctor Mastriano and assist her, please. I'll take Mary with me."

Mary, Alice, the paramedics, and I quickly moved Johanna to Trauma 2 and moved her to the treatment table.

"Alice, I'll need a rape kit; Mary, please call OB and have someone come down for the exam."

As I'd given them orders, I hooked up the pulse oximeter and blood pressure cuff myself and turned on the monitor.

"Jo," I said. "I'll do a brief exam just to check your heart and lungs, but we'll need to wait for the OB/GYN and a police detective."

"OK," she agreed.

I carefully auscultated hear heart and lungs, doing my best not to disturb any possible evidence. Everything checked out, and about a minute later, a female McKinley PD detective came into the room.

"Detective Iverson," she said, introducing herself.

"Doctor Mike Loucks. We're waiting on the OB/GYN Intern before we begin processing the rape kit."

"I need to take some photos with the Polaroid," Detective Iverson said.

"I'm familiar with the process. I've done several of these, unfortunately."

"Miss, do you consent to photos being taken?" Detective Iverson asked.

"Damn straight!" Jo declared. "I want that asshole in prison!"

"Moore, OB/GYN," Doctor Roger Moore, nicknamed 'Saint', announced, coming in.

"Jo," I said. "Are you OK with a male OB/GYN doing the exam?"

"Uhm, I prefer a woman, please."

"I'm the only one available," Doctor Moore said. "Everyone else is delivering babies."

"Mike," Jo said, "you could do it, if you're allowed. But not him."

"May I see you in the corridor, Mike?" Saint requested.

I nodded and stepped out.

"What the hell?" he asked.

"I always ask female patients who are not critical who need gynecological exams if they prefer a female doctor. In this case, one isn't available and because she knows me, she asked me to perform the exam."

"You're not supposed to treat friends."

"She's an acquaintance," I replied. "Not a friend. I dated two friends of hers, and I've seen her maybe three times, and the last time was more than a year ago."

"Who's your Attending?"

"Mastriano or Nielson. Have your Attending call down, but the patient is the one to decide. And I'm qualified to do basic gynecological exams and rape kits. It's signed off in my procedure book."

"Have it your way, but Doctor Carmichael is not going to be happy."

I wanted to say that I couldn't care less if Doctor Carmichael was happy, and that the patient's needs and desires trumped any turf wars, but I remembered the cautions about my attitude.

"I understand," I said. "I just want to honor the patient's request. Go see Doctor Carmichael and have her call down if she has a concern. It'll be a good ten minutes before the exam begins."

He turned on his heel and left, and I went into the trauma room.

"We're ready to begin," Alice said. "I discussed the procedure with Johanna."

I picked up the checklist and gave directions while Alice and Mary helped Jo remove her clothes while standing on the white butcher paper. When Jo was completely undressed, Alice used a small comb on her pubic hair, and then we had Jo get back onto the bed and covered her with a clean white sheet from the rape kit, and I began gathering samples. Once that was completed, I began my full exam.

"I don't find anything except facial and abdominal contusions and vaginal abrasions," I said when I finished my exam. "Do you have any pain anywhere?"

"Just the bruises," she replied. "I think he's hurting more because I managed to kick him in the nuts when he got off me."

"Are you taking birth control?"

"Yeah, I'm still on the Pill."

"Are you OK for the detective to interview you?"

"Yes."

Detective Iverson conducted the interview, and it was clear almost immediately that it was a case of 'date rape'. They'd been making out, and he'd pushed for intercourse, and when she'd refused, he'd called her a tease, among other things, then forced himself on her, pulling aside her shorts and panties and raping her.

"Detective," I said. "You should get a judge to order an STD test for her attacker. I doubt he'll consent."

"I'll make the call!"

"Use the wall phone."

"If that asshole gave me VD, I'm going to kill him!" Jo growled.

Detective Iverson made the call, obviously speaking to a judge who authorized the test. She made a second call to the station to have someone pick up the warrant from the judge and bring it to the hospital.

"Mary, will you get a set of scrubs for Jo," I requested.

Mary left to do that and returned about a minute later. Alice, Mary, and I stepped out while Johana dressed, then went back into the room.

"I can release you when you're ready," I said.

"I should call my parents," she said.

"I believe the uniformed officers did that," Detective Iverson said.

"Mary, come with me and we'll see if they're in the waiting room."

We left the trauma room and went to the triage desk and I asked Bill, a Fourth Year, about the Sterns and he pointed to a couple sitting in the waiting room. Mary and I went through the door to the waiting area and to the couple.

"Mr. and Mrs. Stern?" I asked.

"Yes," the man said. "How is she?"

"Physically, she's fine, with just a few bruises and scrapes. I can take you to see her."

"Did they catch the bastard?" Mr. Stern asked.

"I believe he's in custody, but you can ask the detective who's with Jo."

I led them to the trauma room, then went to report to Doctor Nielson. After I made the report, I went back to the trauma room, and while I was there, a uniformed officer arrived with a search warrant that authorized blood typing and STD testing.

"I'll come with you and observe the blood draw," Detective Iverson said.

I nodded and left the room. I looked at the board over Nicki's head and saw the alleged attacker was in Trauma 2.

Mary, Detective Iverson, and I went into the room.

"I have a warrant authorizing a blood draw for typing and VD," Detective Iverson announced.

"May I see that, please?" Doctor Mastriano asked.

Detective Iverson handed it to her.

"Tom, syringe and tubes for typing and STD," I said.

"WAIT!" Doctor Mastriano ordered. "Mr. Mueller has refused any invasive tests."

"He doesn't have a choice, Doctor," Detective Iverson said. "This court order authorizes me to obtain it by force if necessary."

"Not in my trauma room!" Doctor Mastriano declared.

"Doctor Loucks agreed to draw the blood," Detective Iverson said. "If you interfere, I'll have Officer Brown arrest you."

"Mary," I said. "Go get Doctor Nielson, please."

She left and returned two minutes later with Doctor Nielson.

"What's the problem?" he asked.

"Detective Iverson has a court order for a blood draw, and I agreed to do it," I said. "Doctor Mastriano objected on behalf of the patient, who refused any invasive testing. It's my understanding that the patient cannot refuse a court order."

"Mike, Isabella, let's step out."

The three of us left the trauma room and went to the Attending office.

"State your case, Isabella," Doctor Nielson said.

"I object to using force to perform a medical procedure. If the police want to do it, that's their business, but doctors should not do any procedure against the wishes of a patient."

"Mike?"

"I agree with Doctor Mastriano. When I agreed to make the blood draw, I didn't know the patient had refused any invasive testing. I will, if you order me to, do it, though I prefer not to. I will note the detective threatened to arrest Doctor Mastriano if she interfered."

"An empty threat," Doctor Nielson said. "No physician can be forced to perform a procedure against their will. I won't give an order like that, which I suspect you knew when you suggested you'd follow my order."

I nodded, "I did. I also know the law says that we cannot be forced to do a procedure. They drilled that into us in practice of medicine at the medical school."

"Mike, ask the detective to come in, please."

I went across the corridor and asked Detective Iverson to come to the Attending's office.

"Detective," Doctor Nielson said, "It's the policy of the hospital not to perform any procedures on a patient who has refused them. Doctor Loucks agreed to draw the blood before he knew the patient had objected."

"I have a fucking court order!" she growled. "And it was Doctor Loucks who suggested the blood test for VD!"

"I did," I admitted. "And suggested she get the warrant. When we went to the room to execute the warrant, Doctor Mastriano stated quite clearly that the patient objected. At that point, I asked for Doctor Nielson's assistance, as he's the senior Attending on duty."

"You won't do it?" Detective Iverson asked.

"Not against the patient's will."

"He's a fucking rapist!"

I began to answer and Perry held up his hand so I stopped.

"Whatever else he is, he's a patient, and ethically speaking, we have a duty to him to not perform any procedures to which he objects. I suggest you take him to your lockup and have your nurse draw the blood and send it here for analysis. You can use force there which is not acceptable here at the hospital."

"God damned bleeding heart liberals," she growled.

"I need a few moments with my doctors," Doctor Nielson said.

Detective Iverson left and Doctor Nielson nodded to the door which I pushed closed.

"I don't actually need anything," Doctor Nielson said. "I just wanted to allow Detective Iverson to calm down. How is your patient Isabella?"

"Experiencing some discomfort, but no rupture or other damage from a kick to the groin. He's ready to be discharged, though he's under arrest."

"Mike, are you ready to release the young woman?"

"Yes."

"I did hear from Doctor Carmichael, but I have zero time for turf wars. There was no injury, right?"

"Minor vaginal abrasions, but no tearing and no treatment required. The rape kit was completed."

"Psych or social worker?"

"I don't see any point in keeping her longer, so I'll refer her to social services or a private counselor."

There was a knock at the door and Doctor Nielson called out for whoever it was to come in.

"Doctor Varma needs an Attending in Trauma 3," Nurse Louise said.

"I'll be right there," Doctor Nielson said. "Isabella and Mike, discharge your patients. Do not get into it with the police. Send them to me."

I went back to the trauma room where Jo was waiting with her parents. I filled out the discharge forms and gave her a counseling referral.

"What about the VD test?" she asked.

"He objected, and hospital policy is to not forcibly treat patients. They'll take him to the city lockup and draw the blood there."

"What do you mean?" Mr. Stern asked.

"If he were to fight, someone would have to forcibly subdue him, which is not something we can do here without putting staff at risk. The jail is better suited for that. They'll draw the blood and send it to us. If it's positive for any sexually transmitted diseases, a social worker will be in touch. We'll also run blood typing test to match what we found on exam. Any questions?"

"No," Mr. Stern said.

"Then you're all free to go."

"Mom, Dad, can I have a minute to talk to Doctor Mike?"

"We'll be right outside," her dad said, and they left the room.

"Someone has to stay," I said to Johana. "Either the nurse or my medical student. The Emergency Department rules forbid me from being alone with a female patient. Alice, would you leave us?"

"OK," she agreed.

"What can I do for you?" I asked.

"I wanted to know what happened after you and Samantha broke up."

"I ended up marrying a girl from the Russian Cathedral in Columbus. We married in January."

"Congratulations."

"Thanks. How have the four of you been?"

"Good. I'm working for an architecture firm here in McKinley as a mechanical engineer. Becka, Les, and Samantha are home for the summer, and Becka and Samantha both start law school next month, and Les starts on her MBA. Samantha has a stead boyfriend and they're pretty serious. Les is still seeing the same guy, and Becka has a guy she sees regularly, but they aren't a couple. I saw you have a gig at Stirred Not Shaken in September, and the other three will come home for that, so all four of us will be there."

"It'll be good to see all of you."

Alice came back to the trauma room and let me know that there were two walk-in patients who needed attention so I said 'goodbye' to Jo and Mary and I went to triage.

"Bar fight," Bill said. "One with an obviously broken nose, the other with probable a broken hand."

"Wonderful. Is everyone else busy?"

"Yes."

"OK. Mary, you take the hand, do a primary exam, and arrange for an x-ray. Bring me the chart to sign the orders."

"Will do."

We each called our patient and escorted them to exam rooms, with Alice joining me and Louise joining Mary.

"Mr. Baxter," I said. "Does anything hurt other than your nose?"

"No."

"I'm going to do a quick exam, and then we'll take some x-rays to see how badly your nose is broken."

"OK."

I did the exam and found nothing out of the ordinary, except for the contusions on his face and the quickly blackening eyes, a strong indication of a broken nose. Thirty minutes later, after receiving the x-rays, I called for an ENT consult and also reviewed Mary's findings, which resulted in an admission for surgical repair of the hand.

"With the displacement," Doctor Robbins, the ENT said to Mr. Baxter, "it'll need to be reduced. There's no urgency, so we'll give you pain medication and you can follow up with my office in the morning to make an appointment."

"It can wait?" Mr. Baxter asked.

"Yes," Doctor Robbins said. "Anytime in the next three days is fine. Mike, six hundred of Advil every six hours until I see him."

Doctor Robins left, and I explained everything to the patient, wrote out the prescription for Advil and gave him his first dose. After verifying that he wasn't seeing double or feeling dizzy, I discharged him, then went to take a nap, managing to get sixty minutes of sleep before being woken for an ambulance run just before 5:30am for an MI. He was admitted to Cardiology just before 7:00am and I went to the cafeteria to have breakfast, finding Sophia sitting with some other students.

"OK for a doctor to sit with you?" I asked.

Sophia laughed, "Sit down, Mike! Nobody here will object. Doctor Mike Loucks, Intern, meet Jenny Brown, Fourth Year, and Nancy Burke and Kelly Atkins, Third Years."

"Nice to meet you all," I said.

"Surgeon?" Kelly asked.

"Trauma surgeon," I replied. "I'm a surgical intern, but assigned to the Emergency Department. Trauma surgery is a new specialty. What Match do you hope to get?"

"You and me?" Kelly said brightly, flashing a smile.

"I hate to break it to you," Sophia said, "but he's married and has a daughter,"

"Bummer!"

"I'm flattered," I said, "So besides that?"

"Surgery."

"And you two?"

"Internal medicine," Jenny replied.

"Either trauma or surgery," Nancy replied. "I haven't decided yet. What exactly does a trauma surgeon do?"

"The duties haven't been fully fleshed out, but as a surgical intern I'm allowed to do chest tubes and pericardiocenteses, and I get to occasionally scrub in for surgery. After two years in the ED, I'll be in the direct surgical training program, but assigned to cover the ED and perform general emergency surgery."

"That sounds cool! Will there be other trauma surgery spots?"

"The next one will open when you Match," I replied. "I suggest listing it first, then listing either trauma or surgery here. There are other hospitals with programs as well. Right now I know of Indiana University and the University of Chicago, but I'm sure there will be others. Sophia, are you all set for San Francisco?"

"Robby will have a spot at Stanford, so it's all a question of Matching. I can't schedule my interview yet, obviously."

"You'll only apply in the Bay Area, right?"

"Yes. There are at least a dozen programs that would fit in the general category of neonatal surgery, though only the one that's doing the in utero surgery at the moment."

"I'm sure you'll get it," I said.

"Me, too! But you know contingencies are necessary!"

"Absolutely. Jenny, when is your trauma Sub-I?"

"November and December."

"And your Clerkships?"

"January and February," Nancy replied.

"November and December," Kelly replied. "I really look forward to working with you!"

She flashed another smile and her eyes twinkled, indicating she was flirting.

Sophia and I exchanged a look, and I was positive she'd say something to deter Kelly who seemed to have decided that me being married didn't matter. I finished eating, bade everyone 'goodbye', then headed back to the Emergency Department.

XXX. What Are You Going to Do About It?

August 1, 1989, McKinley, Ohio

"Mike," Nate said from the door to the lounge. "You have a visitor."

"Who?" I asked.

"She said her name is Jenny."

"Around fifteen, right?"

"Yes."

That meant it was Jenny Leonard, the girl who'd lost her brother in an MVA, and who I'd promised to help become a doctor after consoling her. I asked Mary and Tom to wait in the lounge and went to the waiting room where I saw Jenny, who had developed into a beautiful young woman.

"Hi, Jenny," I said. "Come on in."

"Hi, Mike! Or is it 'Doctor Loucks' now?"

"I go by 'Doctor Mike', but you can call me 'Mike'."

I led her to the consultation room and left the door open to deflect any possible questions from anyone in the ED.

"How are things going?" I asked.

"Good. I had all A's for Freshman year. I'll be a Sophomore in a few weeks."

"That's good to hear. How are you feeling?"

"I miss Jeff a lot," she said. "Do you miss your wife?"

"Every day," I replied. "It hurts, but not as bad as it did. I hope that's true for you, too."

"It is. Mom had me talk to a counselor who helped some."

"I did the same thing."

"When did you become a doctor?"

"I graduated at the end of May, then started working in the hospital as an Intern on July 1st. Are you still planning to be a doctor?"

"Yes. I wanted to ask you what classes I should take, I mean, for electives?"

"I would make sure you take every science class available, because the most important criteria for getting into medical school is how well you do in science, and that's what the MCAT, the admission test for medical school, focuses on. Otherwise, take classes that interest you. I found Latin very helpful, but I don't think Hayes County offers Latin."

"No. Just French, Spanish, and German."

"Otherwise, philosophy, psychology, or sociology will all help with your coursework and in becoming a good, well-rounded doctor."

"And you'll help me?" she asked.

"I promised to do that, and I'm not going to break that promise."

"How is your daughter?"

"She's great. Would you like to see her? She's in daycare."

"Yes! I love babies! I just don't want one!"

"I understand that sentiment. I had some friends who were pregnant in High School and it was extremely difficult."

We left the consultation room, I let Ellie know I was taking a break, and then Jenny and I walked to the nursery where I asked Marcie to bring Rachel out, which she did.

"Daddy!" Rachel exclaimed.

I took her from Marcie, then turned to Jenny.

"Jenny, this is Rachel; Rachel, this is my friend Jenny! Say 'hi', please."

"Hi Djenny!" Rachel said, not quite getting the 'J' sound right.

"Hi, Rachel! You're a pretty girl!"

"Would you like to hold her?" I asked.

"If it's OK."

"It is."

I handed Rachel to Jenny, and happily Rachel didn't object to Jenny balancing her on her hip.

"I take it you babysit?" I inquired.

"Yes. That obvious?"

"You balanced her on your hip like a pro!"

"Who watches her when the daycare is closed?" Jenny asked.

"My wife, my sister-in-law, or her grandparents."

"You remarried?"

"In January."

"I think it's important for a girl to have a mom."

"Me, too," I replied.

We stayed for about five minutes, then I handed Rachel back to Marcie, and Jenny and I left.

"Is there anything specific I can do for you?" I asked.

"No. I just wanted to say 'hi' and ask about electives. I called to make sure you were here, and when they said you were, I rode my bike. I'll get my learner's permit in November."

"It sounds as if everything is going well," I said. "Apart from being a bit sad."

"Do you go to the cemetery?"

"Occasionally, though I went more during the first year."

"I go there and read, sometimes out loud. Is that weird?"

"Not at all. I spent a lot of time talking to Elizaveta, and that was a good thing."

"And you think they can hear us and know we're there?"

"I do. I can't tell you how, because it's a mystery, that is, something hidden from us, but I believe it. You remember I wore my cassock, right?"

"You were a pastor of some kind."

"A deacon, but I had to step down in order to get married."

"Really? Why?"

"Because while our clergy are permitted to be married, it has to happen before they're ordained. Because I wanted to marry, and because I had to focus on Rachel and medicine, I really couldn't fulfill my obligations as a deacon."

"Is it OK to come see you again?" she asked as we walked into the Emergency Department.

"Yes, of course. Just call to check if I'm here, and if I'm not, ask when I will be."

"Great! Thanks so much!"

"You're welcome."

"Is it OK to hug you?" Jenny asked.

"It is," I confirmed.

She gave me a quick, friendly hug, then I walked her to the door of the waiting room. Once she'd left, I walked back to the nurses' station to let Ellie know I was available.

"I'm way more fun than that jailbait could hope to be!" Ellie said, her eyes twinkling.

"Her brother died in an MVA about two years ago and I consoled her as a deacon and promised to guide her on her quest to be a doctor. There is nothing more to it than that!"

"Uh-huh. She had the 'I am in the presence of a god' look in her eyes."

"Well, I do have on red scrubs," I chuckled. "But I don't get that vibe at all. And I have to ask you not to imply that ever again."

That list bit was said sternly.

"Sorry, Doctor," she said.

"I don't mind you teasing on occasion," I said. "But that is a line you simply cannot cross."

"Yes, Doctor."

"It's Mike," I said.

She smiled, "Thanks."

"Mike?" Nate called out. "EMS three minutes out with an unspecified groin injury."

"Male or female?" I asked.

"Male. Use Trauma 3."

"OK."

I called Mary and Tom, and the two of them and Nurse Kellie accompanied me to the ambulance bay. Two minutes later, the EMS squad pulled up and Julie, the lone female paramedic, jumped out.

She was smirking, which told me this was going to be 'interesting'.

"Sam Hoffmann, nineteen; BP 120/70; pulse 80; PO₂ 99% on air; penile bleeding due to torn foreskin inflicted dentally when he and his partner were surprised in flagrante delicto."

"Trauma 3," I said, knowing the story was going to be 'interesting'. "Mary, monitor; Kellie, we'll need an Irrigation syringe, saline, and a basin."

"Labs?" she asked.

"I don't see a need," I replied.

We moved Mr. Hoffmann to Trauma 3 and moved him to the trauma table.

"Mr. Hoffmann, I'm Doctor Mike. Can you tell me about your injury?"

"It hurts like hell!" he exclaimed.

"Let me take a look, please," I said.

"Do we have to have chicks in here?" he asked.

"You have a choice about who treats you," I said. "Kellie, Mary, would you step out please?"

Mary frowned, but Kellie gently took her arm and they stepped out of the room.

"Tom, hook up the monitor, please, then get the irrigation syringe, saline, and a basin, please."

"Just the pulse oximeter, right?" Tom verified.

"Yes. No need for the blood pressure cuff or EKG."

"Mr. Hoffmann, Tom is going to put a monitor on the index finger of your left hand, and I'm going to move the sheet to examine you."

An examination of the injured member showed a torn foreskin, as Julie described. I had no experience with foreskins as I'd been circumcised as an infant, so I wasn't sure how severe the tear was, though I was positive it 'hurt like hell'.

"Tom, after you set up the irrigation tray, call Urology for a consult, please."

"Right away, Doc."

"Mr. Hoffmann, I'm going to irrigate your wound and then we'll have a specialist examine you. How did this happen?"

"I was at my girlfriend's house and her dad came home while she was...you know. He opened the door, saw us, and she bit me. How bad is it?"

"I'm not an urologist," I replied. "But it does not look as if there is any damage to your member beyond the foreskin. I'm going to irrigate it with saline. When was your last tetanus shot?"

"I don't remember having one."

"Then we'll give you one and start you on a course of antibiotics. Human bites often cause infections. Do you have diabetes?"

"No."

"Drink to excess?"

"No."

"Are you taking any medications?"

"No."

I finished irrigating the wound and covered Mr. Hoffmann's groin with a clean cloth.

"Meyer, Urology," Doctor Pete 'Oscar' Meyer said, coming into the room.

Under the circumstances, I felt it was more appropriate to call him by his first name, rather than refer to 'wieners'.

"Hi, Pete. We have Sam Hoffmann, nineteen, with a torn foreskin as a result of a bite accidentally inflicted during fellatio. I've irrigated the wound and ordered a tetanus shot as well as a course of antibiotics."

"Hi. Mr. Hoffmann," he said to the patient, "I'm Doctor Meyer from Urology. May I take a look at your injury?"

"Sure."

Doctor Meyer performed the exam.

"Mr. Hoffmann, I recommend a circumcision, given the tearing, which makes a repair difficult, and might well result in circumcision, anyway. There's also a higher risk of infection if we attempt a repair."

"Shit!" Mr. Hoffmann swore. "How bad will that hurt?"

"We'll use topical anesthetic for the procedure and it'll be uncomfortable for a week or so, but it'll heal completely in about two weeks."

"And if you fix it?"

"A similar recovery time, though, as I said, with a risk of needing the circumcision if it doesn't heal properly."

"Remove it," Mr. Hoffmann said. "My girlfriend doesn't like it, anyway."

"Mike, you can give the tetanus injection, but we'll take care of the antibiotics. Send him up when you're ready."

"Will do."

"Mr. Hoffmann, I'll see you upstairs," Doctor Meyer said.

He signed the chart and left the room. I excused myself, stepped out, and retrieved the pre-packaged tetanus shot. I took it to the trauma room and had Tom administer it. Once that was done, I had him call for an orderly while I completed the chart. Ten minutes later, Mr. Hoffmann was on his way upstairs.

"Sorry about that," I said to Mary when I found her in the lounge.

She smirked, "Did his girlfriend really bite off his foreskin?"

"Not off, but enough that he'll need it surgically removed. Not something I'd want to contemplate at his age!"

"Mike?" Ellie said from the doorway. "Detectives Kleist and Tremaine are here about your patient."

"Tom is taking him upstairs right now. What do they want?"

"They just said they wanted to speak to him."

"Send them up to Urology," I replied.

"OK."

She was back thirty seconds later to let me know they wanted to speak with me, so I left the lounge and the three of us went to the lounge in the absence of a Resident's office.

"What can I do for you, Detectives?"

"Tell us about Sam Hoffmann's injuries," Detective Tremaine requested.

I described them, then asked, "What's going on?"

"Her father filed a sexual assault complaint," Detective Tremaine replied.

"She's underage?"

"She's sixteen, but for a minor, a parent can lodge a complaint up until they turn eighteen."

Something of which I was aware.

"You should see Doctor Peter Meyer in Urology," I said. "He has the patient who's going to have surgery."

"I'll want your chart notes, Doc," Detective Kleist said.

"The hospital requires a subpoena for the actual notes," I replied. "But I'll cooperate, of course."

"We'll get it by the end of the day. Preserve all your notes."

"I always do, both the chart and notes in my personal notebook."

"Thanks, Doc."

"From the way the patient described it, it was consensual. You can't cut the guy some slack?"

"Take it up with her dad and the State Legislature," Detective Tremaine said.

I nodded, "Understood."

They left, and I went back to the lounge, where Mary was waiting.

"What was that?"

"She's sixteen and her dad lodged a complaint."

"That's over the age of consent!" Mary protested.

"And under Ohio law, a parent can lodge a complaint for a minor, even if she can legally consent. Given they were caught in the act, and he has an injury from the act, denial on her part won't help."

"Wow. That sucks!"

I chuckled, "Not how I'd put it, but yes."

Mary smirked, "And it really sucks to be him!"

"Some joking is OK," I said. "But you need to be very careful about when and where."

"Sorry," Mary replied quickly.

"That wasn't a reprimand, just a reminder."

"Do you agree with the law?"

"No, but my solution would be to not file charges in a similar situation. What other parents do would be up to them."

"Why not try to get the law changed?"

"I have plenty of other windmills at which to tilt," I replied. "I'm sure you've seen the changes which have taken what used to be mostly a probation offense in the 70s to one that now has penalties approaching forcible rape and manslaughter. I have limited capacity to fight injustice, and I have to pick my battles, most of which revolve around mental health care or hospital policy."

"That makes sense, though I hear doctors make some fairly offensive jokes."

I nodded, "They do. Don't be like them. And be very careful about using medical slang around patients, especially words like 'gorked' or 'gomer'. Ultimately, the answer is simple -- treat others as you would have them treat you."

"Jesus' command?"

"Yes, and combined with his other great command -- 'love one another' -- a perfect approach to medicine, and all of life."

"Mike?" Nate said from the door to the lounge, "Doctor Varma needs help with walk-ins."

Tom came in just then, with perfect timing.

"Mary, Tom, let's go!" I said.

Over the course of two hours, we treated four patients for a mix of minor ailments which ought to have been treated by a primary care physician. Just before lunch, I caught an ambulance run with a rule-out MI that turned out to be severe indigestion caused by what was best described as poor dietary choices. After the patient was discharged, I went to the cafeteria to have lunch with Clarissa. A few minutes later, Sophia came to sit with us, rather than her friends.

"I had a word with Kelly," Sophia said. "I'm not sure it did any good."

"What happened?" Clarissa asked.

"A Third Year," Sophia replied, "who, when Mike asked what Match she wanted, replied 'you and me'. I pointed out that he's married and has a kid, then spoke to her later. Her response was 'all doctors cheat'."

"Not Petrovich!" Clarissa declared emphatically.

"That's what I told her, but she didn't believe me. She has her sights set on you, Mike."

"Then she's going to be as disappointed as Nurse Ellie and Erin Edwards. By the way, I heard through the grapevine Erin is getting married, so that should resolve that situation."

"Why would you think that?" Clarissa asked. "She was willing to be the 'other woman', so what makes you think she's going to be faithful to her husband?"

"Good point. I'll be careful."

"Is Ellie behaving?"

"Mostly. She flirts lightly, but isn't obnoxious, though I did have to speak sternly to her this morning. Jenny Leonard stopped by for a visit and Ellie called her 'jailbait' with all the implications of that word."

"Who's that?" Sophia asked.

"A girl I counseled and consoled after her brother died in an MVA about two years ago. They'd had a fight and instead of going with him to school, she decided to take the bus. He was involved in the MVA while driving to school."

"Survivor's guilt?" Sophia asked.

"Yes. She came back not long after for a tour and asked about being a doctor. I gave her advice and said she should come by occasionally to check in. She did that this morning. And, no, I do not get that vibe at ALL from her."

"She's what? Fourteen?" Clarissa asked.

"Fifteen, and will be a Sophomore. Ellie claims she saw 'hero worship' in Jenny's eyes, but I don't think so, given I was the enemy who let her brother die. I think Jenny might be in awe of me being a doctor, but she certainly doesn't think we're gods because we didn't save her brother."

"I get hit on all the time by patients," Sophia said.

"So does Clarissa! Ask her about the football player from Hayes High!"

Clarissa laughed, "He was cute, not obnoxious like some."

"I had an interesting case this morning," I said with a goofy smile.

"Oh?" Clarissa asked.

"Foreskin injury when a nineteen-year-old and his sixteen-year-old girlfriend were surprised by the father coming home from work unexpectedly."

"I'm a girl, but 'ouch!'," Sophia exclaimed.

"Yeah. He went up to urology for an adult circumcision."

"Double 'ouch!'," she exclaimed. "I'm curious about your position on that. Circumcision, I mean, not sixteen-year-olds, because we KNOW your position on that one, at least in the past!"

"Yeah, well," I chuckled. "As for the procedure, I disagree with my Dutch Calvinist dad. Strongly. He had it done after I was born as 'routine', and I would never contemplate that. I get the religious significance for Jews, but the idea that Christians practice it at all is mind boggling, given the clear statements against it in Paul's letters."

"I thought you said it was «ekonomia»."

"It was, but Christians do not need that sign, as our covenant is different. The so-called Judaizers lost the debate, and rightly so. Medically, there is no reason to perform a circumcision, with the usual arguments, such as cleanliness, being complete BS. Fundamentally, it's an unnecessary procedure, and with the exception of religious ritual, ought never to be performed without medical necessity."

"What's your take on cosmetic surgery?" Sophia asked.

"I object if it's purely for vanity. If it's in response to some kind of disfigurement due to disease, defect, or trauma, I'm OK with it. That said, I wouldn't make it illegal, I just wouldn't participate."

"So similar to your view on elective abortions."

"Yes. Any interesting cases on your services?"

"Just routine," Clarissa replied.

"Same here," Sophia added. "Mike, what is your schedule for September?"

"Monday, Tuesday, and Thursday 0500 to 2100; Wednesday 0800 to 1700 at the Free Clinic; and Friday and Saturday 0500 to 1700. I saw you're on five sixteen-hour shifts that roughly coincide with mine."

"I asked Doctor Casper if I could be assigned to you, and he agreed. I assumed you wouldn't have a problem with that."

"Of course not!"

We finished our lunches, and I headed back to the ED, and as things were quiet, I sent Mary and Tom to have their lunches. We had a busy, but calm afternoon, with no severe trauma and at 6:00pm, after handing over to Kylie, I headed up to the surgical locker room for a shower.

"How are you doing?" Shelly asked when I walked in.

"Good," I replied. "I'm doing my best to control my windmill-tilting impulses."

"Pick your battles wisely."

I nodded, "I made the point earlier today to Mary that it was important to pick my battles, but that was on the topic of a non-medical concern."

We both walked to the showers, then dried off, dressed, and headed for the elevators."

"How do you feel about your Residency so far?" she asked.

"I'm happy. I mean, the hours suck, but they're being reduced to eighty as of next month, which means there are basically dedicated sleep periods in those long shifts. That will make a huge difference."

"What about practicing medicine?"

"I'm mostly allowed to operate autonomously in all but the most severe traumas."

"And your students?"

"I enjoy teaching, and all six of them are eager to learn."

"Would you change anything?"

"I would have said the hours, but given they're being reduced by at least ten, I can't really complain about that. I think the only thing I'd point to is that some Residents and Attendings aren't with the program, so to speak."

"Mastriano?"

"For one, but also the lazy ones on other services. We had a situation where a Resident refused to admit patients despite having empty beds, insisting they were 'too busy' to take patients. It's not the first time with this Resident, and Doctor Northrup was informed."

"You won't find that on the surgical team. Doctor Cutter simply won't tolerate it."

Which was, ultimately, the problem with Doctor Mastriano, and Doctor Northrup had dealt with it, so I didn't mention it.

"Given increasing patient loads, it's something no service can or should tolerate."

"Exactly!" Shelly said as we reached our cars.

"Good night. See you later in the week."

"'Night!"

I got into my Mustang and headed home for dinner and a quiet evening with my wife and daughter.

August 2, 1989, Rutherford, Ohio

On Wednesday morning, Rachel and I left home early so that we could have breakfast at my grandparents' house with my grandparents, my mom, Elaine, April, Liz, and Michael. I'd also stop in to see my dad at work before my lunch with Doctor Mercer. I hadn't seen my half-brother Peter and half-sister Faith in some time, but I didn't feel right stopping at the house when my dad wasn't home.

"I'll take my granddaughter!" my mom said when I arrived at my grandparents' house.

"I believe Grandma has seniority," I said, seeing my grandmother come into the foyer behind my mom.

"Thank you, Mike!" Grandma said. "You're a very wise grandson!"

Mom scowled, "Oh, sure, Mom, feed his ego!"

"I'll leave you two to fight over Rachel," I chuckled, putting her down on the foyer rug.

With her safely, at least in theory, with my mom and grandmother, I went into the living room to greet my grandfather. We shook hands and just as I sat down, Liz arrived with Michael, and Elaine came into the room with April.

"How are things going at the hospital?" my grandfather asked.

"I'm not getting enough sleep, but that was something we knew would be the case. I'm enjoying my work, and I'm able to care for most patients who present without direct supervision."

"All by yourself?" Elaine asked.

"No. Almost always two medical students and a nurse assist me, and for very severe trauma, two doctors work together with the students and nurses. And, of course, I call for help for areas when I need an expert opinion, or if I'm unsure how to proceed."

"Do they check on you the way they did when you took care of me?"

"No, but I report everything to my supervisor and discuss things with them. When I call a specialist for help, they do check my work because the rules require it."

"And everything is OK at home?" my grandfather asked.

"Mikey married a hot eighteen-year-old!" Liz teased. "I'm sure that's OK!"

"Be respectful, Elizabeth," my grandmother admonished.

"Yes, Grandma," Liz replied.

"Everything is good," I said to my grandpa. "You can see Rachel is happy and healthy and loving the fact that her grandmother and great-grandmother are making her the center of attention."

"Breakfast is almost ready," Grandma said, putting Rachel down on the floor with her cousins.

Fortunately, Michael wasn't nearly as rambunctious as Viktor, so Rachel tolerated him, though she was far more interested in April, who was only a few weeks older. Rachel would be very happy on Friday, as Abigail and her parents had returned from Spain, and Rachel hadn't seen Abigail for nearly a month.

"Mike, come to my study for a few minutes before breakfast," my grandfather requested.

We left the living room and went to his study, where he shut the door.

"How are your finances?"

"They're good. I received my first paycheck on Monday, so we're in very good shape. I also received the check in the mail from you. That's the last one, correct?"

"Yes."

"Rachel, Kris, and I are extremely grateful for the assistance. If there is anything I can do for any of you, ever, please let me know."

"Well, I do have this pain..." my grandfather teased.

I laughed, "Fortunately, that hasn't happened yet, but I'm sure it will. Your health is OK? And Grandma's?"

"Yes, thank God! Shall we join the others for breakfast?"

We left the study and went to the dining room for a breakfast, which, sadly, did not include bacon, as it was a Wednesday, but we had waffles, eggs, fruit, and juice. Rachel tolerated scrambled eggs, but really loved waffles dipped in maple syrup.

After breakfast, I helped my grandmother clean up while my mom spent time with Rachel and her other grandchildren.

"How are you doing, Grandma?" I asked as I dried a plate.

"Besides being old?" she asked with a smile.

"What did your doctor say at your last checkup?"

"That my heart is fine, and there was nothing wrong with any of the blood tests. He said I need to take iron and calcium supplements."

I nodded, "That's not uncommon for women who are past menopause. No arthritis or memory problems?"

"None! My fingers don't work quite as well as they once did, but I still do my needlepoint. I also don't drive very much, but with your grandfather here all the time, it's not necessary."

Those were things which also came with age. She was seventy, and my grandfather seventy-two, and both appeared, from what I could observe and what they said, in excellent health for their ages. We had no real information about longevity on the Russian side of my family, as nobody knew how long my great-grandparents had lived.

On the Dutch side, there was a history of heart disease in the men despite complete abstinence from tobacco and alcohol until my dad, who drank. That family history was something to watch out for, and something I'd mentioned to Doctor Smith at my most recent checkup. What it meant was that at around age forty-five, I'd start having an EKG as part of my annual physical.

"I'm glad you're feeling well, and I'm sorry we can't visit more often. Kris sends her regrets, but she had class today at Ohio State."

"May I ask why she's going during the Summer right after you married?"

"So that she can graduate on time even when she takes a semester off after each new great-grandchild."

"She's pregnant?" Grandma asked hopefully.

"No, but we'll start trying soon."

"Nothing will make me happier!"

"Please don't say anything yet. We'll let everyone know once Kris is past her second month."

"I would never betray your trust, Mike!" Grandma declared. "Just keep me supplied with great-grandchildren!"

I chuckled, "We'll do our part!"

"Do you enjoy being a doctor?"

"Very much," I replied. "It's what I've wanted to do since I was ten."

"I'm glad you're happy, Mike."

"Me, too!"

We finished in the kitchen, then had coffee with the rest of the family. Rachel and I stayed until 11:00am, then headed to the building which housed the Harding County Property Division to see my dad. We spent about fifteen minutes with him, and despite my desire to normalize the relationship, it was still strained. We did agree that he, Holly, and the kids would come to dinner sometime in September, once my schedule changed.

Rachel and I left and headed to Lou's to meet Doctor Mercer. We arrived a bit early, and I asked for a booth and a booster seat for Rachel, then took her to the bathroom so I could change her diaper. When we came out, Doctor Mercer had arrived and the three of us sat down in the booth, Rachel in the booster seat next to me.

"She's a beautiful little girl," Doctor Mercer observed.

"She takes after Elizaveta!"

"Obviously! I can see it in her eyes and her nose."

I nodded, "And soon enough, with her hands on her hips reminding me why I ought to bow down before the Tsarina of the Known Universe!"

"Does Kris do that?"

"No, but genetics being what they are, I expect it. I already see something of Elizaveta in the way Rachel cocks her head to look at things, and the way her eyes twinkle when she's about to do something mischievous."

"Do you make those observations to anyone else?"

"No. And I haven't said anything at all to Rachel. She calls Kris 'Mama' and I haven't even pointed to the small framed picture that we added to our icon corner after Kris and I discussed it. We'll do that at some point, probably when she asks who is in the picture with the black ribbon."

"Do you know what you'll say to her?"

"I think it depends on how old she is, but I wrote a letter to Rachel on the advice of the hospital social worker, along with one to Elizaveta. Those were part of my recovery process."

"Writing letters such as those is an effective strategy," Doctor Mercer said. "How are you doing?"

"I'm OK. The problem now is more stress and lack of sleep than anything. That said, Resident hours in the Emergency Department are being reduced to eighty per week from ninety to ninety-four."

"Why?"

"The result of the Libby Zion case in New York. The State of New York changed maximum Resident hours to eighty, with at least twelve hours between shifts. I won't have twelve hours between shifts because we don't have enough Residents, but I will have dedicated time I can sleep, which I don't have now, which was the main point of the New York law. Eventually, we'll match the New York rules, and I expect eventually the AMA will endorse them."

"That's a good thing."

"I think so."

"Have you seen Angie?" Doctor Mercer asked.

"About a month ago. We probably shouldn't discuss her before the hearing on the 23rd."

"Tell me about your wife, if you would."

We were interrupted by the waitress, who took our orders, then I described how Oksana had introduced me to Kris, and how we'd come to a quick agreement to marry, and how things had been since January.

"You do not do anything conventionally," Doctor Mercer said with a slight smile. "But that seems to work for you."

"May I say something that will probably offend you?"

"I think it's probably best if you just say what you're thinking."

"With Liz, you got it exactly right. With everything after that, you got it exactly wrong. Your advice, in each instance, was the opposite of what proved to be the correct course of action. My relationship with Clarissa, my marriage to Elizaveta, Angie's treatment, the situation with Samantha, and my grieving process.

"The bottom line, and the cause of all of those, is pigeonholing people and expecting every person's experience to necessitate the exact same advice or treatment. Oh, sure, there are slight variations, but in each case that I mentioned, you assumed that the 'norm' was the only answer. And in each case, you were completely wrong."

"You don't pull any punches."

"I don't with Attendings, why would I with you?"

"That's going to get you into trouble."

"Which is not a reason not to do it, which is what you implied. Bad advice. Again."

"Did you agree to this lunch to take pot shots at me?"

"No, but you made a statement about my methods, and admitted they worked for me. I pointed out that I acted contrary to your advice in every situation except the one with Liz. If we're to have any kind of relationship in the future, you have to know how I feel. And you also know that I expect blunt talk right back. I don't flinch; I listen and learn."

"I'm going to assume from what you said that you had sex with Samantha Gilbert."

"Yes."

"You're reckless, Mike."

"That's the exact opposite conclusion to which every Attending and Resident who has supervised me has come. Which ought to tell you something."

"In your personal life," Doctor Mercer countered.

"I disagree. Evidence suggests I've evaluated each situation correctly, made the correct choices, and taken the correct action. Every time I went against your advice, except with Liz, it turned out properly, and when you went against my advice, it turned out badly."

"You were lucky."

"I suppose you'll say that about every patient I save from now until I repose. I mean, after all, my judgment is terrible and I always have terrible outcomes, except for dumb luck, right?"

"Again, you're mixing your personal life with medical practice."

"As if those two things could be separated in any way?! Being a doctor is not just what I am, but who I am. And again, I'll point out that despite your belief that I've been lucky, my judgment has been good. Have I made mistakes? Absolutely. I've made them at the hospital, too. But I've rectified those mistakes and learned from them.

"I do need to correct one thing I said -- you were right about telling Elizaveta about the extent of my experience before we were engaged. I misjudged, but I also corrected it. But in all the other cases? Clarissa and I absolutely had to make love because we had to know if a marriage was possible. Marrying Elizaveta was the best possible course of action for me, and despite her repose, was exactly what I needed, and gave me Rachel.

"As for Angie, you never once gave her a real chance. You relied on your statistics and generalized treatment plans, rather than an individualized one. I don't treat every patient who presents in the ED exactly the same way because they aren't the same. Do I consider the standard of care? Absolutely. Do I follow it slavishly? Not when something doesn't fit.

"Samantha's situation was one where I'd completely misjudged her problem, missing the whole 'Catholic guilt' thing because I don't have that experience. You, on the other hand, should have picked up on it because you're Jewish and have mentioned a similar mentality. The problem was, according to Samantha, that you flat-out refused to discuss religion based on a flawed notion that even talking about it with most patients is an ethical violation.

"Let me be even more blunt, Doctor Mercer. You need to rethink your entire approach to psychology. If you can't, you're going to have more disasters similar to the one with Angie. Had I listened to you, I would never have married Elizaveta and Rachel wouldn't have been born. Samantha is in her first long-term, successful relationship. Clarissa and I are as close as we've ever been, and we're going to have a child together."

"WHAT?!" Doctor Mercer gasped.

"You heard me. Artificial insemination, of course, but that was the plan from about halfway through our undergrad work. And yes, Kris is aware, and does not have a problem with Clarissa conceiving via artificial insemination. She does draw the line at conceiving naturally, obviously."

Doctor Mercer shook her head, "As I said, you do not do anything conventionally."

"True. So why do you assume that conventional answers will work with me?"

Doctor Mercer frowned, "You have a point, but only to a point."

"I have it all off my chest now," I said. "But I do want you to give serious consideration to what I've said and treat your patients individually, using the standard of care as a guideline, not a straitjacket."

"You're awfully arrogant for an Intern."

I shrugged, "That doesn't make me wrong. And whatever else I may be, or whatever else I might think, or whatever I might do, my patients come first. Every single thing I do is in the best interest of the patient in front of me, not ones from the past, even when it goes against standard practice. Nothing will ever deter me from being a forceful advocate for my patients, or in Angie's case, for people I love who need medical care."

"Have you been subject to an M & M?"

I smiled, "Yes, but I was on the side of the angels, as it were. I objected to 'standard care' because I was convinced that wasn't sufficient. My Attending disagreed, and I insisted they write their order on the chart and sign it. I was right."

"You're going to be wrong, Mike."

"Of course I will. As I said, I've made mistakes, and despite your diagnosis of 'arrogance', I ask for help when necessary. I'll make an error in judgment on that someday, but so far I've asked for help when I've needed it, and I'm careful about that. But my Attendings have signed off on procedures that no Intern normally does because I'm that good. Call it arrogant, but it's true and I can show you the evaluations and signatures in my log books."

"What happened to humility?"

"You're mistaking self-confidence for arrogance. Would YOU want a trauma specialist or surgeon to doubt themselves? How well would that work out?"

"This is a side of you I haven't seen and wouldn't have expected."

"Thus proving my point, at least partly. But answer my question, please."

"Of course I wouldn't want them to be tentative or lack confidence in their skills."

"You also have to take into account I'm speaking to you the way I'd speak to an Attending who challenged me. I don't speak to patients in this way, or to Kris, and certainly not to Rachel."

"It seems that you've concluded I'm incompetent."

I shook my head, "No, you're a product of the system that trained you, just as I am. And we both know that mental health is poorly understood, and poorly treated because of that poor understanding. I know for a fact that if I remove an inflamed appendix, it's going to resolve the appendicitis.

"Yes, there might be other ailments, and there might be complications, but the appendicitis will be resolved. You can't say that about any mental health condition. I can, in effect, follow the printed instructions in the surgical manual and they will work every time, allowing for complications which are rare. That doesn't work for mental health issues, and yet, that's how you and Doctor Greenberg treated Angie."

Doctor Mercer was quiet for a bit, and the waitress brought our food, which included the strange combination of mac and cheese and French fries for Rachel, but she loved both and I wasn't going to deny her as she had to tolerate my meeting with Doctor Mercer. I said grace, then helped Rachel eat while eating my own lunch.

"I suppose I admitted as much in my statement to the Medical Licensing Board," Doctor Mercer said a few minutes later.

"Yes, and that brings us to the most important question -- what are you going to do about it?

XXXI. You're Quite the Subversive!

August 2, 1989, Circleville, Ohio

"Jesus, Petrovich!" Clarissa exclaimed. "What did she say to that?"

I'd called Clarissa from a payphone before I'd left Lou's, and she met me at the house just after I put Rachel down for her afternoon nap.

"Nothing, really. I didn't expect an answer because I wanted her to think about it."

"You're not concerned she'll change her mind about the hearing for Angie?"

"I'd say she's less likely to do so now because she's on notice about how badly she's screwed up just with me."

"Don't you think you were a bit harsh?"

"Seriously, Lissa? Who else would speak to her that way? I simply took my cues from how Residents and Attendings have spoken to me over the past four years. Think about the situation -- she's in independent practice, so who really watches over her? Even the Chief Attendings at Moore are accountable to the Medical Director and their peers in an M & M."

"The Medical Licensing Board."

"Tell me another bad joke! Look how difficult it is in a clear-cut case of malpractice with regard to Angie! And you know what happens to most complaints."

"Closed with 'no further action'. But are you saying nobody should be permitted to practice independently?"

"No, but some kind of oversight is necessary, and the Medical Licensing Board does not have the resources to do it properly. That's why the majority of disciplinary cases are handled internally at the hospital. Egregious cases are forwarded to the Medical Licensing Board, and they do take action, but that's because the reports come from other doctors or the hospital administration.

"Consider Angie's situation, and how well THAT works with no actual oversight. The insurance company paid the malpractice claim with no admission of actual liability or error by Doctor Greenberg. That means other than in the records of his malpractice insurer, it never happened so far as the public record is concerned. We're remedying that, but only because Lara is providing the money to mount a complaint with actual teeth.

"And think about the end result -- there is no additional money to be had, as all current and future claims were covered by the payment from the malpractice insurer. So there is no benefit to Angie from the process. The Stephens wouldn't have funded it, because they don't have the resources, and it would have been foolish to spend Angie's settlement to go after Doctor Greenberg's license.

"The system we have, and not just for mental healthcare, is rigged in favor of doctors, and despite the strict licensing regime, there is little actual oversight because the process is designed to limit the ability of the public to hold doctors accountable. I absolutely agree there needs to be a way to limit baseless or frivolous claims, but the current rules make it difficult to address even legitimate complaints."

"Would you be willing to have that kind of scrutiny?"

"So long as we work in a hospital, we will. And it's incumbent on us to ensure that our peers hold us accountable and we hold them accountable. And lest you think I'm tilting at windmills again, I did consider asking for an M & M for my 'alien encounter' patient, but rejected it because it had little chance of success and was not the right battle to fight at that time."

"But isn't it similar to Angie?"

"Somewhat. I made the point the best I could, given the circumstances. It's also the case that Mr. Alien Encounter was off his meds. I didn't know that at the time, but Lydia Samson let me know when she was in the ED for a consult. That distinguishes it from Angie's case because being off her meds improved her situation, whereas that wasn't the case with Mr. Alien Encounter."

"Did you know he was taking medication?"

"No, and he wasn't exactly forthcoming. According to Lydia, he claimed the drugs were part of the government conspiracy that includes Area 51, Wright-Patterson Air Force Base, and anything else to do with the aliens who are among us."

"Just out of curiosity..."

"Do I think there is life on other planets? Probably. Have they visited us? Unlikely. And if they have, they took one look around, shook the dust off their feet, and beat it for a planet with actual intelligent life!'

Clarissa laughed, "There might be something to that."

"But in all seriousness, the cases are distinguishable in that Angie was showing signs which contraindicated her diagnosis, while Mr. Alien Encounter was showing signs that confirmed his diagnosis."

"What was that?"

"Paranoid personality disorder. I don't know enough to have a medical opinion, but his behavior did fit the basic DSM criteria. Once he was back on his meds, he became more rational, but it's a good bet he won't remain compliant. It's a similar problem to Angie's in that way. She has always tried to avoid taking the prescribed drugs. And that is likely to be one of Doctor Greenberg's defenses."

"So, how do you counter that?"

"That when she revealed to me that she was not taking her prescribed drugs, I insisted she take them and speak to Doctor Mercer about modifying the treatment regimen, and she complied with my request. She was only taking mild sedatives at the time, not the antipsychotics, and she was perfectly lucid and was making plans. And her approach was VERY different from how she approached it at Taft."

"Either 'do not touch me' or 'fuck me right now'."

"Yes. She was fully aware of her situation, and her goal of regaining her driving privileges was a proxy for regaining the right to consent so she and I could marry and have kids."

"Are you actually going to say that?"

"Yes. It's in the statement I signed for Tom Kirkland, the attorney from Stefan's firm who's handling the case. And I'll repeat that before the Medical Licensing Board at the hearing."

"But as a private citizen, right? Not as a doctor?"

"Correct. I won't wear a medical coat, and I'll make it clear I'm speaking simply as Angie's friend and won't address anything other than directly observed behavior."

"But you just said something that's not directly observed."

"She told me her goal, Lissa. One that was obvious to everyone, including Doctor Mercer and Father Stephen. And Tom Kirkland has a statement from Father Stephen to that effect, so even if I don't say it, it'll still be entered into the record. And you know it was Doctor Greenberg's declaration that marriage was impossible that caused Angie's relapse. That's a fact, and there is nothing Greenberg can do to counter that fact. It really is a question of what punishment will be meted out."

"You know Lawson is going to come gunning for you."

"He can't really do anything to me, despite his threats. Remember, the facts are all on my side, and his buddy settled a malpractice claim AND is being brought before the Medical Licensing Board. I didn't try to treat Angie, and I sent her to Doctor Mercer as soon as I discovered she was non-compliant with her meds. What is Doctor Lawson going to complain about? That I show love for my friend? That I'm concerned for her welfare?"

"What about your policy violation?"

"Iffy at best, because I didn't prescribe any treatments, I simply made a recommendation to the Psych Resident. I humored Mr. Alien Encounter so I could perform a physical. In that way, it's no different from how we sometimes handle kids."

"Your candy bribes?"

"They work, and don't violate policy. If I'd done anything other than perform the physical and recommended humoring him, then Lawson would have a leg to stand on. As it is, he doesn't. And I have the ultimate out."

"Elizaveta?"

"As one component of extreme stress for which I've sought counseling. What is he going to say? I haven't made any medical errors, and I've had perfect scores on my evaluations. So, even if my judgment about the best course of action for Mr. Alien Encounter was off, the combination of stress and my concern for Angie puts Lawson in an impossible situation. I bet he does nothing, even if Greenberg is disciplined."

"You're counting on him to be rational?"

"Yes. What does he gain by gunning for me? His implied threat didn't work, and Doctor Mercer, Doctor Hoffman, and another psychiatrist hired as an expert witness will all testify to the same things I am. I'm not the lone voice crying in the wilderness. Rosenbaum and Mastriano are a bigger threat, but she's more or less defanged because she tried to contradict Northrup and Cutter."

"You don't think the 'adulterous bitch' will try revenge?"

"How will it look when I stated to Doctor Nielson that I agreed with Doctor Mastriano on how to handle the court order for a blood draw?"

Clarissa laughed, "Not good, for her, that is. I'm curious about that."

"About?"

"Your take on it."

"I have an ethical problem with court-ordered procedures in any instance, and in this case there was a simple solution -- transport him to the lockup and have the nurse and deputies there draw the blood. Can you imagine if the patient fought us and had to be subdued in a trauma room? I can't see that ending well."

"I agree. What about the situations we discussed in Practice of Medicine? Jehovah's Witness parents who refuse blood transfusions that will save their kid's life?"

"I'm guided by the Orthodox understanding of medicine, but I also cannot let my faith determine what is or isn't acceptable for someone to believe. It's a difficult call given he competing interests, but in the end, I think I'd err on the side of giving the transfusion. That said, if the kid was old enough to give their opinion, I'd take that into consideration as well."

"What about a court-ordered abortion? Like the one performed on Liz."

"I refuse to perform elective abortions, period. In my view, mental health is not a consideration. That said, you know I don't believe that decision can ever be up to anyone except the woman and her doctor. I simply can't, in good conscience, impose my views on others with regard to medical procedures with are legal under our system, and the Supreme Court has made it clear that a specific medical procedure cannot be made illegal, at least during the first trimester."

"Do you agree?"

"Does it matter? I have a say about my body, not about yours or anyone else's. When I can get pregnant, then it will be up to me. I believe I have the right to give my opinion, but not the right to decide. And that's how all medical procedures are handled. We can't force any patient to accept any treatment, nor can we be forced to provide it, except in very limited circumstances, and with an appropriate court order. But even with the order, no physician can be compelled to perform the procedure.

"With regard to medically necessary abortion, it's one thing for me to say that I'm willing to die for my faith; it's a very different thing for me to say a woman should die for my faith. That's the error the Romans make in the way they handle abortion both theologically and in their hospitals. Orthodoxy objects to abortion, but treats it as it does any other act of 'missing the mark' -- based on the totality of the gravity of the act and the circumstances."

"I've read that some Orthodox bishops want it made illegal."

"And they are within both their legal and canonical rights to advocate that. In the end, though, it comes down to having a responsibility to shepherd their flock, and that includes a proper response to 'missing the mark'. But we're WAY off topic!"

"Yes and no," Clarissa replied. "We will have to face all manner of ethical dilemmas, and Mr. Alien Encounter was the first of many."

"You're forgetting my encounters with some young women from Saint Michael."

"The ones you fucked or the ones you encountered in a medical setting?" Clarissa asked with a smirk. "And I think those two sets overlap, if I read the tea leaves correctly!"

"Smart ass!" I chuckled. "No comment."

"Uh-huh."

She was correct, in that I'd encountered Irina at the Free Clinic and had also been intimate with her after Elizaveta's repose.

"Whatever, Lissa! That's all in the past now."

"How much does Kris know?"

"Very little, by her own choice, as I think you and I discussed."

"Yes, I was just curious if that had changed. You know I won't say anything."

"Nothing has changed. In that way, she's more mature than Elizaveta, who was always trying to figure out who I'd been with. It still bugged her even after two years of marriage. That said, Kitten was exactly who I needed at the time, and I wouldn't do anything differently."

"Your relationship with Kris is very different."

"It is, and it's more of a partnership with shared goals, which is exactly what I need now. I think the past month has proved much of my thinking about relationships to be correct, and only a strong, independent woman could deal with the situation. Elizaveta would have struggled, but found her way through. Kris doesn't struggle."

"Because she still lives what amounts to an independent life," Clarissa observed.

"Yes and no. She's accepted responsibility for Rachel, and you know full well from the past two years that parents don't have a life independent of their children. Rachel is the most demanding person in my life, and everything I do has to consider her, even if the demands of medicine interfere. The balance is difficult."

"Which is my main reason for waiting to finish my Residency before I have our baby. I'll make an appointment with a fertility specialist in about eighteen months to work out a plan with the goal of having our baby about three-and-a-half years from now."

"Perfect timing, given Kris and I will have two kids in the next three years, assuming nature cooperates."

"Circling back to the reason you called, how did you leave it with Doctor Mercer?"

"That we'd speak again after the hearing on the 23rd. Fundamentally, I don't trust her at this point, and it will take time and effort on her part to regain the trust."

Clarissa looked at her watch and said, "Tessa's shift ends in fifteen minutes, and I want to be home when she arrives."

We got up, and I walked Clarissa to the door, we exchanged a hug, and I watched as she walked to her car and drove away. I had some time to simply relax, so I put on music, put my feet up and chilled until Rachel woke up from her nap. I'd just finished changing her diaper when Kris arrived home.

"How did things go?" she asked after we exchanged a hug and a kiss.

"About as I expected," I replied. "Clarissa was here this afternoon, and we talked it through."

"That bad?"

"I basically read off Doctor Mercer and wanted Clarissa's opinion and advice. I want yours, too."

"Let me change and then you can tell me."

She went upstairs and came back down in short-shorts and a tight white t-shirt, obviously not wearing a bra.

"And I'm supposed to be able to think coherently with you dressed that way?" I asked with a silly smile.

"Given you're male, coherent thought is difficult under the best of circumstances!" Kris teased.

"Yeah, yeah," I chuckled.

We sat down on the couch with Rachel playing on the floor in front of us, and I described my conversation with Doctor Mercer and the debrief with Clarissa afterwards, though I had to finesse the situation with Samantha.

"She would have objected to us marrying, wouldn't she?"

I nodded, "I'm positive she would have. Her arguments would have been slightly different, but along the same lines."

"How is it that she can only seem to apply what she considers to be 'normal' without considering the individual?"

"It's the training," I replied. "While she's not an MD, she was trained in a way analogous to our clinical rotations, and doctors are repeatedly reminded that the 'standard of care' is how they'll be judged. That means if you follow the guidelines, you will never, ever get into serious trouble because 'standard of care' is a sufficient legal and ethical defense. That's how Doctor Mastriano avoided any liability for the death of the patient."

"But she was disciplined!"

"For substituting her judgment about my training for that of Doctors Northrup and Cutter."

"So she killed the patient, and that's OK?"

"No, it's not, but because of the way the system is set up, discipline in cases where you follow the standard of care has to be limited. There are competing impulses, mostly driven by malpractice claims -- what's called 'defensive medicine' and rigorous adherence to the standard of care. And 'defensive medicine' has costs, both in terms of resources expended and in subjecting a patient to what might be unnecessary tests.

"For example, in the Emergency Department, the standard is to run a full trauma panel on patients brought in by ambulance. I had a patient where that was totally unnecessary, so I didn't order it. If something had gone wrong, I could have been held responsible for not running the tests, even though it made perfect sense not to run them. I believe I could defend not running them, but nobody would every question me if I did, even if they were unnecessary. My beef with Doctor Mercer is she relied too heavily on 'standard of care' as a defense, but as I said to her, that's a product of our training and of the environment in which we work."

"So you're a rebel?" Kris asked.

"Only insofar as I'm looking out for the best interests of my patients or identifying flaws in the system. And it's not that I would ignore the standard of care, because I wouldn't. But it's only a guideline, except in one instance -- malpractice. Going beyond the standard of care might get me a talking to about expending resources, but my concern is, and always will be, the best interest of my patient.

"As for defensive medicine, it takes resources which could be put to better use. I understand why it happens, and unless there are real reforms to the system, it's not only going to continue, but get worse. Once somebody has a condition where a CAT scan might have saved their life, and their family sues, and obtains a settlement, we'll be doing routine CAT scans, which are far more expensive than a trauma panel by at least an order of magnitude, if not significantly more."

"You know my answer!" Kris said with a smile.

"And you know my response! We already have 'socialized medicine', what we don't have is single payer or complete government control. And I'm not sure either of those would improve things overall. It all comes down to one thing -- are the doctor and patient allowed to determine the best course of treatment without any interference by bureaucrats, be they employed by the government or an insurance company?

"The problem with that, of course, is how to pay for it. And, in the end, no matter what system you have, resources are limited and someone has to decide how to allocate those resources. It doesn't matter to the patient if it's the Medical Director, the County Board, the Federal Government, or an insurance company who denies the allocation of resources."

"But wouldn't it be more efficient without the insurance companies?"

"We have more paperwork for Medicaid and Medicare than we do for insurance claims, and it's likely to get worse."

"I'm not going to win this argument with you, am I?"

"Not unless you find a way to provide unlimited resources! Until then, our argument is about how best to allocate the limited resources and who does the allocation. With your permission, I'll change topics and ask how class was today."

"I'll allow it," Kris replied. "Class was fine. I did receive my grade report from my first class and I earned an A."

"No surprise there!"

"What did you want to do about dinner?"

"Pasta and salad?" Kris replied. "We can have dessert later, after Rachel goes to bed."

"And what exactly did you have in mind for dessert?" I asked with a sly smile.

"I'm sure you'll find something tasty! I know I will!"

August 3, 1989, McKinley, Ohio

"Morning, Kylie," I said to her after checking in with Doctor Williams on Thursday morning. "How was last night?"

"You'd have thought it was a full moon! Three being observed and four waiting for admission. I got zero sleep in the last thirty-six hours!"

"Ugh. Run me through the patients, please."

"Two on banana bags awaiting discharge, probably around 9:00am. Some kind of drinking contest gone wrong at a bachelor party. Third awaiting discharge fell and hit their head, mild concussion and observation will be done around 7:00am. Two admissions for surgery -- one hot appy who'll go up around 10:00am because the on-call team had a stabbing victim they took up about ninety minutes ago. Some kind of domestic dispute which resulted in a meat fork to the gut."

"You had that one, too?"

"I had all the fun. The two other admissions are an apparent suicide attempt with sleeping pills. They're stable and are on a seventy-two-hour psych hold. They'll go up soon, now that vitals are stable after treatment with activated charcoal and lavage. Fourth one is a broken ankle that needs surgery. Ortho was down, but didn't give an ETA on when they'd take him. He just had another dose of morphine."

"Sounds like a fun night."

"That's only the half of it! A gunshot wound went up to surgery just after midnight, a pair of MVAs, a fatal MI and another six 'treat and street'."

"What the heck happened?"

"Who knows? It's only a waxing first quarter moon, so the lunatics shouldn't be out!"

"Go home, take a bath, and get some sleep!"

Kylie glanced around to make sure nobody was in earshot.

"I need some of that relaxation therapy you used to provide, and there are no good candidates."

"I wish I could help, but..."

"Obviously," Kylie interrupted me with a smile, "There is no freakin' chance I'm going to have an affair with a married man, even if you would, which you won't. I'll leave that to idiots like Mastriano!"

"Go get some sleep and I'll see you at our next turnover on Monday morning."

Kylie left, and I met Bob and Len in the lounge, and we went to check on the patients they'd treated together with Kylie and other doctors overnight. I assigned them to ensure the patients waiting on admission were scheduled to go up, and updated the charts on the patients waiting to be discharged.

I'd just finished updating the charts when Ellie let me know the paramedics were bringing in two victims from an MVA, so Bob, Len, and I joined Doctor Williams in the ambulance bay.

"Len, you come with me," Doctor Williamson said. "Mike, we'll take the first patient; you and Bob have the second."

It turned out that neither patient had been critically injured, as both had been wearing seatbelts and the collision was relatively low speed. After a basic exam, I cleared the patient's c-spine and removed the cervical collar. With no injuries beyond minor bruises and a mild cervical acceleration-deceleration injury, colloquially 'whiplash', I wrote up the discharge notes and presented to Doctor Williams, who approved releasing the patient. His patient had similar minor injuries and was released as well.

By 9:00am we'd admitted or released all the overnight patients except the appy, and we'd treated four walk-ins with minor complaints. I had just sat down in the lounge when Nate opened the door.

"Mike, Sheriff's Deputies bringing in an arrestee with a rapid pulse and complaining of a headache."

"Cruiser or ambulance?" I asked.

"Cruiser. Ten minutes."

"Ten minutes? Why so long?"

"No idea. That's what they said on comms. They'll come to the ambulance bay to avoid the waiting room."

"OK."

Just under ten minutes later, Bob, Kellie, and I met the Sheriff's cruiser in the ambulance bay. Deputies McCallum and Sommers got out of their cruiser and Deputy Sommers, a female deputy, opened the back door. They helped a handcuffed female who appeared to be around twenty and who was clad in jeans and a t-shirt from the back seat.

"Name?" I asked.

"Shauna Percy," Deputy Sommers replied.

Bob pushed the wheelchair over and after the deputies switched the cuffs so her hands were in front of her, he helped her into the chair.

"Let's take her to Trauma 2," I said. "Bob, EKG and monitor; Kellie, Chem-20, EtOH, and tox screen."

When we arrived in the trauma room, we helped Ms. Percy onto the treatment table.

"I'll need the cuffs off, please," I said.

"Will, stand at the door," Deputy Sommers requested of her partner.

Once he moved to guard the door, Deputy Sommers removed the cuffs, admonishing her prisoner to behave.

"Hi, Shauna," I said. "I'm Doctor Mike. What's the problem?"

"Besides these two rousting me?"

"That's something to take up with an attorney or a judge," I said. "How are you feeling?"

"I have a bad headache, my heart is racing, and my hands are shaking."

"We're going to draw blood, hook up a heart monitor, and I'll examine you, OK?"

"Yes."

"For the EKG we'll need to remove your t-shirt, but you can keep your bra on. Kellie?"

Kellie helped Ms. Percy remove her t-shirt, then lie back. Bob attached the EKG leads and monitor, and Kellie drew blood. I performed the exam and noticed dilated pupils, and the monitor showed tachycardia, hypertension, and A-fib, and her respirations were fast and deep. My money was on some kind of stimulant, most likely amphetamines.

"When did you start feeling bad?" I asked.

"This morning."

"How long ago?"

"A couple of hours."

"What did you take?" I asked.

She didn't answer, but Deputy Sommers held up a baggie with capsules. I took the baggie from her and examined the capsules.

"Dexedrine," I said. "That's consistent with her symptoms. Shauna, how long have you been using?"

"Since High School," she said reluctantly.

"How old are you?"

"Twenty-one."

"Have you had the symptoms before today?"

"No."

"Did you take more today than you have in the past?"

"Yeah, because I didn't feel it."

Signs of dependency and tolerance, which meant she was likely to suffer withdrawal symptoms, including severe depression. She'd need medically managed recovery once her system had processed her most recent 'hit' of the drug. Assuming, of course, she was interested in quitting.

"How many?"

"Four."

"Your symptoms are consistent with an overdose of dextroamphetamine, or 'dexies'. Are you taking any other drugs or medications of any kind?"

"Birth control pills."

Which also could raise blood pressure, and the combination of those and dexedrine were responsible for her BP of 160/100, which was very high, but would likely resolve without medical intervention once the effects of the dexedrine wore off. I considered giving her medication for hypertension, but she wasn't in crisis, which would be systolic pressure greater than 180 or diastolic pressure greater than 110.

"Your symptoms should wear off in a few hours," I said. "Do you want to go into a drug program?"

"She's under arrest," Deputy Sommers interjected.

"I understand, but her withdrawal will need to be medically managed. I'm not sure the jail can manage that with just a nurse and a small infirmary. Shauna, do you want to quit?"

"If I say 'yes', do I stay here?"

"That's not up to me," I replied. "I'll call for a consultation from Internal Medicine and Psych, and have a social worker come see you. They'll decide if we need to keep you or not."

"I want to quit," she said.

"Fuck," Deputy McCallum swore.

"Can we step out for a moment?" I asked. "Just right outside the door."

Deputy McCallum and I stepped into the corridor.

"You know I'm required to ask those questions, right?"

"Yeah, Doc, but we were hoping to turn her."

"Pushing?" I asked.

"No, hooking. But we busted her on a stop and frisk because she was behaving erratically. We want the guy who provides her the drugs for that, but more because he's running underage hookers. But nobody will talk."

"This is legit? You aren't trying to overcome my rep as a 'bleeding heart'?"

Deputy McCallum laughed, "You do have that rep, but you also take good care of us, so we're not going to give you too much shit. I know you have a job to do, but so do we."

"Not to tell you how to do your job, but get the County Prosecutor to come see her and cut a deal that puts her in detox and a recovery program. I think she might cooperate if you do that."

"I wouldn't bet on it."

"If you were hoping withdrawal would encourage her to talk, then ethically, I have to find a way to keep her here."

"The Sheriff is going to be pissed."

I shrugged, "He has his job, and I have mine. And my job is to provide her with medical help and ask social services to help her get into a program. Either way, she's staying for at least four hours while she comes down, because we have to watch her blood pressure and arrhythmia. Let me go report to Doctor Williams and see if he agrees."

"He's the biggest bleeding heart here!"

I smiled, "I think you'll find that to be a common feeling amongst trauma docs," I replied. "Give me five minutes."

He went back into the trauma room and I went to the Attending's office.

"OK to present?" I asked Doctor Williams.

"Yes. What do you have?"

"Shauna Percy, twenty-one; presented with hypertension, tachycardia, A-fib, headache, and tremors. Dexedrine overdose; using for at least three years and signs of dependency. In the custody of the Sheriff. Also taking birth control pills. Requested detox."

"Blood work?"

"Sent to the lab; Chem-20, EtOH, and tox screen."

"Vitals?"

"BP 160/100; tachy at 110; PO₂ 99% on room air."

"Proposed treatment?"

"Monitor and treat symptoms if they become life threatening. Medicine and Psych consult and referral to the social worker. I'm also going to suggest full-spectrum STD testing as she's accused, among other things, of prostitution."

"Approved. Anything else?"

"No. It'll be up to Medicine and Psych if they admit her, but she's been using long enough that her withdrawal symptoms are going to be severe and I'm not confident the nurse at the County Jail can properly care for her. But that's not something I get to decide."

"Unfortunately, because I think you and I would both admit her and keep her for a week or so, then get her into an outpatient program. But it's not up to us."

"Mind if I play my cards in a specific way?" I asked.

"Shut the door," Doctor Williams instructed.

I did.

"What?" he asked.

"Instead of calling for a general consult, I want to ask Clarissa Saunders to come down. She'll be on the same page, and once she and I agree, then we call the social worker, and finally call Psych."

"I like it. Slightly off the usual flow, but given Psych doesn't like us very much at the moment, a wise course of action. Chart?"

"My fault?" I asked as I handed him the chart.

"No, it's been building for a time. You were just the latest incident, and your earlier run-ins with Lawson exacerbated it. But it's been going on for years because they reject so many patients we think need psychiatric care. Off the record, I supported your approach, and I think you're doing the right thing for your friend."

"Does everyone know about that?" I asked.

"Lawson made a stink about it with Northrup and Cutter, who told him, politely, to pound sand. Do you know his history?"

"No."

"He failed to Match and had to Scramble, and the only Residency he could find that would take him was psych. He applied to eight surgical programs and was rejected by all of them. Rumor has it that the hospital in Detroit where he served his Residency wouldn't hire him as an Attending."

"That explains a lot. Thanks for that insight."

"Let me know if you need help, but for dexedrine, it's palliative care and treatment of symptoms if necessary."

He made notations on the chart, signed it, and handed it to me.

"Thanks, Brent."

I left the office and rather than go to the trauma room, I went to the lounge to use the phone and called Clarissa.

"I'm not doing consults this morning," she said after I explained what I needed.

"Who's your Attending?"

"Vega."

"Tell her I need a favor and get her permission to come down."

"Lawson is going to lose his shit!"

"I have Brent Williams' signature on the chart," I said. "He approved my plan, and besides, what can Lawson really say? I called consults in the order I felt best suited the patient. Not to mention the patient needs to come down from her high before Psych sees her. So I just called you based on her symptoms and then social services to set up the appointment. Can I help it if Jeannie Wilders was free immediately?"

"Nice, Petrovich. You're quite the subversive!"

"Get Maria to sign off, please."

"I'll call you right back. Where?"

"Trauma 2."

We ended the call, and I went back to Trauma 2.

"Shauna, I'd like to run full-spectrum tests for sexually transmitted disease. That would involve both blood draws and swabs of your mouth, genitals, and anus."

"Because they said I hook?"

"No judgment on my part. You don't have to agree, but I strongly recommend you have the test. I can have a nurse do the swab and all the men will leave the room."

"Shauna," Kellie said, "Doctor Mike is giving you good advice. If you've had multiple partners, you really should be tested. I can perform the swabs if you don't want him to do it."

"You think I have VD?" Ms. Percy asked.

"I don't know if you do or not," Kellie replied. "But it appears that you're engaging in high risk behavior, and amphetamine usage lowers inhibitions and causes risk taking."

The phone rang and Bob answered it, then signaled it was for me. I walked over and he handed me the handset.

"Loucks," I said.

"Saunders. I'm all yours!"

I chuckled, "If only that were true!"

"Be right down!"

We ended the call, and I went back to the treatment table.

"That was my colleague from Internal Medicine. She's going to come down and examine you. She's the one who'll decide how long you need to stay. Once she's finished, we'll call a social worker. Eventually, once the drugs wear off, you'll talk to Psych. Do you want the STD tests?"

"Yeah."

"OK. Kellie will draw blood and do the swabs once Doctor Saunders examines you."

Clarissa arrived two minutes later, and I repeated the information I'd given her over the phone as it was protocol for a consult to state the vitals in the room when the consulting physician arrived.

"Shauna, this is Doctor Clarissa Saunders," I said.

"Hi, Shauna, can you tell me what you took and how much?"

"Four dexies about two hours ago."

"And you're a regular user?"

"Yes."

Clarissa performed her exam, then asked a series of questions similar to the ones I'd asked.

"I'd like to admit her and keep her overnight," Clarissa said. "Two hours after ingesting the pills her BP shouldn't be this high. It's likely an interaction with her birth control pills, but we can't be absolutely sure."

"Will you take her now?"

"Yes. I'll call Jeannie Wilders once we get Shauna upstairs."

"Thanks, Lissa. We'll do the STD tests, then Bob will bring her up."

"Shauna, I'll see you shortly," Clarissa said.

She left, and Bob, Deputy McCallum, and I left the trauma room, leaving Kellie and Deputy Sommers with Ms. Percy.

"OK to use the phone?" Deputy McCallum asked.

"Use the one in Consultation 1. The other consultation room is an exam room now."

He walked away and went into the room.

"What did I miss?" Bob asked.

"Ask me later once the patient is upstairs."

He nodded, "Got it."

About five minutes later, Deputy McCallum returned.

"A deputy prosecutor is going to come here and see if we can deal."

"Good," I replied.

Two minutes later Kellie called us back into the room, and after updating the chart, we disconnected the monitors and helped Ms. Percy into the wheelchair.

"Thank you," she said, smiling at me. "I appreciate it."

"Get into a program and stick with it. You're young and have your whole life ahead of you."

They left, accompanied by the deputies and I went to let Doctor Williams know what had transpired.

"Clarissa admitted Ms. Percy based on hypertension more than two hours after ingesting the drugs."

Doctor Williams nodded, "Defensible. Good work, Mike."

"Hopefully she'll stick with the program and turn her life around."

"Hopefully, but that's up to her, not us. Need anything else?"

"Not at the moment. I saw a number of people in the waiting room, so I'll catch some of those."

"OK. Come see me when you need me."

"Will do."

XXXII. Lord Have Mercy

August 3, 1989, McKinley, Ohio

At lunch on Thursday, I met Chancellor Evans from Taft at the diner across the street, hoping to not be paged, but knowing there were no guarantees.

"I'm sorry I've been remiss about having lunch with you," I said.

"It's understandable with your medical training, marriage, and family. How does it feel to be a doctor?"

"Fulfilled. Becoming a doctor was my goal since age ten."

"I'm happy we could do our small part in helping you achieve your goal! And that you're mentoring Antonne Jefferson."

"I haven't seen him over the summer, but we'll resume the mentoring sessions once school starts at the end of the month."

"I know your schedule is crazy, but would you be willing to meet prospective students in November and February? If so, we'd like to put together a 'pre-med' weekend. We'd invite Clarissa Saunders and Sophia Jackson as well."

"A lot will depend on our schedules, but I suspect we'll be able to make the time."

"If the hospital is amenable, we could have the students and their families come there, and perhaps observe."

"You'll need to take that up with Doctor Rhodes," I said. "I'm not sure what his position would be on observation by High School students."

"You're OK with it, though?"

"Yes, so long as you receive permission from the Medical Director. And obviously you'll need to ask Clarissa and Sophia. I should warn you that Sophia is seeking to match in the San Francisco Bay Area, and Robby is going to be at Stanford."

"That's not until next June, right?"

"Correct. Clarissa will be here as long as I am."

"I was reasonably certain that would be the case. If I may change subjects, how is your friend with schizophrenia?"

"Not good," I replied. "I'll be testifying before the Ohio Medical Licensing Board in two weeks, hoping to have her former psychiatrist suspended, though I feel his license ought to be revoked."

"What happened?"

"It's a long story, but the bottom line is that in my opinion, and the opinion of two mental health professionals, he committed malpractice in his treatment of Angie, which made her condition worse."

"I'm sorry to hear that."

"It's a bad situation and the hearing can't fix it, but it can ensure the psychiatrist understands how badly he screwed up."

Chancellor Evans nodded, "On a happier note, I'm looking forward to your concert at the end of the month."

"I enjoy those concerts very much."

We finished our lunches, agreed to meet sometime in September, and I headed across the street to the hospital.

The first task after lunch was to join Doctor Gibbs for evaluations for Bob and Len, both of whom received grades of 4, which were the norm for very good candidates, with scores of 5 being reserved only for the best candidates. After that, it was a busy, albeit routine, afternoon, and I met Clarissa for dinner. I let her know about Chancellor Evans' request, and she agreed she'd participate and thought the hospital was the correct venue.

The evening was quiet until just before 10:00pm when there were three EMS runs and five walk-ins within a fifteen-minute period, portending a night when I wouldn't get any sleep. Two admissions, five quickly streeted, and three being monitored, took us to midnight. I was just about to sack out when Doctor Gabriel asked me to handle a walk-in -- a young girl who appeared to have been struck in the face multiple times.

"Hi, Amelia," I said, looking at the chart. "I'm Doctor Mike. Will you come with me, please?"

I escorted her to Exam 3, and we were joined by Mary, Tom, and Wendy.

"What happened?"

"I got into a fight," she replied.

"Who brought you in?"

"A friend."

"I'd like to do a quick exam -- listen to your heart, your breathing, and look in your ears, eyes, nose, and mouth, then check your stomach, OK?"

"Yes."

I performed the exam, observing only glassy eyes, facial contusions, and a swollen lip. I appreciated no guarding or tenderness in her abdomen. I had two suspicions -- the first was that she had taken some kind of drug, and the second was that her development did not match her claimed age of nineteen. If she was a day over fifteen, then I was Mikhail I, Tsar of All the Russias!

"Amelia, when is your birthday?" I asked.

"October 12th."

"What year?"

She hesitated just briefly before saying, "1970."

I decided on a gambit.

"Do you have your ID so we can put your address on the chart?"

She pulled her billfold from her purse and showed me what even I, as a layman, could tell wasn't her driver's license, as the facial bone structure of the girl in the picture didn't even come close to Amelia's. I ignored that for the moment and wrote down her address, noting her birthdate.

"Thanks. How many times were you hit?" I asked.

"I don't know, maybe four."

Which matched her observable injuries.

"I'd like to get an x-ray to make sure no bones are broken," I said.

"Yes."

"Let me arrange that, please. Just relax here. Nurse Wendy will stay with you. Mary, with me, please. Tom, just wait here."

He gave me an odd look, but acknowledged my instructions, and Mary and I stepped out.

"What's wrong?" she asked. "Usually you would have Tom call radiology."

"She can't consent to the x-ray," I replied. "I either need two doctors with medical licenses to sign off with me, or her parents."

"She's nineteen, right?"

I shook my head, "I think she's fourteen or possibly fifteen. The ID she showed me is not hers."

"You know, she does look awfully young, but some girls look young. We had an undercover police woman at my High School who was twenty-three but passed as a Junior."

"Obviously not well enough if you knew!"

"I only knew after she busted the pot dealer. But then it made total sense why she never went on dates or hung out with kids after school or went to parties. So what do you do?"

"The discrepancy between her claimed age and what I observed is too great to simply ignore and pretend she's really nineteen. My thinking is to get Doctor Gabriel and Doctor Mastriano to sign off and treat her, but also see if you or I can build rapport with her and get her to admit her age."

"Then what?"

"Figure out if she's being abused or if she really was in a fight. The age mismatch suggests another possibility, too, based on a something a Sheriff's Deputy said this morning."

"I wasn't here, obviously. What?"

"They're looking for a pimp and drug pusher who runs underage prostitutes."

"I'll cut his balls off if I see him!" Mary declared fiercely.

"I think that was what Deputy Sommers was thinking as well. Let's go see Doctor Gabriel and see if he'll back our play."

We went to the Attending's office, and I was happy to see both Doctor Gabriel and Doctor Mastriano there.

"What's up, Mike?"

"I have a female patient who was battered. She has facial contusions, a swollen lip, and glassy eyes, suggestive of marijuana use. She claims to be nineteen, but after my gross exam, I believe she's fourteen or fifteen. She has ID, but it's clearly not her given the differences in facial bone structure and offset between her eyes compared to the picture.

"I want to get x-rays, but given I'm convinced she's under sixteen, I need you and Doctor Mastriano to sign off. I'm concerned that if I confront her, she'll leave AMA, and I'd rather get the tests done so we know that she doesn't have any fractures. I'll also draw blood for a tox screen."

"And then what?" Doctor Mastriano asked.

"Then we treat her, most likely with analgesics, and attempt to get her to tell us who beat her."

"You have a suspicion, Mike."

I nodded, "Deputy Sommers this morning said the Sheriff and the McKinley PD are looking for a pimp and pusher who runs underage prostitutes. Maybe the patient really did get into a fight, but I'd say it's more likely she was beaten by an adult male, given the bruising. Whether it's a family member, boyfriend, or pimp, she needs help."

"And if it's a fight?"

"We street her. If not, either a Psych consult or social worker. Given the hour, it'll be Psych."

"Alternatives?"

"Well, I precluded pretending she's actually over sixteen once I stated my suspicions to Mary and then to you. The other option is confrontation with the risk she bolts."

"Who brought her in?" Doctor Mastriano asked.

"A friend."

"Is the friend still here?"

"I don't know," I replied. "Mary, go check with the admit desk, please. Don't say anything, and be surreptitious, so you don't spook anyone. Just get a look at the person who brought her in."

"OK," she replied, and left the office.

"You couldn't let it go?" Doctor Mastriano asked.

"Not once it became obvious, she was lying about her age and with what the Sheriff's Deputies said this morning."

Mary was back a minute after she had left.

"Scruffy looking guy I'd guess was around thirty," Mary said. "Nurse Emily identified him for me without making it obvious."

"OK," Doctor Gabriel said. "I'll sign off on the treatment. Isabella?"

"Sure."

"Mike, get the x-ray and lab work and see if you can get her to admit what's going on. If it's what I suspect, I'll call the Sheriff. Isabella, you go with them, please, given we're treating an underage patient without parental consent."

Doctor Mastriano, Mary, and I returned to Exam 3.

"Amelia, this is Doctor Mastriano, one of my supervisors. We'd like to get some x-rays and draw some blood, and also get a urine sample to check, among other things, for blood. That's standard when someone's been in a fight."

"How long will it take?"

"It depends on Radiology," I replied, then turned to Tom, "Call for a facial series, please. Wendy, if you'd draw blood for a trauma panel, hCG, tox, and get a urine sample. Tom and I will step out as soon as he finishes the call. Do you want us to tell your friend what's going on?"

"Uhm, er, I guess."

"What's her name?" I asked, using subterfuge to not make her suspicious.

"It's a guy. Gary. He's wearing jeans and a black t-shirt."

Tom finished the call and let us know Radiology could take Amelia as soon as we were ready, so I asked him to step out with me.

"What's going on?" he asked once we were out of the room.

"We're pretty sure she's only fourteen or fifteen, and the guy she's with is around thirty. Come with me and we'll see if we can get any clues without making him suspicious."

"You think he's abusing her?"

"I don't know, but a guy of thirty isn't usually 'friends' with a girl who's fourteen or fifteen."

Which I knew from experience, though Paul hadn't been that old when he'd been with my sister.

"Statutory rape," Tom said. "Well, I guess it's Criminal Sexual Assault now."

We went to the waiting room, and I saw Gary, who was dressed as Amelia had said, though I realized that probably was not her name, given the phony ID.

"Gary?" I said.

"Yeah?"

"Doctor Mike Loucks. Amelia seems fine, except for the obvious bruises and fat lip, but we're going to take x-rays of her face to make sure no bones are broken. That will take about an hour."

"Can I see her?"

"Once the x-rays are completed, I'll ask if she wants you to come back, but it's up to her."

"She'll say 'yes'."

"Do you know what happened?"

"Some guy beat her up. She came to me and I brought her here."

"OK," I replied.

I didn't ask about calling the police because the last thing I wanted to do was make him suspicious. Tom and I went back into the ED and waited outside the exam room.

"He looks like a pusher," Tom said quietly.

"And possibly a pimp," I replied. "The Sheriff is looking for a guy running underage girls as prostitutes."

"Guys like that should be strung up."

"Mary suggested she'd perform an orchiectomy."

"Sounds about right."

Mary came out of the exam room with blood vials and a urine sample.

"Doctor Mastriano signed the order," Mary said.

"Tom, take everything to the lab, please. We need the results of the hCG before we run an x-ray."

"You think she might be pregnant?"

"A standard trauma panel for any female who is of childbearing years includes a pregnancy test."

"Got it."

"Mary, I'll leave you in the room and have you try to build rapport. Be very careful."

"You're sure I should do it?"

"Positive. I think she'll be more willing to open up to you as a medical student, but don't push too hard."

"What did the guy say?"

"That 'some guy' beat up Amelia and she came to him for help."

"Consistent with him being her pimp."

"Or pusher," I replied. "Or both."

We went into Exam 3 where I had Wendy draw the blood and had Tom take them and the order to the lab.

"Amelia, Mary is going to stay with you until the lab results come back."

"OK," she said.

Wendy, Doctor Mastriano, and I stepped out of the room.

"She's not nineteen," Wendy said quietly. "Fifteen at most."

"We're all in agreement on that," I replied. "And the 'friend' is a guy around thirty.

"Everything lines up except one thing that makes no sense," Doctor Mastriano said. "Why does the guy bring her and stay with her? In my experience in Los Angeles, the pimps and pushers never hung around, and with injuries like this, they never showed up in the first place."

"What's your theory, Doctor Mastriano?" I asked.

"I don't have one," she said. "I just pointed out something that didn't line up. That's not to say he's not her pimp or pusher."

"A girl my parents are fostering was involved with a guy in his forties at age fourteen and got pregnant," I replied. "She had a fight with her mom and her response was to go next door and screw her best friend's dad. He was arrested the day her baby was born. She'd concealed the pregnancy."

Not to mention the situation with my sister, but I wasn't going to say anything about that, given everything else that had happened. Tom returned then and joined us in the corridor.

"So, are we taking bets?" Wendy asked. "Boyfriend? Pusher? Pimp? Trick? Friend?"

"Any or all of the above," I replied. "I do think Doctor Mastriano has a point about how a pimp or pusher would behave, but what's with the bogus ID and lying about her age?"

"If she claimed to be twenty-one, I'd say for bars," Tom said. "What does nineteen get you?"

"R-rated movies?" Wendy suggested. "Driving? And some clubs let you in at eighteen, but won't serve you booze."

"If Doctor Mike identified the license is phony, wouldn't a cop or bouncer?" Tom asked.

"It doesn't add up," I observed. "Let's see if Mary has anything for us when she comes out."

We waited about ten minutes, and Mary came out, and Wendy went in to stay with Amelia,

"She says Gary is her friend and that her boyfriend hit her."

"Did she admit how old she is?" Doctor Mastriano asked.

"Fifteen, and the ID is her older sister's. Her name is Amber. She doesn't want anyone to call the cops, so she pretended to be her sister."

"There are holes in the story," Doctor Mastriano said. "I think we need to call Social Services."

I nodded, "This isn't our area of expertise."

"I'm going to discuss it with Doctor Gabriel," Doctor Mastriano said.

"OK. Tom, go see what the lab has for us so far. I'm particularly interested in the tox screen and pregnancy test."

He left and was back five minutes later.

"Positive for THC and she's pregnant," he said.

"We need to tell Doctor Gabriel," I said. "Let's go."

The three of us went to the Attending's office, and I shut the door.

"Tom?" I prompted.

"Positive for THC and a positive pregnancy test."

"Mary?" I prompted.

"She admitted she's fifteen, says the guy who brought her in is a friend, and that it was her boyfriend who hit her."

"We can't x-ray her because of her pregnancy," Doctor Gabriel said. "Mike, do you actually suspect broken bones, or was it simply a precaution?"

"Precaution."

"OK. We need to call Social Services," Doctor Gabriel said. "The problem is, they won't see her until 7:00am tomorrow. We can't release her to an adult male who isn't her guardian, given she's under sixteen. There's no medical reason to keep her, so the only way we could do that is a Psych hold, which would obviously be a pretext or call law enforcement."

"What about calling her parents?" I asked. "We at least have an address for the sister. We could check the White Pages for surname and address match."

"Tom, do that," Doctor Gabriel said.

"Amelia DeJong," I said. "That's a Dutch name and isn't common in Ohio. 15 Custer Drive."

"Be right back," Tom said.

He left the office and came back a minute later.

"Charles DeJong, 15 Custer Drive," he said, "555-9898."

Doctor Gabriel pressed the speaker button on his phone and dialed the number. It rang five times before it was answered.

"DeJong residence," a man's voice said.

"Mr. DeJong, this is Doctor Peter Gabriel from Moore Memorial Hospital. Do you have a fifteen-year-old daughter named Amber?"

"She's fourteen. Is she OK?"

"Someone hit her several times, but we don't believe she has any broken bones or other injuries besides bruises. Do you know a man named Gary?"

"He lives next door. Why?"

"He brought your daughter here. We'd like you to come to the hospital so we can release her to you."

"My wife and I will be there in ten minutes!"

"Thank you, Mr. DeJong."

He pressed the button to disconnect the call.

"Do we tell her she's pregnant?" Mary asked.

"Yes," Doctor Gabriel said. "But before her parents arrive. We do not tell them. I'll put that on the chart."

Fourteen was iffy, but it was Doctor Gabriel's decision, and I felt given the unknowns, it was better to handle it the way he'd said.

"Mary should tell her," I suggested. "She developed rapport. Refer her to the Free Clinic?"

"Yes."

"Mary, let's go. Tom, go to triage and wait for her parents, then bring them to the consultation room and let us know."

"OK," Tom agreed, and he left.

Mary and I left the office, and I pulled her aside.

"If she asks why we ran that pregnancy test, you tell her it's a standard test before we run x-rays."

"And the THC?"

"I'll handle that once you tell her."

We went to Exam 3, where Wendy was waiting with Amber.

"Amber," Mary said. "We can't take x-rays because you're pregnant."

"I know," she sighed.

"Let me give you a brochure for the Free Clinic."

"I know about it," she said.

"Amber," I said. "You also tested positive for marijuana. That's not good for your baby. Also, your parents are on their way to get you."

"NO!" she gasped. "They can't know I'm pregnant!"

"We won't tell them," Mary said. "But because you're only fourteen, we had to call them."

A few minutes later, Tom came to the door to let us know that Mr. and Mrs. DeJong had arrived and were in the consultation room.

"Was there a confrontation with the friend?"

"No. It appeared cordial."

"Stay here, please. I'll go speak to them with Doctor Gabriel."

I left the exam room and went to the Attending's office to let Doctor Gabriel know the DeJongs had arrived.

"Isabella, you speak to them with Mike," Doctor Gabriel said. "Remember, just tell them that she was hit, should see her personal physician, and leave it at that."

"OK," she said, and we left the office to go to the consultation room.

"Mr. and Mrs. DeJong," Doctor Mastriano said. "I'm Doctor Mastriano and this is Doctor Loucks. We examined your daughter and other than some bruises and a swollen lip, she's fine. You should take her to your family doctor for a checkup."

"Did you call the police?" Mr. DeJong asked.

"No," Doctor Mastriano said, "because we were able to get in touch with you."

"Can we take her now?"

"Yes. Doctor Loucks will take you to her and give you a discharge form."

"Thank you, Doctor."

I escorted the DeJongs to the exam room, explained the discharge instructions to all three of them. After they left, I went to find Doctor Mastriano, who was at the nurses' station.

"Could I have two minutes of your time in private, Doctor Mastriano?"

We went to the temporary consultation room, as there was no Resident's office.

"What can I do for you?" she asked.

"I strongly prefer 'Doctor Mike'," I said. "I'd appreciate if you refer to me that way."

"I'd quote policy, but I don't think that would matter to you."

"You're Roman Catholic, right?"

"Yes."

"And you call your priests by their last name? Right?"

"Yes, of course."

"I'm Russian Orthodox, which I expect you know, and we call our priests by their first name. When I was a deacon, I was 'Deacon Mike' and my priest is 'Father Luke' and my bishop is 'Vladyka JOHN'. That's my tradition, and I think it's better. I'm not asking anyone else to use their first name, just that I be allowed to be Doctor Mike. May I draw another comparison?"

"I suppose."

"Would you be OK with me calling you Izzy instead of Isabella?"

"No. I've never gone by Izzy."

"And I've never gone by 'Doctor Loucks'. Just consider it, please."

"Or you'll run to Gibbs and tattle?"

"I asked you, politely, as a colleague," I said. "That's the end of it."

"Doctor Mastriano?" Nicki said from the door to the office, "EMS three minutes out with an MI. Doctor Gabriel wants you to handle it. Mike, he'd like to see you."

We left the temporary Resident's office, and I went to the Attending's office.

"You wanted to see me?"

"Angela said you and Mastriano were talking. What's up?"

I shook my head, "Nothing that needs your attention."

"You're sure?"

"Yes."

"Then get some rack time while it's quiet."

"Thanks, Pete."

August 4, 1989, McKinley, Ohio

I managed three twenty-minute naps overnight, which was a far sight better than what had been possible for Kylie. There hadn't been any critical cases, but we had two admissions and at 6:00am still had two awaiting discharge. I left Mary and Tom to watch over those patients and went to the cafeteria for breakfast.

"Hi, Doctor Mike!" Debbie Sherman said when I walked into the cafeteria.

"Hi! When is your trauma Sub-I?"

"December. I start my surgical Sub-I on Monday."

"I look forward to it."

I got in line and Debbie left, as she had already eaten. Once I had my breakfast, I returned to the ED and joined Doctor Gibbs for Mary's and Tom's evaluations. Mary received a rating of 5, as she was, in my mind, an exceptional candidate, and she was given a 'select for match' notation as well, while Tom received a rating of 4.

"What do I need to do to receive a 5 for my Sub-I?" Tom asked.

"Be exceptional. I can't say specifically, except to say be the best in your class, or close to it. Honestly, I think your grade was a close thing, and if you continue the way you are, you'll have a good shot at earning a 5. I promise to do my best to help you."

"Thanks. I'm going to miss working with you. Well, except for the chopper incident!"

"Kellie made the comment that pilots say any landing you can walk away from is a good landing!"

"I still can't believe how calm she was."

"If there's a chance to be on a transport helicopter, take it," I said. "What do you have next?"

"Pediatrics."

"The key there is developing your bedside manner. It's the one service where you're absolutely expected to spend extra time with patients."

"Got it."

Mary returned and the three of us treated walk-ins until lunch. After lunch, we did the same, until just before 2:00pm, Nate called for me.

"Mike?" he called out. "Paramedics four minutes out with a stabbing victim. Doctor Nielson wants you with him."

"OK. Tom, get Mary and meet me in the ambulance bay."

He went to find her while I headed for the ambulance bay, grabbing a gown and gloves as I passed the stand. I joined Perry, Kellie, and Angela, and a minute later, Mary and Tom came out. The EMS squad pulled up and Bobby jumped out.

"Amber DeJong, fourteen; multiple stab wounds; BP 80 palp; tachy at 120; PO₂ 92% on ten liters; hypovolemic; one unit of plasma in."

"Lord have mercy!" I breathed.

"Trauma 1!" Perry ordered. "You know her, Mike?"

"She was here last night after being beaten up," I replied as we quickly moved her to the trauma room.

"Kellie, hang another unit of plasma on the rapid infuser; type and cross-match; Mary intubate; Tom, monitor but hold the EKG until we assess; Mike, wound assessment."

"She's pregnant," I said. "The facial bruises are from last night."

In the trauma room, the paramedics helped us move Amber to the treatment table and everyone sprang into action. I used bandage scissors to cut away Amber's t-shirt and bra and immediately saw four penetrating wounds.

"Three abdominal stab wounds, one chest," I declared. "Hemothorax, which we'll deal with upstairs. Tom, call upstairs and book an OR stat. She can't wait. Perry, she has to go up as soon as the first unit of plasma is in. Kellie, that type and cross-match has to be stat and sent upstairs. Angela, get a gurney!"

"You heard the man!" Doctor Nielson said. "Move, people!"

"Tube is in!" Mary declared. "Hooking up the portable vent."

"OR 2 expecting us!" Tom announced.

"First unit is in," Kellie announced.

Angela came in with a gurney and on my count we moved Amber to the gurney, and immediately Tom, Mary, and I rushed her from the room, heading for the elevators.

"HOLD THAT ELEVATOR!" I yelled.

People in the corridor parted before us, and the elevator quickly emptied, with a nurse holding the button to keep the door open. A minute later, we pushed the gurney into OR 2, where Doctor Aniston, Doctor Lindsay, and Doctor Wilson were waiting with a full surgical team.

"Amber DeJong, fourteen; pregnant; multiple stab wounds -- one to the chest, three to the abdomen; hemothorax; two units of plasma in; intubated; last vitals BP 80 palp; tachy at 110; PO₂ 94% on vent!"

"Mike," Doctor Anniston said, "your students can go back to the ED. Put in a Foley, then scrub in!"

"Tom, Mary, go!" I instructed. "14 French to me!"

As Doctor Anniston began assessing Amber, I picked up bandage scissors from the tray and cut off her shorts and panties, then inserted the Foley catheter. I connected it to the bag and saw it was tinged with pink.

"Blood in the urine in the bag!" I announced, then went to the scrub room, removed my scrubs and baptismal cross, then put on fresh scrubs. I scrubbed as quickly as I could and the scrub nurse helped me with gloves, my cap, and a mask.

"She's under!" the masked anesthesiologist declared. "Five-lead shows sinus tach!"

"Mike, assist Doctor Lindsay on the chest," Doctor Anniston directed.

"Given the location and depth of the wound, we'll need to repair the lung," Doctor Lindsay observed. "I'll extend the wound, sew the lung, then close. You handle the retractor, and Penny will suction."

"OK," I replied.

The phone rang, and a nurse answered and was given a blood type of 'O+' and Beth, a Fourth Year, was asked to retrieve two units from the refrigerator. The nurses hung the blood, and we began the surgery while the other team was performing an ex-lap to locate all the internal injuries.

"Penetrating wound to the uterus," Doctor Anniston announced. "Fetus is not viable."

Doctor Lindsay successfully repaired the wound which had caused the hemothorax and began closing.

"Chest tube tray to Mike!" she ordered.

"16 French," I requested.

"Infrarenal aortic rupture!" Doctor Wilson declared. "Lap pads and suction!"

"No pressure!" the anesthesiologist declared. "She's bleeding out!"

I prayed silently that the surgical team would have the skills necessary to save Amber.

"Two more units!" Doctor Anniston ordered. "Pump them in!"

"Asystole!" the anesthesiologist called out.

"Starting compressions!" Doctor Lindsay declared.

I stopped working on the chest tube because of the chest compressions and watched as Doctor Anniston and Doctor Wilson tried to repair the infrarenal aorta.

"Repair complete!" Doctor Anniston declared. "Keep that blood coming!"

"Stopping compressions," Doctor Lindsay declared. "Mike, auscultate."

"Faint heart sounds," I said. "Getting stronger."

"Pressure coming up," the anesthesiologist declared.

"Sinus rhythm!"

"OK," Doctor Anniston said, sounding relieved. "Let's continue."

I put in the chest tube and confirmed good bilateral breath sounds.

"Hemothorax repaired, chest tube is in," Doctor Lindsay announced.

"Shelly, come run the bowel while I repair a liver lac. Mike, Mary, observe. PGY2s need to know the procedure for running a bowel."

Mary and I were both PGY1s, though I wouldn't be in surgery regularly for nearly two years. I watched as Shelly manipulated the bowel, looking for any injury or leaks, while Doctor Anniston repaired the liver laceration. The final repair was to the uterus.

"Mary, we'll need an OB/GYN for a D&C once the patient is out of the ICU. Let them know."

The surgery was completed, and Mary and I took Amber to the ICU, then returned to the surgical locker room to change.

"Any idea what happened?" she asked as we changed scrubs.

"All I can really say is that she was in last night after being beat up. She was released to her parents, and then EMS brought her in about two hours ago."

"I thought we were going to lose her."

"Me, too," I agreed. "She's not out of the woods yet."

I finished putting on clean scrubs, then headed back to the ED.

"Mike," Nate said. "You need to go to Doctor Northrup's office."

"About?"

"The stabbing victim."

I nodded and returned to the elevator and went to Doctor Northrup's office. I didn't like the fact that it wasn't directly adjacent to the ED, but that would be rectified once we moved into the new building.

"Go right in," Mrs. Andrews, his secretary said.

I went into the office and saw Doctor Northrup, Doctor Williams, Doctor Gibbs, Doctor Mastriano, and Detective Louise Rehling from the McKinley PD and Sarah Vaughn, an investigator with the Sheriff's Department. Mr. Crowe, the hospital legal counsel, was also in the room.

"Have a seat, Mike," Doctor Northrup said.

I sat down and waited.

"Did she make it?" Doctor Gibbs asked.

"Touch and go. She coded on the table due to hypovolemia but we got her back. She's in the ICU and I'd say it's no better than 50/50."

"Doctor, you received the victim last night, correct?" Detective Rehling asked.

"Yes," I said, taking my notebook from my pocket.

"Would you tell me what you observed and what she said?"

I pulled my notebook from my pocket and read my diagnostic notes to her.

"Do you document every patient that way?" she asked when I finished.

"The amount of detail varies, but every patient I treat goes into my notebook, with at least a single line. It's a habit from when I was a student and I had to keep a procedure book. I continued it once I started my Residency. There are no names, though."

"When you discovered Miss DeJong was pregnant and underage, why didn't you report it?"

"I did, to Doctor Williams and Doctor Mastriano."

"Why did you run a pregnancy test?"

"Because it was my intent to x-ray Miss DeJong for facial bone fractures. It's standard practice to perform a pregnancy test on any female patients who are of child-bearing age, which is twelve to sixty, based on menarche and menopause, before x-rays."

"Did you ask her who the father of her baby was?"

"No."

"Did you see who brought her in?"

"A guy named Gary. He had what appeared to be a cordial conversation with her parents when they arrived."

"Did he say anything?"

"Just that 'some guy' beat her up. My medical student spoke to Amber, and she said that her boyfriend beat her up and that Gary was just a friend."

"Do you find it normal for a thirty-year-old male to befriend a fourteen-year-old girl?"

"Excuse me, Detective," Mr. Crowe said. "Doctor Loucks stated that he reported the situation to his supervisors, which is hospital policy."

"That's not what I asked, Mr. Crowe."

"But that is the answer you'll receive. Doctor Loucks is an Intern. If you have questions about how this was handled, those are for Doctor Northrup and Doctor Williams. Do you have any other questions about treatment that Doctor Loucks can answer?"

"Not at this time."

"Mike, you can return to the Emergency Department," Doctor Northrup said.

"Yes, Doctor," I replied.

I left the office and headed back to the ED and found Mary and Tom.

"Did the police talk to you?" I asked.

"They wanted to, but Doctor Northrup and the hospital attorney wouldn't allow it," Mary said. "I'm not sure they can actually prevent it. How is she?"

"She coded on the table due to hypovolemia but we got her back. She's in the ICU, but it's 50/50 at best. She lost the baby."

"Don't you think she should have had an abortion?"

"My opinion on that is complicated, but it should have been her choice, not whoever stabbed her."

"I heard they arrested her dad," Tom said.

"Unless the cops told you that directly, it's a rumor, and you shouldn't repeat it."

"Sorry."

"No need to apologize. That's simply personal advice. What's not advice is not to talk to anyone about the patient unless Doctor Northrup or Mr. Crowe give their approval. Obviously, you have to talk to the cops if they insist, but your answer should always be that you're a medical student and are not qualified to make any medical judgments or observations, and it is, at least in some cases, illegal for you to do so."

"Why?" Tom asked.

"Mary?"

"We're forbidden from making any medical judgments and we're only allowed to say things approved by our Resident or an Attending. Anything else could be construed as a violation of the rules against practicing medicine without a license. Though prosecution is unlikely, saying the wrong thing to the wrong person could lead to dismissal from the program."

"Exactly," I replied. "Tom, can I speak to you privately?"

"I'll go get a Coke," Mary said.

She left the lounge.

"You want to know how to score a 5? Be able to answer the question you asked. The answer is in the study material for Practice of Medicine and in the student guide."

"Sorry."

"Another thing," I said. "You're too quick to apologize. It's better to say that you'll study and know the answer next time, or something similar. Remember what I said about your surgical Clerkship?"

"Find out the surgery and memorize the steps; if we don't know, admit it and state that we'll do better."

"And then you have to back that up. You've copied the flashcards, now you have to study them. And review your material for each rotation regularly. Keep a notebook, not just for procedures, but for each service with literally everything you're taught and study it. You've started doing that; keep doing it."

"How did you get perfect scores for every rotation?"

"I studied. All the time. There was never a time I didn't have my flashcards or a book. Standing in line at the BMV, I reviewed flashcards. Standing in line at Kroger, I reviewed flashcards, and so on."

"Thanks."

"I'll see over the course of the next year, I'm sure, and then I'll see you on your trauma Sub-I. Do what I've said and I promise you'll get all the procedures you can handle."

"I appreciate it."

"Hi, Mike," Kylie said, coming into the room. "The board had nothing with your name."

"I ended up in emergency surgery for two hours."

"Lucky dog! Then I suppose you can take off and I'll see what's waiting out front."

"Thanks, Kylie."

I said 'good night' and headed up to the surgical locker room where, as usual, I ran into Shelly Lindsay in her panties and bra.

"She coded in the ICU about fifteen minutes ago," Shelly said. "They couldn't bring her back."

"Lord have mercy," I sighed.

XXXIII. New Students

August 4, 1989, McKinley, Ohio

"A result of the hypovolemia?" I asked.

"That would be my guess," Shelly replied, "though we won't know for sure until McKnight examines her."

"The McKinley PD and Hayes County Sheriff's Department are investigating. Do they know she died?"

"I have no idea. I'm sure at some point they'll come speak to us."

"I think I better go inform them," I said. "See you next week."

I left the locker room and walked down the corridor to the far end of the building where Doctor Northrup's office was located.

"Excuse me," I said from the door. "Shelly Lindsay just informed me that Miss DeJong died in the ICU about fifteen minutes ago."

"Who was the surgeon?" Doctor Northrup asked.

"Bob Anniston," I replied. "Assisting were Lindsay, Wilson, and me."

"We'll need to speak to him, as well as the doctor in the ICU," Detective Rehling said.

"Mike, you can go," Doctor Northrup said.

I nodded and turned to leave, and as I was walking down the hall, Doctor Gibbs came up behind me."

"Did you run the trauma?" she asked.

"No, it was Perry."

"I heard you took over."

"She was clearly a surgical case, and there was no time to waste, so I simply gave the necessary orders. Did I do something wrong?"

"On the contrary, Perry said you handled it like a grizzled pro -- decisive, authoritative, calm, cool, and collected, and with appropriate urgency. Most Interns can't or won't do that."

"I'm not most Interns," I said with a wan smile.

"No kidding," Doctor Gibbs replied flatly. "I just wanted to say 'good job'."

"I'd feel a whole lot better if we'd done something differently last night."

"Pete is beating himself up as well," Doctor Gibbs observed. "As Doctor Northrup has said, we're not social workers nor are we law enforcement."

"And yet we still somehow failed that young girl."

"They arrested her father," Doctor Gibbs said.

"The cops told you that?"

"Yes. As best I can tell, because they're being cagey, she revealed her pregnancy, and he threatened the boyfriend, which caused an argument, she said something offensive, and well, you can guess what happened next."

"Lord have mercy," I sighed, shaking my head. "But our concern was the guy who brought her in. That seems misplaced after what she said, though the cops sure like him for something."

"Their angle is she blamed her boyfriend, who's her same age, to protect the guy."

"He wasn't behaving the way I'd expect a guy who was at risk for a sexual assault charge would behave. Why bring her here and run the risk of people assuming he's the father?"

"Maybe he didn't think we'd do a pregnancy test, or maybe he didn't think about that at all."

"Or maybe it's as innocent as my relationship with Jenny Leonard."

"Who?"

"Little sister of an MVA two years ago who I counseled."

"Ah, OK. I recall the incident, but not the name. What is your relationship with her?"

"Mentor. She stopped by the hospital to ask about her High School electives. She also wanted to see Rachel."

"Babies are magnets for teen girls!"

"Speaking of babies, who watches Bobby Junior?"

"Bobby's mom. Just be smart about that young girl."

"The bigger risk is medical students who don't care that I'm married."

"One of the ones assigned to you?"

"No. A Third Year who is friends with Sophia Jackson."

"I was surprised she changed her name. Most medical students and doctors don't."

"That was a thumb in her meddling grandmother's eye. 'You WILL teach your children Greek! You WILL send them to Greek school!' Sophia and Robby aren't having any of that and decided that abandoning the Greek last name was the right way to make a statement. Anyway, I need to get a shower and get home for dinner and sleep."

"We'll speak more on Monday, but great job."

"Thanks."

I returned to the locker room where Shelly was just about to leave, but she sat down to wait for me while I showered. Once I was dressed, the two of us headed for the parking lot.

"What did they say?"

"Nothing, really. They asked who led the surgical team, and I answered that question, then spoke privately to Loretta Gibbs. The cops arrested the girl's father."

"Wow!"

"Yeah. I was surprised you waited for me."

"I wanted to make sure you were OK."

"I am. I just wonder if we could have handled things differently last night, but as I'm routinely reminded, we're not social workers, nor are we law enforcement."

"And you know why that latter thing is important, right?"

"We don't want people to forego medical treatment because they think their doctor is going to narc on them."

"Which is why we'll almost always err on the side of not reporting things short of stabbings or gunshot wounds. And mostly we don't snitch on girls fourteen and up, even though technically it's sixteen."

"It was explained that the courts had ruled fifteen-year-olds could access birth control and pregnancy services without parental consent."

"Don't you find it odd that those limits are lower than the age of consent?"

"No, because age of consent laws, at least in Ohio, are structured to prohibit men over eighteen from having sex with girls under sixteen, not prevent girls under sixteen from having sex. If push came to shove, I'd say fifteen is the correct place to set the age limit, though I may change my tune in about thirteen years!"

Shelly laughed, "You sound like every other parent of a present or future teenage girl! Of course, you spent High School and college trying to get laid, right?"

"No comment," I chuckled.

"I'll take that as a 'yes'! I was certainly not a nun in college, though you wouldn't know it from medical school and Residency!"

"You're engaged, right?"

"Yes, but only as of about four months ago. You know what it's like for surgical Residents before PGY4."

"They basically never leave the hospital except to get a few hours' sleep."

"Now, I'm not pulling nights and I'm on a regular surgical team, and get to lead. That lets me have something of a personal life, finally. Oh, before I forget, Doctor Rafiq is transferring to a hospital in Dearborn, Michigan."

"Color me not surprised," I replied. "He's going to a city with a large Arab population. I think it's close to half."

"How do you know that?" Shelly asked.

"The Antiochian Orthodox Archdiocese, a sister jurisdiction, is Syrian, Lebanese, and Jordanian, and they have numerous churches in Michigan that are ethnically Arab. When is his last day?"

"The end of September. They had a Resident die in a traffic accident ten days ago."

"That was fast!" I declared.

"His uncle was hired there as an Attending in June after having worked in California for more than a decade. His uncle knew he was unhappy and called him."

"How did you get the details?"

"Through the surgical Attending grapevine. All the top guys know each other from conferences. Doctor Roth called a friend at that hospital to get an off-the-record scoop."

"So what happens here?"

"Privately? No great loss. Publicly, we'll accept a transfer, and if nobody applies, we'll draft an extra med student in March. Our Resident count doesn't specify how many in each year. You're a perfect example because you're ours, but you aren't in the surgical program, if you understand what I mean."

"I do."

"That said, great job today on the chest tube. You're signed off to do those, right?"

"Yes, and pericardiocenteses as well. I think that proves there's no reason a trauma Resident or Attending can't do them."

"Patience, grasshopper!" Shelly declared. "You're forging a new trail, and you know Cutter isn't going to authorize that at this point. You prove it can be done, and whoever fills the next slot in two years does the same, and then the argument can be made."

"When have you known me to be patient?" I asked with a grin.

"Never! I'm not, either. I was champing at the bit from the middle of Third Year to cut something, anything! You're way ahead of the game."

"Given emergency medicine as we know it is less than two decades old except for the Chicago and Baltimore programs, we've come a long way, but we have a long way to go."

"And we'll get there. Don't push too hard, or you run the risk of wrecking it."

We reached our cars, said 'good night', and each headed home.

August 5, 1989, McKinley, Ohio

On Saturday morning, Kris, Rachel, and I drove to Taft for band practice. We had a good practice, and I let Kim know about my schedule for September and October.

"Is there any time you could practice?" she asked.

"The only reasonable times would be Friday evenings or Sunday afternoons. Neither of those are very good, obviously, but the schedules are being set up to give us dedicated sleep periods, which is why I won't have thirty-six-hour shifts. The problem with Friday is that I have to be at the hospital at 0500 on Saturday, so I need to be in bed early. The problem with Sunday is that's literally the only day I'm with the family during the day."

"I think Mike will be OK without practice," José observed. "The rest of us can meet and Mike can run through his parts at home. Then we re-evaluate in October when he receives his next schedule."

"It probably won't get better until next June," I said.

"We knew this was coming," Kim said.

"And I have no problem with you guys playing gigs without me."

"Nah, we're all cool with limits for now," Sticks said. "Let's play Taft, Stirred Not Shaken, Newtown, and Goshen. Then we'll play only one or two Proms and July 4th. We can figure it out from there."

"That works for me," José agreed.

"And me," Kim said.

"It'll let me spend more time on my concert pieces," Kari added.

"Sounds like a plan, then," Kim said.

I packed up my things, then Kris, Rachel, and I headed home for an early lunch before I left for my shift at the hospital. Doctor Gibbs had come in so we could give Callie and Gabby their evaluations. I did the handover with Kayla Billings, then went to the Attending's office for the evaluations. Both were rated as 4, though Callie did not receive the coveted 'select for match'. I asked Doctor Gibbs about that afterwards.

"Neither Lewis nor Townshend felt she was worthy of that. Remember, it doesn't mean she won't be selected, it simply means she won't be actively recruited. We have a limited number of those to hand out, and I know you agreed Mary should receive one."

"Absolutely. And Bob as well."

"Was she better than Bob?"

"A judgment call that could go either way, but if push came to shove, I'd pick Bob and Mary as the two."

"Which is what we did, based on input from all the Residents."

"Any further fallout from yesterday?"

"No. The cops really do want to blame her older friend, but they have no evidence other than their moral outrage."

"Which I suspect they'd have directed equally at me when Elizaveta ordered me to marry her."

"That did turn heads, at least until people met her."

"The problem with making judgments based purely on age. I know plenty of twenty-year-olds who not only shouldn't marry but probably shouldn't even have driving licenses!"

"Did you hear the news about Mo Rafiq?"

"Yes. It didn't surprise me, really, as he didn't fit in here."

"I'm happy to see him gone," Doctor Gibbs said. "There are a few more Residents I'd be happy to see gone as well."

"Anybody on our services?"

"Besides you?" she asked with a goofy smile.

"I know you love me," I chuckled. "The women who love me the most give me the most grief!"

"Clarissa?"

"Obviously. My friend Jocelyn, my mom, my sister, Elizaveta, Kris, and as sure as the sun rises in the East and sets in the West, eventually Rachel!"

"Going back to yesterday, no real fallout. The cops just had a bug up their butts about her being pregnant at fourteen and our failure to call social services or law enforcement."

"Shelly and I discussed that, and the last thing we want is patients foregoing treatment because they're afraid we'll narc on them. It's always a tough call when we have an arrestee."

"There's discussion amongst the Attendings of creating a policy that requires law enforcement to stand outside the doors of the trauma or exam rooms, rather than be in the room. I think that Doctor Northrup will agree and propose it to the Medical Director."

"The cops are going to HATE that, but I like it. When?"

"It'll be proposed at the Monthly Attendings' meeting next Monday afternoon. Then it's up to the Chief. I hear you and Mastriano are getting along OK."

"I have minimal interaction with her, given every order she might give has to be countersigned. I just go to whoever is running the ED to cut to the chase. We'll see what happens once she's off double-secret probation."

"I believe she got the message. Anyway, I'm out of here. This is supposed to be my day off!"

"And I'm supposed to be working!"

"Then go heal the sick and I'll see you Monday with a fresh crop of medical students!"

Which meant two on Preceptorships on Tuesdays, and three Third Years and three Fourth Years on shift with me at various times. I'd looked at the schedule and didn't recognize any of the names of Third Years. I did know the Fourth Years, but I hadn't worked with any of them when they were Third Years. The only downside was that the Fourth Years would still have to cover the triage desk for August, as the new nursing schedule for covering triage didn't start until September 4th.

The afternoon was routine, though busy, with a mix of walk-ins and EMS runs, but no critical injuries. I took my break about 4:00pm and used my AT&T calling card to call Father Roman. We had a good talk, and agreed that Kris, Rachel, and I would visit him on the second Sunday in September. Until then, he directed me to confess to Father Luke so that I could continue to receive the Eucharist.

After the call, we handled walk-ins until dinner, when I met Clarissa in the cafeteria.

"I heard you had a bad one yesterday," she said.

"We did," I replied, then explained what had transpired.

"And, of course, you're beating yourself up for that, right?"

"Shelly Lindsay and Loretta talked to me about it," I replied. "That doesn't mean I don't wish we'd done something differently."

"Sure, though with the competing priorities, you know what has to come first."

"Yes, of course, but did we do everything reasonable in our power to help her?"

"I'm not sure calling the cops would have turned out better, because her dad would still have found out she was pregnant."

"I'm still trying to sort out why she told him," I replied. "That's the one thing that makes zero sense here."

"You said you gave her the brochure for the Free Clinic. Maybe he saw that?"

"Possible," I replied. "But I would have thought she'd have been more careful, given she knew she was pregnant before she came in. The cops were fixated on the relationship with the older guy, and think she named her boyfriend as the dad to protect the older guy."

"What's your take?"

"That was actually my first thought, but by the end, I didn't get that vibe, which is why I didn't object to Doctor Williams' decision."

"You worked with Mastriano?"

"My problem with her is only laziness," I replied. "If she fixes that, I won't have any problem with her as a doctor."

"Just her cheating?"

"That's her business so long as it doesn't affect anything that happens at the hospital. I did get two pieces of good news."

"Oh?"

"First, the trauma Attendings are recommended banning cops from being in trauma or exam rooms in most cases. That's a good thing because patients are often reluctant to talk in front of the cops, which means we don't get the full story. It will require agreement by Doctor Northrup and the Medical Director, but I think they'll do it."

"That's good. And the second thing?"

"Doctor Rafiq is transferring to a hospital in Dearborn, Michigan."

"Wow! During his PGY2 year?"

"According to Shelly, they had a Resident die in a traffic accident, and his uncle, who is an Attending there, called him. There's a surgical Residency open for transfer as of September 1st, though if it's not filled, they'll draft another med student."

"Think he'll have better luck there?"

"Dearborn is about half Arab, which I think will work better for him, not that I'd ever want him to be my surgeon."

"I'd let Tessa operate on me before him!"

"But only after a thorough oral exam!" I teased. "Though patients don't generally examine their doctors!"

"Kari certainly did!"

"True."

"Sheila?"

"No comment."

"That's a 'yes'. I'd say Elaine was interested, and you shut her down quickly."

"Very. Though she did play it as marriage. But that was a mess I didn't need, and at that point, even eighteen was a question in my mind."

And yet..." Clarissa teased.

"We had this discussion!"

"You know I'm yanking your chain, Petrovich!"

"Obviously! How are things in Medicine?"

"No mysteries this week; just routine care. I'm OK with that, too, because I'm not an adrenaline junkie like you!"

"Fortunately, there is plenty of opportunity for both our styles."

"Mike Loucks, Chief of Emergency Medicine?"

"And Clarissa Sunders, Chief of Internal Medicine!"

"Someday, Lissa."

We finished our meals and headed back to our respective services.

"Mike," Carol, one of the weekend clerks, called out when I returned. "I was just about to page you. Doctor Gabriel needs a surgical consult in Trauma 3."

I hurried to the trauma room and announced myself.

"There's free fluid in Morrison's," he said after giving me the patient's vitals.

I quickly confirmed with the ultrasound machine and called up to the surgical scheduling nurse and booked an OR for an ex-lap for a patient who had sustained injuries in a bicycle accident. I called for an orderly, then escorted the patient up to surgery, where I turned him over to Doctor Burke, and returned downstairs to treat walk-in patients. I did that for the rest of the evening and at midnight, handed things off to Kayla Billings, then headed to the surgical locker room for a shower before heading home.

August 6, 1989, McKinley, Ohio

"My monthly should come at the end of the week," Kris said as we drove to the Cathedral on Sunday morning. "Do we still agree I should stop taking my pills?"

"There's no reason I can think of that would cause me to suggest waiting. It's really up to you at this point."

"No, it's up to us, Mike. A partnership. What do you want? And 'whatever you want' is not an answer."

"But it is, because making you happy will make me happy."

"While I'm sure that's true," Kris replied, "I also want to hear what you want."

"I want to have a baby with you."

"And I want to have a baby with you. So once my monthly begins, I'll stop taking my pills."

"Good."

"John Michael or Charlotte Michelle?" I asked.

"Those are the names we discussed, and I'm fine with them. What if the timing works poorly?"

"You mean it takes time to become pregnant?"

"Yes. Statistically, it takes six months to a year, though, as with all statistics, they don't mean much for any specific couple."

"How long did it take to conceive Rachel?"

"It was the second month after we began trying."

"So, perhaps you are very accurate!"

"You seem to think so!"

"I do! And all teasing aside, is there anything we can do to improve the chances?"

I chuckled, "If my schedule didn't interfere..."

"Yes, well, you signed up for that nearly twenty years ago!"

"True. In all seriousness, there are theories about body temperature variations at ovulation, but they're speculative, and they may or may not work for an individual. Given the window of opportunity, and the motility and lifetime of sperm, making love every day during the most likely fertile time is the best approach. And while I may regret saying this, multiple times per day doesn't significantly increase the odds."

"As if I would say 'no' to that!" Kris said with a soft laugh. "You know I very much enjoy making love with you."

"And I with you. My new schedule will make it possible for us to make a daily attempt, though that's not until September 1st."

"But if understand correctly, that would be the almost perfect time."

"It should. And you'll have about eight months to plan your class schedule from the time you miss your first period, which is more than sufficient. That only leaves the question of the Tsarina's response."

"I think she'll be fine."

"If we give her a sister. I think we'll be in deep sneakers if we give her a brother!"

"Deep sneakers?"

"Bowdlerization of the word for 'feces'."

"I take it you're careful because of our backseat passenger, not me."

"Correct. Can you imagine our darling daughter repeating a certain select group of words at the wrong time? She might give people at church a stroke! Right now, she has no sense of using 'proper' language. And speaking of our darling, did you arrange the celebration of her entrance into the world?"

Kris laughed, "Obfuscating your language?"

"That'll work for a short time. She'll figure it out soon enough."

"Yes. I spoke to Serafima, Alyssa, and Milena. And as I suggested, Lyudmila will help organize things. Sunday at 2:00pm at our house.

"I'll speak to Marcie at daycare about Rachel's other friends. Is this a 'girls only' soirée?"

"I think it would be difficult not to invite Viktor Gennadyevich and your brother Peter and nephew Michael and godson Michael."

"A good point."

"I'll speak to all the parents this week."

"You should invite Clarissa and Tessa, even though they don't have a kid."

"I'll do that. How are you handling the memorial service? You have to work, right?"

"Yes, and they're doing it after Vespers, which is right in the middle of my shift. Viktor knows and understands."

"What do you think I should do?"

"That's a difficult question, but I think, given I have to work, it's probably best if you simply follow your practice of going to Vespers with your parents and sister on Saturday evening. I mean no disrespect to Elizaveta, but our practice can't be bound to choices made by Viktor and Father Nicholas. They knew my schedule when they decided on the time for the memorial service. I'm sure you know that after the first anniversary, it's informal and up to the family.

"And as terrible as this might sound to others, our family is in this car. You're Rachel's mom in every sense of that word that matters. I loved Elizaveta with every fibre of my being, but I have to focus on you and Rachel, not on the past. We remember Elizaveta in our morning and evening prayers, and she's commemorated during the Great Entrance at both the Cathedral and Saint Michael."

"Do you love me?"

"With every fibre of my being," I replied. "You are the perfect wife and perfect mom."

"You might be exaggerating just a bit," Kris countered.

"I don't believe I am," I said as I pulled into the parking lot across the street from the Cathedral. "I do love you, Kris. And I can't imagine life without you."

"I love you and Rachel, and I'm happy we're going to spend our lives together and have more children."

I parked, we got out of the car, and walked across the street and into the cathedral. After we lit our usual candles, I let Subdeacon Nathaniel know I needed to see Father Luke for confession, and he went to the altar, then returned to let me know Father would hear my confession during the Psalms. About twenty minutes later, Father Luke came out from the altar and motioned me to stand with him before the icon of Christ. He said the opening prayers, then asked the usual question.

"What is on your heart, Michael?"

"I'm actually not sure if my behavior in a situation in the hospital with a patient was correct."

"First, did you act in Christian love?"

"I think that's the real question. A young girl died, and I feel, well, I suppose the only word I can use is 'guilty'."

"Can you explain without violating any confidentiality rules?"

I nodded and explained the situation with the fourteen-year-old girl, leaving out any names or even specific injuries.

"Lord have mercy," Father Luke said quietly when I finished relating the story.

"That was my response as well," I replied. "I still don't know if I did the right thing."

"I'm not sure what you might have done differently, except call Family Services or the Sheriff yourself, but from what I understand, you don't think she was abused, even if she was underage."

"As best as my medical student and I can determine, her baby's father was a close-in-age boyfriend."

"I think, in the end, you have no culpability here, and certainly could stand before the judgment seat and defend your actions. You didn't kill that poor girl, nor do I think you had sufficient reason to override the decisions of your superiors. I have a strong feeling that you'll encounter situations like this in the future."

"I'm sure I will."

"And you don't believe you made any medical errors?"

"I don't believe anyone did. It really does come down to whether or not some kind of intervention would have prevented her death. I'm not sure you can say confidently that is the case."

"No, I can't."

"I think, then, that the best answer is that it's OK to feel bad, but not to blame yourself. Is there some way I can mention the young girl during the Great Entrance?"

"I think, given her name was published in the McKinley Times, I think you can safely use it. Her name was Amber."

"Is there anything else on your heart, Michael?"

"Nothing that I feel needs confession."

"You're keeping your assigned prayer rule and fasting rule?"

"Yes, and I spoke to Father Roman yesterday. I'll see him in early September."

"Then I'll say the absolution prayers."

He said them, I kissed his epitrachil, then returned to stand with Kris and Rachel, who had been joined by my in-laws. Four hours later, after Matins, the Divine Liturgy, and a light lunch, we headed home for a quiet afternoon and evening.

August 7, 1989, McKinley, Ohio

On Monday morning, I checked in with Doctor Gibbs, then met with Jim Fitzgerald so he could hand over two patients waiting for admission. He also introduced me to Krista Sandberg, a Fourth Year, and Al Baker, a Third Year. When Jim left, I asked both Krista and Al for their procedure books.

I was disappointed in the limited number of procedures Krista had in her book, and that gave me pause. This was only Al's second rotation, so his limited experience was no surprise, given he'd been in Pediatrics for his first rotation. I returned their books, asked them to keep an eye on the two patients waiting on admission, and went to see Doctor Gibbs.

"What's up?" she asked when I came to the door.

"Mind if I come in?"

"No."

I went in, shut the door behind me, and sat down.

"What's the scoop with Krista Sandberg?" I asked. "She has about half the procedures I'd expect a Fourth Year to have after a Cardiology Sub-I."

"I honestly don't know. Jim didn't mention that."

"The very first thing I do with a new med student is look at their procedure book. It actually tells me more than an evaluation. Mind if I talk to Alana Pace or Leila Javadi?"

"Not at all. Residents discuss med students all the time, even outside their service."

"Thanks. It's calm at the moment, so I think I'll run upstairs and see which of them is available before rounds."

"Fine with me!"

I left her office and went upstairs to Cardiology and found Leila Javadi in the Resident's office.

"Hi, Leila," I said. "Do you have a few minutes to discuss a student?"

"Come in; which one?"

I closed the door and sat down.

"Krista Sandberg. Her procedure book is pretty sparse for a Fourth Year starting their second Sub-I."

"Remember Felicity Howard?"

"Yes."

"Similar attitude, but without the skills and intelligence. I'm not saying Krista is not intelligent, but she's not as smart as she thinks she is, and feels the world owes her everything she wants. She's quick to complain about discrimination and unfair treatment, but it really was a reflection of her knowledge, skills, and abilities. You turned Felicity around, and she's started a Cardiology Sub-I today. She'll be treated as the above-average student she is."

"In your opinion, is Krista dangerous?"

"Let's just say I would keep a close eye on her at all times. A very close eye."

"Wonderful."

"How are things going otherwise?" Leila asked.

"Good, except for the fourteen-year-old girl."

"I heard. This morning's paper suggested to me the police don't know for sure what happened."

"I think they're barking up the wrong tree with the older guy. Mary Anderson was confident the patient was being truthful about the father of the baby being a boy who was about a year older. I do need to get back downstairs, and thanks for the heads up on Krista."

"You're welcome. One more piece of advice, off the record."

"Off the record," I confirmed.

"Don't be alone with her."

"Thanks."

I left Cardiology and headed back down to the ED, checked to see that Clarissa had admitted the two patients, which she had, then went to Doctor Gibbs' office.

"Leila Javadi compared Krista to a Third Year I was paired with during my Cardiology Sub-I. Do you remember discussing how to handle Felicity Howard?"

"Vaguely."

"Cutting to the chase, Leila advised, not to leave Krista alone with a patient."

"Then you need to be the best teacher you are able to be, watch her like a hawk, and make your own evaluation. And don't let her kill any patients."

"I'll do my best. Anything further on the DeJong case?"

"No. We're out of it unless someone tries to bring a malpractice case, but Mr. Crowe says that's a longshot because there's no legal obligation for us to call the police or Family Services if a fourteen-year-old is pregnant by a close-in-age boyfriend, and there's no sign of abuse."

"OK. Let me go see what I can do with Krista."

I left her office and went to the lounge where my students were waiting. I wanted to speak to Krista alone, but I also needed to heed Leila's warning.

"Your procedure book seems a bit light," I said to Krista. "Who was your Resident for Cardiology?"

"Abbott was the main one, but also Javadi."

Abbot was a good teacher, and if she didn't trust Krista to do procedures, I'd have to be extremely careful, as Leila had suggested.

"How comfortable are you doing triage?" I asked.

"It's pretty simple, right? Basic exam and bring anyone who has cardiac or breathing problems straight in. Why?"

"You'll be on the triage desk with Nurse Libby on afternoons this week. We'll catch walk-ins this week, though we'll handle traumas if necessary. Let's go see what they have for us now."

The new procedure for the triage desk was that charts were placed in a rack near the clerk's desk, and the clerk would ensure that they were handled first-come, first-served based on the priority set by the triage desk. The point was to limit the ability of Residents to cherry pick cases. I picked up the first chart and reviewed it, then handed it to Krista.

"We'll use Exam 3," I said to Nate, who wrote it on the board. "Krista, bring the patient in, please."

She went to bring the patient in, and as they walked past us, I signaled Al to follow me. In the exam room I waited for Krista to introduce me, but she just stared blankly, so I held out my hand for the chart.

"Hi, Mr. Sanchez," I said to the twenty-three-year-old man. "I'm Doctor Mike and my students are Krista and Al. What brings you in today?"

"I work landscaping and stepped on a rake and it went into my foot."

"Do you know when you had your most recent tetanus shot?"

"No."

"OK. We'll examine you, clean your wound, suture if necessary, dress it, and give you a tetanus shot. Can you remove your shoe and sock, or do you need help?"

"I can do it."

He removed his left shoe and sock and after I washed my hands and gloved, I checked his foot. The injury wasn't too bad and simply needed to be irrigated and dressed. I did that, explaining to my students each step, then had Kellie administer the tetanus shot. Once the patient was walked to Patient Services, I asked both Krista and Al to join me in the consultation room, as there was no Resident's office to use.

"I treat my students as trainee doctors," I said. "And I want things done a specific way. First, when you bring in a patient, you give their name and their presenting complaint."

"I didn't know," Krista said quickly.

"Now you do. Once I'm comfortable with you, I'll have you run patients and do minor procedures under supervision. Impress me, and I'll allow you to do them without me watching."

"Third Years, too?" Al asked.

"Irrigating wounds, suturing, blood draws and injections. You learned how to do all of those during Second Year. Now is the time to start on live patients."

"Excuse me, Doctor," Krista said, "but shouldn't I get preference as a Fourth Year?"

"Absolutely, and you will, and if you demonstrate to me that you can do those things, despite having a thin procedure book, then you'll learn to intubate. Are you able to read an EKG?"

"I know how to hook them up, and I know what a normal rhythm looks like, but that's all."

"Did you ask Doctor Abbott or Doctor Javadi to teach you to read them?"

"No."

"Then you're going to learn. Get your cardiology textbook and read the two chapters about EKGs. There will be a quiz on Thursday."

"Seriously? This is a trauma rotation!"

"And nearly every trauma has an EKG. I could read them as a Third Year."

"Shit," Al swore under his breath.

"Don't sweat it. You haven't had a cardiology rotation yet. When you do, ask your Resident to teach you. If you want a head start, read the textbook and I'll help you."

"But I get a quiz?" Krista asked indignantly.

"This is your eighth rotation, and you've had two cardiology rotations; Al has had one rotation, and it wasn't cardiology. You're going to be a doctor in ten months, he has twenty months. My job is to make sure that on June 1st, when someone says 'somebody call a doctor', you can respond as a doctor. This rotation is when it gets real. What specialty are you planning?"

"Internal Medicine."

"Everything you learn here will be relevant to working in Medicine. You need to prove to my satisfaction that you're ready to be a doctor. That's true of every Sub-I, especially Medicine."

"Can I speak to you privately?" she asked.

I considered, then said, "Al, step out into the corridor, but leave the door open."

He stepped out and moved to the other side of the corridor.

"What did you want to say?" I asked.

"Why are you riding me?" Krista asked.

"It's my job to teach you, and I shape my methods to the needs of the student. With limited procedures in your book and an admission that even after a cardiology Sub-I you can't read an EKG, I decided that the best course of action is to challenge you and see if you can live up to my standards."

"Yours?"

"Mine. My job is to teach you, but also to discuss your evaluation with Doctor Gibbs. There is nothing easy here, and you're going to have to step up and fill your procedure book, because interview committees are going to want to see it. If it's as light as it is today, they won't list you for the Match, and you'll be stuck Scrambling, or possibly fail to Match. That's the trajectory you're on."

"You know that from a minute with my procedure book?"

"It's the permanent record of what you've done. I also spoke with Doctor Javadi."

"She didn't treat me fairly!" Krista protested.

"Even if that's true, you are still responsible for learning. I had a Resident treat me like crap and assign me as much scut as possible, because they didn't like me. I did everything requested to the best of my ability and found opportunities to learn from other doctors."

"You obviously don't like me."

"Whether I do or not, I'm going to teach you if you're willing to learn, and give you the procedures if you put in the effort. It's up to you. What do you want to do?"

"Learn."

"Then let's go."

XXXIV. How Did You Know?

August 7, 1989, McKinley, Ohio

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."

XXXV. Do You Get Used To It?

August 7, 1989, McKinley, Ohio

Fill out your procedure book," I said to Al as we walked back to the ED after an uneventful flight to and from OSU. "You now have one flight; you need four more, and either your MD or certification for Advanced Life Support, and my signature, and you'll be certified as a flight surgeon."

"Whoa! Seriously?"

"Seriously. I qualified the week after I graduated from medical school. I was short of the required number of flights, but the paramedic ride-alongs that new trauma, medicine, and surgical Residents will do going forward count as well."

"But surgeons don't fly, do they?"

"Rarely. It's almost always a trauma doc, or, more rarely, someone from Medicine."

"Your Residency is both trauma and surgery, right?"

"Yes, and there will be at least one trauma surgery slot here for your Match, but it's going to be highly competitive. That said, surgeons will be doing trauma rotations, and you could, after PGY5, apply for a trauma Attending role. Well, that's the plan; no guarantees."

"You're giving me reasons to match here rather than in Virginia."

"That's home?"

"Arlington. My dad is a lobbyist and my mom is a Congressional aide."

"That's convenient," I replied.

Al laughed, "You would think, but Dad is a defense lobbyist, and a Republican, and Mom works for Nancy Pelosi, a first-term Democratic Congresswoman from San Francisco."

"I'm a Reagan Democrat and my wife is a card-carrying socialist, so I can relate."

We arrived back in the ED and while Al updated his procedure book, I checked in with Ellie, then went to see Doctor Gibbs.

"All the way both ways in the helicopter this time?" she asked with a smile.

"Two good engines both ways! I didn't even think about what happened last time. I think it's the positive vibes from Kellie."

"You two seem to have a perfect working relationship."

I nodded, "She gives me good advice and seems to anticipate what I need and what needs to be done."

"The qualities of an excellent nurse. Going back to the patient you transported, how the heck did you pull calcium gluconate gel from thin air? I'd have had to look that up!"

"Honors chemistry," I replied. "I remembered hydrofluoric acid has an affinity for bonding with calcium, and I know the IV treatment for hypocalcemia. I then remembered reading an article in JEM about acid burns and gave the orders."

"You're a natural," Doctor Gibbs said. "There's a reason you're called the most promising young doctor in the hospital."

"Clarissa Saunders would disagree with you, and point out she scored higher on Step 2 of the MLE!"

"By a point!" Doctor Gibbs declared. "Meaningless in the larger scheme of things."

"So you would think, but trust me, I'll hear about it after she and I retire in fifty years!"

"It's a good thing you come as a matched set and we have both of you!"

"Changing topics, I'm sure you'll hear from Krista about me taking Al on the flight."

"And if Krista were my student, she'd be on scut for the entire month," Doctor Gibbs said.

"You know my take on that," I replied. "While I'll heed Leila Javadi's advice of watching her carefully, I won't relegate her to pure scut. I've already spoken to her twice and given her strong direction on how to improve. I have to give her a chance to do so."

"If you've had to have two separate conversations with a Fourth Year on the first day of a rotation, you have to know she doesn't belong here."

"I have twenty bucks in my pocket which say that you and Doctor Northrup assigned her to me for exactly that reason. She'll either be Felicity or Tim, and that has to be because of her, not because of me. We've had this discussion in the past, and I haven't changed my opinion."

"Remember, this morning I said I didn't know why her procedure book was light."

"And yet, I'm sure you read her previous evaluations, so you at least had a clue that she was a poor performer, and that's why she was assigned to me."

"What's your plan?"

"I assigned her several pieces of homework. First, to learn how to read an EKG, something she should have done during her cardiology Sub-I. She admitted she hadn't asked Leila Javadi or Barb Abbott to teach her. Second, to find out who Sir William Osler was. She didn't know, and neither did Al, and the medical school is partly to blame."

"How so?"

"His book is optional reading for Practice of Medicine. It ought to be required, even if it's subversive with regard to the way most medical schools handle First and Second Year students. McKinley has instituted Preceptorships precisely because of what Osler taught, yet they don't assign his seminal work as required reading material. And yes, I'll make that point to Nora Mertens when next I see her."

"What brought that on?"

"Krista was academically talented but is clinically deficient."

"So like Felicity?"

"I know a fact about Felicity's past, which explains her initial animosity to me, which I cannot share, so I think the two situations are distinguishable. It's also the case that I was a fellow student, whereas now I'm an Intern."

"An Intern who is as good as any Attending here, present company included. If you weren't, we wouldn't have signed off on you basically operating on your own with minimal supervision."

"Speaking of that, was your offer to help earlier simply an offer to help, or making sure I wasn't in over my head?"

"Yes," Doctor Gibbs replied with a smile. "You shouldn't be surprised at that."

"I'm not, nor am I bothered by you checking up on me. Despite all the accolades, I'm still a very junior physician."

"And you haven't let it go to your head. You make the right calls, but you also ask for help when you need it. Just remember -- arrogance kills."

I nodded, "I'll remember."

"Conduct your students' training in the way you see fit, so long as you can defend it if necessary."

"I'm curious as to how you feel I should handle discussing Krista with the other Residents at shift turnover?"

"I'd say you tell him what you personally discovered -- that her procedure book is light and that she'll need close supervision. I believe that fits within your desire not to poison the well, as it were."

"It does."

"Have you had a meal break?"

"No. I ate a granola bar when we took off from OSU for the return trip."

"And then fell asleep, right?"

"Yes."

"Take your meal break."

"I'll make it my dinner break given it's nearly 4:00pm."

"OK."

I left her office and headed to the cafeteria, returning to the ED about twenty minutes later. Al and I handled four walk-ins before he and Krista went off shift at 6:00pm, with Serenity Cooper and Walt Foster relieving them.

As was my usual practice, I asked Serenity and Walt for their procedure books and thumbed through them. Both of them had what I considered to be a typical number of procedures, with Serenity having completed a Medicine Sub-I and Walt an OB/GYN Clerkship.

"Any thoughts on the Match?" I asked Serenity.

"Nuclear medicine," she replied. "My dad is a physicist who works for Fermi National Laboratory outside Chicago. I think what he does is cool, but I'm not interested in being a physicist."

"You're from that area?"

"Naperville."

"That's where my dad's family lives," I replied. "My mom's family is from Ohio. What about you, Walt? I know it's almost two years away for you."

"Surgery," he said. "I decided during my Preceptorship. You're wearing surgical colors; why?"

"I'm training to be a trauma surgeon," I replied. "I'm on the surgical staff, but assigned to the Emergency Department. I'll end up with what amounts to a dual Residency in emergency medicine and general surgery, and spend most of my time in the ED."

"That's cool!"

"Mike?" Josh, the evening clerk, called out. "Paramedics four minutes out with an MI. Use Trauma 3, and Penny is your nurse."

"Thanks," I replied. "Serenity, Walt, let's go."

The three of us went to the corridor, and I ensured they put on gowns and gloves, then we joined Penny in the ambulance bay waiting for the EMS squad to arrive.

"Penny, CBC, Chem-20, ABG, and cardiac enzymes; Serenity, you'll hook up the EKG and pulse oximeter, cut away the shirt if necessary; Walt, switch the oxygen from the portable bottle to the hospital system. If the paramedics are performing CPR, I'll give new instructions."

About two minutes later, EMS Squad 4 arrived, which meant John and Roy. When it pulled to a stop, John jumped out.

"Charles Ramsey, fifty-eight; complained of chest pains and shortness of breath; tachy at 120; BP 90 palp; PO₂ 95% on five liters; IV saline TKO."

"Trauma 3!" I ordered. "Mr. Ramsey, I'm Doctor Mike. We'll take good care of you."

We quickly moved Mr. Ramsey into Trauma 3 and onto the treatment table, and everyone sprang into action. Both Serenity and Walt performed their assigned tasks with reasonable speed as I performed the primary exam. When I heard Serenity push the power switch on the EKG, I looked up.

"Inverted T wave," I said. "Mr. Ramsey, you're having a heart attack. Walt, call for a cardiology consult, please. Serenity, Foley catheter; I'll guide you. Mr. Ramsey, we're going to insert a catheter to drain urine, as you're very likely going to need a cardiac procedure."

I completed my exam and then talked Serenity through the Foley catheter insertion, though she had done several during Third year.

"Lyon, Cardiology," Doctor Judson Lyon said, coming into the room with a student in tow. "What do we have, Mike?"

"Hi, Judson. Charles Ramsey, fifty-eight; complained of chest pains and shortness of breath; tachy at 120; BP 90 palp; PO₂ 96% on oxygen by mask; inverted T-wave, loud second heart sound, and possible increased jugular venous pressure, all indicative of pulmonary embolism. Patient is catheterized; full cardiac trauma panel ordered."

"Got it!" Judson replied. "Mr. Ramsey, I'm Doctor Lyon, a cardiologist. I'm going to do a quick exam and then we'll take you upstairs."

He repeated my exam, then ordered heparin, which Penny administered.

"Cade," he said to his student, "call upstairs and tell them we're bringing up a suspected PE for an angio. Mike, we have this."

"Walt, get a gurney and assist in transport," I instructed. "Serenity, print a strip, then switch to the portable monitor; Penny, portable oxygen."

Three minutes later, Mr. Ramsey was on his way up to Cardiology.

"Serenity, bring that strip with you so we can examine it when Cade returns."

I'd decided that it was incumbent on me to teach all of my students to at least read a basic EKG and ensure they were able to at least call out the deviations from normal sinus rhythm, even if they couldn't propose a diagnosis.

"You could tell he has a pulmonary embolism simply based on exam and EKG?" she asked.

"That's my suspicion," I replied. "You heard Doctor Lyon say 'suspected PE' after I said the symptoms were 'indicative' of a PE. Formal diagnosis requires imaging, either an angiogram or an ultrasound. There are a number of other heart ailments which have similar signs, but shortness of breath, chest pain, and inverted T-wave, and increased jugular venous pressure all point in that direction. Doctor Lyon was sure enough to order heparin, which is the primary treatment."

"If you knew, why not administer heparin right away? she asked.

"Let's wait for Walt to return so he can hear the conversation."

"OK."

Five minutes later, Walt returned, and we went to the lounge.

"Any trouble during transport?" I asked.

"No. We took him straight to the cath lab, and they sent me back."

"OK. Serenity, ask your question."

"If you knew the diagnosis, why not administer heparin?"

"It was a judgment call. The patient wasn't cyanotic, which gave us more time. Given that, I preferred to wait for the Cardiology Resident to decide what he wanted to do. The main reason for that is the minute the patient crosses the red line that spans the corridor, he belongs to the other service. Because of that, it's better, if possible, to let them make the decision. Had Mr. Ramsey been cyanotic, had LOC, or any signs of imminent death, I'd have intervened beyond ordering blood tests and the EKG and calling for a consult.

"Speaking of the EKG, neither of you has had a Sub-I in cardiology, but you're going to get a head start because every physician who works in the ED needs to be able to at least describe the arrhythmia even if they can't diagnose it, and know when calling a cardiology consult is necessary, because many arrhythmias are not primary to heart disease. Serenity, let's look at that strip."

I explained the grid system and the PQRST system of evaluating the EKG and explained the phrase I'd used 'inverted T-wave'. I also pointed out that Cardiology would switch from a five-lead to twelve-lead EKG, which would provide further information and help narrow down the diagnosis, something we generally did not do in the ED.

"So," I concluded. "Get your cardiology textbook and read the two chapters on EKG, assuming you understand the basic heart rhythm. If not, go back a chapter and read about electrical impulses and normal heart rhythm. Walt, I didn't see any reference to EKGs in your procedure book."

"Only fetal monitors," he replied.

I took my trauma notebook from my pocket, flipped to the correct pages, and handed it to him.

"Copy these two diagrams and the lists of leads for five- and twelve-lead EKGs. You should memorize both, but for now, focus on five-leads as that's nearly always what we use here. Next week, I'll give you a chance to show me what you've learned in that regard. Serenity, as soon as we have a case that requires intubation, I'll have you do that, assuming we have a second doctor available to conduct the primary assessment while I teach you.

"The one downside of this rotation is that for the rest of August, Fourth Years are still manning the triage desk. As of September 1st, it'll be nurses. That means you'll have to sit at the triage desk from 6:00am to noon tomorrow. On the plus side, that means you should be able to catch a nap at some point overnight, and my advice to both of you is to sleep if and when you can."

"I heard they're reducing your hours," Walt observed.

"Yes. The goal is for Interns in the ED to not work more than eighty hours in a week, as opposed to between ninety and a hundred. And they're killing the thirty-six-hour shifts. You know why, right?"

"Some case from New York where Residents caused a patient death," he replied.

"Honestly, the system killed Libby Zion, not the unsupervised PGY1 and PGY2. There was no trauma Attending on duty at the hospital, and her personal physician didn't communicate properly with the hospital physicians. Those two Residents were at the very end of a thirty-six-hour shift, had poor supervision, and didn't have all the information they needed. To put all the blame on them, as some have done, is simply wrong."

"You have those now, right?"

"Yes, but the key difference is that policy at Moore Memorial has always required an Attending physician on site for the ED. That's not true for other services, but I expect that to change over time. The same is true for Resident work hours on other services. The problem, of course, is that more Residents will be needed and that costs money, which is always in short supply."

"Mike?" Josh called out from the door. "Arm lac in Exam 4 with serious bleeding. Penny is with the patient."

"Thanks."

Serenity, Walt, and I left the lounge and went to Exam 4, where the patient was lying on the treatment table.

"This is Mr. Marsh," Penny said. "Severe laceration of his lower arm. Pulse 90; BP 90/60."

"Hi, Mr. Marsh," I said. "I'm Doctor Mike and these are my students, Serenity and Walt. How did you cut your arm?"

"My girlfriend tried to stab me."

"Let's take a look, please."

I did and saw a very deep wound and appeared to involve tendons.

"Penny, let's put on a fresh pressure bandage, please. Walt, call the surgical scheduling nurse and let her know we have a severe laceration which will require sub-cu sutures and potential orthopedic repair due to tendon involvement. Mr. Marsh, I'd like to do a primary exam, which means listening to your heart and lungs."

"OK, Doc."

I did the exam and noted nothing atypical, but the slightly low blood pressure indicated he needed volume. Given he was going up for surgery, the correct course of action was IV saline.

"Penny, IV saline, and type and cross match for surgery."

"Right away, Mike!"

"They'll be ready in twenty-five minutes," Walt announced.

"Mr. Marsh, when did you last eat?"

"About 5:30pm," he replied.

I noted that on the chart, as the anesthesiologist would want to know, despite the repair most likely being done under local rather than general anesthesia.

"Any allergies?"

"No."

"Any negative reactions to anesthesia, including at the dentist?"

"Nah, I've had cavities filled and never had a problem with those shots."

"Any difficulties swallowing or eating?"

"No."

"When was your last tetanus shot?"

"I don't recall having one."

"Then we'll make sure you get one once the surgeons repair your arm."

"You can't just stich me up?"

"No, because I'm concerned about tendon damage, so we need an orthopedist to evaluate the arm, which he'll do upstairs. Also, the cut is deep, so you need more than just simple sutures."

"Serves that bitch right that she was arrested."

"How did you get here?"

"The McKinley PD brought me here."

"OK. We'll keep you here until they have the OR ready upstairs. Penny, pulse oximeter and the new automatic BP cuff. Call me if his pressure drops."

"Will do, Mike."

"Mr. Marsh, we're going to see other patients, but we'll be close by."

"Thanks, Doc."

Walt, Serenity, and I left the room and I saw three charts in the rack.

"Serenity, take the first chart and tell me what you'd do."

She picked up the chart and scanned it.

"Migraine headache," she said. "H&P and trauma panel."

"Male or female?" I asked.

"Female, so...pregnancy test if warranted."

"Criteria?"

"Any sexual activity since her most recent period."

"Do you know how to ask?"

"Yes. I ask 'is there any chance you might be pregnant', and clarify if necessary."

"Then you and Walt bring the patient in, Walt should take vitals, and you proceed as you suggested. I'll observe, then we'll step out and assess."

"Can I ask a quick question?" Serenity inquired.

"Sure."

"Why did the nurse call you 'Mike' instead of 'Doctor'?"

"That's my preference," I replied. "You two need to use 'doctor' because not doing so will unhinge some of the more traditional medical practitioners here."

"Doctor Mike is a trouble maker!" Doctor Nielson said as he passed by.

"Love you, too, Perry!" I chuckled. "Go get your patient, Serenity. Use Exam 1. Introduce yourself as a Sub-Intern, and when I come into the room, introduce me as 'Doctor Mike'."

She acknowledged my instructions, then she and Walt went to get the patient from the waiting room, and I waited about fifteen seconds before I followed them into Exam 1 with nurse Angela.

"Miss Atkins, this is Doctor Mike, my Resident."

"Hi," I said. "Proceed, Serenity."

Walt took vitals while Serenity took a textbook history and then conducted a textbook exam. Once they finished, we stepped out into the corridor to confer.

"Tell me what you want to do now," I said to Serenity.

"Uhm, CAT scan?"

"Is that a guess, or are you sure?"

"A guess," she admitted.

"Wisdom is the ability to say 'I do not know' when you actually don't know. Guessing will kill patients and end your medical career."

"Sorry."

"No need to apologize," I replied. "Your first Sub-I was Medicine and they, rightly for their service, teach you to throw out ideas. That's all fine and good for the classroom or a corridor convo in Medicine, but I'm asking you to treat this patient, so guessing is off limits. Please don't take this as a reprimand, just as something for the future."

"Then I don't know what to do next."

"Walt, any thoughts?"

"No clue."

"Honestly, that's the right answer for both of you. Ms. Atkins said she had tried Excedrin, and it didn't help. Given everything she said is consistent with a migraine, and she hasn't been here before, our next step is what we call a 'migraine cocktail', which is basically Excedrin with higher dosage -- 500mg acetaminophen, 300mg acetylsalicylic acid, and 100mg caffeine."

"Oral or IV?"

"She's able to swallow, so oral," I replied. "Write it on the chart for my signature, then give the order to Angela. You say 'Nurse, migraine cocktail, please' and say that it's on the chart."

"What do I tell the patient?"

"That our first step is to see if we can control the migraine with medication, and we'll decide on the next steps when we see if the cocktail is effective. If she asks questions and you are not absolutely sure of the answer, just look to me and I'll answer. Remember, that's what I expect to happen, though by the end of September, it should happen less. Ready?"

"Yes!"

We went back into the room and Serenity explained her plan to Miss Atkins, then gave Angela the order. Angela looked to me and I nodded, and she left to get the necessary pills from the drug locker. Once Miss Atkins had taken the pills, we dimmed the lights and said we'd check on her every fifteen minutes to see how she was doing.

When we left the room, we went to check on Mr. Marsh, whose blood pressure had come up a bit after the saline IV had been started, and after checking my watch, I had Walt call for an orderly to transport Mr. Marsh to surgery in a wheel chair, and to accompany them.

"Let's get our next chart," I said to Serenity. "We'll debrief once Walt returns."

"But I did OK?"

"Textbook," I replied. "And that's exactly where you should be. Grab the next chart.

We handled six more walk-ins before the waiting room was empty, then met in the lounge for a debrief. Given the time, I went for a nap in the on-call room. I managed about thirty minutes before Nicky woke me.

August 8, 1989, McKinley, Ohio

"MVA coming in," she said. "Doctor Mastriano asked for your help. Five minutes."

"Thanks, Nicky. Where are my students?"

"In the lounge. I'll let them know."

A minute later, I met Doctor Mastriano and Nurse Billie on the ambulance bay.

"You asked for me, Isabella?"

"Unrestrained single MVA," she said.

I hated those because they were nearly always train wrecks with little chance.

"What do you want?"

"Airway then neuro,"

"I want to give my student a chance to intubate."

"One try," Doctor Mastriano said. "Then you take over."

"That was my plan."

"Does your other student know how to set up an EKG?"

"We just began going over that."

"OK. He should draw a trauma panel and Billie will set up the EKG."

"Got it. Clear on that, Walt?"

"CBC, Chem-20, ABG, EtOH, pregnancy test if female."

"Plus type and cross match. Take the vials straight to the lab and wait for the blood type."

"OK."

Over the next two minutes, I reviewed the procedure with Serenity, finishing just as the EMS squad pulled up.

"Ross Baldwin, nineteen; unrestrained MVA; multiple internal injuries; compound fracture right leg and right arm; pulse thready; BP 70 palp; PO₂ 89% on ten liters by mask; GCS5; cervical collar and backboard."

"Trauma 1!" Doctor Mastriano ordered.

We quickly transported the patient to Trauma 1, and the six of us, including the paramedics, lifted him onto the trauma table. Surprisingly, the patient had no visible head injuries, and a good airway, so I did a quick neuro assessment while Doctor Mastriano did a primary exam and Walt drew blood.

"Change of plans," Doctor Mastriano declared. "Billie, large bore IV and a unit of plasma on the rapid infuser! Serenity, EKG and monitor! Hold on the intubation!"

"Pupils sluggish," I announced. "No sign of CSF or blood."

"Pneumothorax," Doctor Mastriano declared. "Mike, chest tube!"

"Billie, 36 French, and a chest tube tray to me. Serenity, get the portable ultrasound, please."

I inserted the chest tube and connected the Thora-Seal, then guided Serenity with the intubation procedure. She was slow, as I'd expected, but she got it right, and we hooked up the vent.

"Good tidal CO₂," I announced. "Foley?"

"Yes."

I went to the cabinet, got an 18 French tube and kit, then inserted the Foley and hooked up the bag.

"Obvious blood in the bag!" I declared. "Blood in the Tora-Seal as well."

"Probable surgical belly," Doctor Mastriano announced. "Poor distal pulses in both legs. Negative Babinski."

"Too many things wrong," I said, saying a silent prayer. "What do you want to do?"

The monitor blared before she could answer.

"V-fib!" I declared. "Paddles to Doctor Mastriano."

I shoved the ultrasound cart out of the way as Billie moved the crash cart next to Doctor Mastriano. Before the machine charged, the monitor went monotone.

"Asystole!" I declared. "Starting compressions."

I began CPR and Doctor Mastriano called for epi, twice, but we didn't get a blip on the monitor. She asked me to halt compressions so she could auscultate, but shook her head.

"No heart sounds," she said. "Resume compressions."

I did and after an ampule of bicarb and a third round of epi resulted in no heart sounds, she once again shook her head. She checked the patient's pupils, listened again for heart sounds, then removed her stethoscope.

"Pupils fixed and dilated, no pulse, no heart sounds, no electrical activity. Time of death, 00:57."

"Serenity, check his wallet for a donor card," Doctor Mastriano said.

Serenity picked up his jeans, which had been cut off and pulled out the patient's wallet.

"Driver's license isn't signed," she reported.

"Likely useless due to the internal injuries," I said quietly.

"Agreed," Doctor Mastriano replied. "Serenity, check to see if he has someone here in the waiting room. If so, take them to the consultation room and let us know."

Serenity left and Doctor Mastriano and I completed the chart and the death certificate, which she signed.

"His mom and dad are in the consultation room," Serenity said.

"OK. Mike, let's go inform them."

"Serenity, Walt, follow along," I said.

The four of us went to the consultation room where Mr. and Mrs. Baldwin were waiting.

"How is our son?" Mr. Baldwin asked as soon as we walked into the room.

"Hi, Mr. and Mrs. Baldwin," Doctor Mastriano said. "I'm Doctor Isabella Mastriano, an emergency medicine specialist, and this is Doctor Michael Loucks, a trauma surgeon. Ross was brought in by the paramedics with severe injuries due to a high-speed automobile accident. Despite our best efforts, using all our skills and capabilities, his heart stopped while we were treating him. We used every possible means to revive him, but we were unable to do so, and he died."

"NO!" Mrs. Baldwin screeched. "NO!"

"Can we see him?" Mr. Baldwin asked as he put her arm around his wife.

"Yes. Give us a few minutes, and then we'll take you into see him. Walt, please let Billie know that Mr. and Mrs. Baldwin will be in to see their son. Mike, will you take care of that?"

"Yes, of course," I replied.

She left, and I sat down at the table.

"Can we call the chaplain for you?" I asked.

"We don't go to church," Mr. Baldwin said.

Walt returned and let me know that the room was ready.

"Mr. and Mrs. Baldwin," I said, "you're going to see wires, tubes, and other equipment we used to try to save your son's life. Legally, we're not allowed to remove them until the pathologist completes his examination. If you'll come with me, I'll take you to him."

We left the room, with Serenity and Walt following after us, and I escorted Mr. and Mrs. Baldwin to Trauma 1. When we entered the room where her son was covered up to his chest with a sheet, Mrs. Baldwin gasped and began sobbing. After about five minutes, they were ready to leave, so I walked them out, retrieved an information sheet, and handed it to Mr. Baldwin.

"This explains the process," I said. "We'll work with any funeral home you choose."

"Thank you, Doctor," Mr. Baldwin said. "I'm sure you did your best."

"Thank you," I said.

They left, and I went to the lounge and basically collapsed onto the couch as the adrenaline wore off. Both Serenity and Walt sat down.

"First one?" I asked.

"Yes," Serenity said. "I mean, I saw people pronounced during Third Year but was never invited into the room to tell the loved ones."

"I didn't see any during my Preceptorships," Walt added.

"The words Doctor Mastriano used are an example of what to say, though the words don't need to be exactly the same. There are two important things. First, you absolutely must use the word 'died', not a euphemism of any kind. Second, you never give a cause of death, though it is OK to say that the patient's heart stopped, and we were unable to revive them. Then offer spiritual assistance, but don't engage in speculation on the cause of death."

"Do you have any idea?" Walt asked.

"The simple answer is 'injuries sustained in an MVA which are incompatible with life' and the cause could be any number of things. I obviously can't say for sure, but what we know, including blood in the Thora-Seal and the urine bag, I'd say the odds point to a major vessel rupture or fat embolism from the fractured femur. That said, the Babinski indicated spinal damage, so we won't know until Doctor McKnight performs an autopsy."

"Do you get used to it?" he asked.

"I think that depends on what you mean. Fundamentally, you have to accept that it happens and move on to the next patient. I know it seems cold-hearted, but you don't have a choice. If you can't simply accept it as a part of the job, don't Match for emergency medicine. Another way to look at it is that if it weren't for the paramedics and doctors, far more people would die.

"If you recall from the very brief history of emergency medicine from the first week of medical school, experience in Korea and Vietnam led to the first 'shock trauma' unit opening in 1966 at Cook County Hospital in Chicago. Before that, Emergency Rooms, such as they were, were usually staffed by surgeons, not with experts in trauma. Those early Emergency Rooms were just that -- rooms near the hospital entrance where patients were evaluated.

"The first modern paramedics were in Los Angeles a few years later, after then Governor Reagan signed The Wedsworth-Townsend Act, which created paramedic services. That's actually the name of the pilot episode of the TV show Emergency which used actual cases from LA County. Before that, ambulance services were pretty much what one of the doctors I spoke to called 'scoop and run'.

"There was serious opposition from doctors to paramedic services, but a simple statistic convinced Governor Reagan to sign the bill -- soldiers who had been seriously wounded on the battlefield during the Vietnam War had better survival rates than individuals who had been seriously injured in motor vehicle accidents on California freeways."

"Wow!" Serenity gasped. "That's for real?"

"Yes. It was a detailed study that showed getting the wounded to medical help beyond the corpsman or medic was the key. You know about the 'Golden Hour', I'm sure. In Korea and Vietnam it was helicopters, here it's paramedics. We've only had paramedic service in Harding and Hayes Counties for about eight years, and our firemen-paramedics are just being trained in Advanced Life Support, and the squads are being updated.

"You'll start seeing the paramedics rotate through the ED next month, and trauma Residents will do ride-alongs with paramedics. That will give them a chance to experience rescue first-hand, as well as mentor the paramedics. In addition, surgical and medicine Residents will rotate through the ED with eight-week stints. That's mainly to increase staffing to handle patient loads, but also to provide additional training."

"Was there anything different that could have been done?" Serenity asked.

"That's a tricky question," I replied. "We basically followed the protocols. What are the priorities?"

"Airway, Breathing, and Circulation," she replied.

"Tell me what we saw, please."

"He had a good airway, because his PO₂ was not at a dangerous level and he was breathing, albeit labored. You resolved that with the chest tube and Doctor Mastriano ordered a transfusion. The EKG showed normal rhythm, though he had a fast pulse..."

"Use the medical term, please, when discussing with medical staff."

"He was tachycardic with a sinus rhythm. You conducted a neural assessment while Doctor Mastriano conducted the physical exam. The paramedics had splinted his arm and leg, and put on a cervical collar. You saw evidence of blood in his abdominal and chest cavities, so the next step would have been the ultrasound, but he coded and couldn't be revived."

"In less than ten months, that could be you running a trauma. What else could we have done?"

"Not much, I guess."

"If it was an aortic rupture, even being on the surgical table and open most likely wouldn't have changed anything. There was one of those last month where a twenty-year-old woman coded on the table from an aortic transection. She bled out in seconds and despite a surgical team being with her, they couldn't save her. Anyway, I'm going to take a nap."

I got up, left the lounge, and went to the on-call room. I put on my sleep mask and climbed into the bottom left-hand bunk and my head had barely touched the pillow when Billie came to the door.

"Unresponsive toddler brought in by his parents. Doctor Mastriano wants your help. Trauma 3."

I nodded, removed my sleep mask, got back out of bed, and hurried to Trauma 3, asking Billie to get my students. I saw Doctor Mastriano examining the toddler as Bonita was situating an oxygen mask.

"Lucy Leahy, sixteen-month-old female found non-responsive in her crib," Doctor Mastriano declared. "Hook up an infant EKG, please."

I began working as Serenity and Walt came into the room.

"Walt, page Pedes, stat," Doctor Mastriano ordered.

"Sinus rhythm," I announced. "A bit tachy, but not extremely for an infant. PO₂ 98% on the mask. What do we know?"

"Mother went to check on the toddler and found her unresponsive."

The EKG alarm sounded.

"SVTs!" I announced. "Run of six."

"Mike, go question the parents, please."

"Right away. Serenity, stay here to assist; Walt with me."

Walt and I left the trauma room, and I went to the triage desk and asked for the toddler's parents.

"Mr. and Mrs. Leahy," Natalie, a Fourth Year, said. "He's the one with the beard."

"Thanks."

I went into the waiting room, introduced myself, and asked Mr. and Mrs. Leahy to follow me to the consultation room.

"How is she?"

"Doctor Mastriano is examining her now," I said. "I need to ask you some questions to help us figure out what's wrong with Lucy."

I had them sit down, and I took my small notebook from my pocket.

"When's the last time Lucy ate?"

"I nursed her around 11:00pm," Mrs. Leahy replied.

"Does she eat solid food?"

"Applesauce and small amounts of baby food from jars."

"She's eating OK?"

"I think so. She nurses the usual amount of time and likes her applesauce."

"Have her bowel movements been regular?"

"Yes. She dirties her diapers pretty much on schedule."

"No diarrhea?"

"No."

"Is she on any medications?"

"No."

"When was her last pediatric visit?"

"Just after her first birthday, so about four months ago."

"And she's had all her vaccinations?" I inquired.

"I think so. I always do what the doctor says."

"Who's her pediatrician?"

"Doctor O'Neill."

"Has she been sick recently?"

"No. A runny nose back in March, but nothing since."

"Any vomiting or rashes?" I asked.

"No."

"Has she been fussier than usual?"

"Not really. I mean, I think she cries like a normal baby, usually when she has a dirty diaper or is hungry."

"Is she walking?"

"She just started, but she's unsteady."

"Is your home childproofed?"

"You mean cabinet locks?" Mr. Leahy asked. "Yes."

"I know it's improbable for a baby Lucy's age, but is there any chance she might have had access to cleaning supplies, pesticides, fertilizer, paint, or anything of that nature?"

"No way!" Mr. Leahy said. "Everything is out of reach and we're super careful!"

I smiled, "I wasn't accusing you; it's an important thing for us to ask. Has Lucy been to the hospital at all?"

"Never," Mrs. Leahy replied. "Well, besides now and when she was born."

"Any family history of heart disease or neural disorder?"

"Not on my side," Mrs. Leahy said. "Tom's dad had a heart attack at age fifty-five."

"I was thinking more congenital. No diabetes in any close relatives?"

"No."

"Is there anything you can think of that I haven't asked about? Anything out of the ordinary?"

"No."

"OK. Walt will escort you back to the waiting room and I'll work with Doctor Mastriano to figure out what's wrong with Lucy."

"Can we see her?" Mrs. Leahy asked.

"Give us a few minutes and I'll send Walt out to bring you in when Doctor Mastriano says it's OK."

XXXVI. Inner Peace

August 8, 1989, McKinley, Ohio

"I thought someone dying before my eyes was the worst thing I'd see," Walt said after Lucy Leahy was admitted to pediatrics.

"Lumbar punctures on kids are rough," I replied. "I'll raise you third-degree burns and drowned toddlers."

"You've basically convinced me to stick to surgery," he said.

"Emergency medicine is not for everyone," I replied. "It's not the hardest speciality, and not even the hardest emotionally."

"Which one is that?" Serenity asked.

"In my opinion, it's pediatric oncology. In pediatrics, the little humans mostly get well and go home; in pediatric oncology, they don't. I believe that doctors and nurses on that service are automatically qualified for sainthood."

"I don't think I could do that," Serenity said.

"Me, either."

"Is a lumbar puncture a procedure you could do?" Walt asked.

"No. It's a specialized pediatric procedure. For adults, it's done by Medicine. I've only seen four in two years and six weeks of clinical work."

"What's the worst procedure you'll have to do?"

"An escharotomy," I replied. "That's cutting down burns to minimize the damage from edema or to reduce pressure on the heart and lungs. You haven't smelled anything bad until you smell burnt flesh, and cutting into it is worse. I've observed, but haven't done one. I will, eventually. And now I'm going to make a likely futile attempt at sleeping."

I went to the on-call room and this time I managed to sleep for an hour before I was woken to help treat two firemen and two civilians for smoke inhalation from a barn fire. None of them were serious, and their PO₂ levels weren't too low, nor were their CO levels high, so after an hour of oxygen therapy, they were all released.

"Take your meal break," Doctor Mastriano suggested.

I called up to Medicine and Clarissa was able to take her break, so we met in the cafeteria. We got our food, then went to sit at a table by ourselves.

"How are your students?"

"Three good, one troublesome. You?"

"All four are pretty good. What's wrong with the troublesome one?"

"Her procedure book had about half the typical procedures for a Fourth Year, and when I questioned Leila Javadi about it, she said I should keep a very close eye on her AND shouldn't be alone with her."

"Uh-oh."

"Yeah. The most damning thing Leila said was that Krista was Felicity, but without the skills or intelligence."

"Ouch!"

"I'm sure she'll bitch to someone about me taking my Third Year on the helicopter."

"Too bad you decided to re-marry! You could have been the Flying Monk!"

"Orthodox monks don't wear wimples!"

"What was it this time?"

"Hydrofluoric acid burns to arms, face, and neck. I didn't hear how it happened, but with 30% burns, transport to the burn center is recommended."

"How the heck do you treat that?"

"The firemen cut off all his clothes and flushed him with water, then we applied calcium gluconate gel and transported him. My biggest concern was his eyes, but OSU will have an eye specialist who can handle that better than we can at this point."

"No engine trouble?" Clarissa asked with a sly smile.

"Nope. And I slept on the way back. I figure if Kellie can be that calm, so can I!"

"Am I being replaced, Petrovich?" Clarissa asked.

"A harem of work wives! Now there's an idea!"

Clarissa laughed, "You had that option! But all silliness aside, what are you doing about your student?"

"She'll have her chances. You know I don't believe in the 'all scut, all the time' treatment. And despite that, I'm sure she'll bitch given what Leila said and the fact that she objected when I insisted she learn how to read an EKG and said I'd give her a quiz on Friday. Fortunately, I only have her for twelve hours on my thirty-six-hour shift."

"I dread getting a rehabilitation assignment."

"This one wasn't intentional like Felicity or Tim; I went to Leila after seeing Krista's procedure book. I'll speak to Kylie tomorrow morning about it. Anything interesting on your service?"

"No, and that's exactly the way I like it! I like to have time to think and my idea of a good day is not seeing forty patients for a few minutes and never seeing them again. You, on the other hand, are an adrenaline junkie!"

"And medicine needs both styles," I replied. "I'm happy to be a feeder service for your pill-pushing operation!"

"Now that's low, even for you Petrovich!"

"Right," I chuckled. "Because you've never given me a hard time about anything!"

"Did you get any sleep?"

"On the helicopter, and then an hour. I take it you got more."

"About three hours total. I'm the one the nurses come to, of course, and I catch the consults as well. I heard there's no surgical Resident overnight in the ED when you're there."

"Because I'm the surgical Resident! PGY1s in surgery actually have less experience than I do because I did two trauma Sub-Is and a pathology Sub-I. Honestly, the new plan of having surgery and medicine Residents do eight-week stints in the ED during their first years is going to make a huge difference."

"And let you bums work no more than eighty hours!"

"The way I described it is that we now have programmed sleeping hours, and you know why."

"Libby Zion."

"It'll change on all other services over the next few years as they hire more Residents."

"How are things with Mastriano?"

"Fine. She's not trying to sleep all night, and she's treating me OK."

"Amazing what double-secret probation will do to an attitude!"

We finished our meals, and I headed back to the ED while Clarissa went back to Medicine.

The morning was fairly routine with my students and I handling nine walk-in cases and one EMS transport. During the afternoon, I had my two Preceptorship students as well, though, as the rules required, they simply observed. When 6:00pm finally rolled around, I went to daycare to get Rachel, who had been dropped off by Kris that morning. She greeted me with a hug and a sloppy kiss on the cheek, and then we left the hospital to head home.

August 9, 1989, Circleville, Ohio

"What's your plan for the day?" Kris asked when we got out of bed on Wednesday morning. "Other than seeing the counselor?"

"I'll spend the day with Rachel. We have no place to go and nothing planned after counseling except Vespers tonight."

I got Rachel from her bed, changed her diaper, and then the three of us went downstairs to have breakfast. After breakfast, we said our morning prayers, and then Rachel and I walked Kris to her car so she could head to OSU for her class. Kris and I exchanged a kiss, Rachel hugged her and kissed her, and then Rachel and I watched as 'Mommy' drove away.

We went back inside, I dressed Rachel, then drove to the Korolyov's house to leave her with her aunt for the morning.

"I promise we won't get into too much trouble!" Lyudmila said in a lilting French accent similar to her sister's.

"Somehow, that doesn't reassure me," I chuckled. "I'll be back in about two hours to rescue my daughter!"

I hugged Rachel, she immediately went to Lyudmila, and didn't look back. I rolled my eyes, because I was chopped liver compared to her «tante préférée», who did her best to spoil her rotten. I figured if an aunt wasn't doing that, she was probably doing something wrong, and when my nephew Michael was a bit older, I'd do the same for him and any other kids my sister and Paul had.

About twenty minutes after I left the Korolyov's, I walked into reception at Maryann Manning's office, and five minutes later, she brought me into her private office.

"No," I said.

"'No'?" she asked.

"The answer to your question two weeks ago."

"Are you always this annoying?"

"I'd say if you asked the people who know me best and for the longest time, you'd find the answer to be a resounding, unanimous 'yes'!"

She flipped through her notebook and nodded.

"You say that," she said, "but everything you've said indicates that's how you act now."

"Actually, I'll counter that and say it's how I react, not how I act. And it's all verbal, and I simply point out the things I find to be wrong. Do I push the edge of the envelope? Absolutely. Do I say too much? I'm sure that's the case. But I don't actually do anything that crosses the line."

"Your line."

"Other than spending too much time with patients and trying to work with patients with mental illness in a way that best suits them, not me, I don't cross the lines set by medical best practice."

"So, why did your mentor send you to me?"

"Because she's concerned that my idealism and my obsession with what happened to my friend Angie will lead me to burn out or become cynical, and that will impact my work and my personal life."

"That is often the case when idealism runs headlong into cold, hard reality. And the key thing is to find a balance where you don't lose your idealism but don't obsess over things you can't change."

"But I can't ignore them, either."

"It's about balance, Mike. There's a Swedish concept called «lagom» which means moderation, in a way where all things are in balance."

"Orthodox would call that 'inner peace', and it's achieved through 'hesychasm', something my «staretz» has prescribed. Unfortunately, I'm not fastidious about it, and I'm still stuck at stage one."

"It seems to me, then, that you don't belong here and you should see your «staretz» instead of me. When will you see him next?"

"The 10th of next month."

"Let's do this -- see him, tell him everything you've told me, and see what he says. Perhaps he'll want to speak to me to gain some insight into treating a doctor who is devout enough to seek spiritual guidance from a monk."

"Perhaps," I replied.

"Call for an appointment after you see him."

"I will. Thanks, and I'm sorry I basically wasted your time."

"You didn't. You spent time contemplating what I said, which is all that I can ask. The solution is found within you, all I can do is provide insight and guidance."

"I've heard that before from the counselor who worked with Angie. I'll call you some time after the 10th."

We said 'goodbye', I left her office, and headed back to the Korolyov's to retrieve my daughter. When Lyudmila let me in, I saw Rachel playing with a teenage girl.

"That's my friend Cheryl. We're hanging out today. Rachel could stay if you had things to do."

"I planned to spend the day with Rachel," I said. "So I'd like to take her home."

"«Rachel, ton père est là!» Lyudmila called out.

"Daddy!" Rachel exclaimed.

"You're teaching her French?" I asked.

"«Mais oui!» Lyudmila said with a twinkle in her eye.

"Go to your dad," Cheryl said. "He's a hunk!"

"And he belongs to my sister!" Lyudmila said, suddenly sounding like 'mama bear', but then turned to me and said, "of course, not the better sister!"

I laughed and shook my head as Rachel came over to me. She reached up her arms for me to pick her up.

"Thanks for watching her," I said. "See you at church tonight."

Rachel and I left the house, got into the car, and headed home.

"What should we do now?" I asked my nearly two-year-old toddler after we walked into the house.

"Sing!" Rachel exclaimed. "Daddy git'ar"

"I think we can do that."

"Raffi?" she asked.

"We can watch your Raffi tape as well," I said.

"Yes!" Rachel giggled.

We went into the house and I got my guitar and sheet music, and played Rachel's favorite songs, and after I played for about an hour, I made some tea, gave Rachel a cup of juice and a sliced banana for a snack. With her happily munching her banana, we sat down to watch Raffi In Concert With The Rise And Shine Band, which contained her overall favorite song, Baby Beluga. When the tape finished, we went to the backyard to play with a ball, then took a walk. When we returned to the house, we had lunch, and then I put Rachel down for her afternoon nap.

Once Rachel was in her bed, I put on one of my Mozart CDs and sat down with the McKinley Times. I'd only read the first two pages before the phone rang. I got up and went to the kitchen to answer it.

"Korolyov-Loucks residence; Mike speaking."

"Hi, Mike. This is Leland Crowe from Moore Memorial. I'm sorry to bother you on your day off. Do you have a moment?"

"Yes. What can I do for you?"

"You keep diagnostic notes, correct?"

"Yes, I do."

"Do you keep those notebooks permanently?"

"No. I have them going back about six months. I retain them so that if a case reaches an M & M, I have my personal notes to supplement my memory and the chart. Which case?"

"Mary Josephson, age fourteen."

"I'm not surprised."

"Would you bring me that notebook when you come to the hospital? I'm positive the charts are accurate and I have Doctor Gibbs' statement, but I want to make sure there are no landmines lurking."

"Absolutely. I'll drop it off at your office tomorrow morning."

"Just out of curiosity, do you ever remove pages?"

"No. And each set of notes is dated, with a time, and has the chart number."

"Perfect!"

"Is there an actual problem?"

Mr. Crowe laughed, "No attorney will ever give you a definitive answer to that, as no matter how obvious or cut-and-dried a case might be, there are no guarantees. In my professional opinion, there is no cognizable claim, but in the end, the courts would decide if they could bring a claim or not."

"Let me rephrase -- is there anything you feel we did incorrectly?"

"No. Every step was defensible, and the decision to report the pregnancy to Family Services in compliance with the law provides an excellent defense. There is nothing to worry about from your perspective -- you had a nurse in the room at all times, and you reported to Doctor Gibbs in line with hospital policy. I'll let you go."

"OK, I'll bring the notebook tomorrow."

"Sorry to disturb you on your day off."

"It's OK. Rachel is napping, and I was reading the newspaper."

We said 'goodbye', I hung up, and went to the study, retrieved the correct notebook, put it in my bag, then returned to reading my newspaper. I finished not long before Rachel woke up, and after changing her diaper and giving her a snack of sliced apples, we went for another walk, then returned home so I could start dinner. Kris arrived home from school, we had dinner, and then left for the Cathedral for Vespers.

After Vespers, we returned home, I read to Rachel, we said our evening prayers as a family, and then Kris and I put Rachel to bed. Once she was in bed, we left her room and I touched my wife's arm.

"What do you say to a bubble bath, lovemaking, and then sleep?" I suggested.

"I say 'yes'!"

August 10, 1989, McKinley, Ohio

"Morning, Lor," I said when I arrived in ED on Thursday morning.

"Morning, Mike. Did Mr. Crowe reach you?"

"Yes. I have my diagnostic notebook. I'll take it upstairs at 8:30am so I can hand it to him or his secretary directly."

"Don't worry about this. He'll swat it away without working up a sweat. I've seen several complaints like this, and I'm positive the only reason it's come this far is that the dad is an attorney."

"I'm not fretting over it," I replied. "I just wanted to let you know. I need to go do the turnover with Kylie."

"Go heal the sick!"

I left the Attending's office and found Kylie in the lounge and received the handover of two patients waiting on admission -- one to Pediatrics and one to Medicine. She asked to speak to me privately, so I followed her to the locker room.

"What did you do to Krista?" Kylie asked, as she began undressing.

I turned, so I wasn't looking directly at her.

"I noticed her procedure book was light, then spoke with Leila Javadi, who warned me that she's Felicity without the intelligence and skills, and also warned me not to be alone with her."

"OK, I didn't get that angle, but she certainly thinks you're sidelining her. She bitched about Al getting procedures and getting the helicopter. She said she thinks you're sexist."

"That would be her best line of attack, but I'm not going to put her on pure scut, even though that's the norm for someone like Krista. How did she do during the past twelve hours?"

"I think Leila's analysis is accurate," Kylie said. "Krista doesn't know as much as she thinks she does, nor does she know as much as she should."

"Fixable?"

"Probably not by you, because of how she feels about you, and I honestly don't think she's worth the effort. Give her the procedures she can do, challenge her to learn, but in the end, it's on her."

"That was my initial strategy. I challenged her to study the EKG section of the cardiology book and that I'd quiz her today. I also instructed her to find out who Sir William Osler was."

"Your hobby horse! Not that I disagree with you about the implications of that quote."

"I plan to suggest his seminal work be made mandatory."

"You just love to stir up the hornets' nest! Now I need a shower, so unless you're going to join me..."

"You know the answer to that."

"Of course!"

She went to the shower, and I left the locker room and went to the lounge, where Krista and Al were waiting.

"Good morning," I said. "Krista, who is Sir William Osler?"

"He founded Johns Hopkins and created the first Residency program."

"Yes. Did you discover anything else about him?"

"As in?" she inquired.

"His methods?"

"You mean learning in the wards, not in the classroom?"

"Yes. That was the point I made earlier. I'd maintain that actual learning begins with clinical rotations. Being able to pass tests is what allows you to actually start learning to be a doctor. Did you review the EKG sections in your cardiology textbook?"

"Yes."

I pulled three sample strips from my pocket and handed them to her.

"Describe these, please. Just in general terms, not a diagnosis."

She looked at them for about a minute before answering.

"This one is sinus tachycardia," she said. "And this one has ST elevation. And the last one is V-fib."

"Good. Those three things are the most likely arrhythmias that you'll see. At this point, you don't need to know the specific causes, just be able to call out what you see. Al, did you memorize the pad placement and leads for a five-lead?"

"Yes. Right side, white; left side, black; fourth intercostal, brown; right below the ribs, green; left below the ribs, red."

"Very good. A good way to remember them is smoke over fire, clouds over grass, chocolate on the chest."

"That's cool! Thanks."

"Al, check on the admissions; Krista, get the first walk-in chart and get basic vitals and confirm their presenting complaint. Al, you can meet us after you check on our patients."

While I wasn't going to give Krista pure scut, I was going to give her opportunities with walk-ins, where, for the most part, she couldn't do any real harm. I waited five minutes, then headed to Exam 3, stopping to receive an update from Al about the admissions, both of whom would go up in the next ten minutes. He followed me into the exam room.

"Mr. Harrington, this is Doctor Mike Loucks."

"Good morning, Mr. Harrington. Krista?"

"Tom Harrington, fifty-eight; tachy at 116; diaphoretic; complains of headache, fatigue, lightheadedness, and blurred vision."

"Thanks, Krista. Mr. Harrington, when did these symptoms start?"

"I've felt tired the last few days, had the headache last night, and when I woke up this morning, I felt lightheaded and had blurred vision."

"When did you notice your heart rate changing?"

"This morning. Doc, I need to lie down. I feel as if I'm going to pass out."

"Go ahead. Al, let's raise his feet, please."

"Trendelenburg?" Krista asked.

"No, just his feet."

Al adjusted the bed to raise Mr. Harrington's feet.

"Mr. Harrington, have you been sick recently? Or noticed any changes in your bodily functions?"

"No," he replied.

"Any injuries or strenuous activity?"

"No."

"Are you a diabetic?"

"No."

"Any recent dental work or medical procedures?"

"None. Just my annual physical for work in March."

"I'd like to do an exam, including listening to your heart and lungs, and checking your glands and abdomen, among other things."

"Sure, Doc."

I washed my hands, put on gloves, and began the exam. I found nothing out of the ordinary except his tachycardia and contemplated the next steps. The symptoms were such that the differential diagnosis list was, in effect, the entire diagnostic handbook.

"I don't find anything obvious from my exam," I said. "The next step is going to be blood tests. Before I order those, would you describe what you've done the last few days?"

"What do you mean?"

"Did you work? Take regular meals? Do anything out of the ordinary?"

"Breakfast, lunch, and dinner pretty much like clockwork; I've worked every day this week. I'm a construction foreman. I go to bed around 10:30pm and get out about 5:30am."

"Coffee?"

"Yeah, I take a full thermos to work every day."

Too much caffeine might explain his symptoms, but most likely wouldn't have been sudden onset.

"Has that changed recently?"

"Not in the last forty years since I had my first job as a gofer."

"Your appetite is good?"

"Absolutely. I've actually felt a bit hungrier than usual recently."

"Have you changed your diet at all?"

"I added a mid-morning and mid-afternoon snack about two weeks ago. Usually an apple or banana in the morning and peanuts in the afternoon."

"OK," I said. "I want to do three things -- a complete set of blood tests, an EKG, and also a rapid glucose test."

"What's that?"

"To check your blood sugar. Your symptoms all line up with a condition known as hypoglycemia -- low blood sugar. Let's do the EKG first. Al, would you hook up the monitor?"

I supervised him and saw what I would call textbook pad placement. He attached the leads correctly, then turned on the monitor, which showed exactly what I'd suspected -- sinus tach. After observing for a full minute, I had Al shut off the machine and disconnect the leads, but leave the pads in place in case we needed them.

"Other than your heart beating fast, your EKG is normal," I said. "We'll do the blood tests now. Krista, glucose meter, lancet, test strip, and alcohol wipe, please. They're in drawer C-2. Al, once I do this, draw for CBC, Chem-20, ABG, and glucose panel."

Krista got the equipment for me and I drew a drop of blood onto the test strip and waited for the meter to register.

"58," I replied. "Did you eat breakfast?"

"No," Mr. Harrington replied. "I wasn't feeling well."

"What about dinner last night?"

"Steak, corn on the cob, bread, and pie for dessert."

"Your blood sugar is a bit low," I said. "We'll give you something to eat and then re-check your blood sugar. Al, draw the blood. Krista, get Mr. Harrington a package of cheese crackers and a bottle of apple juice from the supply room."

"What's wrong?" Mr. Harrington asked.

"I don't know just yet; that's the point of the blood tests."

"What could be wrong?"

"As I thought to myself when I heard your symptoms, they ruled out almost nothing. Let's see what the blood work says, so we can narrow it down to something other than the contents of the diagnostic handbook my students have in the pockets of their lab coats."

"Can I ask why you have on red and everyone else is wearing blue?"

"I'm a surgical Intern," I replied.

"Who'd you piss off to get sent to work in the ER?"

I chuckled, "Nobody. My specialty is trauma surgery, which is a surgeon who is assigned to the Emergency Department. When there aren't trauma cases, I see patients who walk in as you did this morning. Let's get your blood drawn, and then eat what Krista brings you. I'll come check on you in a bit."

"Thanks," he replied.

I left the room, passing Krista, who went into the room. I filled out the chart, then went to the phone at the clerk's desk and dialed Internal Medicine and asked for Clarissa.

"Petrovich? What's up?"

"Phone consult," I said. "I'm not ready for anyone to come down yet, but I want to run something by you."

"Sure, what?"

I walked her through my H&P, and my 'treatment', such as it was, and asked what she thought.

"Not a diabetic, right?"

"Right."

"No signs of drug or alcohol abuse?"

"None."

"And this is recent onset, right?"

"Yes."

"So it's not likely congenital, as it would have shown up when he was a kid. The most likely cause is an infection or sepsis. Get the blood work done and see how he responds to the food, checking every twenty minutes."

"Will do. What else might it be?"

"If his Chem-20 and CBC are normal, and his A1C and serum glucose are low, you want an endocrinology consult. If there's anything abnormal in the Chem-20 or CBC, call me."

"Yes, but what diagnoses?"

"Pull out your handbook!" Clarissa declared.

"Right, because the symptom cluster excludes about ten percent of the handbook!"

"If it's not infection or kidney or liver disease, you're looking at some kind of tumor or endocrine system failure. You should know that!"

"And right here is why we specialize. I have so much to remember for trauma that I've noticed peripheral knowledge is fading. I challenge you to come down and intubate, insert a chest tube, or perform a blind pericardiocentesis!"

Clarissa laughed, "I'll pass! I'll leave that to you adrenaline junkies! Call me when you have your lab results if you aren't sure if it's Medicine or not."

"Medicine is the dumping ground for patients nobody else wants!"

"Oh, shut up!" Clarissa exclaimed. "Call me when you know anything! Oh, wait, that would be never!"

"Very funny, Lissa!"

"Let's have lunch or dinner if you can escape the madhouse."

"The inmates are absolutely running the asylum!"

We both laughed, said 'goodbye', and I hung up.

"How's Mrs. Doctor Loucks?" Nate asked.

"Same as always!" I chuckled.

I returned to the exam room to verify the blood had been drawn and that Mr. Harrington had eaten his cheese crackers and had drunk his apple juice. Once I confirmed that, I wrote the orders for the repeat glucose stick test onto the chart and instructed Krista to perform those tests every twenty minutes.

"Do you have someone here with you, Mr. Harrington?"

"My wife."

"We can bring her in if you want."

"Please."

I instructed Al, who had returned from taking the blood to the lab, to find Mrs. Harrington and he brought her into the room. After a brief recap, I promised to check on him, then my students and I left the room.

"What do you suspect is wrong?" Al asked.

I shrugged, "What I said is true -- take out your diagnostic handbook and look up the symptoms. They cover about ninety percent of what you see in there. And despite the physical exam, I can't rule out infection, sepsis, a tumor, or a host of other conditions.

"I called Doctor Saunders in Medicine and ran it by her, and our next step is based on the blood test results. If there are elevated or low levels for liver or kidney function, or abnormalities in the CBC, then it goes to Medicine. If not, then it goes to endocrinology because the most likely problem is overproduction of insulin, which could be caused by a tumor or a hormone imbalance.

"There's an important lesson to learn here. Care to speculate what that might be?"

"Not to say anything to a patient about a diagnosis when you aren't sure?" Al suggested.

"That's true, because we don't want to worry them unnecessarily, but not the point I was making. You can take a second shot at it."

"I'm not sure," he admitted.

"And that's a perfectly acceptable answer, not just as a medical student, but as a doctor. Does that give you a clue?"

"You called another Doctor because you wanted a second opinion."

"Exactly. Never be afraid to ask and never be afraid to admit you don't know, and absolutely never be afraid to ask for help. Even if you're given a hard time, which is always the case with Doctor Saunders, that's better than not asking and missing something or making an error."

"During my Preceptorships, they implied strongly that we're supposed to know literally everything."

I nodded, "And the MCAT and MLE test for book knowledge, and are basically a way of weeding out students without the intellectual chops to be a physician. As I've said, the first two years of medical school are actually an entrance exam. In June, you actually began training to be a physician.

"The point of the questioning during your Preceptorships is to see if you had the initiative to study without being told. How many times were you caught out before you realized you needed to study the procedures beforehand?"

"The first two times," he admitted.

"Then what?"

"A Fourth Year clued me into the trick of checking on the scheduled surgeries for the day and studying the night before."

"And on a clinical rotation for surgery, you get the procedures the night before, study them, and be ready to answer, because if you can't, you'll receive a sub-par evaluation."

"But shouldn't you know the diagnoses?" Krista asked.

"For some things, yes; but we don't ever make final determinations on anyone who is admitted. Why is that?"

"Division of labor, right? They made a point in practice of medicine that, except for a GP, everyone has an area of specialization."

"Yes, though I'd say Family Medicine is a specialization, and some hospitals are now offering Residencies in that specialty. They may be generalists, but they specialize in primary care just as in the ED we specialize in immediate care. There's another reason that's related."

"I'm not sure I should say what I'm thinking."

"On the contrary," I said. "If a doctor, nurse, or professor asks you a question, you answer it, even if you think they might not like the answer."

"That you don't have the knowledge or experience to make the diagnosis."

"Bingo. I'm trained, and being trained, to recognize and treat acute, emergent cases that are an immediate threat to life or limb. Diagnosing a tumor or a systemic problem is not something I'm trained to do. It's possible I'll come to that conclusion, but if I find an elevated white count, what's the correct procedure?"

"To call for a consult."

"Yes."

I checked my watch and sent Krista back to do another glucose stick test.

"60," she replied.

"OK. It's only been twenty minutes since he ate, so let's check again in twenty minutes. For now, grab the next chart and bring them in. Al, did the patients go up?"

"Yes, both of them."

Five minutes later, I went into Exam 1 to see the patient Krista had brought in.

"Doctor Mike, this is Becky Matthews,"

"Hi, Becky," I said to the young, blonde woman who I guessed was about twenty, was holding her left arm with her right hand.

"Should I worry about the red shirt treating me?" she asked.

I chuckled, "Trek medical is usually blue, though at the risk of associating myself with a certain doctor I despised, Pulaski wore red scrubs when she operated on Picard."

Becky rolled her eyes, "Star Fleet has exactly one competent heart surgeon in the entire quadrant?"

"I hear you! Krista?"

"Becky Matthews; nineteen; complains of significant shoulder pain after a fall; vitals normal."

"Specifics, please."

"BP 110/70; pulse 72; PO₂ 99%."

"Becky, do you think you can take off your t-shirt?"

"I can't really move my arm, so no."

"Then we'll need to cut it so I can examine your shoulder."

"Two bucks down the tubes!"

"I'll get you a red scrub shirt to replace it."

"Cool!"

"Al, go up to the surgical locker room and get a small red scrub top, please."

"Right away, Doctor!"

He left, and I had Krista carefully cut the sleeve and shoulder of Becky's t-shirt. It was obvious from just a visual exam that she'd dislocated her shoulder.

"I believe you've dislocated your shoulder," I said. "We need to get x-rays to verify, then we'll have someone from Orthopedics reduce it."

"Reduce?"

"Put it back in place. Most cases are simple and we can simply manipulate your arm to put your shoulder bones back in place. The x-rays will tell us if there are any complications."

"OK."

"An important question -- is there any chance you could be pregnant?"

"I'm on the Pill."

"Which is very effective, but not absolute. Have you had sex since your last period?"

"Yes."

"Krista, draw blood for a rapid pregnancy test, please."

"Why?" Becky asked.

"Because on the off chance you're pregnant, we don't want to zap you with x-rays. If you are pregnant, then we'll call Ortho to evaluate you, likely with ultrasound, to see if we can avoid the x-rays."

"Oh, sure, ruin my entire day!"

"The odds are on your side. With proper use, one woman in a hundred will become pregnant at some point over the course of her use of oral contraceptives. Would you like something for the pain?"

"Yes, please."

"OK. While Krista draws the blood, I'll have a nurse get you some ibuprofen."

I wrote all the orders on the chart, then left the exam room. I asked Ellie to have a nurse bring 600mg of ibuprofen to Becky, then went to check on Mr. Harrington.

"How are you feeling?" I asked.

"No change," he replied. "The girl was in before and checked my blood sugar."

"It's still a bit low," I said. "Just rest and we'll have the full lab results back in about twenty minutes."

"Thanks."

I returned to the room where Becky was as Wendy was administering the ibuprofen. Krista had a nursing student carry the blood to the lab as we had a female patient and policy didn't allow me to be alone with her. Al returned with the red scrub top, and I set it aside until Becky could put it on.

"Once the results come back, which will take about fifteen minutes, we'll determine the next steps."

"OK," she agreed.

"One thing I mention to all sexually active patients is that oral contraceptives are not effective against sexually transmitted diseases. I can provide you with a pamphlet on 'safe sex' from the McKinley Free Clinic if you want."

"That's where I got the Pill, and they gave me the pamphlet."

"OK. See you in about fifteen minutes."

We left and Krista went to do another glucose stick test.

"65," she said when she came back out.

"Coming up, but not enough. Chase the labs, please."

"Mike," Nate called out. "Paramedics four minutes out with a possible MI."

"It's going to be one of those days! Krista, forget what I just said. Nate, would you chase the labs for Mr. Harrington in Exam 3 and let me know when the lab calls with the results of the RPT for Exam 1."

"Will do."

Krista, Al, and Kellie all accompanied me to the ambulance bay to wait for the squad to arrive. I gave preliminary orders, and we were ready when Bobby jumped out of the cab.

"Male, mid-forties; found down on the sidewalk; CPR performed by civilians; no pulse; epinephrine times two; IV saline TKO."

"Al, get an Attending! NOW!" I ordered.

Bobby and his partner pulled the gurney from the back of the squad and I jumped onto the gurney and began compressions, taking over from the fireman who had been performing them in the squad. They pushed us towards the trauma room and I called out orders.

"Kellie, amp of epi IV push. Krista, take over bagging in the room. Ellie! Another nurse!"

In the room, I got off, and we transferred the patient to the trauma table and I got on and resumed compressions as Doctor Gibbs came into the room along with Wendy.

"Found pulseless," I declared. "Epi going in. Wendy, ABG, Chem-20, cardiac enzymes, and tox screen!"

"Al, take over compressions," Doctor Gibbs ordered. "Mike, intubate."

We swapped places, she gave a quick listen, then Al began CPR. I called for the necessary drugs, and once they were in, I performed rapid sequence intubation, then hooked up the vent. I asked Al to hold compressions and listened for breath sounds.

"Bilateral breath sounds!" I announced. "Resume compression. Krista, EKG."

A bit of contortion was necessary, but she managed, then turned on the monitor.

"PEA!" I declared. "Kellie, atropine, IV push!"

"Defib?" Krista asked.

"Not for PEA," I replied.

"Atropine is in!" Kellie announced.

"No change!" I declared.

"Hold compressions," Doctor Gibbs ordered about thirty seconds later. She listened, then ordered "Resume compressions."

"Another meg of epi?" I asked. "Plus bicarb?"

"Kellie, do that!" Doctor Gibbs ordered. "Krista, swap with Al. Al, call Cardiology and tell them to get down here, NOW!"

"Epi and bicarb are in!" Kellie announced.

Krista took over compressions while Al went to the phone.

"No change," I announced.

"We need to know the underlying cause!" Doctor Gibbs declared.

The probable causes were a list of 'Hs and Ts', six conditions with each letter, and I quickly ran through them in my head -- hypovolemia; hypoxia; hydrogen cation excess, commonly known as acidosis; hyper- or hypokalemia; hypothermia; hypoglycemia; tablets or toxins, meaning drugs or poisons; tamponade; tension pneumo; thrombosis; thromboembolism; trauma.

Bicarb would have solved the acidosis problem, and there were no signs of bleeding, external or internal, ruling out hypovolemia. His PO₂ was 92%, ruling out hypoxia. The problem with calcium was it could go either way, which meant we needed labs to know. The same was true for 'tablets or toxins'.

"Tension pneumo, cardiac tamponade, MI, or thromboembolism," I replied.

"Strong, Cardiology!" Doctor Strong announced as he came in.

"Forty-three-year-old male," I announced. "Found down on the sidewalk; CPR performed by civilians and firefighters; PEA; epi times two, atropine times 1, bicarb times 1."

"Your list is right," Carl said. "Continue compressions, 1 meg of epi every three minutes. Syringe with a cardiac needle and electrical lead to Mike!"

"Tamponade?" I asked.

"It's either that, a blood clot, or an embolism. If it's not tamponade, we're not going to fix this."

"Stop compressions," Carl ordered. "Go, Mike!"

I began the procedure while Doctor Strong listened to the patient's heart, checked his jugulars, and his eyes.

"Only a tiny amount of fluid," I said as I drew back the plunger on the syringe.

"Resume compressions!"

"Al, take over!" I instructed.

Two more amps of epi changed nothing.

"How long has he been down?" Doctor Strong asked.

"At least twenty minutes," I replied. "Probably closer to thirty."

"One more round of bicarb and epi," Doctor Strong said.

That was done and still there was no change.

"We're out of options," Doctor Strong said. "Halt compressions. If his heart doesn't start on its own, we're done."

It didn't and about four minutes later, the monitor finally showed asystole.

"Call it, Mike," Doctor Strong instructed.

I said a silent prayer for the patient's soul, then said, "Time of death, 07:28."

XXXVII. At Least

August 10, 1989, McKinley, Ohio

"He's McKnight's now," Doctor Strong said. "Any next of kin?"

"Not that we know of," I replied.

"Wendy, death kit, please," Doctor Gibbs ordered.

"Al, Krista, stay with Wendy and observe," I said. "I'll check on our other patients. Kellie, with me, please."

The doctors filed out of the room, and first I went to check with Nate, who had the labs for Mr. Harrington. I quickly reviewed them and saw literally everything except his blood glucose and A1C were mid-range, but both the A1C and glucose were very low. I picked up the phone and called for an endocrinology consult, then asked Nate about the pregnancy test for Becky, which was negative.

"Nate, call for an orderly with a wheelchair for Ms. Matthews. I'll see her as soon as I speak to Mr. and Mrs. Harrington."

"On it!" Nate declared.

Kellie and I went into Exam 3 to see Mr. Harrington.

"I have your blood test results," I said. "Everything except your blood sugar is within normal ranges, and most of them are right at the midpoint. I've called for a doctor from Endocrinology to come down to do an exam and give us an opinion for the next steps."

"What do you think?"

"All we know right now is something appears to be causing your body to produce too much insulin. I'm not a specialist, so I don't want to speculate. I'll be here when the endocrinologist examines you and we'll discuss the possibilities. I'll be back in about two minutes, as I need to see another patient."

Kellie and I left and went to Exam 1.

"Good news," I said with a smile. "You aren't pregnant. An orderly will come with a wheelchair to take you to Radiology for x-rays, then someone from Orthopedics will come down to decide what to do next."

"You can't just pop it back in?"

"I could," I said. "But that could result in nerve damage or other complications. Let's see what the x-rays and the orthopedist have to say. OK?"

"OK."

We left and returned to Exam 3 just as Doctor Matt Keller, an endocrinology Resident, arrived and announced himself.

"Hi, Matt," I said, then reviewed my findings with him.

"Hi, Mr. Harrington," he said. "I'm Matt Keller from endocrinology. I'd like to examine you and then we'll discuss the next steps."

Mr. Harrington agreed and Matt began the exam.

"Doctor Mike?" Patty, a nursing student, called out from the door. "The family of the MI, the Noonans, is here. They're in the consultation room. His name was Jack."

"Thanks, Patty. Mr. Harrington, I need to speak to a patient's family. Doctor Keller will speak to you once he's done and fill me in."

I left the room and asked Patty for their names, then went to the consultation room.

"Hi Mrs. Noonan," I said. "I'm Doctor Mike Loucks. Would you have a seat, please?"

"How's my dad?" a teenage boy asked.

"Please sit and I'll explain."

They both sat down, and I did as well.

"Mrs. Noonan, your husband was brought in by the paramedics who were performing CPR. A team of doctors and nurses made every possible attempt and used every skill and ability in an attempt to revive him, but we were unable to do so, and he died."

"What?!" she gasped. "He's only forty-four!"

"My dad died?" the boy, who I guessed was about fourteen, asked.

"I'm sorry, yes. His heart was not beating when he was brought in, and we continued CPR, administered drugs, put him on a ventilator, and used several procedures, but to no avail. His heart simply wasn't pumping any blood."

"But how?" Mrs. Noonan asked. "He's so young!"

"An autopsy will determine what happened," I replied. "All I can say is that when the paramedics and firemen reached him, passers-by were performing CPR on him. I can take you to see him, if you like, or call a chaplain."

"We're Catholic," the young man said.

"I can call Father Clifton, if you like."

"He needs last rites," Mrs. Noonan said.

"OK. Stay here, please, and I'll make the call. Would you like to see your husband?"

"With our priest."

"OK."

I left the room and went to the clerk's desk, found the number for the rectory on the list, and dialed the number. A secretary answered and called Father Clifton to the phone.

"Father, it's Mike Loucks at Moore Memorial," I said. "I have two of your parishioners here who need you, and a need for last rites."

"Who?"

"Jack Noonan," I replied.

"Lord have mercy! What happened?"

"All I can say now is that his heart stopped and CPR and drugs didn't solve the problem."

"I'll be there in fifteen minutes. Should I ask for you?"

"Yes."

We said 'goodbye', I hung up, then went to let the Noonans know Father Clifton was on his way. That accomplished, I went to the trauma room to let my students and Wendy know that I'd be bringing the family into the room in about twenty minutes, then went to see Becky. She wasn't in the room, and a check with Nate revealed that the orderly had arrived to take her for her x-rays.

"Are any of the walk-ins in immediate need?" I asked.

"No," Nate replied.

"OK. Then I'll be in the lounge. Let me know when Father Clifton arrives."

He acknowledged me and I went to the lounge, filled my mug with coffee, and sat down on the couch to relax for a few minutes before the priest arrived. About a minute later, Matt Keller came in.

"I'm going to admit Mr. Harrington," he said. "My money is on an insulinoma, as nothing in his history or symptoms indicates any of the other typical causes of hypoglycemia."

"OK. I'll have him sent up once I'm done with the family of the MI we lost. His priest is on the way."

"I don't envy you guys down here in trauma. I rarely have to even tell people they're terminal. I don't know how you do it."

"And I don't know how pediatric oncology does it."

"People qualified for instant sainthood," Matt said, then left.

Just over ten minutes later, Nate ushered Father Clifton into the lounge.

"How are you, Deacon?" Father Clifton asked.

"We don't retain titles when we voluntarily leave our clerical office," I replied.

"Forgive me," he said. "I'd completely forgotten that you had asked to be laicized. What can you tell me about Jack Noonan?"

"Not much. He was brought into the ED in full arrest, and never had a heartbeat. According to the paramedics, he was found on the sidewalk, and citizens were performing CPR. The paramedics continued that, gave him epinephrine, and brought him in. We put him on a ventilator, continued CPR, and tried more drugs. The monitor showed PEA -- Pulseless Electrical Activity -- which is not a shockable rhythm, and then asystole."

"Any idea what might have caused it?"

"No, and I can't speculate. Doctor McKnight will perform an autopsy and let the family know."

"OK. I've done these before. I assume the usual protocol with the breathing tube and other medical devices still in place, and covered with a white sheet?"

"Yes. I'll take you to Mrs. Noonan and her son, though I don't know his name."

"John, same as his dad, though his dad usually went by Jack."

We left the lounge and walked to the consultation room where the Noonans were waiting. Father Clifton greeted them and they spoke for a minute before he turned to say that they were ready. I explained what they'd see, then led them to the trauma room where Wendy and my students were waiting.

"Krista, Al, please step out; Mrs. Noonan, stay as long as you like. Nurse Wendy will stay with you."

"Thanks, Doctor," she said.

My students and I stepped out into the corridor.

"Al, Mr. Harrington is being admitted to Endocrinology. Call for an orderly and escort him there, then come find us. Krista, grab the next walk-in chart, please."

She was about to do that when I saw an orderly pushing Becky Matthews into the ED following her x-rays. Krista and I followed them into the exam room, and I let Becky know that as soon as I heard from Radiology, I'd have someone from Ortho come down to examine her.

The rest of the morning was busy, I assisted Doctor Jackson from Ortho in reducing Becky's shoulder, and handled a number of walk-in cases. At noon, I was able to get away to have lunch with Clarissa and Sophia.

"How's your Fourth Year?" Clarissa asked.

"Well, she read her cardiology textbook and passed my basic EKG quiz, so there is that, but Kylie spoke to her and...Sophia, this is confidential."

She shook her head and rolled her eyes, "As if I didn't know that!"

"It had to be said," Clarissa interjected. "Go on, Mike."

"Kylie said Krista felt I was sidelining her and agreed that Krista isn't as smart as she thinks she is. Kylie doesn't think Krista is salvageable."

"Which, of course, you took as a challenge."

"I have to try. I honestly don't care if she likes me or not, or thinks I'm treating her badly. What matters is if she's willing to learn. She showed me one thing, and that's a start."

"Even with Leila's negative comments?"

"Even with those, though I will heed her advice to not leave Krista alone with a patient. I'll use nurses and Al, or be with her myself. I think her next test is intubation. But I have to find the right opportunity."

"Someone who needs it, but is not so critical that two failed attempts won't kill them."

"Exactly."

"What do I need to do to get that procedure, Mike?" Sophia asked, smiling and batting her eyes.

"Ask my WIFE that question in that way!" I chuckled. "If you survive, you can do it!"

Clarissa and Sophia both laughed.

"In all seriousness," I continued. "I'd have trusted you to do it as a Third Year."

"The difference between us and Mike," Clarissa said, "is he gets off on those adrenaline dumps!"

"I wouldn't go THAT far," I chuckled. "But I do thrive on them. Pretty much a requirement for a trauma doc. And the long-term exposure will help with surgery, because I won't have adrenaline dumps when the inevitable happens and the bovine excrement hits the air circulation device."

"Any interesting cases this morning?" Clarissa asked.

"Not really. We were busy with Intern scut -- walk-ins, but we also had an MI who was brought in receiving CPR."

"Not one of the five percent who make it out of the ED?"

"Correct. PEA then asystole. Nothing we did changed a damned thing. That said, I have to commend his fellow citizens who were performing CPR when the paramedics arrived, even if it was ultimately fruitless. Young guy, though, with a fourteen-year-old kid. I turned them over to Father Clifton."

"Any updates on the hearing next week?"

"No. The only thing that would change at this point is if he accepted a suspension without contesting it, which I can't imagine he would, because his license is really at risk. A reprimand is most likely, and a one-year suspension would be extreme, based on historical precedent. Maybe we'll get lucky, but I'm not holding my breath. That said, at least we do have a shot at the suspension, even if the odds are long.

"On a completely different topic, I heard that Deputy Turner challenged Emmy to a shooting competition. They're going to an outdoor range in Zanesville, but the date isn't set. They're waiting on approval from the two Sheriffs, which I suspect will involve significant wagering!"

"Bet it all on Emmy to win, right?" Clarissa asked.

"I wouldn't bet against her, that's for sure. Her dad, «мудак» that he is, taught her to shoot when she was five, and she's been a crack shot since age twelve."

"Back to using Russian again, Mike?" Sophia asked.

"Mike won't call someone an 'asshole' in English," Clarissa smirked. "Even if they are."

"And Len Nelson is certainly the poster child for that word," I said.

"Speaking of assholes, how is Rosenbaum's 'other woman'?"

"Several whacks on the nose with a rolled up chart appear to have done the trick with Doctor Mastriano," I replied. "She's not giving me any grief, and we've worked together on several patients."

We finished our lunches, and each headed back to our services. I was looking forward to being able to teach Sophia, but that was still about three weeks away. During the afternoon, I handled walk-ins with Al as Krista was at the triage desk. I was also looking forward to September 1st when nurses would take over intake completely.

At 6:00pm, Krista and Al went off shift and Serenity and Walt came on, and a few minutes later, I had dinner with Doctor Javadi and Doctor Vega, as Clarissa was busy with a patient who was, in Medicine terms, 'circling the drain' and they weren't quite sure why.

We handled walk-ins and two paramedic runs for MVAs, but things quieted down just before midnight, when I went to the on-call room to sack out, along with Doctor Varma.

August 11, 1989, Circleville, Ohio

"How was your shift?" Kris asked when I arrived home on Friday evening.

We were immediately interrupted by our toddler demanding to be picked up.

"Hi, Rachel!" I said.

She hugged me and gave me a slobbery kiss on the cheek, then I answered my wife's question.

"I actually managed to sleep for two hours around midnight, then about ninety minutes starting at 4:00am. My students and I only lost one patient, but he was basically dead when he got to us. How about your day?"

"Going to class, doing homework, and, of course, rescuing Rachel from her Fridays with my sister!"

I laughed, "That's what I said to Lyudmila on Wednesday!"

"I know! She told me! I also hear that her friend Cheryl thinks you're a 'hunk'!"

"And your little sister made sure Cheryl knew I was taken, though, of course, had to add that it wasn't by the 'better sister'. Speaking of that, did you know Lyudmila is teaching Rachel to speak French?"

"My sister is a subversive!" Kris declared. "At least to YOU!"

"I might have noticed!" I chuckled. "She's treating me in ways similar to how Liz treated me, though with a French flair."

"«J'ai faim, papa!»" Rachel declared.

"She's hungry," Kris translated.

"Your sister and I are going to have words!"

Kris laughed, "You do realize she's doing that to tease you, right?"

"Yes, of course," I replied. "If I didn't know better, I'd say she has a crush."

"She does, but it's innocent. Her friend Cheryl, on the other hand, has one that is NOT."

"I have all the women I need in my life already! You, Rachel, Clarissa, and Loretta!"

"So we'll have a baby boy?" Kris asked.

"NO BROTHERS!" Rachel said firmly.

"You've made that point before, young lady, but it's not up to you!"

My daughter pouted, then gave me the usual look she had when she didn't appreciate being corrected.

"Dinner is ready, Mike. Shall we eat?"

"Sounds good."

"I take it from what you said we'll go to bed at a normal time?"

"Yes."

"And make love?"

"«Absolutement!»" I replied, causing her to groan then laugh at my terrible pronunciation.

August 13, 1989, Loveland, Ohio

Saturday had been typical, with band practice, grocery shopping, and a stop at the record store before I'd had my Saturday shift at Moore Memorial. Now, on Sunday morning, we were at Saint George in Loveland.

"How are you, Michael?" I asked my godson who I'd helped deliver nearly two years previous.

"Happy!" he said. "Zoo today after church!"

"That sounds like fun. What animal is your favorite?"

"Giraffe!" he exclaimed.

"Great! Sheila, how are you?"

"Pretty good. Do you know Jeremy?"

"I do not," I said, then extended my hand to the man next to Sheila. "Mike Loucks."

"Jeremy Mains," he replied. "Catechumen. You're a doctor, right?"

"Yes. This is my wife, Kris, and our daughter, Rachel."

"Daddy? Angie?" my daughter asked, spotting Angie walk into the church.

"Go ahead," I said.

I watched as Rachel hurried over to Angie as fast as her little legs would carry her. Rachel reached up and Angie picked her up, then she and her mom made her way over to us.

"Hi, Mike," Angie said.

"Hi, Ang. How are you?"

"I'm OK," she replied, a beat slow, as usual. "I'm happy to see you."

"And I'm happy to see you, too. How is Aikido?"

"I go three times a week. Are you going to your dojo?"

"No. I have thirty-six-hour shifts, so there simply isn't time."

"That's unconscionable!" Mrs. Stephens protested.

"I don't disagree, and in fact, we'll have slightly reduced hours starting next month because of an incident in New York. I can tell you more at lunch because the bells are ringing, so it's time for Matins."

We all went into the nave, lit our usual candles, and then I put Michael down on the floor and Angie did the same with Rachel. The two of them went over to where two other toddlers were sitting and plopped down with them, while we adults stood in a small cluster. At Eucharist, as was traditional, I took Michael forward, fulfilling one duty of a godparent. I'd been somewhat lax so far, though I had sent him a card and gift for his name day.

When the services ended, about three-and-a-half hours after they'd begun, we joined the rest of the congregation in the parish hall for lunch.

"Michael and Rachel get along really well," Sheila observed. "You never know..."

"Actually, that's canonically prohibited," I said. "Because Michael is my godson, Rachel is his spiritual sister, so marriage is prohibited by the canons."

"You're joking!" Jeremy exclaimed.

"No, he's right," Kris interjected. "It has to do with the obligations and duties of the godparent. He is, spiritually, a father to Michael, even if not biologically. In a way, not all that different from my relationship with Rachel from a legal point of view."

"So much for THAT idea," Sheila groused.

"Is it OK to ask how you came to be his godfather?" Mrs. Stephens asked.

"Somebody had the world's longest labor and needed attention from a lowly med student!" I chuckled. "My godson was decidedly not interested in being born!"

"TELL me about it!" Sheila said, shaking her head.

"You helped deliver Michael?" Angie asked.

"I was there," I replied. "But that was before I was a doctor. I helped with monitoring Michael while he was in Sheila's womb, and making sure Sheila was doing OK."

"Do you ever deliver babies?" Angie asked.

"No, and I am very, very happy about that! I have enough excitement in the emergency room without that."

"Well, now I have to find another suitable girl for Michael!" Sheila declared.

"Well, my adopted sister, Elaine, has a daughter named April, who was born right around the same time as Michael and Rachel. They're at Holy Transfiguration."

"Adopted sister?" Mrs. Stephens asked.

"Yes. My mom and Stefan took Elaine in as a foster child and decided to adopt. Elaine was pregnant at fourteen and decided to keep the baby."

"Fourteen?!" Mrs. Stephens gasped.

"It happens," I said.

"What about the baby's father?"

"Not in the picture."

"Same here," Sheila said. "Though I was over eighteen."

Both April's biological dad and Michael's biological dad were in prison. April's for aggravated criminal sexual assault, and Michael's for drug offenses.

"Hi, Michael," Father Stephen said, coming over to the table. "How are you and your family?"

"Father, bless!" I said, turning up my palms for a blessing, which he gave. "We're fine, thank you. As you can see, Rachel is growing like weed!"

"We have a small pack of toddlers, which I'm sure you saw in the nave."

"Six toddlers all sitting quietly together is both beautiful and frightening!" Sheila exclaimed.

"Terrorists and toddlers," I chuckled.

Everyone except Jeremy laughed because they'd heard me say that on more than one occasion.

"Mike likes to ask the difference between terrorists and toddlers," Father Stephen said for Jeremy's benefit. "With the distinction being you can negotiate with terrorists!"

Jeremy laughed, "Having been on the receiving end of Michael's demands, I can't argue with that."

"Daddy!" Rachel exclaimed. "Walk!"

"Speaking of that..." I chuckled, then turned to my daughter "Let me finish my lunch, and we'll walk."

"Walk! Now!"

"For that response, young lady, you'll sit for ten minutes and not move," I said firmly.

"NO!"

"Wow," Father Stephen said, quietly. "I think we know where that fiery temperament originated."

"It's absolutely a Kozlov trait," I replied. "Though that information has not yet been conveyed. It'll be a few years, most likely."

"Elizaveta was that volatile?" Sheila asked.

"You have NO idea!" I chuckled. "The petulant toddler next to me put her hands on her hips the other day and I had flashbacks. But the only mom she knows is Kris, and communicating the information has to be done carefully."

"Not on my account," Kris said. "But for our daughter's sake, so she's neither confused nor does she ever feel guilty because of the circumstances."

"So sad," Angie interjected.

"I'm missing something, obviously," Jeremy said.

"I'll fill you in later," Sheila said.

We finished eating, but I made Rachel wait the full ten minutes before we bade everyone goodbye and left the temple. Kris, Rachel, and I walked hand-in-hand, with our daughter between Kris and me. When we finished our twenty-minute walk, I changed Rachel's diaper, and we left the church to stop by my dad's house for a brief visit on our way back to Circleville.

August 16, 1989, McKinley, Ohio

On Wednesday, I left Rachel with Anna and Yulia and drove to Frisch's to meet Father Nicholas. We greeted each other, I sought his blessing, and we were seated.

"Were you able to attend the Vesperal Divine Liturgy for the Dormition on Monday evening?" Father Nicholas asked.

"No. I was on shift from 6:00am Monday to 6:00pm yesterday. Kris and Rachael went to the Cathedral with her parents and sister. But that was to be expected."

"Yes, of course, I was simply asking, as I don't see you very often now."

"Without belaboring the point, worshiping at Holy Transfiguration was no longer spiritually healthy for me."

"And you blame me for that," he said.

"I'd put the blame on whatever configuration of genes created the vascular defect that killed Elizaveta. Everything else flowed from there. That doesn't relieve either of us of our responsibility for our actions, but neither of us is to blame."

"Do you drive your instructors as mad as you have your spiritual fathers?"

"I am nothing if not consistent!"

"I will give you that. And persistent, too."

I smirked, "I want to be nothing if not persistent!"

"What did I just miss?" Father Nicholas asked.

"A line from one of the dumber Star Trek: The Next Generation episodes - 'Samaritan Snare'. A spacefaring race that has limited intelligence is great at using technology. I found the entire episode offensive and insulting. But I derailed the conversation. Sorry."

"How do your mentors at the hospital deal with you?"

"With a rolled-up newspaper," I chuckled. "I get my nose whacked and told to behave. I usually do."

"Because you can't simply walk away."

"May I be myself in answering that question?"

"Could I stop you?"

"Yes. If you say 'no', I'll use a different line of reasoning."

"And, of course, you know me well enough that I want to hear what The Rudder has to say!"

I chuckled, "I have read Pedalion by Nicodemus of the Holy Mountain."

"Of course you have. You're also probably the only non-monastic in the diocese who has read The Philokalia, and understands it. So?"

"I have not 'run away' in any canonical sense, as the believer is bound to his bishop, not to a local parish, and for the laity, they may, under the canons choose any church they wish."

"You were always very good at finding the loopholes. You know the flaw with that argument, I'm sure."

"That when those canons were written, the vast majority of faithful attended the only church in their city, and thus, changing churches meant changing bishops, of necessity. Our mobility in the modern age has also changed the accessibility of more distant churches, in that I can cover a day's ride by horseback in under an hour by car. But, to counter your argument, our bishops do not limit the laity from moving to a new parish unless the goal is to escape discipline, but that would usually involve the layman changing bishops, as changing parishes wouldn't actually escape.

"And the lay/clergy distinction is actually at the heart of our disagreement about Ghost -- Doctor Greg Casper. You and I both know what I told him was accurate, but I could only say it as a layman. Had I been clergy at the time, I would have been required to defer to you, and not even bring it up to him. I know you disagree with my thinking on the matter, and I understand, but in my role as physician, I give my patients all their options and help them decide. I honestly think you might have convinced him had you presented it as an option rather than a compulsion."

The waitress came and took our orders, which were salads for both of us, given it was a Wednesday.

"Do you second guess your mentors at the hospital?"

"Absolutely. Not only is that accepted, but it's also expected, so long as it's done in private. And, before you ask, if there are treatment options available that have not been discussed, I have an obligation to present them to any patient under my care. If they are under the care of another physician, then I take it to an Attending and they decide what to do. But that's a relationship similar to clergy and a bishop. If I were practicing independently and someone came to me for a second opinion, I have zero obligation to affirm the finding of the primary physician."

"I'm tempted to say you should have been a lawyer, but I believe your calling is the healing arts."

"Canon lawyer, maybe," I replied. "Our justice system, such as it is, is too much «akriveia» and too little «ekonomia»."

"You feel it's too strict?"

"I feel the penalties meted out often do not fit the crime."

"Speaking of that, and going further down the rabbit hole, how have your visits with Lee's killer been?"

"I believe we're developing a relationship. I wouldn't call it a friendship, but it might turn into one. I'm the only person who visits him. His ex-wife, son, and daughter have basically declared him an unperson, which actually fits his view of himself. Murdering Lee means he is not one of the Elect, and as such, is condemned to everlasting suffering in Hell. Perhaps, over time, he'll see God's love through my actions, and understand he can repent and turn back to God."

"Do you pray with him?"

"Attempting to do so would be foolish. I'm careful to limit my references to Scripture or theology. He's not ready to hear them, and may never be. But, thankfully, he was given life without parole and not the death penalty, so there is plenty of time."

"Back to the main topic, may I say I find you very frustrating."

"You aren't the only one, but it's also the case that I found you very frustrating. Rather than ask to meet me outside the temple, you, on multiple occasions, confronted me when I was trying to worship."

"His Grace took me to the woodshed over that, and I owe you an apology."

"I accept and owe you one for walking out."

"Also accepted."

"You know, the more I think about the question of blame, there's more than just the congenital defect that ended Elizaveta's life. I'm reasonably certain much of it traces back to Bishop ARKADY."

"Sadly, knowing what we know now, is that any surprise? He profaned the office of bishop in many ways, and his spiritual judgment was poor, and his personal conduct worse."

"I agree," I said. "but I feel compelled to point out that had he not proposed my ordination, I would never have married Elizaveta and I wouldn't have Rachel, and despite the tragedy surrounding Rachel's birth, I can't imagine a world without her."

The waitress brought our salads, Father Nicholas said the blessing, and we began to eat.

"At the risk of sounding like my grandmother, are you and Kris still planning children sooner rather than later?"

"Yes. Much to Rachel's annoyance, we intend to give her a brother or sister about this time next year. Actually, she'll accept a sister; a brother is a non-starter because she finds little Viktor to be annoying."

"He reminds me very much of Joe when he was that age."

"I made a similar comment. Hopefully Geno can exert a positive influence on him, though Geno and Joe both had the same dad, so who knows?"

"It's interesting, because that defies the nature/nurture argument, as they both are sons of Viktor and Yulia, and were both raised in the same environment, along with Elizaveta."

"Middle child syndrome," I said. "Elizaveta and Geno were very much alike, albeit with the differences traditionally found between Orthodox men and women."

"Have you said anything to Rachel as yet?"

"No, though I suspect Yulia has; in the interest of peace, I'm not going to say anything unless she says something in front of me, or Rachel says something. I know Viktor has inveighed on Yulia to let it go, but I believe you know how effective that might be."

"I do."

"The extra set of grandparents won't tip Rachel off, though, given my mom and dad both remarried, so she has two sets on my side. It'll be when she realizes that neither Kris nor I are related to Yulia and Viktor that Rachel could figure out that something had happened, and eventually piece together the icon of Elizaveta and the small framed photo with a black ribbon we recently added to our icon corner."

"Everything is good between you and Kris?"

"Yes. It's a very different relationship from the one I had with Elizaveta, but she's exactly who Rachel and I needed."

"All things being equal, you exercised good judgment in your choice of spouses. No shrinking violets for you."

"Somebody has to keep me in line! And Kris has reinforcements in a certain daughter who reminds me in so many ways of her biological mom."

"Temperament?"

"The worst was hands on her hips and the identical look Elizaveta would use when she disapproved of something I had said or done."

"How are you handling the 26th?"

"I have a shift that day, so we won't be able to attend the memorial service. We're having a party for Rachel on Sunday with her friends and their parents. Kris, Rachel, and I will celebrate at brunch on Saturday because I have a shift that begins at noon. I let Viktor know that I'm not going to be able to make the memorial service. I'll stop by the churchyard on my way home from the hospital on Friday night and say the abbreviated prayers for the departed."

"You know you're welcome at Holy Transfiguration at any time."

"I do, but at this point, I believe being at the Cathedral is better for me and my family."

August 18, 1989, McKinley, Ohio

"I see you brought a chaperone!" Anicka teased when Kris, Rachel, and I walked into the room behind the stage before Code Blue's concert at Taft.

Fortunately, I'd managed two hours of sleep very early on Friday, so I wasn't completely wiped out from the thirty-six-hour shift.

"Somebody has to keep Mike out of trouble!" Milena teased.

"ABI!" Rachel squealed.

"RACHEL!" Abi exclaimed.

"I'll take them," Milena said. "We'll sit in the back, away from the speakers."

"Rachel," I said. "Go with Aunt Milena and behave."

"Yes, Daddy!"

"Why do I feel as if she has her fingers crossed behind her back?" Sophia asked.

"Because of who her dad is!" Anicka replied.

"I love you all," I said flatly.

"Just how much did my husband misbehave in college?" Kris asked with a silly smile.

"As much as Clarissa would allow!" José declared.

"She did a pretty good job of keeping him in line," Anicka observed.

"She still does," I said pretending to be rueful.

Everyone laughed, Milena left with the girls, and my bandmates and I began setting up.

"Mike, is it OK to introduce you as 'Doctor Mike Loucks'? Robby asked.

"Sure. In fact, you can just say 'Doctor Mike' without my last name."

"No red scrubs?" Kris asked.

"No. We're 'Code Blue'," I said. "So I wear blue scrubs, which go along with José's Chelsea football jersey, Sticks' DePaul Blue Demons jersey, and Kim's blue outfit."

"You know, I never put that together because you wore blue scrubs except in the ICU. José, you know proper football?"

"Obviously! None of this silly hand-egg game where you can't use your feet to advance the ball!"

"He's not from here," Sticks said with a grin. "So what does he know?"

"EXCUSE ME?!" my wife exclaimed in what I knew was faux outrage.

"I think we might need a new drummer," I said to Kim.

"You might be right! Kris, could we save the Robespierre impersonation and give Sticks his 'haircut' AFTER the concert?"

"Let's all play nice, kids!" Sophia suggested.

"Mike," Kim said, "I meant to ask last Saturday, but how is your schedule for the next two months."

"We should have no conflicts," I replied. "I finish my Friday and Saturday shifts at 5:00pm."

"Excellent!"

"FIVE MINUTES!" the stage director called out.

Everyone calmed down and focused at that point, and we all took our places. Robby and Sophia had come up with a new bit of patter, given we'd done so many concerts at Taft, this one a riff on Joe's Garage which was the song we had decided we'd play to open our act. From there, we played Paradise by the Dashboard Light, and another ten songs to complete our first set.

As was the norm, I played my balalaika between the first two sets, and José played Piel Canela between the second and third sets. Because it wasn't a prom, we ended the third act with Kris and I singing Endless Love, and after the roaring applause, our encore consisted of Dust in the Wind, I Melt with You, and finally Like a Surgeon, which brought down the house.

"Ladies and gentlemen!" Robby said into the mic. "Doctor Mike, lead vocals and backing guitar!"

"José Ochoa, lead guitar and backing vocals!" Sophia said into her mic.

"Kim Liang, keyboards and backing vocals!" Robby announced.

"Randy 'Sticks' Mason, drums and backing vocals!" Sophia added.

"Kari Hendricks on violin!" Robby announced.

He handed me the mic, and I added "And our special guest vocalist, my wife, Kris Korolyov!"

Everyone came to the center of the stage, held hands, and bowed to the crowd who were giving us a standing ovation.

"Bummer Sierra is here," I said to José as began packing up our instruments.

"Playboy José has retired and hung up his cleats! And he has NO complaints."

"Not if he knows what's good for him, anyway!" Kari teased.

We finished packing our instruments, then mingled with the assembled students, with Kris at my side and Rachel in my arms. José had Sierra on his arm, which mostly deflected the flirting, but even with Kris and Rachel with me, a few girls flirted. After about fifteen minutes, we left the building to walk to Doctor Blahnik's house for an after party with select music students.

"When you were single, I bet concerts were a serious opportunity to get into trouble," Kris said lightly.

"You'd easily win that bet," I replied.

"No details or numbers because it's really none of my business, but I'm going to surmise that you took advantage of that situation on at least one occasion."

"At least," I chuckled.

XXXVIII. Special Delivery

August 19, 1989, Circleville, Ohio

"My monthly started," Kris said as we got out of bed on Saturday morning. "Do we agree I stop taking my pills today?"

"Yes," I replied. "Well, unless you want to confer with the Tsarina for her opinion!"

"I think not!" Kris said lightly. "She may have her opinion, but it's not up to her, as you remind her when she objects to a baby brother!"

We took our usual joint shower, and after we dressed, we found Rachel playing in her room. The gate we put across the door prevented her from going anywhere, but that would need to go soon, as it was approaching the time when girls could start to potty train, and Rachel was telling us now every time she urinated, which was the most important indication that a toddler was ready to be potty trained.

After I gave Rachel a quick sponge bath, I put on a fresh diaper, dressed her, and then the three of us went downstairs to have breakfast. Rachel had zero interest in bottles, so she drank milk from her sippy cup, in addition to having Cheerios, banana, and waffle. She wasn't a fan of bacon, but she would eat sausage, so long as it was mildly spiced. After we ate, we cleaned up, then said morning prayers.

There was no band practice, as we didn't practice after gigs, so we went to Kroger earlier than usual, stopped at the bakery, then headed home to spend a few hours together as a family before my Saturday shift at Moore Memorial.

"What time are we leaving in the morning?" Kris asked.

"Matins is at 8:30am at Holy Transfiguration, so about 7:30am so we're not late. The wedding is at 3:00pm, and we'll go to my sister's house after lunch, then back to the church."

"How long did you and Tasha date?" Kris asked.

"Off and on for about three years. Her dad severely limited how often we could see each other. And you know the rest -- being ordained and the demands of my medical training."

"And then she married Nikolas Antipov, had Larisa, and divorced not long after."

"Yes, and I'll share this with you as my wife, because Tasha and I had been together."

"She told him she was a virgin?"

"No. She revealed she had missed the mark in that regard before they were betrothed. After they married, he...hmm...considered her sexuality to be a sign of 'harlotry', to put it in polite terms."

"She was that wild?" Kris asked with a twinkle in her eye.

"He was that prudish," I replied. "He would consider some of the things you and I have done to be signs of 'harlotry'."

"Oh, please!" Kris exclaimed, rolling her eyes. "He sounds like some of those crazy monks who think sex is only for making babies, and never for any other purpose, under any circumstances."

"Bingo. On the other hand, that is the reason we'll be having sex for the next few months."

"The main reason, but not the only one!" Kris countered.

"I suppose we're allowed to enjoy it," I said with a smirk.

Kris simply rolled her eyes and shook her head. We played with Rachel, then at 11:00am, we had lunch, and after we'd eaten, I headed to the hospital for my shift.

August 19, 1989, McKinley, Ohio

"Mike," Nicki called out just after I'd checked in, "Paramedics three minutes out with an active labor."

"Page the OB Resident, stat!" I ordered.

"Right away," she confirmed.

"Jake, Heather, let's go," I said to my students.

"What do we do?" Jake asked.

"Pray the baby has the good grace to wait for the OB Resident to arrive!"

"Mike," Nicki called out as we gowned. "OB is backed up. They'll get down here as soon as they can."

"Call back and demand an OB nurse with a delivery tray! Do not take 'no' for an answer. Then call for a neonatal cart."

"You're going to deliver?" Doctor Varma asked.

"Got any other ideas? I don't think a cork will work. You could take it."

"No, thanks! I'll stick to explosive diarrhea in Exam 3!"

He disappeared into the exam room and I caught a whiff of what he'd mentioned and decided delivering a baby was a better choice.

"Need help?" Doctor Mastriano asked from behind us.

"I certainly won't refuse!"

The four of us, along with Nurse Alice, went to the ambulance bay just as the EMS squad turned into the hospital driveway. They pulled up, and Roy jumped out of the cab.

"Daphne Reardon, seventeen; active labor; pulse 90; BP 130/80; PO₂ 99%. No other complaints."

"Exam 2," I ordered, electing not to tie up a trauma room.

"Hi, Daphne," I said as we began moving to the exam room. "I'm Doctor Mike. When are you due?"

"Last week," she gasped.

"Did your water break?"

"Yes, in the ambulance."

"Are you on any medication?"

"Pre-natal vitamins."

Once we were in the exam room, the seven of us carefully moved Daphne from the gurney to the exam table, which fortunately had stirrups.

"Alice, stirrups, please; Heather, monitor, no EKG; Isabella, primary survey; I'll do the internal exam; Jake, check with Nicki on OB."

Everyone sprang into action and once we had Daphne's feet in the stirrups, Alice cut away her shorts and panties.

"OB says they're busy," Jake announced.

I suppressed a groan.

"It's you and me, Mike," Isabella declared.

"Heather, IV Ringer's!" I ordered.

"IV Ringer's!" Heather repeated as she moved to get the IV kit and bag.

"Pulse 110; BP 135/80; PO₂ 99%," Doctor Mastriano announced. "Daphne, you're doing fine."

Alice squirted lubricant onto my gloved hand. I inserted my fingers and almost immediately encountered the baby's head.

"She's crowning!" I exclaimed. "Heather, get that IV in and get two surgical towels! Alice, Betadine! Daphne, do NOT push; Jake, go personally to OB and get a neonatal cart. Do not let anyone stop you. Just take one."

"Yes, Doctor," he acknowledged and left the room.

Daphne groaned as she had a contraction.

"Don't push!" I commanded.

Alice quickly painted Daphne's thighs with Betadine, something that wasn't strictly necessary, but was advised for emergency deliveries.

"Drape the towels over your arms," I said to Heather. "And I'll hand the baby to you so I can clamp and cut the cord. Daphne, when your next contraction begins, I want you to push!"

"O...K...she gasped."

The brief pause to wait for the next contraction allowed me to run through what I'd learned in my OB rotation, which was now two years in the past.

"Alice, get a vial of Pitocin in case we need it," I ordered.

That was something that would be included with a standard OB tray, which I did not have.

Daphne groaned again.

"Contraction!" Doctor Mastriano announced. "Mike?"

"Daphne, push!"

She did and her baby moved down the birth canal. She pushed again and delivered the baby's head. I carefully rotated it as I'd been taught, verified the cord hadn't prolapsed, and asked Daphne to push again, delivering the baby's shoulders. At that point, the little boy easily exited the birth canal, and I transferred him to Heather's waiting arms.

"You have a baby boy!" I announced. "Doctor Mastriano, suction bulb!"

She moved to use a small rubber bulb to suction mucous and other fluids from the baby's nose and mouth, and was greeted with a strong cry.

"Clamp!" I demanded.

Alice handed me a normal ED clamp, which would have to do for our purposes, and I clamped the cord close to the baby's navel. I placed another clamp a few inches further along the cord, then Alice handed me surgical scissors, which I used to cut the cord.

"Apgar?" I asked Doctor Mastriano.

"Estimate at 8," she replied.

The monitor blared.

"WHOA!" Heather exclaimed. "Her BP just dropped!"

Before a conscious thought of why, I KNEW what had happened as Daphne moaned and blood gushed from her vagina.

"Alice! Amp of Pitocin in the IV bag!" I ordered as I began a gentle external uterine massage.

"Blood loss volume?" Doctor Mastriano asked.

"Estimate 300ccs on the floor," I said. "Let's hang a unit of plasma to be safe."

Jake came into the room pushing a neonatal cart, followed by an irate nurse who was berating him and demanding immediate return of the cart.

"Nurse!" Doctor Mastriano commanded. "LEAVE THIS EXAM ROOM!"

Fortunately, the nurse complied and Jake set the brakes on the neonatal cart and plugged it in.

"Heather, place the baby on the warmer, please."

"How's she doing, Mike?" Doctor Mastriano asked.

"Just that one gush of blood," I said. "Her BP is already coming up. Do you want to manage the placenta or check the baby?"

"I'll manage the placenta; you delivered, so you check the baby."

We quickly switched places, I changed my gloves, and went over to the bawling infant on the warmer. I warmed my stethoscope bell by holding it under the heat lamp for a few seconds and verified what I knew from the loud bawling -- the baby had clear lungs and a strong heartbeat. I checked his eyes, which were clear, and saw no signs of jaundice.

"She's coming around, Doctor," Heather announced.

"Wha...what...happened?" Daphne asked.

"You lost some blood," I said. "But you're OK, and you have a very healthy baby boy. Would you like to hold him?"

"Ya...yes," she said.

I carefully picked up the baby and carried him to his mom and helped her hold him.

"Hi, Tommy," she cooed.

"Five minute Apgar is 10," I announced. "No jaundice."

I had one more thing to do, and that was the heel stick to verify blood glucose. Tommy cried loudly when I pricked his heel, but there was no helping that.

"Blood glucose is normal," I announced.

"Cartwright, OB," Doctor Marilyn Cartwright announced, coming into the room with a student.

I was tempted to give her a piece of my mind, but that could wait.

"Daphne Reardon, seventeen; delivered a baby boy vaginally with no tearing; lost about 300ccs of blood; Pitocin and Ringer's, plus a unit of plasma; LOC about two minutes; Pulse 110; BP 90/60; PO₂ 99%. Well-formed baby boy; initial Apgar 8; five-minute Apgar 10; no jaundice; glucose 38; good breath and heart sounds."

"Hi, Daphne, I'm Doctor Cartwright from OB. Looks like you had an adventure! How are you feeling?"

"Tired and weak," Daphne said.

"Let me examine you and your baby, then we'll get you upstairs. Mike, I have this."

"OK," I replied. "Jake, Alice, stay, please, until our charges are taken upstairs."

Doctor Mastriano, Heather, and I left the room and stripped off our gowns and gloves.

"Mike?" Doctor Williams called out. "Got a minute?"

"Yes," I replied, certain I knew what it was about.

I waved to Heather to follow and wasn't surprised to see Doctor Mastriano walking with us to the Attending's office.

"Let me guess," I said. "An irate call from the charge nurse in OB, right?"

"She said your med student stole a neonatal cart."

"They'll get it back in about twenty or thirty minutes," I replied. "It's occupied by a newborn baby boy that Isabella and I delivered because OB was too busy to bother to come down, or even send us a nurse with a delivery tray."

"She left out that part," Doctor Williams said.

"Of course she did," Isabella interjected. "They blew us off. Mike did a fantastic job on the delivery."

"How are mom and baby?" Doctor Williams asked.

"Good," I replied. "A bit of blood loss following delivery, but Pitocin and plasma resolved that. Baby is healthy, and mom won't need sutures. Marilyn Cartwright basically kicked us out of the exam room, but I left Jake and Alice with her and her student. They'll take mom and baby upstairs."

"I'll give Norm Zenker a call. Make sure the chart is fully updated with all the relevant details."

"Will do."

We left his office and Heather and I went back to the exam room, picked up the chart, and made all the necessary entries and notation, including the flat-out refusal of OB to send a doctor or a nurse, and my order to Jake to appropriate a neonatal cart. That would keep him out of trouble. When I'd completed the chart, I signed it and set it down on the counter.

"Let me see the chart, please," Doctor Cartwright requested.

I handed it to her, anticipating her response. She was a Resident, so anything she said carried the same weight as what I said. In the end, Doctor Northrup and Doctor Zenker would fight it out, if necessary.

"You didn't have to be a jerk about it," Doctor Cartwright said.

"I simply recorded the facts," I said. "Let's leave it to our Attendings to sort out."

"Doctor Mike?" Daphne said.

"Yes?" I asked, moving over next to the bed.

"Thank you."

"You're welcome. Tommy is the first baby I've ever delivered."

"Wow! Really?"

"Really. I'm a trauma surgeon. I was trained to deliver babies, but it's not what I normally do. Good luck with your son."

"Thanks."

I left the room and Nicki waved me over.

"Mr. and Mrs. Reardon are in the waiting room."

"Let me check and see if Daphne wants to see them."

I went back into the room.

"Your mom and dad are here," I said. "Do you want to see them?"

"They can wait until she's upstairs," Doctor Cartwright said.

"Daphne is still in the ED," I said. "So it's up to me. Daphne?"

"Yes, please."

"I'll bring them in for a minute."

"Against my advice," Doctor Cartwright declared.

I wanted to give the typical teenage response -- 'whatever!' -- about the turf war, but I simply let it go. Heather and I went out to the waiting room.

"Mr. and Mrs. Reardon?" I asked.

A couple who were sitting side-by-side stood up, and I walked over to them.

"Your daughter is fine; she delivered a healthy baby boy about fifteen minutes ago. She wants to see you, but you'll only be able to stay for about two minutes because we need to get her upstairs to OB."

"Did you deliver the baby?" Mrs. Reardon asked.

"I did."

"Thank you!"

"You're welcome. If you'll follow us, I'll take you to your daughter and grandson."

Heather and I escorted them into the exam room and I introduced them to an obviously unhappy Doctor Cartwright, and they both moved to Daphne's side.

"He's beautiful, Honey!" Mrs. Reardon said.

"Doctor, why is she being given blood?" Mr. Reardon asked.

"She lost a small amount right after she delivered, which is not out of the ordinary. In the Emergency Department, we're very cautious, so we gave her a unit of plasma to ensure there were no problems. Her vital signs are good, and both your daughter and grandson are fine."

"Thank you, Doctor," Mr. Reardon said.

"This was the first baby he delivered, Dad!" Daphne declared, sounding stronger.

"First?"

"I'm a trauma surgeon," I said. "But we all know how to deliver babies, and there wasn't enough time for an obstetrician to get here after the paramedics brought Daphne in."

That wasn't quite true, but I wasn't going to air our dirty laundry in public, given Daphne and Tommy were both OK.

"Dad, do you have your Polaroid?" Daphne asked.

"In your mom's purse," she said.

"Doctor Mike, could we take a picture?"

"Sure," I agreed.

I posed with Daphne and Tommy while her dad took three Polaroid pictures, one of which he handed to me. I thanked them, then Heather and I left.

"Half-a-dozen walk-ins waiting," Nicki said.

I'd noticed a relatively full waiting room, so that didn't surprise me.

"Heather, grab the first chart and we'll get started."

Four hours later, after treating eight walk-ins and handling one paramedic run, I managed to get a dinner break and called Clarissa, who met me in the cafeteria. After we got our food, I handed her the Polaroid.

"Something you need to tell me, Petrovich?" Clarissa asked with a smirk and an arched eyebrow.

I chuckled, "I didn't place the order; I was just the delivery service."

"Wait! What?!"

"OB blew us off, so I delivered little Tommy there."

"Jesus, Petrovich! I can't leave you unattended for thirty seconds without you finding ways to get into mischief!"

"It's not my fault that OB completely blew us off! I asked for a consult and they were 'too busy'; I asked for a nurse with an OB tray and they didn't send one; I finally sent my Fourth Year to steal a neonatal cart and an OB nurse followed him, berating him the entire way."

"What the...?"

"Who knows? Brent Williams called Norm Zenker, and they got into it, so I think Brent kicked it to Northrup."

"Any complications?"

"About 300ccs of blood on the floor, but just that one gush; Pitocin and plasma brought her BP back. OB delivered the placenta, then took her up. In addition to a healthy baby, Isabella Mastriano and I worked together, and she actually gave me a compliment in front of Brent Williams."

"Will wonders never cease! How old is that girl? She looks young."

"Seventeen, but her parents seemed supportive."

"There are actually a few rational people out there!"

"All the ones I saw in the two parishes growing up and in college had rational parents. Orthodox Christians generally don't wig out about it, even if they disapprove of the behavior that led to that point."

"And if that were Rachel?"

"I wouldn't love her any less, and I certainly wouldn't do anything to interfere with my relationship with my grandchild, who had no control over his or her birth! That said, I'd strongly prefer the traditional order of betrothal, crowning, baby."

"I saw her and Abi on Friday night, and those two are going to be holy terrors when they're teenagers!"

"What makes you think Milena's daughter, who is also Anicka's granddaughter, will be trouble?" I asked with a grin.

"YOU! But you can't get the trifecta!"

"God forbid! Kris and I are still going to be together when that is possible. Not to mention I'm twenty-five years older!"

"If Anicka can be with a guy who is that much younger..."

"You're a troublemaker, Lissa!"

"Why do you think God put me here?" she asked with a smirk.

"I might point a different direction for the source of the thorn in my side!"

"You didn't put your thorn in my side, Petrovich!"

"Oh, stop!"

"If you prick me, do I not...leak?" Clarissa smirked.

"Well, Commander Datette, you absolutely were fully functional and there were a broad variety of techniques employed!"

"Datette? Seriously?"

"Dat-annette?" I suggested.

"Ugh."

"Datress?" I offered. "Or maybe Datrix?"

"Just stop it!" Clarissa demanded. "Data is an asexual android who happens to have male anatomy!"

"I'm not sure about that. I'd say his positronic matrices were encoded for being male in the same way my body is encoded by XY and yours by XX. Except for very rare genetic anomalies, those are immutable. It's implied that the positronic matrices have some immutable properties, and I suspect gender is one of them. But that's idle speculation because no such thing exists at this point. The best we have is animatronics and scripted responses."

"Do you think we'll get there?"

"Computers are increasingly more powerful and smaller, so I think we'll see continual improvements. What we'll have by the 24th century is as unknowable as the twentieth century was to the sixteenth! Well, unless you're a time traveler or alien like Leonardo da Vinci!"

Clarissa laughed, "That's your explanation for him?"

"Give me a better one! In the early sixteenth century, he excelled as a painter, draftsman, engineer, scientist, theorist, sculptor, and architect! Mr. Black pointed out that da Vinci made substantial discoveries in anatomy, civil engineering, hydrodynamics, geology, optics, and tribology, but because he did not publish his findings, they had little direct influence on subsequent scientific and technological advances."

"Tribology?"

"Greek, of course. It has a false friend in 'tri', but the root is actually 'tribo', which means 'I rub', and it's the science of surfaces interacting with each other. Think friction, lubrication, and wear."

"Hmm..." Clarissa smirked.

"Nice to see you down in the gutter with me, Lissa!" I chuckled.

"You don't really think he was a time traveler or alien, do you?"

"Of course not, but him being a polymath so far ahead of his time makes you wonder."

We finished our meal, and I returned to the ED while Clarissa went back to Internal Medicine."

August 20, 1989, Rutherford, Ohio

On Sunday morning, we'd left the house as planned and arrived at Holy Transfiguration in Rutherford about ten minutes before Matins began. Rachel was happy as she was able to sit on the floor with Tasha's daughter Larisa, Elaine's daughter April, and two other toddler girls. I almost laughed aloud when Larisa shooed off two boys who wanted to sit with them, knowing that in about ten years, it would be the boys trying to avoid the girls. My nephew Michael chose to sit at my feet, rather than with my sister and Paul.

Worshiping at Holy Transfiguration always brought back memories of growing up, and seeing Mrs. Orlov made me smile when I thought about how she'd helped me overcome my fear -- terror, if I was honest -- of talking to Tasha as a teenager. That seemed a lifetime ago, as did everything else that had happened growing up. I remembered longing to be a doctor, and how far in the future it had seemed, and now, I was standing in the same nave as a doctor, thinking how long ago I'd been in fourth grade.

Many of the same people were in the nave, though significantly older, and there were plenty of new people who I knew only in passing. The parish had largely recovered from the scandals that had occurred while Father Herman was pastor, and the parish had an excellent shepherd in Father Alexi, who was basically my age. Missing, of course, was my dad, who didn't attend church, and in some ways, saw himself similar to how Frank Bush saw himself.

When the services ended, everyone left the church, as the parish hall was being set up for the reception, which would follow Tasha's marriage ceremony, which meant no shared meal. Kris, Rachel, and I drove to Liz's house, where we were joined by my grandparents, my mom and Stefan, and Elaine and April.

"Three Michaels!" my step-father observed.

"Yeah, well, I sure as heck wasn't going to use my dad's name!" Liz declared.

"Elizabeth," Mom warned.

"Well, it's true!" My sister replied feistily.

"Be polite, Liz," Paul said.

Liz rolled her eyes the way she always had when she'd been corrected as a teenager, and I couldn't help but laugh.

"Mike had an exciting day yesterday!" Kris declared. "He delivered a baby!"

"Not by choice!" I quickly interjected.

"In the ER?" Mom asked.

"Yes. The patient came by ambulance in active labor with the baby crowning. I called for OB, but before they could arrive, it was time to deliver, so with help from another doctor, a nurse, and medical students, I managed not to drop the baby!"

Everyone laughed.

"I have a picture," Kris said, proffering the Polaroid I'd brought home.

"How old is this girl?" my grandmother asked. "She looks so young."

"Seventeen," I replied. "The baby's name is Tommy."

"And they ruined the picture by including you?" Liz teased.

"The baby would have needed supplemental O₂ if YOU had been there, Lizard Breath!"

"Children, play nice!" Mom ordered.

"It's hard to believe they're twenty-eight and twenty-five!" Paul said, shaking his head.

"Be careful, Paul Reynolds!" Liz threatened.

Just then a timer rang, signifying that the soup Liz had put in a crock pot before church was ready, so after I changed Rachel's diaper, we all went to the table to eat. I'd brought Rachel's food with us, but I did get her to try the beef, barley, and vegetable soup, which she seemed to like. She really liked the fresh black bread my grandmother had made and brought with her, as did I, though I had significantly more butter on mine.

When we finished lunch, we put the kids down for naps in the hopes that they'd do OK during the crowning ceremony and reception. The adults spent the next two hours together, then after changing Rachel into a cute dress, we headed back to Holy Transfiguration.

"Congratulations, Tasha!" I said when I saw her in the narthex in a simple white dress. "You look beautiful!"

"Thank you, Mishka!"

She ducked into a classroom and shut the door, and we found a place to stand just inside the nave. About ten minutes later, Father Alexi, Chris, Tasha, and the Orlovs took their places, and the betrothal and crowning services began. About an hour later, everyone gathered in the parish hall for the reception.

"Will there be dancing?" Kris asked when we took our seats at a table with the rest of my family.

"Yes. Father Alexi received a blessing from the bishop to allow dancing in the parish hall on this occasion. We're not as strict as ROCOR on that topic. I hope you won't be scandalized when Father Alexi dances with Matushka Nicole!"

"No, and I'm also not scandalized by the fact that she is visibly pregnant, nor the means of becoming so!"

"I would hope not!" I chuckled. "Given that's on our agenda!"

"Gross, Mikey!" Liz declared.

"And just how did Michael Paul enter this world? Hmm?"

Liz stuck her tongue out at me and I just laughed. A minute later, Father Alexi gave a blessing, and some of the teens went to the tables which held the food to prepare plates for the wedding party. Once they were done, the rest of the congregation, plus Chris' family and friends, lined up to get their food. I ended up in line right behind Susana Razumovsky, who smiled and surreptitiously winked.

"How are you, Susana?" I asked.

"Great! School starts in a week, and I'm looking forward to it. Do you think Rachel would be OK if I picked her up? I'm not sure she remembers me."

"Rachel, this is Susana," I said. "She helped take care of you before Mommy."

Susana picked up Rachel, who didn't protest.

"She looks so much like..." Susana said, her voice trailing off.

"She does. You've met Kris, right?"

"Yes, of course! Hi, Kris."

"Hi, Susana. I didn't know you were part of the group Serafima put together to help Mike."

"It was mostly girls from Saint Michael," Susana said. "It was only Natalie and me from Holy Transfiguration. Well, and Tasha, of course. Mike, did you know Natalie married?"

"No. It must have not been at church because we see the announcements in the bulletin."

"She eloped to Vegas with a guy about two weeks ago."

"Not Orthodox?"

"No. A guy she met while working. She only knew him a few weeks before they got married."

"That's crazy, even by my standards!"

Kris and Susana both laughed, then Susana had to put Rachel down as we'd reached the food tables. We filled our plates, then returned to our tables to eat. Once everyone had eaten, Chris and Tasha cut the cake, then had their first dance to Every Woman in the World by Air Supply. I danced with Kris, and the two of us danced with Rachel, but I felt it wise not to dance with anyone else.

Fortunately, Chris and Tasha left just before 8:00pm, which allowed Kris, Rachel, and me to head home without giving offense, as we would have a potentially long day on Monday with our interviews for Kris' citizenship application.

August 21, 1989, Columbus, Ohio

"I prefer to affirm, not swear," I said when the INS Examination Officer asked me to raise my right hand.

"Do you affirm that all statements you will make shall be truthful and complete, to the best of your knowledge?"

"I do."

"Then we'll begin. State your name, address, birthdate, and social security number."

I did, and the officer wrote all of those items on a form, then asked a series of basic background questions, including my birthplace, my parents' names, my siblings' names, my education, and any credentials.

"No medical license?"

"No. You become a doctor upon graduation from medical school, and work under the supervision of a licensed physician. I'll take my trauma boards sometime next year to become certified and receive my license; I'll take surgical boards in about six years."

"What exactly is a 'trauma surgeon'?"

"The simplest answer is that it's a trained surgeon who works in the Emergency Department, what you probably call the ER. Most doctors do one or the other -- surgery or emergency medicine. I'm doing both, with the goal of being better prepared to treat serious injuries."

"OK. Have you ever gone by any other names, even casually?"

"Petrovich, Mikhail, Mishka, Mischa, Mikey, and Mike."

"I'll assume the last five are all derived from your first name, but Petrovich?"

"From my dad's name. It's typical for Russian friends to call each other by their patronymic, which serves as a middle name. Only one person calls me that -- my friend and colleague Clarissa Saunders. In Russian, my name would be Mikhail Petrovich Loucks. As you can see on the questionnaire, my mother's maiden name is Borodin, which is Russian. Loucks is Dutch."

"Do you have any ties to the Soviet Union?"

"Only in the sense that my maternal grandparents escaped from the USSR and came to Ohio via Alaska. Similarly, Kris' grandparents emigrated to France from the USSR."

"Do you speak Russian?"

"Passably," I replied, electing not to use my 'retarded toddler' comment with a government official.

"Did you bring certified copies of your birth certificate, marriage certificate, and your first wife's death certificate?"

I removed them from the folder, which contained dozens of documents that either the government had requested or John Burge, our attorney, had suggested. He was with Kris, as after a discussion just before my interview, he had confirmed his opinion that I didn't need representation.

"What were the circumstances surrounding your wife's death?" he asked.

I gave him the strict medical answer, and wasn't surprised when he asked me to explain, which I did.

"How did you meet Kris Korolyov?"

"We were introduced by her cousin, Oksana Korolyov, who I've known since I was in grade school."

"When was that?"

"August last year."

"And you married on January 1 this year?"

"Yes," I replied, suppressing the urge to tell him to look at the marriage certificate on the table in front of him.

"Why so quickly?" he asked.

"We met, were attracted to each other, discussed our life goals, the practicality of a marriage given the hours I need to dedicate to the study and practice of medicine, Rachel's needs, and our shared faith."

"Tell me about your wedding ceremony."

I described the ceremony and waited for the question I knew was coming.

"Where did you take your honeymoon?"

"My medical training didn't allow much time off, so we simply stayed at the Hotel LeVeque for five nights. Once I'd graduated from medical school, we went to Gatlinburg, Tennessee and stayed at the Greystone Lodge for nine nights. We took our daughter with us."

"You mean, your daughter."

"No, I mean our daughter. Kris adopted Rachel in April, and we changed Rachel's name to Korolyov-Loucks."

"But Kris did not change her name, correct?"

"Correct. In France, women don't change their legal names, and we honored that."

"How often are you and Kris intimate?"

"As often as possible," I replied. "But I work thirty-six-hour shifts, so it's irregular given my need to sleep after those shifts."

"What side of the bed do you sleep on?"

"The right side as you stand at the foot of the bed."

"You consummated your marriage the same day as your wedding?"

"Yes."

"When is that last time you had intercourse?"

"Friday night."

"Where?"

"In our bed."

"Moving on, do you share a bank account?"

"Yes."

"Whose name are your cars registered under?"

"My Mustang is in my name; Kris' Tempo is in both our names."

"And your lease?"

"Both our names."

"What about the utilities?"

"Those are in my name, because of the necessary credit checks. Kris graduated from High School in May and started at Ohio State in July."

"Do you have your pay stub?"

"I do," I said, taking it out of the folder, along with the 1099 for Code Blue, and sliding them across the table.

"What is 'Code Blue'?"

"A band I have with some friends that we started in college. We played a gig on Friday night and Kris and I sang Endless Love as a duet, which we've done since she and I became betrothed last September."

"Betrothed?"

"Engaged. Russian Orthodox Christians use the word 'betrothed', and there's a church ceremony associated with it. It's separate from the crowning ceremony, which is what our marriage ceremony is called."

"Who officiated at your wedding?"

"Bishop JOHN of Ohio, whose secular name is Jeremiah Loch."

"Moving on, what do you and Kris do together?"

"Remember, I work ninety hours a week, and have to sleep, so we have limited time. On Saturday mornings, we go to band practice, then do our weekly shopping. We attend Vespers, which is evening prayer, on Saturday evenings, then Matins and the Divine Liturgy on Sunday morning. That's morning prayer and then the rough equivalent of a Roman Catholic Mass. We have dinner together at home on Wednesdays, Fridays, and Sundays, and once a week, Kris comes to Moore Memorial Hospital so we can have dinner on a night when I have a long shift."

"Who cares for Rachel?"

"We share duties," I replied. "I do most of it when I'm home, otherwise it's Kris. When she's in class, Rachel alternates between the hospital daycare, her grandparents', her aunt's, and her best friend's houses."

"Which grandparents?"

"My deceased wife's parents," I said, electing not to use 'reposed'. "The aunt I mentioned is Kris' sister, Lyudmila. The best friend is Abi Greene, daughter of a professor I'm friends with who teaches at William Howard Taft."

"Who is your wife's best friend?"

"Her sister, actually. Her closest friends are two girls from church, Viktoria and Deborah, and she's also close friends with my friends Clarissa and Lara. And her cousin, of course."

"Who's your best friend?"

"Doctor Clarissa Saunders."

"A woman?"

"Yes. A colleague I met in college."

"Best male friend?"

"Robby Jackson, a PhD candidate in biochemistry."

"Can you explain your version of an interview conducted in Chicago on July 18th, 1985?"

What I wanted to say versus what I would say were very different.

"The INS officer was concerned about my first wife's age, and whether we were legitimately married. Many of the questions were of the same character as you asked today. We answered them, and I believe my wife expressed her outrage, though I can't be sure because we were in separate interview rooms. Once the officers who interviewed us were satisfied, which took about twenty-five minutes, we were admitted."

"Moving on. Do you plan to have children?"

"Yes. In fact, Kris stopped taking her birth control pills on Saturday. Our hope is to have a baby in July or August."

"Who cared for your daughter between her birth and your marriage?"

"I did, with significant help from women from church, my friends, a professor, my deceased wife's family, and my family. My grandfather and some of his friends paid my rent and paid the utilities."

"Why was that?"

"Medical school is basically a full-time thing, especially the last two years, when I was on clinical rotations which were between sixty and eighty hours per week. That meant I couldn't work. I had savings, but it would have completely depleted them and left me no margin of error."

"Moving on, again. Have you been truthful with me today?"

"Yes."

"Are you engaged in an attempt to deceive me or commit immigration fraud?"

"No."

"That's all the questions I have for you. Your wife will receive a determination letter in six to eight weeks."

"Thank you."

"I'll make some photocopies, then return your documents. Please wait here."

He left and returned about five minutes later.

"Have a nice day, Doctor Loucks."

"Thank you. You too."

He escorted me to the lobby of the office, and I sat down to wait for Kris. About forty minutes later, she came out, along with her attorney, John Burge. Mr. Burge and I shook hands and I could tell from his eyes that we shouldn't say anything in the office. We left the office, rode the elevator down to the ground floor, then walked to the parking garage.

"I think it went well," Attorney Burge said. "I didn't sense any indication they felt Kris was being deceptive, which, in the end, is what matters."

"Not the truth?" I asked.

"Technically, yes, but if they feel you're being deceptive, they'll dig and could, ultimately, deny the application based simply on that sense of deceit. And remember, immigration is discretionary, and appeals of adverse determinations are difficult, at best. But don't worry about that. Kris was charming and answered all their questions."

"Thanks," I said.

"Kris, you have your citizenship test on the 31st, so make sure you study. Assuming you pass, which I expect, you'll receive a determination letter sometime in late September or early October."

"Thank you," Kris said.

Kris and I shook hands with Mr. Burge, then walked to our cars so Kris could go to class and I could get to the hospital for the remainder of my shift.

XXXIX. Ohio State Medical Licensing Board

August 23, 1989, Columbus, Ohio

After lunch on Wednesday, I took Rachel to stay with her aunt, then drove to Columbus to meet Tom Kirkland in advance of the hearing later in the afternoon. I met him at a coffee shop down the street from the Medical Licensing Board offices on East Broad Street.

"I think they're going to come at you hard," Mr. Kirkland said. "From their perspective, you're the most dangerous witness, so they're going to do everything they can to put your future at risk."

"Why me, rather than Doctor Mercer?"

"They can't hurt her; they can hurt you. You'll come before the board for your license and they're going to try to poison the well."

"I'm not going to run away."

"I was positive that was true, or I wouldn't have listed you as a witness. For you to withdraw would strengthen their position. The key to surviving this is not falling for any of their traps. No matter what they ask, or how they ask it, you're testifying as Angie's friend, not as a doctor. I'll emphasize that all of this occurred before you graduated from medical school."

"So how do you want me to answer."

"All you need to do is corroborate what Doctor Mercer and Mrs. Stephens say. Don't let Doctor Greenberg's attorney lead you off that path. No matter how you think the hearing is going, it will go worse if you deviate. Our argument is simple -- Angie had a clear picture of the future, had put together a long-term plan, and was implementing it. When Doctor Greenberg became aware of that plan, he acted contrary to best practices. But remember, YOU can't say that last part."

"Understood."

"Then let's go."

We left the coffee shop and walked down the sidewalk to the building, which housed the medical licensing board. Mr. Kirkland gave our names, and we were directed to the hearing room, where Lara and Clarissa were waiting. I also saw Doctor Mercer, and to my surprise, Doctor Lawson.

"That's the Psych Chief from my hospital," I said quietly to Mr. Kirkland. "We need to talk."

"We have a few minutes, let's step out into the hallway."

We did and moved a short distance from the door to the hearing room.

"He's not on the witness list," Mr. Kirkland said. "But the Board will probably allow it. What's he going to say?"

"He'll likely describe an incident with a mentally ill patient who I treated. I felt the best approach was to humor the patient, and I was having success. The Psych Resident rejected my plan and that resulted in an agitated patient who had to be medicated. He'll say I'm a cowboy, or something similar. On the flip side, he threatened my career if I testified today."

"Will you say that on the stand?"

"If he tries to assassinate my character, yes."

"I'll make a judgment on whether we need to raise the issue or not. You answer my questions, and you don't go beyond where I lead you."

"OK."

We returned to the hearing room, and I sat down next to Clarissa, noting that Mr. and Mrs. Stephens had arrived, as had Doctor Underwood, who had first treated Angie when we were at Taft.

"You OK?" she asked quietly.

"I'm not going to be intimidated."

"Good."

"Uh-oh," I said as Doctor Paul Forth walked into the room.

I got up and moved to where Mr. Kirkland was sitting.

"That's Doctor Paul Forth," I said. "He and I had in-depth conversations about Angie."

"What can he say that will hurt us?"

"That, at the time, I agreed Doctor Greenberg made a clinical decision based on the usual standard of care. My response was more nuanced, but that's how he'll spin it."

"He's also not on the witness list," Mr. Kirkland said. "When was that conversation?"

"During my Third Year, sometime in March last year."

"That might actually work in our favor. One late addition would probably be allowed, as I said. But given the conversations weren't in the last few weeks, these are not 'unavoidable circumstances'. Thanks for letting me know."

I returned to my seat just as the members of the Review Board entered the room. They all took seats at a long table in front of the room, and the Chairman banged his gavel to call the meeting to order.

"In the matter of Doctor Jules Greenberg," the Chairman, Doctor Brewer, announced.

The five-member panel was introduced, all of whom were active, practicing physicians, none of whom were psychiatrists. I wasn't sure if that was a good thing or a bad thing.

"Is counsel for the complainant here?"

"Tom Kirkwood on behalf of Mrs. Joanna Stephens, natural guardian of Angela Marie Stephens, and Laura Bragg, next friend of Angela Marie Stephens."

"And counsel for Doctor Greenberg?"

"Arthur Braun, of Volstead and Braun representing Doctor Greenburg. With me is my colleague, Evan Miller."

"We've all read the complaint. Mr. Kirkwood, you may begin."

"Doctor Brewer and members of the Committee. The matter before you is straightforward. I will present witness and expert testimony that Doctor Greenberg callously disregarded clear contraindications to his treatment of Miss Stephens. May I call my first witness?"

"You may."

"I call Doctor Michael Peter Loucks."

I got up and moved to a chair that Mr. Kirkwood indicated.

"Doctor, would you raise your right hand, please?" Doctor Brewer asked.

"Doctor, I request my right to affirm rather than swear."

"Do you affirm that the testimony you give before this committee will, to the best of your knowledge, be true and accurate."

"I do."

"Mr. Kirkwood?"

He had me state my name, address, and current employment.

"Mr. Chairman, despite his recent graduation from medical school, Mr. Loucks is not testifying as a physician, but as close friend to Miss Stephens, to events that occurred before he completed medical school. As such, he is not providing medical judgment, and I ask that he be treated as a layman for the purposes of this hearing."

"Mr. Braun?"

"Doctor Loucks is a physician, and is subject to the rules of this committee, including discipline for any statements he might make. I ask the committee to take official notice that he is a practicing physician."

"Mr. Kirkwood?"

"None of the events which occurred, nor any statements made about Miss Stephens to anyone, occurred or were made as an MD. In fact, many of them were made before Doctor Loucks even entered medical school, and the majority of them before he entered his clinical rotations. There is no witness that Mr. Braun can call, and no evidence that he can present, which shows any statements about Miss Stephens made as a physician. No testimony given today will cover any events which occurred after May 25th, 1989, the date of the McKinley Medical School graduation."

The Chairman turned off the microphones and consulted with the doctor on either side of him, who each asked the doctors on the end of the table, with the answers communicated in voices too low for any of us to hear.

"The Committee will consider any statements made by Doctor Loucks about events before May 25th to be those of a layman. Doctor Loucks, I caution you to keep your answers factual, and not diagnostic, or this decision may be reconsidered."

"Yes, Mr. Chairman," I acknowledged.

"Is it OK to call you Mike?" Mr. Kirkwood asked.

"Yes."

"Mike, would you describe your relationship with Miss Stephens, beginning with when you first met her?"

I spent fifteen minutes describing how I'd met Angie, how our relationship had progressed, and the series of incidents which had led to her being diagnosed with schizophrenia.

"What happened after that?"

I described marrying Elizaveta, our friendship with Angie, then Elizaveta's death, and how Angie had changed.

"You observed Miss Stephens making long-term plans, with specific goals, and then executing those plans?"

"I did."

"Did you have an occasion to discuss her actions with her?"

"Yes."

"What were those interactions?" Mr. Kirkwood asked.

"When she first put her plan into action, she stopped taking her medication. She confided in me that she had done so, and I insisted that she adhere to the treatment plan established by Doctor Greenberg and Doctor Mercer, a clinical psychologist, and that she discuss the situation with Doctor Mercer."

"Did she comply?"

"To the best of my knowledge, yes."

"What happened next?" Mr. Kirkwood asked.

"She confided to her priest, outside of confession, that her goal was not just her driving license, but marriage to me. Because of direction from our bishop, her priest notified Doctor Mercer about Angie's statements. Doctor Mercer communicated those to Doctor Greenberg. The next thing I knew, Angie was in the hospital under sedation."

"Then what?"

"Her care was moved from Doctor Greenberg to Doctor Hoffman. Doctor Greenberg challenged that move, but was unsuccessful."

"As Miss Stephens's closest friend, what can you say about her behavior just prior to her final meeting with Doctor Greenberg?"

"That she was very much like the Angie I met at Taft in late 1981 -- a normal, but quirky eighteen-year-old. I and my closest friends were all quirky, so she fit right in. In other words, Angie was, in layman's terms, back to normal. She was working, taking classes, practicing Aikido, and going to church. She knew what she wanted, and she was, within the restrictions placed on her by the State of Ohio, taking steps to accomplish her goals."

"When did things change?" Mr. Kirkland asked.

"December 1987, after the communication from Angie's priest."

"And how is Angie now?"

"Similar to how she was after her diagnosis."

I wanted to add 'due to medication', but I had to be VERY careful about that.

"Which means?"

"Barely able to care for herself and unable to work."

"And that changed in December 1987, after her intentions were communicated to her doctors?"

"Yes."

"Thank you. I have no further questions of this witness, Mr. Chairman."

"Mr. Braun?"

"Good morning, Doctor Loucks. It's good to see you again."

I'd expected that, so I was ready to tell a 'little white lie' of social convention, despite being under oath.

"And you as well," I replied.

I made sure to keep my tone light, but all I could think of was that I now fully understood what the Holy Apostle Paul meant by a 'thorn in his side', and it did not appear that God would remove this particular thorn any time soon.

"Doctor," he said, emphasizing the word, "did you have occasion to speak to Doctor Paul Forth and Doctor William Lawson about Miss Stephens?"

"Objection, Mr. Chairman," Mr. Kirkland said.

"On what grounds?" Doctor Brewer inquired.

"Both doctors are employed at Moore Memorial, a teaching hospital, and any conversations were of a didactic nature. Medical students are not only requested, but instructed to ask wide-ranging questions and explore non-traditional responses with the aim of education. To attempt, years later, to hold a medical student accountable for questions he or she asked would do a grave disservice to medical training.

"I will also point out that neither Doctor Forth nor Doctor Lawson appear on the witness list submitted by Mr. Braun. The fact that he led with that question indicates an attempt to sway the committee to allow him to sandbag Doctor Loucks and Miss Stephens' guardian and next friend by relying on what amounts to trickery to bring in their testimony without depositions or interviews."

"Mr. Braun?"

"It's a legitimate question that will show that Doctor Loucks admitted that the actions of Doctor Greenberg were warranted and justified by the standard of care."

And he'd managed to get the testimony in, even if his witnesses were disallowed, which I had to tip my hat to, despite feeling the thorn dig deeper into my side.

"The questions and speculations of a medical student during clinical rotations," Mr. Kirkland countered, "are not only privileged but also, as I said, an expected, even required, part of medical training. I'm going to raise my objections now to Mr. Braun calling those two physicians who do not appear on any witness list, nor are their names listed in any responses by Mr. Braun on behalf of Doctor Greenberg."

"Doctor Loucks," Doctor Brewer said, "these conversations, were they diagnostic in nature?"

"Yes, Doctor," I replied.

"Then I'm not going to allow this line of questioning. Mr. Braun, you may continue."

"But, Mr. Chairman..."

Doctor Brewer held up his hand, "Mr. Braun, would you like to be called before the Bar and have every word uttered in law school examined to see if you might have said something which was legally in error and have that used to disbar you for unlicensed practice of law?"

"No, but..."

"I'd say that answers my question. Do you have further questions?"

He frowned, but I knew that wasn't the end of it.

"Doctor Loucks," he said.

"Excuse me," I interrupted, "but we all know I'm a doctor as of May 25th. You can say the word without emphasizing it every time."

I was hoping he'd say something to the Chairman about me being uncooperative or whatever, but to his credit, he didn't, and continued.

"You testified that you advised Miss Stephens about proper use of her medication, did you not?"

"Not," I replied. "I advised her to follow the directions of her physician, which I was required to do by my oath as a medical student."

"Did you or did you not instruct her to take medication?"

"I instructed her to follow the prescription she had been provided by her treating physician. I also instructed her to report her non-compliance to Doctor Mercer, again, as I was required to do by my oath as a medical student to not practice medicine in any way."

"Did you communicate with Doctor Fran Mercer about Miss Stephens' treatment?"

And this line of questioning didn't fall under medical training, so there was no way I'd be able to avoid answering.

"I did, at her invitation."

"And in the course of those conversations, did you object to Miss Stephens' treatment program?"

"I did, and sometimes quite insistently, to a clinical psychologist, who is not an MD, who asked my views."

"When did those conversations take place?"

"After Angie was hospitalized."

"Never before?"

"Before that, Doctor Mercer provided advice on how my deceased wife and I could best support Angie and her parents. I also saw Doctor Mercer for pre-marital counseling."

And for Liz's situation, but I wasn't going to bring that up.

"What specifically did you say?"

"What I've said here -- Angie had shown self-awareness, was making detailed, long-term plans, and was taking the steps to achieve them."

"Did you claim Doctor Greenberg had committed malpractice?"

"Yes, and that was borne out by the settlement reached by his insurance company."

"No liability was admitted," Mr. Braun said quickly. "And that is not relevant because it was settled."

"You brought up malpractice," I said with a grin. "I simply noted what occurred."

"Did you, at any point, propose a treatment plan for Miss Stephens?"

"No. I pointed out the negative outcome and expressed my belief that Angie's behavior was not properly taken into account."

"So you made a diagnosis?"

"No, I reported observed behavior to Doctor Mercer and pointed out to her that it had, in my opinion, not been taken properly into account."

"You obviously felt Doctor Greenberg was wrong. What would you have done differently?"

"It wasn't my place to make that decision," I said.

"I'm asking what you would have done had it been up to you?"

"And that's a question I cannot answer. I wasn't aware of Doctor Greenberg's actions until after the fact. All I can say is that inside of twenty-four hours after her statement to her priest, she went from working, caring for herself, practicing Aikido, and being able to carry on normal conversations, to being medicated in the hospital. At that point, there was nothing to do, except hope for recovery."

"You're saying you never proposed a course of treatment, nor gave an opinion on how to proceed?"

"Never. All my comments to Doctor Mercer, and to the doctors who helped train me, were all after the fact, and thus, purely hypothetical, similar to case studies."

"Did you have an affair with Miss Stephens?"

"Angie and I spent a lot of time together, but we were never a couple, and beyond a single kiss during Freshman year at Taft, there was no intimate behavior."

"Isn't it true that the other residents of your dorm called her 'Mrs. Loucks'?"

"Yes, that's true."

"And you would have us believe that there was no intimate behavior when the average person would assume a married couple was engaging in intimate behavior?"

"They called her that because, as my sister put it, Angie and I went to church together, prayed together, ran together, practiced karate together, and acted as if we were married, minus sex. My friend and colleague, Clarissa Saunders, made the same observation. I offered, at one point, to get engaged, reserving sexual intimacy for after our marriage, and Angie couldn't even take that step."

"But you wanted to have sex with her?"

"As a college Freshman with strong feelings for a pretty red-haired girl with green eyes? With all due respect to her and her parents, absolutely. But her reaction to that solitary kiss changed everything, and as I said, I set that desire aside because of her reaction."

"And after you lost your wife?"

"Angie was a ward of the state, and was declared incompetent, and as such, could not consent. One of her goals, before she was hospitalized, was to get her driving license, which she saw as her first step to have her found competent, and then to marry and have children. She clearly expressed that to me before she said it to her priest. I made it clear that she had to take one step at a time, and that no promises could be made."

"So you gave her advice on how to overcome the state's determination of incompetency?"

"I did, in the sense that I referred her to an attorney who specializes in such things and advised her to follow his instructions. I defer to professionals, Mr. Braun. I never once took matters into my own hands."

"Does that include treating patients in ways that go counter to the instructions of Attending physicians?"

"Objection," Mr. Kirkland said. "First, Doctor Loucks cannot discuss any patients without their consent or an order from the Medical Licensing Board for a review of records. Second, any such incident, if it occurred, would have occurred after May 25th, and is not relevant to this inquiry."

"I think I'd like to hear it," Doctor Brewer said. "Doctor Loucks?"

"If Mr. Braun will specify the case to which he is referring, I'll answer in a way that protects patient privacy."

"Mr. Braun?" Doctor Brewer inquired.

"Specifically, a patient with delusions who you chose to treat outside protocols."

"Well," I said, "as an Intern in trauma surgery, I'm subject to the policies of the Emergency Department, which I didn't violate. I did make a suggestion to the Psych resident about a preferred way forward, but they rejected that suggestion."

"Doctor Loucks, would you be more specific, please?" Doctor Nelson, one of the other Board members requested.

"A patient came into the ED complaining his body had been infested by aliens. Upon exam, he stated that aliens had inserted tracking probes into his brain via his nasal passages. He had wrapped aluminum foil around his head to block the signals. In order to be able to perform a primary exam, I explained that I'd leave the foil in place, and once I'd completed my exams and run appropriate tests, I'd call the hospital's alien expert."

There was laughter in the room from everyone except Doctor Greenberg, Doctor Lawson, and Mr. Braun. Even Doctor Forth laughed.

"The patient expressed surprise that I believed him, and I stated that I needed to take him seriously so I could treat him. He asked if the alien expert was a secret, knowing we were a government, that is county, hospital, and compared it to the alien spacecraft and bodies housed at Wright-Patterson Air Force Base in Dayton."

"Allegedly housed, right?" Doctor Wilson, the only female on the Board inquired.

"Of course," I chuckled. "But the point is, Hangar 18 in Area B is rumored to have those things, and not everyone who believes that, or the rumors about Area 51 in New Mexico, is diagnosable mentally ill. I put them in the same general category as people who believe Erich von Däniken's theories that extraterrestrials influenced modern technology. It's quirky, but not necessarily a sign of mental illness.

"That said, I was reasonably sure he either was suffering from a mental illness or perhaps had a tumor, might be under the influence of mind-altering drugs, or might have some other condition which might cause paranoid delusions. I ordered a CBC, Chem-20, glucose panel, and a tox screen.

"He protested about the tox screen, saying he wasn't on drugs and I suggested the aliens might have injected him with something. He accepted that, saying they were crafty, and complied with the exam and blood draws. He was completely compliant, calm, awake, and oriented times three. My nurse observed that I'd been unconventional, but that it had worked because the patient was calm.

"At that point, I presented my plan to the Chief Attending, Doctor Loretta Gibbs, who asked questions, suggested that Psych was going to be unhappy that I'd humored my patient. She agreed I'd done no harm, and probably some good. She reviewed my plan and signed the chart."

"So you had a signed chart from your Attending, which reflected your actions and approved your plan?" Doctor Brewer asked.

"Yes. The chart, if you were to request it, would show my notes about humoring the patient with the goal of completing the exam and obtaining test results. When I received the results, I discussed them with the patient. Literally nothing was outside normal parameters. The patient proposed that was because the aliens were using technology we could not detect. As a fan of Star Trek, I agreed an advanced alien race could certainly do that. At that point, I informed the patient I was calling a specialist to see him."

"Meaning Psych, right?" Doctor Brewer asked.

"Yes. I assumed, and that assumption was borne out later, that the patient would not react well to a psych consult. When the on-call Psych Resident came down, I presented the case outside the room so I could explain my somewhat unconventional approach. I noted that I had followed all ED protocols with regard to H&P, then suggested that because the patient was calm and cooperative, the Psych Resident should continue the kabuki play.

"The Psych Resident objected, saying that wasn't protocol. I replied that my goal was to provide the best possible care, and if that meant going along with his hallucinations and delusions in the short term, I felt that was the best course of action. The Resident made it clear that their Attending would not agree, then expressed frustration that the ED Chief Attending had signed off on my approach.

"I countered that we had a docile, cooperative patient who believed we were going to help him, as opposed to one who thought we were in league with his enemies. The Resident insisted that she had to follow protocol and at that point I asked my nurse to prepare five of Haldol because I was positive we were going to need it.

"I pleaded with the Psych Resident to simply introduce herself as a specialist and she responded that I shouldn't have fed his hallucinations or delusions. At that point, I was positive about what was going to happen, so I asked the Resident to wait until I could have my medical student and an orderly available.

"The orderly and my student stood outside the treatment room, and I made a final attempt to continue my charade by introducing the Psych Resident as 'the specialist I mentioned'. I was pleased when the Resident simply gave their name and title, without stating they were from Psych, but her language and tone of voice after that made it clear she was skeptical.

"That caused the patient to become agitated, and claim that the Psych Resident didn't believe him. The Psych Resident stated that there were no such thing as aliens, which caused the patient to lose control, and begin screaming about a coverup and how the Psych Resident was 'one of them'. It quickly got to the point where safety required administration of Haldol, which I ordered. I noted that on the chart, along with the fact that the patient had been docile and cooperative prior to the Psych consult. The patient was admitted at that point."

"As you say, unconventional," Doctor Brewer said. "But I don't believe anything you did violated standard emergency medicine protocols. Mr. Braun?"

It was all I could do to keep from smiling because that one statement by Doctor Brewer defanged the entire argument.

"Doctor Loucks," Mr. Braun said. "Would you tell us about being defrocked by your church?"

"Objection," Mr. Kirkland said. "That has no probative value here."

"I'd like to answer," I said quickly, before the Chairman could rule.

"Go ahead, Doctor," Doctor Brewer said.

"I was not 'defrocked', I requested to be returned to the order of the laity, which is comparable to a military officer resigning their commission. The Orthodox Church ordains married men, but men who have been ordained may not marry. My wife reposed -- that's the word we use for a loved one who dies -- and that meant I was, in effect, forced into a vow of chastity, as clergy not permitted to marry, nor are twice-married men ordained.

"At the time, I had an infant daughter to care for, on my own, as my wife had reposed only hours after giving birth due to a congenital condition. I felt, very strongly, that my daughter needed a mother, and that was not possible so long as I was a deacon. In addition, I had not made a vow of chastity, and was not prepared to make one, directly or indirectly, at age twenty-four.

"That led me to approach my bishop and ask to be returned to the order of the laity. There was no discipline of any kind, and I remain an authorized catechist, and I'm a lay chaplain with a prison ministry. So, to put it simply, your information is in error. I can provide the necessary documents and testimony to back that up if need be."

"Doctor Loucks," Doctor Wilson asked. "My condolences. Would you mind sharing the cause of your wife's passing?"

"She suffered an intraparenchymal bleed, due to a congenital arteriovenous malformation. A slight rise in blood pressure was enough for the nidus to expand and bleed. Per the pathologist at Moore Memorial, because it was proximal to the medulla oblongata, it is 'routinely fatal'."

"Thank you," she said.

Mr. Braun was frowning because his foolish question had garnered me sympathy from the panel, which couldn't help him. I actually hoped he'd ask more questions, but instead, he wisely declined. I was allowed to return to my place near Clarissa and Lara, and Mr. Kirkland called Doctor Mercer as his next witness.

Under questioning from Mr. Kirkland, she confirmed my testimony about Angie's behavior, and said something I wasn't able to say -- that Angie's behavior was indicative of improvement, and should have been encouraged, and intervention had been contraindicated. I was happy with everything she said, though I knew the cross-examination would be where the problems occurred.

"You're not an MD, correct?" Mr. Braun asked.

"That's correct," Doctor Mercer said. "As I said to Mr. Kirkland, I have a PhD in psychology, and I'm licensed to practice in Ohio."

"As such, you are not qualified to make medical judgments, is that correct?"

"I'm not permitted to prescribe medication, but otherwise, I am permitted by my license to diagnose and treat all forms of mental illness, as well as provide behavioral counseling."

"So you were not the treating physician in this case?"

"No."

"And you concurred with Doctor Greenberg's medical judgment?"

"Initially, yes."

"And you were the one who, after consultation with Doctor Greenberg, delivered the message to Miss Stephens?"

"Yes."

"And at that point, you agreed with him?"

"I did."

"And at the time, you believed his actions conformed to the usual standard of care for patients with schizophrenia?"

"Yes, at the time."

"And you communicated that to Doctor Loucks?"

"I did."

"What led you to change your mind?"

"A conversation with my mentor, Doctor Laura Paulus."

"Is she a medical doctor?"

"No, she, too, is a PhD psychologist."

"And it was because of her, not because of influence from Doctor Loucks?"

"Doctor Loucks challenged me, and after hearing his challenges, I went to my mentor, Doctor Paulus, to discuss what he had said."

"And what did she tell you?"

I nearly broke up laughing, because he'd just walked into a buzz saw.

"She said, after hearing the facts, that she felt a suspension was warranted, and if it were her, that she'd revoke Doctor Greenberg's license because he ignored clinical signs of which he was completely aware, and that Mike, that is, Doctor Loucks, was correct and I should apologize, which I did."

"Did Doctor Paulus ever examine Miss Stephens?"

"No."

"So, she made that determination based simply on your reports?"

"Yes."

"And you acted on that completely uninformed advice and wrote your statement?"

"It wasn't uninformed," Doctor Mercer said. "She had all the information she needed to give me advice."

"But she never saw Miss Stephens, so she had only third-hand information, correct?"

"Yes," Doctor Mercer admitted.

He had no further questions for her, and Mr. Kirkland called Doctor Mark Edmonds, a psychiatrist in private practice in Columbus, who was serving as an expert witness. His testimony covered the standard of care for schizophrenia. He confirmed everything that I'd observed and made an unequivocal statement about it.

"I believe Miss Stephens showed clear indications of recovery, which is seen in a small number of patients. The DSM makes it clear, as does the literature, that when such behavior is observed, the only correct course of treatment is to support the patient, and if warranted, attempt to wean them from all medication. What should never be done is tell the patient that they can never recover, as that is not only harmful, but completely inaccurate."

"You're saying," Mr. Kirkland asked, "that the standard of care was different because of her behavior."

"Yes," Doctor Edmonds confirmed. "A diagnosis of schizophrenia is based only on observed behavior, therefore cannot be supported when a physician observes behavior which shows long-term planning and thinking 'outside the moment'."

"Could this be merely a difference of opinion?"

"No. I've reviewed all the records, and it is inarguable that she showed signs of recovery. While that does not mean she had recovered, the treating physician must take every possible step to support the patient in their endeavors. In this case, it would have been to do whatever was possible to allow her to continue working, going to school, practicing martial arts, and guide her in her attempt to obtain her driver's license."

"Thank you, Doctor," Mr. Kirkland said.

Arthur Braun stood and began his questioning.

"How much are you being paid to appear?" Mr. Braun asked.

"My usual expert witness fee is $500 for one day," Doctor Edmonds said. "I waived it in this case."

'BOOM!' I thought. I hadn't been aware of that, and hoped against hope Mr. Braun would be foolish enough to ask 'why', as I could only imagine that would hurt his case.

"You're receiving no fee for your testimony?"

"Correct."

"Are you related to or friends with anyone in this case?"

"No, though I have been an expert witness for Mr. Kirkland in other cases."

"How many cases have you testified in?"

"About two dozen."

"And always for the patient making a complaint?"

"Yes."

"Going back to waiving your fee, was there any quid pro quo?"

"No. I found the case to be so egregious, I offered to testify without my usual fee."

Another 'BOOM!' moment. Barring some kind of recovery by Mr. Braun, I felt there was a very good chance Doctor Greenberg would have his license suspended.

"Did you have a chance to examine Miss Stephens before her most recent hospitalization?"

"No."

"So you are relying only on second-hand or third-hand information?"

"I was asked to examine the records in the case, which I've done, and I'm providing my analysis based on those records."

"So, as I said, you do not have first-hand information, correct?"

"I was not the treating physician, so that would be the case."

"Thank you, Doctor."

Mr. Kirkland had no further witnesses, which surprised me a bit, as I'd expected at least one of Angie's parents to testify. The Chairman called for a fifteen minute comfort break so Clarissa, Lara, and I went to use the facilities, then bought soft drinks from a machine.

"Lara, what's a 'next friend'?" I asked.

"The person who acts on behalf of someone with some sort of disability to bring their own suit. It applies to the inability to retain legal representation as well as what you would normally think. In this case, I'm paying Tom Kirkland, so he felt it was best to include my name on the complaint to take away any avenue of attack."

"And you can be sure Arthur Braun would find it," I said.

"What is it with you and that guy?" Clarissa asked.

"The Biblical 'thorn in my side'," I replied. "I swear, he has to be looking for cases where I'm involved!"

"Possible," Lara said. "But his firm is the premier criminal defense firm in Cincinnati, with a strong reputation throughout the state. If you can afford them, you go to them, even if you're from Cleveland or Toledo. Each case has been someone with money, right?"

"I suspect so," I replied. "The only one I don't know for sure was Jack Strickland, but I believe his dad is a doctor in the Cincinnati area."

"So that fits," Lara said. "What's your take?"

"A couple of bad moments for Mr. Braun, and I think we're on course for some kind of suspension. A reprimand is certain."

"I agree," Clarissa added. "There doesn't seem to be any way out for them. Maybe they can do damage control, but what really concerns me is Forth and Lawson, who can hurt Mike pretty badly."

"I don't think so," I countered. "By keeping everything before May 25th, the worst they can do is tarnish me, but do you think Doctors Gibbs, Casper, Nielson, Gabriel, or Taylor are going to care? And I know what Cutter, Roth, and Lindsay think of Psych! And I let Mr. Kirkland know what Doctor Williams told me about Lawson."

"What's that?" Lara asked.

"He failed to Match for surgery and had to Scramble. The only Residency he could find that would accept him was psych. He had applied to eight surgical programs and was rejected by all of them. According to Brent, the hospital in Detroit where he served his Residency wouldn't hire him as an Attending."

"Holy shit!" Clarissa exclaimed. "Now we know his problem!"

"And Mr. Kirkland will use that if Lawson tries to come gunning for me."

"Does Lawson know you know?"

"He does not. And I bet he doesn't remember calling me for a consult when I was a Fourth Year for my friend Jenny. Mr. Kirkland knows about that, too."

"Jesus, Petrovich!" Clarissa said. "You have HIM over a barrel!"

"So it would seem. Shall we go back in?"

We downed the remainder of our Cokes, then headed back to the hearing room. When the Chairman reconvened the hearing, Mr. Braun did what I expected, and tried to call Doctor Forth.

"Objection," Mr. Kirkland said. "Despite these proceeding being less formal than court proceedings, neither witness appears on the list submitted last week, nor were any supplementary filings made in advance. I contend that neither Doctor Forth nor Doctor Lawson, who I expect to be called, have any testimony that is of probative value.

"At best, they would attempt character assassination by implying that statements made in a didactic setting are material to this hearing. They are not. Nothing they have to say is about the actual case, only about Doctor Loucks, whose testimony was not medical in nature, and was confirmed by Doctor Mercer and by written statements submitted by Mrs. Stephens, Miss Lara Bragg, and Miss Anna Wilson."

"Mr. Braun, do your witnesses have anything to say about Miss Stephens or about the case?"

"Mr. Chairmen, we're allowed to impeach witnesses," Mr. Braun said. "Given the relationships between Doctor Loucks and all the witnesses who gave statements, impeaching him, impeaches them."

"I'll allow you to call them, but you may not ask any questions related to statements or questions Doctor Loucks might have said or asked during his clinical rotations. That is strictly off limits."

Mr. Braun frowned, then said, "I withdraw Doctor Forth, but call Doctor Lawson as an expert witness."

"Mr. Chairman," Tom Kirkland said. "May I have two minutes to confer with counsel?"

"Yes."

I leaned over so both Lara and Clarissa could hear and said, "Hammer time."

They conferred, and I suppressed a laugh when Mr. Braun went to Doctor Lawson, whose face hardened. He turned to glare at me, then spoke to Mr. Braun, who went back to the table where he had been sitting.

"Mr. Chairman, may I have fifteen minutes to confer with my client?"

"We're adjourned for fifteen minutes."

Lara, Clarissa, and I went into the hallway, and this time Mr. Kirkland and the Stephens joined us.

"I take it you explained life to him?" I asked.

"Yes. I made the point that I would get all of that on the record, and paint it as personal animosity against you. That would hurt Doctor Lawsons' reputation more than he could hurt yours. I also have, in my possession, a statement from Doctor Shelly Lindsay to that regard."

"Really?!"

"She got in touch with me, offered to write the statement on the condition that I only use it if Doctor Lawson was called and attempted to, in her words, 'throw you under a bus'."

"Somebody loves you, Petrovich!" Clarissa declared.

"She's been looking out for me since we lost that patient in the OR," I replied.

"You know it's not your fault, right Petrovich?"

"I know, but that doesn't change how I feel about the situation."

"What could you have done?"

"Nothing. It's emotional, not intellectual, which is why Shelly has been talking to me. I'm sure you remember my reaction to the autopsy case with the young girl who was raped and murdered."

"Warranted. And you certainly wear your heart on your sleeve."

"Tom, may I speak with you?" Arthur Braun asked from a few feet away.

XL. Waving the White Flag

August 23, 1989, Columbus, Ohio

Tom Kirkland smiled, then turned, "Sure, Arthur."

They walked away and went into a room.

"White flag," Lara said. "They're going to offer some kind of agreement equivalent to a plea bargain."

"You think?" I asked.

"There's no other reason for Greenberg's counsel to speak to mine. Just wait."

About five minutes later, they emerged from the room, and Mr. Kirkland asked Lara and Angie's parents to join him, which they did.

"Not you?" Clarissa asked.

"I'm not party to the suit, even if I'm pulling the strings, so to speak. We did that on purpose.

About two minutes later, Lara came out and walked over.

"Greenberg will accept a ninety-day non-prejudicial suspension. Tom Kirkland thinks he's looking at a year if we go to the end of the hearing, but, as he warns, we can never be sure how the board will vote. They could let him off the hook completely, or with a reprimand."

"What do the Stephens think?" I asked.

"Same as me -- it's up to you."

"What does 'non-prejudicial' mean?"

"He gets his license back automatically. If the board imposes a suspension, it can be either prejudicial, which means he has to apply for reinstatement, or non-prejudicial, which means he only has to refrain from seeing patients for ninety days, then can resume. Tom doesn't think they'd give him a prejudicial suspension based on a single incident with this fact pattern."

"Take it," I said. "We thought he might not even receive a reprimand when we started."

"OK. I'll right back."

She walked away, leaving me alone with Clarissa.

"That was wise," Clarissa observed.

"I achieved my goal," I said. "He paid a settlement to the Stephens for Angela's future care in the malpractice suit, and he's admitting an error before the State Medical Board."

"Lara didn't say he was admitting error," Clarissa objected.

"No, but by accepting the suspension, he has to admit the allegations were true. I'm sure he'll be permitted to make some kind of statement, and he'll admit that, in hindsight, he made an error in judgment. That will satisfy everyone. Heck, that admission without a suspension would be enough for me."

"That was what you insisted Doctor Mercer do."

I nodded, "Admit your error, learn from it, and move on. Call it medical «metanoia». Which, by the way, is the point of our M & M conferences. Identify the error, learn from it, and move on. Nothing developed or said in those conferences can be used in any way, shape, or form against the treating physician. They're almost as sacrosanct as the confessional, and hence, the parallel I drew by using «metanoia»."

"An interesting parallel" Clarissa declared. "I hadn't considered, but then again, I haven't been immersed in Orthodox Christianity from my first breath."

Lara and the Stephens returned, and Mr. Braun went into the room where Tom Kirkland had remained. They emerged two minutes later and went back into the hearing room. We followed them and took our seats. About five minutes later, the Chairman reconvened the meeting.

"Mr. Chairman," Arthur Braun said. "My client will accept, and the complainant will not object to, a ninety-day non-prejudicial suspension."

"Will Doctor Greenberg be sworn and admit to the complaint?"

"Again, with agreement from the complainant, he will admit to an error in judgment based on a negative outcome."

The Chairman turned off the mics and conferred with his colleagues, and by their nods and facial expressions, I knew the answer before he announced it.

"The Board will accept your offer. Doctor Greenberg, come forward, please."

He did and was sworn in.

"Members of the Committee," Doctor Greenberg said, "after carefully considering my actions and the negative outcome in this case, I admit that I made an error in judgment in my choice of treatment methods for Angela Stephens. I did not assign sufficient weight to her observed behavior, which led me to follow the usual standard of care, which turned out, in this case, to not be appropriate. I apologize to Angie, her parents, her friends, and this Board, and will accept a ninety-day suspension. Thank you."

"Thank you, Doctor Greenberg," Doctor Brewer said. "Your license is suspended as of this moment, and will automatically be reinstated on the ninety-first calendar day from today. You are prohibited from practicing medicine in any form, and from having any contact with your patients. You're instructed to turn over their care temporarily to another licensed physician. You may, of course, discuss the cases with this physician, but treatment decisions are up to them. Any violation will result in an immediate, indeterminate, prejudicial suspension and you would be referred to the local prosecutor for practicing medicine without a license. Do you understand?"

"I do," Doctor Greenberg said.

"You'll receive a letter outlining what I've just said. Do you have any questions?"

"No."

"Then this hearing is adjourned."

He banged the gavel and everyone left the hearing room.

"Mike?" Doctor Mercer called out.

I stopped and walked back to her.

"Should I call you 'Doctor Loucks'?"

"Mike is fine," I replied. "I go by Doctor Mike professionally, but colleagues call me Mike."

"And I'm a colleague?"

"I don't hold grudges," I replied.

"Now that this is behind us, I'd like to restore our relationship, if you think it's possible."

"Doctor Paulus really got on your case, didn't she?"

"Not just about this," Doctor Mercer admitted.

"Kitten?"

"Yes. I'm not surprised you knew that."

"Elizaveta being sixteen was a hobby horse you wanted to ride into the sunset," I said.

"I think you're mixing your metaphors!" Doctor Mercer countered.

"Could be, but it fits," I replied with a smile.

"Call me in the next few weeks; I'd like to get together and catch up."

"I will. And thank you."

"You're welcome."

"Dinner?" Lara asked after Doctor Mercer had walked away.

"I don't think I should. I need to rescue my daughter from her crazy French aunt, then meet Kris at home so we can have dinner and go to Vespers at the Cathedral. We'll see you and Nathan on Sunday for Rachel's birthday party."

"Crazy French aunt?"

"My fifteen-year-old sister-in-law, who is teaching my daughter French and otherwise being a serious troublemaker!"

Both Clarissa and Lara laughed, we hugged, and after speaking briefly to the Stephens, I went over to Mr. Kirkland and thanked him. After shaking his hand, I hurried to my car for the drive to the Korolyovs' house.

August 24, 1989, McKinley, Ohio

"How did it go yesterday?" Doctor Gibbs asked when I arrived in the ED on Thursday morning.

"Ninety-day non-prejudicial suspension with an admission of an error in judgment."

"Wow! What happened?"

"Doctor Greenberg and his counsel felt the risk of a longer suspension was too great after the Chairman ruled in our favor on some key issues. Lawson and Forth were there, but in the end, they couldn't testify."

"What could they have testified to?"

"That in the course of my psych rotations, I had admitted that no doctor should be punished for a judgment call on treatment. But the Board refused to allow that testimony because they didn't want to set a precedent that might deter med students from asking questions or giving their opinions. They limited all testimony by me or about me to my relationship with Angie and her observed behavior."

"So the rumors that Lawson was gunning for you were true."

"They weren't rumors," I replied. "He actually threatened me, but in a way that had plausible deniability. Ultimately, though, he was boxed in by information I had about him failing to Match for surgery despite applying to eight programs and having to Scramble for psych, and that his hospital in Detroit wouldn't hire him as an Attending.

"Add in the fact that he actually called you for me to make a consult as a med student, and allowed me to do intakes as a Third Year, and he had nothing. The Board did hear about 'Mr. Alien Encounter' and the Chairman said I hadn't violated any principles of emergency medicine, so even that was defanged. In the end, rather than take the risk, and have Lawson publicly exposed as being driven by personal animosity, they chose the least risky course of action."

"I think I'd avoid Lawson and Forth for a while."

"I certainly won't go out of my way to see them, and consults are always Fourth Years or Residents. And it's not like there's any love lost between Psych and the ED. And I had support from the surgical team."

"I'm not surprised. How is Krista doing?"

"Average work," I replied. "I'd rate her a three at this point, up from a two. She has a Medicine Sub-I next, so they'll make or break her, as that's her choice for the Match. If she survives that, she'll have her surgical Sub-I, and you know how that works for Fourth Years. It's sink or swim."

"Which will she do?"

"Scrape by, unless she picks up the pace. There's no way she'll Match here, because Shelly Lindsay and Owen Roth will see the same things I have in her procedure book and her attitude. She was smart enough to stop being bitchy around me, but Libby reported that she has a bad attitude at the triage desk."

"Every med student does!"

"Not every."

"OK, not the one who might actually be the alien that 'Mr. Alien Encounter' was concerned about!"

"Which would explain my approach to treating him, now wouldn't it?" I asked with a grin.

Doctor Gibbs laughed, "Hiding in plain sight!"

There was a knock at the door and Ellie opened it and stuck her head in.

"Multi-victim MVA," she said. "At least three victims. First one three minutes out."

"What's free?" Doctor Gibbs asked.

"Trauma 1, 2 and 4," Ellie replied.

"Let's go, Mike. Ellie, ask Doctor Varma to join us and we'll need nurses."

"Already assigned. You have Wendy and Jamie, Mike has Kellie, and Naveen has Angela."

"If there's a fourth victim, give them to Ghost; Ron will have to handle walk-ins."

"Got it!"

I went to the lounge to get my students, and we gowned, gloved, and met the team in the ambulance bay to await the paramedics.

"I'll take the first, Mike the second, Naveen, the third," Doctor Gibbs directed.

Two EMS squads turned into the driveway, then pulled up in front of us. I focused on the second patient, who was being bagged by a firefighter.

"Female, late twenties; unbelted passenger; crush injuries to the chest; fractured arm; forehead lac and contusion; tachy at 120; BP 70 palp; PO₂ 92%; difficult to bag; LOC on site, IV saline TKO; cervical collar and backboard."

That PO₂ was sufficient that I felt I could give Krista her shot at intubation, but only one shot.

"Trauma 2!" I ordered. "Al, monitor then Foley; Krista, bag and I'll walk you through an intubation; Kellie, hang a unit of plasma, type and cross match, CBC, and rapid pregnancy test!"

"EKG?" Al asked.

"Let's see what we have first!"

We quickly moved the gurney, and I called out to Ellie for another nurse, and she came into the room herself. With concerted effort, we moved the patient to the trauma table.

"Ellie, 24 French and intubation tray to Krista!" I ordered.

I saw the questioning look in her eyes, and I didn't disagree, but I had to give Krista the chance. I began my primary exam by auscultation, and immediately found decreased breath sounds from the left lung.

"Tension pneumo! Ellie, I'll need a chest tube tray. Krista, hold off on intubation until I get the tube in, but keep bagging."

"PO₂ 90%, pulse 130, BP 60/20!" Al announced as he moved to insert the Foley catheter.

"She's bleeding internally," I said. "But we need to get the lung re-inflated first."

I slung my stethoscope around my neck and began the thoracostomy necessary for the chest tube. As soon as I cut through the subcutaneous tissue muscle, a gush of blood ran out and the patient's BP bottomed out.

"Ellie, two units on the rapid infuser!" I ordered.

I got the chest tube in and sewed it in place, but didn't worry about taping it.

"Easier to bag?" I asked Krista?

"Yes."

"Where's that blood?" I asked.

"Large bore in," Ellie announced. "Units running in now!"

The patient's BP came up a bit, so I could move on.

"Al, five-lead," I ordered as I cleared the patient's C-spine so I could remove the cervical collar.

"Krista," I said as moved to examine the patient's abdomen, "stop bagging and put the patient in the 'sniffing position'."

"What?" she asked.

That meant she hadn't read the textbook, and it was my fault for not checking first.

"I'll need to do it," I said. "Get me a portable ultrasound, please. We'll discuss after."

She moved, and I quickly inserted the tube, had Ellie bag, and listened. Once I heard good breath sounds," I instructed Ellie to hook up the ventilator.

"Need help?" Ghost asked, coming in.

"I won't turn it down," I said. "Chest tube and vent, about to check the belly. Neuro survey, please."

"Got it."

"Al," I said. "Call upstairs; I'm positive she's surgical. Tell them sinus tach; needs an ex-lap; flail chest; blood in her urine; lost 400ccs during thoracostomy; three units in."

"Sinus tach; ex-lap; flail chest; blood in the urine; lost 400ccs during thoracostomy; three units in," he repeated.

Krista, who was obviously unhappy, pushed the ultrasound in and two minutes later, I confirmed what I had already known.

"Fluid in Morrison's; likely splenic lac; possible liver lac. Let's move! Ellie, portable vent; Kellie, disconnect the EKG and monitor. Al, get a gurney!"

Everyone did as instructed and we transferred the young woman to the gurney and quickly made our way towards the elevator, following right behind Doctor Gibbs and her patient. That meant that at least one scheduled surgery was going to be pushed, if not both, and I was going to get to scrub in.

"Al, stay with the patient; Krista with me up the stairs so they can share the elevator."

Three minutes later, we wheeled our patient into OR 3, where Doctor Burke was waiting with a Resident, three nurses, and a student. I called out the information as we moved the patient to the surgical table.

"Mike, scrub in," he said. "Your Fourth Year can observe."

I'd have strongly preferred keeping Al as he intended to Match for surgery, but there was no reasonable way to make that substitution once Doctor Burke had made his decision.

"Al, go back downstairs and see Ghost," I said. "Krista, with me!"

We went to the scrub room, completed the process with the help of Millie, the scrub nurse, then, with my usual black surgical cap in place, returned to the OR.

"Mike, you're the third surgeon. Stand next to Rob to assist."

I acknowledged and moved, holding retractors, and suctioning as necessary, but mostly watching them work, which was typical for any Resident before PGY3. It took the best part of two hours to repair the abdominal injuries as well as the bleeder in her chest that had resulted in the blood loss during the thoracostomy. When the surgeons had closed the incisions, Krista and I were excused and the patient was taken to recovery, and would certainly go to the ICU and need attention from Ortho.

"Why didn't you let me intubate?" Krista asked as we entered the stairwell. "You said you'd talk me through it!"

"Let's wait until we're someplace more private," I said.

She was quiet, and I led her to the temporary Resident's office, but kept the door open.

"You didn't know the 'sniffing position'," I said. "That indicates you don't know the textbook steps, which is a prerequisite. I should have asked beforehand, but as a Fourth Year, you should have taken the initiative to learn. And that's particularly true given what happened with the EKGs. That alone should have clued you in."

"Oh, right! Like I'm supposed to magically know what I need to know and study?"

"The first thing I and my study group members did when we were starting a new rotation was find out what the standard procedures for that rotation were, and read the relevant textbook material. It's all in there, and if you read the optional material, which you should have known to do after I asked about Doctor Osler, it's all in there."

"You're not being fair!" she protested.

I wanted to say that life wasn't fair, and list Elizaveta, Lee, and Sandy as primary examples, not to mention the young patients who had died in my presence over the previous two years.

"Your lack of initiative, even when prompted, is the cause of your current complaint, not anything I've done."

"How can I learn, if you won't teach me?!"

"How can I teach you, if you won't learn?" I countered.

"What?! How can you say that?"

"Because your medical training is your responsibility. My job is to teach you, your job is to learn. But learning isn't limited to your shifts in the hospital. It means studying anatomy, studying your textbooks, and being proactive. I shouldn't have had to tell you to learn to read an EKG, you should have read your textbook before your cardiology rotation and then asked Doctor Javadi to teach you further."

"I didn't know."

"Let's assume that's the case. I gave you an assignment to learn, then quizzed you. From that, you should have learned a lesson. On your surgical Preceptorship and Clerkship, you had to read about the procedures before they were performed to be able to answer the quizzes during surgery. From that, you should have learned a lesson. Finally, you should have known that learning to intubate is a standard trauma procedure for Fourth Years. You didn't read the textbook, which I know because it expressly describes the 'sniffing position' and calls it that."

"Mike," Ellie called out from the door. "Walk-ins are seriously backed up."

"Two minutes," I replied.

Ellie left, and I turned back to Krista.

"You have five weeks left in this rotation. If you don't have an intubation in your procedure book, you're going to have a tough time Matching for anything except dermatology or psych, and even those will be tough with the paucity of procedures in your book. I suggest you take a break, find your emergency medicine textbook, and learn the procedure. I'll give you a shot if you can tell me the procedure from memory. If not, no chance."

"Take a break?"

"Your call, but we have limited time."

"I'll go home and get my book."

"OK."

She left, and I went to find Al, but he was helping Ghost, so I asked Ellie for assistance from Kellie.

"Can't stay away from me?" Kellie teased.

"I know a good nurse when I see one!"

"I'd say flattery would get you everywhere, but I know you're more than a little married!"

"Being a little married is like being a little pregnant!"

Kellie laughed, and I grabbed the first chart from the rack.

"LOL, seventy-eight, weak and dizzy all over," I chuckled.

"Want to play the lottery and try slot two?" Nate asked.

"No. I'll take this one."

"Where are your students?" Kellie asked.

"I sent Krista to learn the procedure for intubation, and Al is with Ghost because I was in surgery."

"Mike Loucks, Wunderkind! Able to deliver babies one-handed, perform surgery with his eyes closed, and avoid Ellie's clutches!"

"Well, one out of three! Wheelchair, please.

Kellie retrieved a wheelchair, and we went out to the waiting room.

"Mrs. Olson?" I called out.

"Over here," a young woman in her twenties called out.

Kellie and I moved over to where the young woman was sitting with an older woman who looked confused.

"Hi, I'm Doctor Mike," I said.

"Hi, I'm Tracey Copeland and this is my grandma, Alice Olson. She didn't get out of bed this morning, won't talk, and I can't get her to eat."

"Mrs. Olson?" I said and when she didn't respond, I tried again with slightly more volume.

"When did this happen?" I asked Tracey.

"She was fine last night when she went to bed. Normally she's up around 7:00am, but when she wasn't up by 8:00am, I went to check on her. I tried to get her to eat, and when she wouldn't, and wouldn't talk, I dressed her and brought her here."

"You did the right thing," I replied. "Kellie, let's help Mrs. Olson into the wheelchair and take her to Exam 3."

"Can I come with her?" Tracey asked.

"Yes, of course."

Kellie and I helped Mrs. Olson into the wheelchair, then Kellie pushed, and both Tracey and I followed. In the exam room, Kellie and I helped Mrs. Olson onto the exam table. She could walk and stand, but had a blank look on her face, and wasn't communicating.

"Kellie, let's put her on a nasal canula then get a CBC, Chem-20, ABG, cardiac enzymes, and glucose panel," I said. "Tracey, I'm going to examine your grandmother, we'll draw blood, we'll put her on an EKG, and give her oxygen as a precaution. You can sit in the chair next to the treatment bed."

Tracey sat down and Kellie and I began the procedures I'd specified, each of us telling Mrs. Olson what we were doing, but other than a slight moan, when Kellie drew blood, Mrs. Olson didn't react. The EKG showed normal sinus rhythm, though her pulse was a bit low at 60, while her BP was 130/80, which was OK, and her PO₂ was 98% on the canula. I detected no physical signs, and she had proper reflexes. Kellie gave the blood to a student nurse to take to the lab.

"Kellie, let's get her a liter of D5 Ringer's, please. Tracey, we're going to give your grandmother an IV with glucose and electrolytes, because you said she hasn't had anything to eat or drink."

"What do you think is wrong?"

"Right now, I don't know. Other than being non-responsive, nothing is obviously wrong. The EKG shows her heart is beating normally, her blood pressure is fine, and her pulse is a bit low."

"I think that's normal. She used to run marathons."

"That would explain it. How long ago?"

"She ran half marathons after she turned forty-five and only stopped about six years ago."

"Has she been sick at all?"

"No."

"And she's active and eats properly?"

"Yes."

"Are you her caregiver?"

"She doesn't need one. Mom and Dad work, and grandma lives with us. I'm in college, and I work at Kroger during the Summer."

"Taft?"

"Yes. I'm a Junior."

"Is there any history of diabetes in your family?"

"No."

"OK. I don't believe your grandmother is in any immediate danger, so we'll wait to see what the lab results show. We'll send a nursing student in to sit with you until the lab results come back."

"OK. Can I call my mom?"

"Yes. Kellie, my students are busy, so would you get a student nurse to come in, then take Ms. Copeland to the consultation room?"

"Right away, Mike!"

I updated the chart, and Kellie brought Rose, a nursing student, into the room, then escorted Tracey to make her phone call.

"Rose, please keep an eye on the monitor. If she comes around, there are any alarms, or her blood pressure drops below 50 diastolic, call me."

"Yes, Doctor."

I left the room, and Kellie walked over to me.

"What are you thinking, Mike?"

"It doesn't fit anything other than asymptomatic cerebral infarction -- no symptoms other than cognitive functions. It could also be the after effects of a Transient Ischemic Attack. If the labs don't show some kind of electrolyte imbalance, elevated cardiac enzymes, or hypoglycemia, then we'll call neuro and get a CAT scan."

"No thrombolytics?"

"If it is a stroke, it could be hemorrhagic, in fact, it likely is, and thrombolytics would make it worse. We have thirty minutes before the labs are back, so let's see what we have next in our game of walk-in roulette."

"Doctor Mike?" Al said, coming up to me. "Doctor Casper released me."

"What did you do?"

"Sutured an arm lac; he signed my procedure book."

"Good. Let's see what's next in the walk-in lottery! Get a chart, please, and bring the patient into Exam 1."

He took the first chart from the rack, looked it over, and went to the waiting room.

"I'm going to get some coffee," I said. "Then confer with Doctor Gibbs."

I went to the lounge, poured myself a cup of coffee, then went to the see Doctor Gibbs. I presented my patient and my plan.

"You're comfortable waiting?" Doctor Gibbs asked.

"No, but Neuro will want to rule out other causes before they'll authorize a CAT scan, and my patient isn't showing any signs other than aphasia, which could have non-neurological causes. We'll have the blood test results in about twenty-five minutes, I have her on a D5LR IV, an EKG, and oxygen prophylactically, and a student nurse is sitting with the patient and her granddaughter. Given how the patient presents, would you authorize the CAT scan without Neuro?"

"No, but I'm not you!"

"I'd need your signature, and a certification that we can't wait for Neuro, which I don't believe you would give."

"Speak freely, Mike."

"Honestly? It's a toss-up. If we don't find anything, there's a good chance Medicare kicks it back, and too many of those would lead to significant risks to our reimbursement rates. I think it's BS, but, unfortunately, he who pays the piper calls the tune. I want to do it, but I can't justify it under the hospital guidelines."

"Listen to you sounding like an Attending! Or a Chief!"

"I blame you, Shelly, and Carl!" I chuckled. "But in all seriousness, I know we have limited resources and we have to manage them. It sucks, but in this case, 'wait for the labs' is the answer. With more funding, we could do it. But I also wouldn't take money away from the new ED, which will save more lives than paying for a few extra CAT scans."

"Mike Loucks, socialist! The needs of the many outweigh the needs of the few! Or the one!"

"OK, Doctor Spock! And I don't mean the baby doctor! But triage isn't socialist, at least the way you mean -- it's a reasonable application of limited resources. Every system, capitalist or socialist, has to do that. The 'all or none' thinking is simply wrong, because it is literally impossible to supply everything to everyone, no matter what we're talking about. Heck, even Star Trek deals with resource limitations in their supposedly perfect socialist, egalitarian world."

"Your thinking has evolved."

"More like my idealism has run head-on into the brick wall of reality. I have more patients to see."

"Go heal the sick!"

I left the office, returned my coffee mug to the lounge, then went to Exam 1 where Al was with a young woman and Nurse Lisa, conforming to the rules about male doctors being alone with female patients.

"Julie, this is Doctor Mike."

"Hi, Julie," I said.

"Hi."

"Julie Perez, twenty-six," Al said. "Presents with a complaint of numbness and tingling in her left foot. Pulse 76; BP 110/70; temp 36.7°C. No other complaints."

"Julie, this is a teaching hospital," I said. "If you're amenable, I'll have Al take your medical history and examine you. I'll be right here the whole way."

"That's fine," she said

Al sat down on the stool and asked Julie about her medical history, any drugs, recent injuries, medications, and so on. Nothing stood out, so with a look to me, he began his exam, which included asking Julie to walk several steps, as well as checking her reflexes.

"No motor or reflex impairment," Al said.

"So, what do you want to do?" I asked.

"I don't know," he admitted.

"A perfectly legitimate answer for a student. Your next step is a neuropathy test. Have you seen one performed?"

"No."

"OK. Observe, and you'll know how to do one in the future. Becky, neuropathy probe, please."

I washed my hands, put on gloves, then accepted the small metal probe.

"Julie, I'm going to touch this to your skin on your feet, ankles, and calves, then on your hands, wrists, and lower arm. You tell me each time you feel it, OK?"

"Yes."

I began with the leg that wasn't bothering her and she had no trouble detecting each touch of the probe. I repeated the test on her left leg, and she missed five touches, three on her big toe, and two on the ball of her foot. I repeated the test with both hands and arms, and she had no trouble detecting them.

"No back pain of any kind?" I asked.

"None."

"OK. We'll draw some blood, and once we see the results, I'll have a specialist examine you."

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

"Right now, all I can say is that you're exhibiting peripheral neuropathy, that is, loss of sensation in your foot. There are numerous causes, most of which are easily treatable. Becky, CBC and glucose panel, please."

Becky acknowledged my orders, and Al wrote them on the chart, which I signed.

"What are those tests?" Julie asked.

"A CBC is a Complete Blood Count and is exactly what it sounds like -- a count of each type of cell in your blood. The main thing we'll look for is an elevated white count, which is a sign of infection. A glucose panel measures your blood sugar. The reason for that test is that a high level of blood sugar is one common cause of peripheral neuropathy. Just relax, Becky will draw some blood, and I'll be back when we have more information."

"Thank you, Doctor."

"You're welcome! Al, with me, please."

We left and went to Exam 3 to check on Mrs. Olson. There had been no changes, and the lab results weren't back, so I asked Al to get the next chart. I took the opportunity to empty my bladder, then went to Exam 5, where Al was waiting with a male patient in his fifties.

"Joseph Nylander, fifty-six; complaining of severe indigestion; BP 130/90; Pulse 100."

I looked at the patient and made a snap decision.

"Hi, Mr. Nylander, I'm Doctor Mike. We're going to move to another room. Al, Trauma 2."

"What's wrong?" Mr. Nylander asked.

"I think you might be having a heart attack."

Al and I escorted Mr. Nylander to Trauma 2 and had him lie down on the treatment table, and I waved Kellie to join us.

"Al, monitor and five-lead," I ordered. "Kellie, nasal canula."

I quickly washed my hands, put on gloves, then did a quick exam. Once Al had the equipment hooked up, I looked up at the monitor that Al had turned on. There was no clear arrhythmia on the five-lead, but that only ruled out an ongoing ST-Elevation Myocardial Infarction, or STEMI.

"Kellie, nitro tab sub-lingual, then draw blood for Chem-20, lipid panel, and cardiac enzymes. Get the blood to the lab, stat."

"Sublingual nitro," she repeated. "Draw for Chem-20, lipids, and cardiac enzymes."

"We're going to give you medication which should relieve the pain," I said. "And we'll draw blood to check to see if you've had a heart attack."

"I thought the monitor would show it," he countered.

"Not always, and they only show what's happening right now, whereas blood tests will tell us what happened in the past four to six hours."

Kellie placed the nitroglycerin tablet under Mr. Nylander's tongue, drew the blood, then gave it to a student nurse to take to the lab.

"BP dropped," Al announced. "100/70."

"Why would that happen?" I asked.

"The nitroglycerin."

"Yes. Mr. Nylander, how does your chest feel?"

"It doesn't hurt nearly as bad," he said.

"When did the pain start?"

"Maybe an hour ago."

"What were you doing?"

"Sitting at my desk."

"Any exercise this morning?"

"I have a treadmill at home, but that was around 6:00am and the pain didn't start until much later."

Which was typical for unstable angina, but that didn't rule out a Non-STEMI.

"Have you had pain like this before?"

"After eating at Taco Bell," he replied.

I chuckled, "I hear you! Did you eat any spicy food last night or this morning?"

"No. I usually don't get indigestion except from Taco Bell. But I can't quit it!"

"Do you smoke or drink to excess?"

"Never smoked, and I'll have a shot of bourbon three or four times a week."

"How often do you exercise?"

"Thirty minutes on the treadmill three times per week; doctor's orders."

"For anything specific?"

"I had put on about fifteen pounds."

"Taco Bell will do that."

"That's what he said! But I took off the weight, so he doesn't give me too much grief about my addiction to really bad Mexican food."

That gave me another clue about what might be wrong -- atherosclerosis.

"Kellie, IV saline and push 250mg ASA, please."

"Saline IV, push 250mg ASA," Kellie repeated, as Al wrote it on the chart.

"We're going to give you an IV, along with some additional medication," I said.

"What's got you worried, Doc?" he asked as Kellie inserted the IV.

"Atherosclerosis, which is a narrowing of your blood vessels. Your Taco Bell diet might be coming back to haunt you in other ways than gaining weight. How are you feeling?"

"Much better. Can I ask a question?"

"Sure."

"Everyone I saw coming in but you is wearing blue. Why are you wearing red?"

"I'm a trauma surgeon," I replied. "I work for the Chief of the surgical service, but I'm assigned to the emergency department."

"And they have you handling walk-in cases?"

"Everyone does, but I'm an Intern, which is the low man on the ladder, so I do more walk-ins than anything."

"You seem pretty smart for a brand-new doctor."

"He is very smart," Kellie said. "You have the best doctor in the Emergency Department."

"I thought you guys always wore white coats."

"It's optional for my service," I said. "We only wear medical coats on rounds, and always over a shirt and tie, not scrubs. Medical coats are standard on most services. In the Emergency Department, medical students always wear them, and most Attendings, that is, senior doctors, do as well. Surgeons don't wear them in the OR."

"Thanks for answering my questions."

"I'm going to go check on my other patients. Al will stay with you to watch the monitors. He's one of my best students."

Kellie and I left, and Nate signaled me to come to his desk. He let me know the lab had called with Mrs. Olson's results, and that a student nurse had chased them for me. I looked them over and saw nothing out of the ordinary for a woman of Mrs. Olson's age, though her blood sugar was a bit low. That wasn't surprising, given she hadn't eaten breakfast.

"Zilch on the labs on the aphasia," I said to Doctor Gibbs from the door to her office. "I'm going to call Neuro."

"What's your best guess?"

"Hemorrhagic stroke followed by a tumor. Given the sudden onset, I don't think it's neurological disease."

"I concur."

"Thanks."

I left and went to the nurses' station and used the phone to call for a neurological consult, then went into the room where Mrs. Olson and her granddaughter were.

"Your grandmother's blood tests came back normal, except for slightly low blood sugar, but I attribute that to eating nothing since last night. The IV we gave her should take care of that. I've called our neurology department to send someone to examine your grandmother, and they'll be here shortly."

"What do you think is wrong?"

I contemplated if I should demur, but decided I could answer.

"Most likely, she's had a very mild stroke, but we'll need to do a CAT scan to verify that. I'll confer with the neurologist once they complete their exam."

"Will she recover?"

"The answer to that question will have to wait until we complete further tests."

The door opened and Nate let me know that Mrs. Olson's daughter was in the waiting room.

"Rose, would you escort Mrs. Copeland in from the waiting room?"

"Right away, Doctor!" she said brightly.

She left and returned about a minute later.

"What happened?" Mrs. Copeland asked the moment she was in the room.

"Grandma didn't wake up at her usual time, so about 8:00am I went to check on her and she wasn't able to talk, so I dressed her and brought her here. This is Doctor Mike, who's trying to find out what's wrong."

"Hi, Mrs. Copeland," I said. "We've run several tests and in a few minutes, a specialist from neurology will examine your mom."

"What's wrong?"

"We don't know yet. Our next step is most likely a CAT scan to see if she's had a stroke."

"NO!" Mrs. Copeland gasped.

"We don't know for sure," I said trying to soothe her. "All the tests have come back normal so far, and her heart and lungs are in excellent condition for a woman of her age. Those are all positive signs."

"Vanderberg, Neuro," Lucy Vanderberg announced coming into the room with a male student.

"Hi, Lucy," I said. "Alice Olson, seventy-eight; presented with aphasia; blood work shows no anomalies except low blood sugar consistent with no food intake since last night; nasal canula and D5 Ringer's. Patient's granddaughter discovered the patient in this state about 8:00am and brought her in by private vehicle. No reported injuries, no reported illnesses. Recommend a diagnostic CT. This is Mrs. Copeland, Mrs. Olson's daughter, and this is Tracey, her granddaughter."

"Hello," Lucy said to all three women. "Mrs. Copeland, I'm going to examine your mom, and then we'll take her for a CAT scan. Mike, I'll admit her either way."

"OK. Tracey, Mrs. Copeland, you're in good hands with Doctor Vanderberg. She's an excellent neurosurgeon and will take good care of your mom and grandmother."

"Thanks so much!" Tracey gushed.

"You're welcome. Rose, you can go about your duties."

I updated the chart as Lucy began her exam, signed it, then filled out the admission form, which I also signed. I set the chart on the table, then left the exam room and went to check on Mr. Nylander, who was feeling OK, and had what appeared to be normal sinus rhythm on the monitor.

I got some coffee, then reviewed the lab results for Julie Perez, which were completely normal for a healthy young woman. Given that, I returned to the exam room where Lucy Vanderberg was completing her exam.

"Lucy, I have another one for you," I said.

"OK. Luke, call radiology and let them know we need a CAT scan stat, then call for an orderly with a wheel chair. Mrs. Copeland, I need to check another patient, but I'll be back shortly."

Lucy stepped out, and I presented my second case.

"Let's go see her," Lucy said

XLI. You're Still a Pain in the Ass, Loucks!

August 24, 1989, McKinley, Ohio

"Julie Perez, twenty-six," I said. "Presents with a complaint of numbness and tingling in her left foot, with onset early this morning. Pulse 76; BP 110/70; temp 36.7°C. No other complaints. Nothing remarkable on exam; nothing remarkable in the blood work. No motor or reflex impairment, but a neuropathy test showed lack of sensation for five touches on her lower leg, three on her big toe, and two on the ball of her foot. Moderately active with no family history of neuropathic disease."

"Hi, Julie, I'm Doctor Lucy Vanderberg from neurology. I'm going to examine you, and very likely ask some of the same questions Doctor Mike asked."

It had actually been Al, but there was no point in correcting that, as I'd listened to the entire exchange and Al had done a very good job.

"OK," Julie agreed.

Lucy performed her exam, including a neuropathy test, confirming my findings.

"Mike," Doctor Vanderberg said, "let's get a complete set of x-rays from the knee down, on both legs. I'll review those before we decide next steps."

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

"The most likely cause of the symptoms you're exhibiting is compression neuropathy, that is, something pressing on a nerve in your leg. The x-rays are to rule out a cyst or other condition that might cause it. If the x-rays are negative, we'll try soft-tissue treatment, which, in layman's terms, is massage therapy, as muscle tension or tightness can cause the symptoms you're experiencing. I'll come back and see you once we have the x-rays."

"Thanks."

"Mike, call me when you have the films."

"Will do," I replied. "Thanks, Lucy. Julie, I'll make the arrangements and be right back."

I followed Doctor Vandenberg from the treatment room, electing to make the call from the clerk's desk as otherwise I'd have been alone with Julie. I called Radiology and arranged for the x-rays, then called for an orderly. I asked Kellie to join me, then went back into the treatment room to let Julie know that an orderly would take her to Radiology in a wheelchair.

I left the room and returned to check on Mr. Nylander. His labs were back, and showed no elevated cardiac enzymes which strongly suggested he hadn't had a heart attack, and when combined with the EKG, indicated either unstable angina or atherosclerosis. That meant a toss-up of a cardiac consult or referring him to his personal physician and advising him to see a cardiologist.

I had a very strong feeling that I could safely street him, but the last thing I wanted was a bounceback MI caused because his arteries were seriously occluded. The counterargument was that he wasn't having an MI, and could reasonably safely schedule a non-emergency stress test and cardiac echo.

"I don't see any signs of a heart attack," I said to him. "Your cardiac enzymes are normal, as is your EKG. Give me ten minutes to confer with a colleague, and I'll let you know the next steps."

"Mind telling me what you think?"

"Not at all. The two most likely diagnoses are unstable angina or atherosclerosis, and those aren't mutually exclusive. Both are treatable, and neither of them are immediately life-threatening. The options are admitting you for further testing or releasing you with instructions to see your personal physician and a cardiologist. My inclination is for the latter, because you'll be far more comfortable sleeping at home than here at the hospital.

"But, as we discussed earlier, I'm an Intern, so I need to discuss this with my mentor to confirm my findings. That said, if you prefer, I can call a cardiologist who'll examine you and decide between those two options. Generally speaking, with your symptoms, cardiology would give the same opinion I just provided. But before you decide, I want to at least discuss this with my mentor."

"Thanks for the total honesty," he said. "So far, you seem to have done everything right."

"Thanks. Al, you can come with me to present to Doctor Gibbs. I don't believe Mr. Nylander is at any immediate risk."

Kellie moved to check Mr. Nylander's IV while Al and I headed to the Attending's office to see Doctor Gibbs. I presented the case and my recommendation.

"I think you're right," she said. "Will the patient accept being streeted with a referral?"

"Yes. I discussed the two options before I came to present. I did state that I would call a cardiologist if he insisted, but he didn't seem inclined to do that. Al watched the monitor for a good twenty minutes and saw nary a blip. All symptoms resolved with nitro and ASA, as I mentioned. I'll street him and tell him to take a daily low-dose aspirin until he sees his personal physician."

"Approved."

I handed her the chart, she made some notations, signed it, and handed it back.

"Al," Doctor Gibbs said, "run me through how you'd deliver this information to the patient."

"Well, given Doctor Mike already suggested the course of action, I think simply saying that we confirmed our diagnosis with you, and we don't believe he's in danger of an immediate heart attack. As such, he should follow up with his personal physician as soon as possible, and see a cardiologist. I'd advise him to take a daily low-dose aspirin tablet until told otherwise by his doctor or a cardiologist, and if he experiences further symptoms, he should call 9-1-1. And lay off the Taco Bell."

"Good job. Mike, you deliver the diagnosis and treatment plan."

"Will do," I replied.

Al and I left and returned to the treatment room to advise Mr. Nylander, and he, as I had been positive he would, accepted the plan of seeing his doctor and a cardiologist. While I filled out the discharge paperwork, Al disconnected the EKG and pulse oximeter, then removed the IV. I went over the discharge instructions with Mr. Nylander, referred him to the cardiology practice in the nearby medical building, then directed him to Patient Services.

"Thanks, Doc," he said. "I appreciate you explaining everything."

"You're welcome."

After Mr. Nylander put on his shirt, Al escorted him to Patient Services, and I checked with Nate, who said that the orderly had taken Julie for her x-rays. Al and I went to the lounge to get coffee, and I saw Krista on the couch reading a textbook.

"Let me know when you're ready for your quiz," I said to her as I poured myself a mug of coffee.

"High-speed, head-on MVA coming in," Ellie said from the door to the lounge. "Ghost asked for you to join him. Three minutes out."

"Be right there," I replied. "Krista, your choice if you want to keep studying or join us. Al, let's go."

I didn't wait for Krista's decision, as I didn't have time to debate or discuss it, and only she could save herself at this point. Al and I quickly left the lounge, put on disposable trauma gowns and gloves, and headed for the ambulance bay where Ghost, Angela, and Matt, a Fourth Year, were waiting.

"Where's your other student?" Ghost asked.

"Studying the procedure for RSI, as directed," I replied.

"Let's chat after this trauma."

"OK."

"Matt, intubate; Al, EKG and monitor, then Foley. Angela, full trauma panel; Mike, evaluate lower extremities and be ready for a pneumothorax or hemothorax."

Everyone acknowledged his orders and a minute later, the EMS squad rolled to a stop in front of us and Bobby hopped out.

"Male, nineteen; high-speed, head-on MVA; belted; tachy at 120; BP 80 palp; PO₂ 93% on ten liters; severe crush injuries to both legs; severe hematoma left temple; facial and left arm lacs; GCS 7; 5mg morphine; IV saline TKO."

"Trauma 1!" Ghost ordered.

With that blood pressure, he was most likely bleeding internally, though it could also be an effect of the morphine they'd given him.

"Single car?" I asked as we hurried into the trauma room.

"Two," Bobby replied. "Other driver exsanguinated on site."

In the trauma room, we moved the patient to the trauma table, and everyone got to work.

"Tube is in!" Matt announced.

"Good breath sounds right and left," Ghost announced.

"V-tach!" Al announced. "Pulse 140, BP 70 over unmeasurable, PO₂ 93%."

"Compound fracture right tibia," I called out. "Crush injury left tibia. Need an ortho consult."

"Foley is in," Al announced. "Blood in the bag."

"Belly is rigid," Ghost said. "He'll need an ex lap before ortho. Al, get the ultrasound for Mike."

Five minutes later, having confirmed free fluid in the patient's abdomen, we were on our way up to the OR. I wasn't invited to scrub in, so Al and I returned to the ED. I poured out the cold cup of coffee, refilled it, and Krista said she was ready to explain the procedure for Rapid Sequence Intubation.

She went through the procedure sufficiently well that I felt I could try to talk her through an intubation. I drank my coffee, then went to check Julie's x-rays. I saw a cyst just below her knee that was most likely the cause of her problem, which made resolving it simple, and the only possible complication would be if the cyst were malignant. I called Lucy Vandenberg, and she came down to review the films.

"I agree," she said. "That cyst is absolutely the cause of her symptoms. It's outpatient surgery and a general surgeon can do it because it's pressing on the nerve, not involving it. Street her with a referral to the outpatient clinic."

"Will do. Thanks, Lucy."

"Good job reading the x-ray."

"Thanks," I replied.

"If you ever want to do REALLY challenging work, come see me when you pass your general surgery boards."

"I like adrenaline far too much to do neuro! And I have to feed my caffeine addiction. That doesn't bode well for rooting around someone's brain with surgical instruments!"

Lucy laughed, "That is the one thing I miss, but you're right."

She left and Krista, Al, and I went to see Julie.

"You have a cyst," I said. "Let me put the x-rays up on the light panel and I'll show you."

I went over to the panel and showed her the small cyst just behind the lower portion of her knee.

"That's it?"

"Yes. You'll need surgery to remove it, but it's an outpatient procedure. I'll write you discharge orders, and you can go down the corridor, through the main lobby, and about thirty feet down the next corridor. That's where the outpatient center is. The nurse there will schedule an appointment for you."

"What do I tell her?"

"I'll give you a referral sheet that has the details. Give it to the nurse and she'll explain everything to you and get you onto the schedule."

"Thanks very much," Julie said. "Can you tell me what caused the cyst?"

"The surgeon and the pathologist who'll examine it after it's removed are best suited to answer that question. The x-ray really doesn't tell us more than that it's there and how big it is."

I sat down and wrote out the referral form for Julie's outpatient procedure, then filled out the discharge form. I handed her both, advised her she could take Tylenol or Advil for any discomfort, and then directed her to the outpatient clinic. Once she was on her way, I suggested to Krista and Al that they take their meal break, and I went to find Ghost. We went to the temporary Resident's office, and he shut the door.

"What happened with Krista?" he asked.

"Right before you came into the first MVA, I was going to talk Krista through an intubation and she didn't know what the 'sniffing position' was."

"Oh, for Pete's sake!" Ghost exclaimed. "She's a Fourth Year halfway through her trauma Sub-I!"

"I realize. I partly blame myself, because I should have asked as soon as I saw how light her procedure book was. After she observed the surgery on that MVA, I instructed her to take a break, get her textbook, and memorize the steps for Rapid Sequence Intubation. When Ellie let me know about the most recent MVA, I gave Krista an option of studying or joining the trauma. She chose to study, and when I asked after the trauma, she could repeat the steps sufficiently to be guided through them."

"You may not want to hear this," Ghost said, "but not everyone who wants to be a physician is cut out to be one. Krista is not. I know you think she's a reclamation project, but I honestly don't believe she can be reclaimed. You spoke with Leila Javadi and you saw Krista's procedure book and you've heard about her previous reviews. Do you feel she's qualified to be a doctor?"

"I think the correct answer is I'm not ready to say she's not. "

"How would you rate her?"

"Ask me in about five weeks."

"She's had three weeks, Mike. I don't believe she's going to turn it around. I know you're predisposed to see the good in everyone, and that's admirable, but our evaluations are not about finding the good, or giving someone the benefit of the doubt. I've heard the same things about Krista from Doctor Baxter and Doctor Billings, as well as Doctor Gibbs. You've heard it from Doctor Gibbs, Doctor Javadi, and you've seen her procedure book. Is it, as she says, that everyone is out to get her, or is she just not cut out to be a physician?"

"I believe that too often opinions are formed and become self-fulfilling prophecies. For every Tim Burg, there are three or four Felicity Howards, and the ratio might even be greater."

"So all of us are wrong, and Mike Loucks is right?"

"As you pointed out, I'm predisposed to see the good, and to believe everyone can be saved. That translates into believing people can be successful in their endeavors with proper support and encouragement."

"Let me know when the Reds put you into a game as a reliever instead of John Franco, or the Bengals bench Boomer Esiason, so you can start. Or, given your predilection for hockey, when Mario Lemieux steps aside so you can play. Or, to switch professions, when President Bush asks you to take command of the USS Nimitz."

"Interesting analogies, but there's a major flaw. Were I a AAA minor leaguer, a college Senior starting for Ohio State, or the XO on a carrier, then the analogy would actually work, because I'd be basically qualified for those roles, similar to having an undergrad degree in biology, having scored well enough on the MCAT to get into medical school, and having passed step 1 of the MLE. Neither you nor I could walk onto a ball field and make a team any more than a High School Senior could walk into the hospital and be a Sub-Intern."

"Then assume you are in one of those roles -- playing AAA ball for the Nashville Sounds, the Reds farm team. Does that guarantee you'll ever make it to the Majors? And if you do, that you'll ever be a starter? Or, in Franco's case, a closer? Would winning the Heisman Trophy twice guarantee you being a great NFL player? Or would being XO on a carrier guarantee you command?"

"Archie Griffin?" I asked.

"Decent rookie year, but then four years without a touchdown and only mediocre stats."

"But he did make the NFL!" I countered.

"And yet, by all evidence, didn't belong there, despite being one of the greatest college football players of all time, and the only one to ever win the Heisman Trophy twice. That is, in fact, an excellent parallel -- great undergrad performance, good MCAT, good classroom work, and passing step 1 of the MLE, but then flaming out.

"Allowing for the differences between sports and medicine, that is exactly what is happening here. We're the equivalent of scouts, evaluating players and determining which ones we want to draft, hoping to get the best possible prospects onto our team. The difference is, we don't have minor league teams to which we can assign our draft picks. They have to be starters from the moment they're drafted.

"And let's compare to a specific known quantity. Think back a year to your first trauma Sub-I. You were trusted to do things usually reserved for Interns. And that was true of every member of your study group. I'm going to ask a question and I want a completely honest answer from you, without any qualifications -- would you have accepted Krista to your study group?"

"Yes," I replied. "Unequivocally. The problem with her is NOT academics or book knowledge, but clinical skills."

Ghost smiled wanly, "I walked right into that one."

"You did," I replied.

"Then forget I even asked that question! But the point remains -- she is not ready to call up to the majors. Of your six students, across all your shifts, where would she rank?"

"Last," I replied.

"And if you had to decide between Al and Krista for a procedure, which one would you trust to do it?"

"Al," I replied.

"Think about that, Mike. He's a Third Year in his second rotation. Krista is a Fourth Year in her eighth rotation. I understand you rooting for the underdog and believing in the innate goodness of every individual, but in the end, that's not what we're about. We're about saving lives. Can Krista save a life? You certainly could as a Fourth Year, as could Clarissa, Maryam, Fran, Peter, and Nadine. Krista probably belongs in research, if she wants to stay in the medical field."

"Is it Doctor Gibbs' intention to give her a failing grade?" I asked.

"I think that is the only way to send a clear message that she should consider her alternatives."

"She believes she's being treated unfairly."

"Do you think that's the case? Have you treated her unfairly?"

"I'm dissatisfied with how the Emergency Department has handled this," I replied.

"But was it unfair, or was it a reflection of her skills and abilities, or lack thereof? And it's not just the ED, Mike. YOU immediately noticed her procedure book was seriously deficient, and took it upon yourself to speak to Leila Javadi to get another opinion."

"Krista still has five weeks to improve," I countered.

"That's true, but do you really believe she can do that?"

"It doesn't matter if I believe it; it matters if she believes it and acts on that belief."

"And yet, in the end, what she thinks is of only passing interest. It's the judgment of Attendings and Residents that matters. If she can't convince us, she has no future in clinical medicine. You and I discussed that early on -- now it's her turn to ask for admission to the guild. You made the point, time and again, you had to satisfy us to be invited in, and you made damned sure you did, as did your friends. Hold her to the same standard as you hold yourself, which is, as you and Father Nicholas have pointed out, the entire point behind the 'do not judge' command Jesus gave."

"This is where I'd use a specific Russian word with Clarissa!" I chuckled.

"I'll probably regret asking, but which one?"

"«мудак»," I replied. "It means a-hole. And is said in a tone that conveys my displeasure with my own words being turned on me. Which, of course, is what pissed off the religious leaders in Jesus' time. And the jury that tried Socrates."

"I believe the correct response is to say 'Physician, heal thyself'."

I smiled, "«Ατρέ, θεράπευσον σεαυτόν». Or, perhaps you prefer Medice, cura te ipsum."

"Fucking showoff!" Doctor Casper said, shaking his head.

"I try," I chuckled. "Though I did stoop to quoting Jerome, who did almost as much damage as Augustine of Hippo when it comes to what passes for Western Christianity."

Ghost laughed and shook his head, "I should have known the latent theologian would make an appearance."

"Hey, YOU quoted the Scriptures, so what did you expect? That said, it is an ancient proverb, and a similar phrase was used by Aeschylus in the 6th century BC."

"OK, how in Loki's name do you know that?!"

"The Norse God of chaos, also known as the trickster," I replied with a grin. "He could be my patron! It came up in my reading when I was studying to be a catechist. The Greek and Latin I quoted are directly from the New Testament -- the ancient Greek text and Jerome's Vulgate. The reference to Aeschylus, along with similar Hebrew proverbs, was in a commentary on Luke's Gospel."

"And you know Loki!"

"A course in world religions at Taft taught by a Roman Catholic priest, who also taught Latin."

There was a knock at the door and I reached over and opened it to find Ellie.

"EMS two minutes out with an MI for you, Ghost," she said. "Mike, Doctor Varma needs help with walk-ins."

"Thanks, Ellie," Ghost said. "Let's get to work, Doctor!"

"Ellie, is Kellie available?" I asked. "My students are on their meal break."

"I'm available!" she said with a wink.

I chuckled, "Nice try, but I'd need trauma services if I took you up on the true intent of that offer."

"Kellie is all yours!"

"Thanks."

I went to the clerk's desk and grabbed the first chart in the rack. I scanned the chart for the thirty-six-year-old woman, which showed pulse, BP, and PO₂ were all in range, temperature slightly elevated at 99.9°F, with the only complaint being lower-left quadrant pain. I checked the board for an available room, wrote the patient's last name on it, then Kellie and I went to the waiting room and I called out for the patient, Ms. Collins. She identified herself, and after I introduced myself and Kellie, we escorted Ms. Collins to Exam 3.

"What brings you to us today?" I asked.

"A sharp, shooting pain in my lower back which seems to spread to my, uhm, lady parts."

I almost laughed, but managed not to. There were plenty of people who were prudish about their bodies, and that often led to the use of euphemisms.

"Is it constant?"

"No. It's not regular, as in, like once every hour, but when it hurts, really hurts and lasts for maybe forty minutes."

"Does it occur in some relation to your meals? Say, two hours after a meal or some regular pattern like that?"

"No."

"What about in relation to having a bowel movement or emptying your bladder?"

"Not that I've noticed."

"Any constipation?"

"No."

"Do you eat a lot of nuts or seeds?"

"No."

"Is there any chance you could be pregnant?"

"Heavens no! I take my Pills religiously!"

"Let me rephrase that question -- have you engaged in intercourse since your last period?"

"Yes."

The most likely differential diagnoses were, in order, diverticulitis, kidney stones, bowel obstruction, ovarian cyst, or ectopic pregnancy. Less likely were appendicitis or gallstones, as those typically had right-side pain, not left. Of course, there were other potential causes, but those were the ones I'd need to rule out.

"I'm going to have Kellie draw some blood and get a urine sample, then I'll do an exam."

"What do you think is wrong?" Ms. Collins asked.

"The list of possibilities is fairly long," I replied. "And most are easily treatable. Let's see what the exam and test results show, then we can discuss the potential cause."

"OK."

"Kellie, CBC, Chem-20, pregnancy test, and basic urinalysis."

"Pregnancy test?!" Ms. Collins gasped. "Why?"

"Because the Pill, even with perfect use, is not a guarantee. Your OB/GYN should have discussed that with you. The failure rate for the Pill is reported multiple ways, but the one I think best reflects the situation is that over the course of their lives, one woman in a hundred will become pregnant while using the Pill. Another statistic is that the pregnancy rate for women on the pill is about 3 in 1000 per year."

"That is the LAST thing I need," she sighed.

"Kellie will take you to the restroom so you can provide a urine sample, then bring you back and draw a few tubes of blood. I'll be back in about five minutes."

She acknowledged me and I left the room and went to the lounge, where Al was studying his trauma textbook.

"Is Krista at the triage desk?" I asked.

"Yes. We came back about a minute ago. I just sat down. I saw you had a patient on the board, but didn't want to interrupt."

"It's OK. You just come to the exam room and let me know you're back. If there's a reason for you not to come in, I'll tell you."

I filled a paper cup from the water cooler, downed it, then sat down to relax for a few minutes, and give Kellie a chance to take care of the blood draw and urine sample. Just as I was about to get up, Kellie came into the lounge.

"Ms. Collins' urine sample had a slight pinkish tinge," Kellie reported.

I nodded, "Hematuria is a sign of kidney stones, which was my second option after diverticulitis. Let's go do the exam."

Kellie, Al, and I returned to Trauma 3, and after introducing Al as my student, I performed a physical exam on Ms. Collins, finding tenderness at her costovertebral angle, which was between her twelfth rib and her vertebral column. That was the area of her kidney, and was further indication I was on the right path.

"Al, would you get the portable ultrasound, please?"

"Right away, Doctor!" he said, then left the room.

"I strongly suspect you have kidney stones," I said to Mrs. Collins. "While we're waiting for the blood test results to come back, I'm going to do an ultrasound to rule out an ovarian cyst."

"Kidney stones? What causes that?"

"There are a number of things, including genetics and diet. Once we have the blood work back, and I see the ultrasound images, I'll refer you to a urologist."

Al returned with the ultrasound machine, and I checked for cysts, and for completeness, ectopic pregnancy, then searched for the kidney stones. I wasn't able to locate them, but ultrasound wasn't the best way to see them; a CAT scan would be much better for that purpose.

"No ovarian cysts," I said. "Your lab results will be back in about thirty minutes. Just relax until then. Are you in pain now?"

"Yes, but it's not terrible."

"We'll get you something for that. Kellie, 600mg ibuprofen, please."

The three of us left the room, and while Kellie went to get the medication, I checked with Doctor Gibbs and took my meal break. I went to daycare, picked up Rachel, and then went to meet with Antonne, Paul, Julius, Jordan, Conchita, and Danika. As I expected, Conchita asked to give Rachel her lunch, and when Rachel didn't object, I agreed.

We had a nice lunch and caught up on what they had done during their Summer break. When we finished, I took Rachel back to daycare, then returned to the ED just as Al was bringing back the test results for Mrs. Collins. Everything looked normal except a small amount of blood in her urine and a slightly high calcium level, both of which tended to confirm my diagnosis. I presented to Doctor Gibbs, and after she signed the chart, I discharged Ms. Collins with a referral to a urologist.

The afternoon was relatively calm, with a series of fairly mundane walk-ins, and at 6:15pm, I met Kris and Rachel in the cafeteria for dinner.

"Is everything still the same as we discussed for tomorrow?" Kris asked.

"The White Coat Ceremony is at 3:00pm. Loretta said I can leave at 1:45pm, so I plan to drive home, shower, dress, and get back to the ceremony to give my speech. The ceremony ends around 5:00pm. I'll leave then, come home to get you, and then we'll go to the Holiday Inn. Lyudmila is staying at the house with Rachel, right?"

"Yes. My parents will bring her to the house around 5:00pm and come get her at 11:30pm. How do you dress?"

"Shirt, tie, and medical coat. I rarely wear my medical coat, but that's the attire for the ceremony."

"To the banquet, as well?"

"No. I'll put on my suit coat for that."

"Is wearing my blue dress OK?"

"I prefer it on the floor next to the bed," I teased.

Kris laughed softly, "After the banquet! Though we should probably hang it up."

"Oh, I suppose..." I replied with faux resignation.

"How was your day? she asked.

"Fairly typical, mostly walk-ins, but a pair of MVAs -- auto accidents. I was able to scrub in on one of the surgeries and was allowed to hold a retractor."

"I find it so strange that you and your friends are so excited about something so easy and simple!"

"Because it's the first step. If you're trusted to do that, you'll be trusted to do more. It's how things started with every procedure I'm allowed to do -- simple things like drawing blood, hooking up EKGs, putting in Foley catheters, and so on. You build on each step, gaining experience and earning trust. That's why I'm mostly left to work independently, though I do have to present cases to Attendings and gain approval in most instances."

"Daddy?" Rachel said.

"Yes?"

"Daddy home?"

"Daddy can't come home tonight," I said. "He has to help sick people."

She pouted, but there wasn't anything I could do about it. On the plus side, in a week, my shift would change, and I'd be home every night. If Rachel were a bit older, she might understand the concept of a week, and I couldn't even use 'sleep times', which I'd heard people use, as Rachel napped in the afternoons.

"She misses you," Kris said. "I do, too, but I made the deal."

"Fortunately, we're going to eighty hours maximum, and I'll be home every night. We'll just need to adjust her sleep schedule because I won't be home until about 9:30pm on Mondays, Tuesdays, and Thursdays. I'll be home by 5:30pm the other nights."

"We should find some time on Sunday to sit down with your new schedule and figure that out," Kris observed.

"We should," I agreed.

We finished our meal, and I walked Kris and Rachel out to Kris' Tempo. I kissed them, told them I loved them, then headed back into the hospital for the remaining twenty-three hours on my shift.

August 25, 1989, McKinley, Ohio

"Did you get any sleep?" Clarissa asked when we met for breakfast on Friday morning.

"About seventy minutes total," I replied. "I think half the county decided it was the perfect night to call 9-1-1."

"And you have the alumnus speech and the banquet to go to."

"I'll manage. I can sleep in tomorrow. I let Kim know I wasn't going to make band practice."

"How are you guys working that?"

"I'm going to practice at home by playing for Rachel. We'll have one group practice session before each concert, probably on the Friday evening before the concert. It's not a perfect solution, but it'll work. How was Medicine last night?"

"You should know!" Clarissa replied. "You sent me three last night all by yourself!"

"I have to move them out somewhere! Either admit or street. No sleep?"

"About two hours in thirty-minute stretches, because SOMEBODY kept waking me up!"

"Poor baby!" I teased.

We finished our breakfast, then headed back to our respective services. Serenity, Walt, and I had a busy morning, mostly handling walk-ins, but also admitting one rule-out MI for an angioplasty. Just before noon, Doctor Gibbs asked to see me.

"I heard from Ghost you had a conversation about Krista, and he said you expressed concern about how we're teaching her, or rather, not teaching her."

"It's my opinion that so long as a student is part of the program, we should spare no effort in training them to be physicians."

"Even if they're unqualified?" Doctor Gibbs asked.

"If they were truly unqualified, they wouldn't be here. Or are you saying that people receive passing grades even when they're unqualified?"

"Not from me, they don't."

"Which doesn't address the question I asked in the way you know I meant it. If she was truly unqualified, and it appears some people think she is, then why did she not fail her rotations, especially in Cardiology? There's a difference between being sub-par and being unqualified."

"Are you arguing we should accept sub-par candidates merely because they want to be physicians?"

"Not at all," I replied. "I wouldn't accept her for the Match, that's for sure. But that's a very different thing from saying she's unqualified. As I pointed out to her, her procedure book tells a story that will make her Match options extremely limited. She has roughly five weeks to rectify that."

"And if she doesn't?"

"Then the system will work. My argument is that she should at least be given the opportunity to improve."

"And do you think she will?" Doctor Gibbs asked.

"As I said to Ghost, what I think isn't particularly relevant. What Krista thinks is all that matters. If she doesn't think she can improve, then it's 'game over'. If she does, and cannot, then she receives either a below-average grade or fails. If she does improve, then we've achieved our mandate to teach. Let me ask this -- what's the goal of assigning her scut for the next five weeks? To punish her? To encourage her?"

"To protect our patients and to allow us to expend our limited resources on training students who we feel are far better candidates. You admitted to Ghost that Al is much better."

"I did, but I'm judging him as a Third Year. And I'd like to point out the number of times someone had to lecture me, whack me with a rolled-up newspaper, or otherwise correct me."

Doctor Gibbs smiled.

"And each and every time it was either pulling back gently on the reins to keep you from bolting, a disagreement on the application of limited resources, or about philosophy of care. Never once did anyone have to talk to you about your clinical work. And I don't mean your bedside manner, because in a perfect world, we'd all have time to do it that way.

"Think about the difference -- you were so good that we had to rein you in so that you didn't make a career-ending decision because your heart was in the right place, but you didn't have the experience to know better. I was the same way. So were Ghost, Gabriel, and Nielson. Those are all physicians you look up to and respect. Tell me, privately and not for repeat outside this office, what you think of Doctor Varma."

"A competent trauma specialist," I replied.

"Those are damning words from you, Mike! Now compare him to Krista. Is there any comparison? They're only one year apart, and I'd lay serious money on you believing she's not even competent at this point. And I'd make an equally large bet that you'd say that Al was, Third Year or not."

"I didn't mean to denigrate Naveen. He's a good doctor."

"Yes, he is. Would you compare him favorably to Leila Javadi, Shelly Lindsay, or Carl Strong? Or is he good and they're great?"

"I understand what you're getting at, but I don't see Krista as a lost cause. She could be a competent doctor and there is a need for competent physicians."

"Listen to what you're saying," Doctor Gibbs counseled. "'Could be' says you have concerns."

I shook my head, "I didn't mean it that way. And you, and others, said things similar to that about me. That I had the potential to be a great doctor."

"Let's say we do it your way, and in a week, when schedules change, the paramedic training program begins, and she's assigned to someone else for most, if not all of her shifts, what happens?"

"Isn't that up to her? Our obligation is to train her. Her obligation is to learn. I've explained that to her and pointed out what she needs to do. Why not give her a chance?"

"What do you think we've been doing?" Doctor Gibbs asked. "And remember, Kayla Billings has Krista for twelve hours, just as you do, and I've sought her input as well.

"You're concerned that I would back up Krista's claim of being treated unfairly, and that would create a firestorm."

"That was suggested by at least one person."

"Ghost, of course, as he's the only one with whom I've had an in-depth conversation about Krista in the past two weeks. My answer, to any inquiry, would be factual and be about observed events, not about what I felt someone was thinking. In other words, I'd only speak to things I knew and could back up, not to questions about what someone else might be thinking. That's how I handled the situation with Melissa Bush."

"And when you're asked if you think Krista was treated fairly?" Doctor Gibbs asked with an arched eyebrow.

"I could rightly say that I gave her every opportunity, but can't say anything about what anyone else had done. You haven't told me to stop trying to teach her, though you did suggest she be what you've called a 'scut monkey', similar to how Doctor Rafiq was treated by surgery."

"Do you think that was justified?" Doctor Gibbs asked.

"He was a terrible teacher," I replied. "And had a bad attitude. Doctor Cutter and Doctor Roth felt he needed to learn a tiny bit of humility and change his attitude. But the way they treated him wasn't out of line for how surgeons are typically treated before they reach PGY3."

"And is Krista's treatment out of line for a below-average student? Something you immediately recognized simply by looking at her procedure book?"

"Out of line? No. The correct way to do things? Also no."

"You're still a pain in the ass, Loucks."

I chuckled, "So I've been told."

XLII. Focus On Learning

August 25, 1989, McKinley, Ohio

"Good afternoon," I said to the assembled incoming class of medical students. "Every morning, when you get up and look in the mirror, you see the person primarily responsible for your medical education. It's not the deans, it's not the professors, it's not the doctors on your clinical rotations. It's you. Period. No exceptions and no excuses.

"You have one simple task for the next four years -- learn. And that is on you, not on anyone in a long white coat. Yes, of course, we are tasked with teaching you, but, in the end, you have to learn. And that means taking responsibility for learning, even from poor teachers and even in adverse circumstances.

"You cannot succeed by being passive, though you need to temper your aggression based on your skills and knowledge. There will come a time when you have to demand to be taught, and that demand might well be rejected. Don't take a 'no' as a 'no', but as a 'not now'. Ask. Ask again. Ask why. Will some doctors and professors find you annoying? Damn straight!

"Just before I left the hospital so I could attend this ceremony, I was told, and not for the first time, that I'm a pain in the ass. I don't take that as an insult, rather, I wear that as a badge of honor. I ask questions, I challenge answers, I make observations. That's all part of learning. And learning continues, even more intensely, when you change from a short white coat to a long one.

"And even when you attain the coveted role of Attending Physician, you will still learn. And you're responsible for that continuing education, be it from journals, seminars, conferences, or one-on-one instruction. If you don't learn, you fall behind. If you fall behind in the next four years, you won't Match. If you fall behind after the Match, you won't become an Attending. And at any stage, you might wash out.

"You'll face many challenges, both in learning to be a physician and in your personal life. You'll encounter many things which can trip you up over the next decade -- academics, lab work, clinical rotations, stress, lack of sleep, and physical health. You can earn academic honors and fail clinical rotations. I've seen that happen. You can be a top-ten student and lose your life to stress. I've seen that happen, too.

"Right here, right now, resolve to take control of your medical education. Right here, right now, resolve to challenge us to teach you. Right here, right now, resolve to learn. Right here, right now, resolve to be the best physician you can be, and put together a personal plan to achieve that. Nobody is going to do it for you; only you can do it.

"Finally, never forget that you're asking for admission to a very selective, exclusive guild. To gain admission, you have to satisfy every person involved in your training. Failing to do that means you won't be a physician, no matter how badly you want it. Succeed, and you'll have the most rewarding, fulfilling career in the world."

I left the podium and rejoined the other doctors at the back of the room.

"A Loucksian address if there ever was one!" Doctor Strong said quietly. "A reaction to Krista Sandberg?"

"Yes," I replied, my voice just above a whisper. "I felt they needed fair warning."

"It's an important message," Doctor Lindsay observed.

When the ceremony ended, the medical school deans walked over to where I was standing with the doctors from the hospital.

"That wasn't what I expected," she said with a smile. "We were sure you'd give your usual service speech."

"I felt it was warranted," I replied. "My second option was to focus on Doctor Osler's prescription for medical training."

"He was addressing Residency," Doctor Warren said.

"And yet, it applies just as much to medical students as it does to Residents. You know I'd like to see medical schools be six years, and take High School graduates, rather than those with undergraduate degrees. Two years of classroom work rather than six, and four years of clinical rotations would serve the profession better."

"That would require wholesale revision of the system," Doctor Worth observed.

"And your point is?" I asked with a grin.

"We can't just do that," Doctor Worth said. "Our accreditation depends on following the pattern. Being first risks our students not being selected for the Match due to licensing regulations in fifty different states."

"So confer a Bachelor's degree," I said.

"Which requires basically four years of coursework," Doctor Worth replied.

"It's done similar to how I proposed in Europe," I said.

"Good luck convincing the 'Europe is socialist' crowd to copy anything Europe does," Doctor Strong interjected.

"Europe is not socialist, the perverse fantasies of some Americans to the contrary notwithstanding. And I should know, because I'm married to an actual socialist!"

"I bet that leads to interesting pillow talk," Doctor Lindsay teased.

"Interns do not have time to talk in bed," I chuckled. "We sleep!"

"Uh-huh."

All the assembled doctors laughed. Given my schedule, I bade them 'goodbye', then left to head home so I could spend a few minutes with Rachel before Kris and I headed to the banquet.

August 26, 1989, McKinley, Ohio

Saturday morning was typical, with band practice, grocery shopping, a trip to the bakery, and a stop at the record store. At lunch, we celebrated Rachel's second birthday, though her big party would be on Sunday afternoon after church. Instead of cake, we had cupcakes which Serafima had baked, and Rachel managed to eat more than she wore, unlike her first birthday.

I gave Rachel her bath, then left for my shift at the hospital. As I wouldn't be able to attend the service Viktor had scheduled for that evening, I allowed a bit of extra time so I could stop at Saint Michael the Archangel. I visited with Elizaveta, said abbreviated prayers for the dead, and placed flowers on her grave before heading to the hospital.

At Moore Memorial, I went to the surgical locker room to change, then headed to the ED, where I received the handover from Kylie. There was only one patient waiting on admission to Medicine, and once Kylie had filled me in, I went to find Jake and Heather, my Saturday medical students. I found them in the lounge, but before I could even greet them, nurse Terry let me know Doctor Mastriano needed my help with a central line in Trauma 2.

"I've seen a few, but haven't done one," I said. "I'll need to call for another surgeon to come down to supervise. Let me make the call, then I'll go see her."

I called upstairs, explained what I needed, and the charge nurse said that Doctor Blake would be right down. I thanked her, then went to Trauma 2.

"What do we have?" I asked.

"Jenny Smith, twenty-two; IV drug user, probable heroin OD; no veins for an IV."

"I've only observed central lines. Doctor Blake is on his way down to supervise me. He should be here in a moment. Did you try an ankle?"

"We couldn't get a good vein."

"Status?" I asked as I washed my hands and put on gloves.

"Naloxone in the field; intubated; Foley with decreased urine output; pulse 58; BP 100/60; PO₂ 92%; CBC, Chem-20, tox screen, pregnancy test, full-spectrum STD test."

"There's an MI risk," I said. "Let's get her on a five-lead."

"Kurt," Doctor Mastriano said to her Fourth Year, "Five-lead, please. Terry, set up the ultrasound, then central line kit to Mike, but we'll wait for Doctor Blake."

At the mention of his name, he walked in.

"I hear you need supervision for a central line," he said.

"I've seen three, but never done one."

"What are your risks?"

"Hemothorax, pneumothorax, hematoma, and inadvertent arterial puncture."

"What do you do?"

"Trendelenburg; sonogram to define anatomy if there's time; lidocaine cutaneously, subcutaneously and around internal jugular. Then, using the Seldinger wire technique, insert the guidewire. Next, make a 3mm incision in the skin, cutting away from the wire so as not to damage it. Pass the dilator over the wire and gently but firmly dilate a tract through to the internal jugular. Sponge as necessary to clear the field, then grasp the Seldinger wire and remove the dilator and pass the central line over the Seldinger wire. Once the line is in place, remove the wire. Suture, dress, and connect to the IV."

"Proceed," Doctor Blake directed.

I nodded and, with help from Terry, I followed the steps carefully and methodically, knowing I had a bit of time. I completed the procedure, Doctor Blake checked my work and pronounced the central line was properly inserted.

"Let me have your procedure book, and I'll sign off for you to do this solo."

"Thanks," I replied.

I stripped off my gloves and took my procedure book from my back pocket, and handed it to him. He wrote the procedure, wrote his approval, then signed the book. He handed it back and left the room.

"Anything more, Doctor Mastriano?" I asked.

"Call me Isabella, please. And that's all for now. Thank you."

"You're welcome."

I left and went to find my students who were just coming out of the exam room with the patient being admitted to Medicine. They walked over to me, allowing the orderly and the Third Year from Medicine to escort the patient.

"What schedule do you two have for next month?" I asked.

"We're both on 0600 to 1800 Monday through Saturday," Heather replied. "Basically, we'll be with you on every shift except the one where you're at the clinic."

I hadn't checked on any of the medical student schedules except Krista's and hadn't been surprised that she was on shifts that mostly didn't overlap with mine. I didn't like that, because I felt nobody would even give her the shot she deserved, even if she was ultimately unqualified.

Unfortunately, I wasn't likely to be able to do anything about similar situations in the future, as I wasn't an ED Resident, despite working in the ED. That meant I would never be Chief Resident on either service, as I'd serve my third year of Residency as a Surgeon, and the ED Chief Resident was always a third year. Because I wasn't a dedicated surgeon, and would spend most of my time in the ED when I wasn't in the OR, I wouldn't be the Surgical Chief Resident, either.

That didn't particularly bother me, as it would mean administrative work, which I didn't particularly enjoy, and I didn't feel not being a chief would interfere with my career progress. I most likely wouldn't be Chief Attending either, though I could, ultimately, be Chief of Emergency Medicine, but that was more than ten years away.

We had a busy afternoon, with nothing remarkable, and I had no trouble meeting Clarissa for dinner at 6:00pm. After dinner was equally busy, but also unremarkable, and I left the hospital just after midnight.

August 27, 1989, McKinley, Ohio

Sunday morning was typical with Kris, Rachel, and me attending Matins and Liturgy at the Cathedral. We didn't stay for the meal after liturgy, as we had to be home to set up for Rachel's party. We had help from Elias and Serafima and Lyudmila, and everything was ready at 2:00pm when the first of Rachel's dozen toddler guests began arriving along with their parents. Rachel's most important guests were Abi Green, Larisa Antipov, Viktoria Kozlov, April Webber, and three girls from daycare -- Melanie, Kathy, and Jennifer. She was far less happy to see Viktor Gennadyevich, my brother Pete, my nephew Michael, and my godson Michael.

Rachel was also happy to see Clarissa and Tessa, though she was happiest about her Aunt Lyudmila, as they seemed to be forming a strong bond. That was a good thing, though I could do without Lyudmila teaching Rachel to speak French, which she was doing simply to annoy me. Of course, being able to speak a foreign language was an advantage, and French was far more useful than Russian, so it wasn't really a bad thing.

The kids all had a wonderful time, and I spent most of my time with Joel, Elias, and Subdeacon Mark, as all the other kids had been brought by their moms, with the exception of April and Peter, who had come with my sister. The other invitees -- Viktor and Yulia, my mom and Stefan, and Kris' parents, all arrived for dinner at 5:30pm. My dad and Holly had been invited, but had declined.

After dinner, cake, and presents, we said evening prayers with everyone, including those who weren't Orthodox, and then all of Rachel's guests left. She had her bath, we read The Bears' Picnic, and then we put her to bed.

"Care to come to bed to see if we can arrange for a sibling for our daughter?" I asked Kris.

"Three times to make sure?" she asked invitingly.

I happily took her hand and led her to the bedroom.

August 30, 1989, Southern Ohio Correctional Facility, Lucasville, Ohio

My Monday to Tuesday shift had been relatively calm, and I'd managed to get some sleep on Monday night. Now, on Wednesday, after spending the morning at home with Rachel, we left to have lunch with Clarissa and then drive to Southern Ohio Correctional Facility so I could see Frank Bush. I endured the usual security checks and questions, and eventually was ushered into the visitor's room. Two minutes later, Frank Bush was escorted in and sat down across from me.

"Thanks for the book," he said. "I'm enjoying it."

"You're welcome. How have you been?"

"I have a completely regimented day with no freedom. How do you think I've been?"

"I was more concerned about your physical and mental health," I replied.

I was concerned about his spiritual health as well, but I didn't feel he was ready to hear anything like that just yet.

"Physically, no complaints, but prison is mind-numbing. I have an advanced degree, so Ohio won't allow me to take correspondence courses on their dime, and I have no personal resources. Pretty much the only intellectual stimulation is books, and as much as I like to read, there comes a point when it no longer helps."

"I thought you played chess," I countered.

"I'm not particularly popular with the small group of dedicated players."

"Would you like to play while we talk?"

"Sure."

I got up and asked the guard for a chess set, which he provided, and Frank and I began playing while we talked.

"What book can I get you next?" I asked.

"A Time to Kill by John Grisham or The Russia House by John le Carré."

"I'll get both of them for you," I said. "If you wanted to take a correspondence course, what would you study?"

"History has always been a hobby of mine."

"Let me speak with someone at Taft and see what I can arrange. I can't promise, but I will try."

"The cynic in me wants to know what you get out of this?"

"It's not about what's in it for me, it's about fulfilling Jesus' instructions in the parable of the sheep and the goats --

All the nations will be gathered before Him, and He will separate them one from another, as a shepherd divides his sheep from the goats. And He will set the sheep on His right hand, but the goats on the left. Then the King will say to those on His right hand, 'Come, you blessed of My Father, inherit the kingdom prepared for you from the foundation of the world: for I was hungry and you gave Me food; I was thirsty, and you gave Me drink; I was a stranger, and you took Me in; I was naked, and you clothed Me; I was sick, and you visited Me; I was in prison and you came to Me.'

Then the righteous will answer Him, saying, 'Lord, when did we see You hungry and feed You, or thirsty and give You drink? When did we see You a stranger and take You in, or naked and clothe You? Or when did we see You sick, or in prison, and come to You?' And the King will answer and say to them, 'Assuredly, I say to you, inasmuch as you did it to one of the least of these My brethren, you did it to Me.'"

"You don't think I knew that and had to quote it?" Frank asked.

"I think you know the words, but you don't know the spiritual truth. As Keith Green reminds us, the only difference between the sheep and the goats is what they did and didn't do."

"Works righteousness."

I shook my head, "Not according to James. We can discuss it if you wish, but I only cited the verses because you questioned my motivation."

"How are your friends?"

"If you mean Robby and Sophia, they're married and likely moving to California so she can serve her Residency at a hospital specializing in pre-natal surgery."

"He walked away from the lifestyle? Commendable."

I wasn't about to take that bait, as that conversation could have no positive outcome.

"Saturday was my daughter's second birthday," I said, changing the subject.

"They grow up so fast. One day Melissa was in a crib and, seemingly, the next she was in medical school. It was the same for James."

I won the first chess game as white, then Frank won the second as white, and I won the rubber match as black as we drew for pieces. While we played, we discussed my Residency, and he reminisced about his as well. By the time we finished the third game, our time was almost up.

"I'll let you know what Taft has to say," I said. "And I'll get those books ordered for you. My next visit will be on a Sunday afternoon in September. I suspect three weeks, but it could be the last Sunday of the month. Is there anything you need?"

"Not that I can think of," he replied.

"If you're interested in understanding me, there are some other books I could send you."

"Trying to convert me?"

"No, just trying to answer your question of 'why?' and give you some insights you might not otherwise have. I'll send them, and you can decide if you want to read them or not, and if you want to share them with others or not. I think you'll gain a very different view of what I believe than the one you, Tim Saddler, and others have in mind."

"Why not?"

"Then I'll send you Becoming Orthodox, by Father Peter Gillquist who was part of Campus Crusade for Christ before he converted; Common Ground by Jordan Bajis, which explores the common faith between Evangelicals and Orthodox Christians; The Eucharist by Father Alexander Schmemann; and two books by Vladimir Lossky -- Orthodox Theology and In the Image and Likeness of God."

"You know I might not read them, right?"

"I know. If you decide not to, then donate them to the prison library. I enjoyed our visit."

"It's the one thing that breaks the monotony here."

"I'll see you in September," I said. "If you need anything, write or call, please; I'll accept the collect call charges."

We shook hands, which I was allowed to do as a chaplain, and he was escorted from the room. A guard escorted me out, and I had to wait about ten minutes before Clarissa and Rachel arrived from the park where they'd gone to wait. Clarissa got out so I could get into the driver's seat and she went around to the passenger's side.

"Hi, Rachel!" I said, getting into the driver's seat.

"Hi, Daddy!"

"Did you have fun with Clarissa?"

"We played!"

"Great!"

"How did it go?" Clarissa asked.

"He's opening up more," I replied. "We discussed his Residency, and I saw a slight spark of life in him. He said prison was mind-numbing, and I believe it. Just my few interactions with him so far have made it clear that prison is not the correct solution for most crimes, and for those where it's necessary, then it needs to be rehabilitative, not penal."

"Manson?"

"The classic question, but he, too, is made in the image and likeness of God. We have no idea what might happen with any prisoner who is given proper care, both physical and psychological, and who we attempt to rehabilitate. Our job is to provide those things, what the prisoners do with them is up to them. I object to any dehumanizing or inhumane treatment."

"That does fit your nature. Still thinking of prison ministry?"

"Down the road, yes. Let's get through our Intern year first!"

"You seem very happy."

"I am. I'm doing exactly what I wanted to do since I was ten, I have a wonderful daughter, a wonderful wife, and wonderful friends. I was a bit melancholy on Saturday when I stopped by Elizaveta's grave, but it passed almost as soon as I stepped into the hospital."

"That's your true element. How are things with Mastriano?"

"She's softened ever since I backed her up a few weeks ago."

"Rumor has it she broke things off with Rosenbaum," Clarissa said.

"I try to avoid the whole Days of our Lives or General Hospital gossip circle!"

"I overheard two nurses."

"I hope it's true, but in the end, it's none of my business. Back to happiness -- are you happy?"

"I'm a doctor, we're practicing together, I have Tessa, and you and I are going to have a baby. I'm not sure how I could be happier!"

August 31, 1989, McKinley, Ohio

"May I speak to you privately for a moment, Doctor?" Krista asked just after I arrived at the hospital on Thursday morning.

"Let's go to the temporary Resident's office," I suggested.

We left the lounge and went to the temporary Resident's office, and I asked Krista to leave the door open.

"What can I do for you?"

"You're the only one who is giving me a chance, and I think Doctor Gabriel purposefully assigned me to a shift that doesn't match yours."

I suspected she was correct, but I had to be very careful about how I answered.

"I can't speak to Doctor Gabriel's motives or thinking," I said. "He made the schedule without input from me, except insofar as he asked me about my choice of shifts. I didn't know which shifts you would have, and he didn't mention anything to me about you or about anyone else's schedule."

"Did you know the schedules were changed last week?"

"No. I only looked at it last Friday. I can't speak to any changes because I didn't know until you just told me."

"I'm positive you think I've been treated unfairly."

"The only thing I can say is that I've done my best to help you succeed. I honestly can't speak to anything I haven't seen. Have you spoken to Doctor Baxter, Doctor Billings, or Doctor Gibbs?"

"But what do you think?"

"I make a point of only stating what I know or can reasonably deduce from things I've actually observed. I know it sounds as if I'm being evasive, but I honestly can't speak to what happens with other doctors when I'm not there to observe."

Krista frowned, "I should have expected that answer. I'm sorry I put you on the spot. If I ask Doctor Northrup to change my schedule and assign me to you, would you support that?"

"I won't object," I replied. "But I also can't interfere. Make your case, and if Doctor Northrup asks if I'll accept you, I'll say yes."

"Is there anyone you'd lobby for?"

"No. I've told students who have asked to be assigned to me to ask the Chief Resident. I don't want to be accused of favoritism. I've been accused of being on the receiving end of that accusation, and it's ugly."

"You don't feel you were given extra privileges?"

"I earned them," I replied. "And that's what I've been trying to tell you from the get-go. Each success builds on previous success. It started with academics, but then my wife and I ate more bananas than I could count because I was practicing suturing every single day, so that when I had my first opportunity, I nailed it. Because of that, I was permitted to do other procedures, and my success doing those procedures led to others, and so on and so on and so on. Remember the first thing I noticed?"

"You said that my procedure book was light."

"Which conveys a message to anyone who reviews it. Remember what I said about Matching?"

"That it would be a problem if I didn't fill it out by the end of this rotation. That's what I want to do, but I'm not being given the chance."

"Have you spoken to Doctor Billings or Doctor Baxter?"

"No. I think they're both writing me off and it's not fair."

"You should speak to them," I replied. "But go make your case to Doctor Northrup. He's usually in around 8:00am, but his assistant is in at 7:30am, and she can tell you when you can see him. I'll cut you loose for that."

"Thanks."

We left the temporary office, and I saw four charts in the walk-in rack, which meant Doctor Varma would be swamped, so I instructed Krista to get the first chart, bring the patient in, do an H & P, then come get me. I went to the lounge and asked Al to observe, fulfilling the advice Leila Javadi had provided. About ten minutes later, Al came to get me and said Krista was ready to present.

"Mr. Ramsey," Krista said, "this is Doctor Mike."

"Hi," I said.

"Hi, Doc."

"Krista?" I prompted.

"Mark Ramsey, thirty-three; presents with a tick attached to the back of his neck; pulse 78; BP 120/80; temp 37.8°C; no other complaints."

"Proposed treatment plan?" I asked.

"Clean with alcohol; forceps removal, straight line without rotation; clean with alcohol again; prophylaxis with broad-spectrum antibiotics."

I nodded, "Approved. Mr. Ramsey, we're a teaching hospital, and I'd like Krista, who is a Sub-Intern, to remove the tick. Are you OK with that?"

"Sure," he agreed.

"Krista, proceed; do you know the correct antibiotic and dose?"

"No."

"With no admitted allergies, 500 megs vancomycin initially, then 125 megs four times per day for 10 days."

I wrote the order on the chart and then sent Al to ask a nurse to get the appropriate vancomycin capsules. He'd need a prescription, which I'd need to have Doctor Gibbs or Doctor Nielson write, as I couldn't do that, per hospital rules, until I received my medical license. I observed as Krista removed the tick and disposed of it by placing it in a vial and disposing of it in the hazardous waste bin.

Al returned with the vancomycin, which Mr. Ramsey took. I then excused myself to get the prescription form from Doctor Gibbs, and once I had it, I returned to the room. I filled out the discharge form and handed it and the prescription form to Krista.

"You're all set, Mr. Ramsey," Krista said. "Take the full course of antibiotics, even if you don't feel sick. Follow up with your personal physician as soon as possible, and if you do feel sick, or the wound becomes painful, please come back to the Emergency Department right away. Do you have any questions?"

"Is it OK to wash my hair?"

Krista looked to me.

"There is no reason not to," I said. "The wound is small and will heal quickly."

"Thanks, Doc. Thanks, Krista."

"Al will escort you to Patient Services," I said.

We all left the room, Krista updated her procedure book, and handed it to me to sign.

"Thanks," she said.

"You're welcome. Remember, you build on each success."

"If I'm given the chance," she replied.

I nodded in response, as Doctor Casper walked up to us and I didn't feel like getting into a discussion with him about Krista.

"I need a surgical consult," he said. "Hot appy."

Which was one of the simplest surgical procedures, but I wouldn't be allowed to perform the surgery, which would have been true even if I'd been assigned to the surgical service. It would be nearly two years before I'd do any kind of invasive procedure beyond chest tubes, central lines, and pericardiocentesis.

"Let's go take a look," I replied. "Krista, get the next walk in, please."

She grabbed the next chart, and I followed Ghost into Exam 4.

"Mr. Andrews, this is Doctor Mike, a surgical Resident. He's going to examine you and confirm my diagnosis."

"Hi, Mr. Andrews," I said.

"Hi, Doc. Will you do the surgery?"

"No. I'm assigned to the Emergency Department to evaluate surgical cases. One of our senior surgeons will perform the procedure."

I conducted a basic exam, including palpation of his abdomen, then used the ultrasound and appreciated an inflamed appendix, something that wasn't always possible.

"He needs to go right up," I said. "The inflammation is severe. I'll call upstairs."

"Ellen," Ghost said to his Fourth Year. "Call for an orderly, stat."

I went to the phone and called the scheduling nurse and let her know I was sending up a hot appy, and she assigned the patient to OR4. I let Ellen know when she returned, signed the chart, then left the room. I saw on the board that Krista had taken her patient to Exam 1, so I went there where she and Al were completing the initial exam.

"Mary, this is Doctor Mike," Krista said. "Mary Hartman, nineteen; complains of headache, fatigue, and weakness. Pulse 80; BP 120/70; PO₂ 98% on room air. No other complaints. Her roommate at Taft brought her in."

The patient was very thin, and I had a sneaking suspicion.

"Hi, Mary," I said. "I'm going to do a quick exam to confirm what Krista reported."

"OK," Mary agreed.

I auscultated her heart and lungs, finding nothing remarkable, as I'd expected. I then used an otoscope and when I examined her mouth, I saw obvious signs of enamel erosion from her teeth.

"Krista, glucose stick test, please," I requested.

"What's that?" Mary asked.

"I want to get a quick read of your blood sugar," I replied. "When did you eat last?"

"Breakfast when I got up about ninety minutes ago, before I ran."

And I had a strong bet she'd eaten, then purged. If she'd eaten, her glucose should be between 130 and 180, but I made a bet with myself that it would be low.

"75," Krista reported.

"That's awfully low for having eaten an hour ago," I said. "What did you have to eat?"

"An apple," she replied.

Apples had fairly high fructose content, though absorption was attenuated by the fiber they provided. That said, her blood sugar should have been higher.

"What about dinner last night?" I asked.

"Chicken Caesar salad," she replied.

"Are you dieting?" I asked.

"Always," she replied.

"I'm a bit concerned about your low blood sugar. That would explain your headaches, fatigue, and weakness. I'd like you to eat some peanut butter and crackers, and drink some apple juice, and we'll check your blood sugar again. That will tell us if your body is having trouble processing carbohydrates. I'll also have blood drawn, OK?"

"Yes, Doctor," she replied.

"Is there any chance that you might be pregnant?"

"No. None."

"Are you taking any medications?"

"No."

"Krista, Chem-20 and glucose panel," I said. "Al, get some peanut butter crackers and a bottle of apple juice, please. We'll do a repeat glucose test thirty minutes after she eats."

Al went to get the food while Krista drew the blood. I had Al take it to the lab, and Krista and I waited while Mary ate the crackers and drank the juice. Once she finished, Krista and I left the room, promising to return in about thirty minutes.

"What am I thinking?" I asked her.

"I honestly don't know. I mean, obviously, her blood sugar is low, but you clearly have something in mind."

"Tell me what you observed."

"Nothing remarkable," Krista replied. "Her pulse is a bit high, but otherwise, nothing."

"That's what you didn't see. What did you see?"

"A college-age girl who appears to be healthy," Krista replied. "But I clearly missed something."

"Some subtle clues," I replied. "First, she's very thin. Second, there was evidence of enamel erosion on her teeth when I examined her mouth."

"Bulimia?" Krista asked.

I nodded, "It's a strong possibility. What are the characteristics?"

"I'd have to look them up," she said. "But I know it's about vomiting after eating."

"That's part of it, yes. It's characterized by binge eating followed by purging or fasting. Think about her complaint and how little she's eaten in the past twelve hours, the condition of her teeth. That's a strong indication. But there's one contraindication."

"What's that?"

"She's extremely thin. Does that change our diagnosis?"

"I thought anorexia didn't involve vomiting."

"There's a subtype of anorexia that involves purging. There was another clue for anorexia -- she runs. Anorexics often exercise excessively."

"How did you know so quickly?"

"That's the key to emergency medicine," I replied. "All her symptoms pointed to low blood sugar. Given how thin she is, I had a suspicion, and checked her teeth. Assuming she is bulimic or anorexic, what would you do?"

"It has to be a psych consult, right?"

"Bulimia is generally related to depression, anxiety, or bipolar disorder. We don't know the cause for anorexia, but it's also treated by counseling. Before we call psych, there is one other card to play, which I strongly prefer. Any ideas?"

"Not that I can think of."

"A consult with a nutritionist. They'll do a complete survey and give us a good idea if we're on the right path. It could be something else. Once the blood work comes back, we'll call for a consult. The nutritionist/dietician starts at 8:00am, so it won't be too long a wait."

"Is this going to count against me?" Krista asked.

"No. You're still learning diagnostic skills. May I give you some advice?"

"Sure."

"Focus on learning. That means asking questions, even if you feel you might look bad. If you don't ask questions, you aren't going to learn."

"Mike?" Nate called out. "Doctor Gibbs needs you in the ambulance bay. High-speed MVA. Two minutes."

"Thanks, Nate. Krista, let's go."

We gowned and gloved and entered the ambulance bay just as the EMS squad was turning into the driveway. I took a moment to look across to the field where the new Emergency Department wing was slowly taking shape, then cleared my mind to focus on receiving a patient who had likely suffered severe trauma. When the squad rolled to a stop, Bobby jumped out.

"Seventeen-year-old male; high-speed, single vehicle MVA; unbelted; severe trauma to the head; GCS 4; crush injuries to the chest and left extremities; BP 60/20; pulse thready at 120; PO₂ 91% on five liters; saline IV and a unit of plasma."

"Trauma 2!" Doctor Gibbs ordered.

Bobby, Sam, Doctor Gibbs, Kellie, Angela, Matt, Krista, and I quickly moved towards the trauma room.

"Mike, assess for chest tube and internal bleeding," Doctor Gibbs ordered. "Angela, type and cross match and hang another unit; Kellie, full trauma panel; Matt, intubate; Krista, switch the five-lead to our unit, then Foley."

We all worked together to move the patient from the gurney to the trauma table, and once Bobby and Sam moved out of the way, we began work. I quickly assessed the patient needed both a chest tube and surgery for internal bleeding, but we had to stabilize him first.

"Sinus tach," Krista reported.

I glanced up at the monitor to confirm and saw no other anomalies.

"Get the Foley in," I instructed. "He's going to need an ex-lap and a chest tube. Recommend pressers, Loretta. He won't survive being opened up with his blood pressure bottomed out. Recommend a second unit as well."

Doctor Gibbs gave the orders, and I called for a chest tube tray.

"Blood in the urine bag," Krista announced.

"Forget it," Doctor Gibbs announced. "Both pupils are fixed and dilated and I see CSF in both ears."

"Mannitol?" I suggested just as the monitor blared.

"V-fib!" I declared. "Shock him?"

"Crash cart!" Doctor Gibbs ordered. "Charge to 180!"

Three successive shocks of 180, 200, and 250, with doses of epi between them, didn't resolve the V-fib. A few seconds after the last shock, the monitor blared again.

"Asystole," I reported.

"Let him go," Doctor Gibbs said. "There's no point in flogging him."

I reached over and silenced the monitor.

"Time of death, 07:22," Doctor Gibbs announced.

XLIII. .38 Special

August 31, 1989, McKinley, Ohio

"Mary's labs are back," Al said, coming up to me and handing me the printouts.

"What did you see?"

"Low blood glucose; low A1C; borderline hypokalemia and hyponatremia."

"Thanks. Krista, what does that tell you?"

"That she likely has the eating disorder you suspected."

"I agree. It's been long enough that we should do another glucose stick test to see if the apple juice and peanut butter crackers had the proper effect."

We went back to the exam room, and I informed Mary of her test results, and then Krista performed the glucose stick test.

"90," she reported.

"OK," I acknowledged. "Mary, I'm going to have a nutritionist come speak to you about your diet. I don't believe you're taking in sufficient calories given your activity levels. That would explain all of your symptoms."

"I hate gaining weight," Mary countered.

I nodded, "I understand, but in my professional, clinical opinion, you're underweight for your age, height, and sex. But I'm a trauma doctor, not a nutritionist or dietician. Let me have someone come speak to you and investigate."

"I don't think that's necessary," she replied.

"I do, and your symptoms will get worse and you might even pass out. Your blood glucose was low, and much lower would be dangerous. If you leave, you'll have to sign an AMA form -- that you're leaving against medical advice, and another doctor will come talk to you to confirm. It's in your best interest to at least speak with the nutritionist."

"I don't want to," she said.

"Then let me go fill out the paperwork and bring in another doctor to confirm your decision."

"It's not necessary. I just want to leave."

"I understand, but in order to protect the hospital and me from legal problems, in the case that you do pass out and hurt yourself or someone, I really need you to sign the form. I promise it'll take less than ten minutes. Would you do it for me, please?"

"You could really get in trouble?"

"Yes. There's a law, the Emergency Medical Treatment and Active Labor Act, that requires evaluation and treatment of anyone who comes into our Emergency Department."

"OK," she said, acquiescing.

"We'll be right back," I said.

Krista, Al, and I stepped out of the room into the corridor.

"You'll just let her leave?" Al asked.

"Legally, I have to," I replied. "She hasn't expressed a desire to harm herself nor anyone else."

"But she is harming herself, right?"

"Not in a way that would allow me to act," I replied. "Let's go see Doctor Gibbs or Doctor Nielson."

We walked down the hall to the Attending's office and neither of them was there, so I checked with Ellie, who said Doctor Nielson was in the lounge. The three of us went there so I could speak with him. I presented the patient, and he frowned.

"I don't like it," he said.

"Neither do I," I replied. "But unless we put her on a psych hold, she's going to leave. And I don't think suspected anorexia is sufficient for a hold. She's stable, the food raised her blood glucose to a reasonable level, she's lucid, intelligent, and has good hygiene. She's thin, but not emaciated.

"She rejected a nutritionist and I can't imagine she'd speak to a pshrink. If I wanted to try for a bank shot, I'd use subterfuge to have Psych be the second doctor on the AMA form, but they won't do it. They'll insist on identifying themselves as Psych and that would blow the whole thing out of the water."

"You're referring to your choice with regard to handling Mr. Alien Encounter?"

"Yes. Everything was fine until the Psych Resident decided to wreck what had been a successful encounter. They'd likely do that here, too. Doubly so because it's one of my patients."

"Krista, Al, excuse us," Doctor Nielson said. "Mike, let's go to the office."

We left and went to the Attending's office.

"Are you suggesting Psych would retaliate against a patient because of what happened with Lawson's friend?"

"I would never make that accusation," I replied. "But they do not agree with my methods, and that has been the case for a few years. I've seen the very real effects of how textbook approaches to mental healthcare have devastated lives and worsened care for individuals we could help. I mean, seriously, is Mr. Alien Encounter better for what they did? He was harmless and preferred not to be on his meds. I understand that non-compliance with medication is a problem, but if the patient is not dangerous and is functioning, even in a quirky way, why are they on meds?"

Doctor Nielson nodded, "I get you, and you absolutely have a surgeon's distaste for drugs."

"And yet, I make regular use of them in the ED with no objections. There is a difference between the use of life-saving drugs and drugs that, well, drug someone into submission to some foolish idea of 'normal'."

"You are going to have to find a way to work with Psych," Doctor Nielson counseled. "Even if you're right, you can't dictate to them how they run their service. And at this point, the well is poisoned with regard to suggestions coming from you."

I nodded, "I understand. The thing is, I only care about what is best for my patients, not what is best or easiest for me. If that's a problem, well, then I made a very, very bad decision in fourth grade."

"It's not a problem, in and of itself, obviously, as it's the basic guideline for physicians. But when you go counter to the accepted standard of care, it does come back on you, for better or worse. Fill out the AMA form and let's go see your patient and I'll see if I can convince her to change her mind. I doubt it, because if there's anyone here who's more empathetic and more patient-focused than you, I don't know who it might be."

We went to the nurses' station where I filled out the AMA form, then asked Krista and Al to join us, and the four of us went into the treatment room.

"Mary, this is Doctor Nielson, one of my supervisors," I said. "He wants to discuss your decision to leave AMA."

"Hi, Mary," Doctor Nielson said. "I've looked over your chart and discussed it with Doctor Mike. We really do believe it's in your best interests to speak to a nutritionist, but as he said, that decision is ultimately yours to make. I'm concerned that you might pass out and harm yourself or others because of your low blood glucose levels. Your potassium and sodium levels are low as well, which usually are a sign of improper nutrition, and can also lead to the kinds of symptoms you reported."

"I don't want to," Mary said.

Doctor Nielson nodded, "OK. If you'll sign this form, you're free to go."

He handed her the clipboard with the form I'd filled out.

"Why does it say I could die?" she asked after reading it over.

"Because you could," I interjected. "If you were to have a syncopal event -- that is, in common terms, a fainting spell -- while you were driving or in some other situation where there was some kind of risk of serious injury, you could die."

"But anyone could faint at any time," she countered.

I nodded, "That's true. But your risk is much higher than the average person your age. The decision is yours, and I encourage you to speak to a nutritionist. If you choose not to, and you do leave, you need to eat better."

"I'm fine," she said, signing the form.

She handed the clipboard back to Doctor Nielson, got up, and walked out.

"We'll see her again," I observed once the door had closed. "Most likely transported by EMS."

"Unfortunately, I think you're right," Doctor Nielson said.

"Isn't there anything we can do?" Al asked.

"Do you think she'd tolerate a psych consult if she wouldn't speak to a nutritionist?"

"No, but couldn't they put her on a hold?"

"They could," Doctor Nielson interjected. "But they won't, because they'd have no legs to stand on if she challenged them. If there was any indication she was purposefully harming herself, they might. She's not eating properly, but if that were cause for a psych hold, about ninety-five percent of the county could be put on a hold!"

"Isn't the evidence of purging enough?" Krista asked.

"Not really," Doctor Nielson said. "Prior to the ACLU lawsuits in the late 70s and early 80s against involuntary commitment, we had more leeway, but even then, she wouldn't have met the criteria."

"In the end," I said, "no matter what the ailment, we can only offer treatment, not force it without a court order, and there is no chance we'd get one in this case."

"What about referring her to a social worker?" Al asked.

"She doesn't meet the criteria," Doctor Nielson replied.

"It just stinks that there is nothing we can do," Al observed.

"That is something we all have to accept. In the end, only the patient or their designated representative can decide."

We left the room and Nurse Lisa came up to me.

"Doctor Varma has a five-year-old who is non-communicative. He wondered if you had a moment to see if you could get him to open up."

"How did he present?"

"A fractured wrist; Doctor Varma suspects it's a result of abuse."

"Which is a good reason for the kid to clam up," I replied. "Which room?"

"Exam 5."

"Mary, Al, let me do this with Naveen and Lisa, please. There will already be too many people in the room if Naveen's students are there."

They went to the lounge, Doctor Nielson walked over to the nurses' station, and I followed Lisa to Exam 5. I waited in the corridor at her request, and Naveen stepped out to speak to me.

"John Tyler; five; fractured wrist, likely the result of abuse; bruises consistent with abuse as well. Mother claims he's 'accident prone'. Nothing appreciable on auscultation and vitals in range for a five-year-old."

"Nutrition?"

"Good, along with hygiene."

"Is the mom in the room?"

"Yes."

"Let's see if we can get her out."

"She refused."

"Did you order x-rays?"

"He's waiting on Radiology."

"That's the way to do it," I said. "She can't go into the room with the x-ray equipment. How do you want to play it?"

He smiled, "Surgical consult. Radiology should call any minute now."

As if on cue, Julie, his Fourth Year, stuck her head out of the exam room and said Radiology was ready. Doctor Varma, Lisa, and I went into the exam room.

"Hi, Mrs. Tyler," I said. "I'm Doctor Mike, a surgical Resident and with your permission, I'll examine John, then take him for his x-rays."

"OK," she agreed.

"Hi, John," I said to the five-year-old. "I'm Doctor Mike. How are you?"

He didn't answer, but I could tell from his eyes that he understood what I'd asked him.

"I need to check your wrist, then we're going to take some x-rays."

He said nothing, and the only reaction I had from his was flinching when I carefully examined his wrist. I noticed contusions on his arms, and one on his lower back when I listened to his lungs. It was my belief that Doctor Varma's conclusions were correct about John being abused.

"Lisa," I said. "Let's get John into a wheelchair, and you and I can take him to Radiology."

She acknowledged me, and once Julie had retrieved a wheelchair, she helped John into it. I opted to push, and Julie held the door. As I had expected. Mrs. Tyler got up to follow us.

"You should wait here," I said to her. "You can't go into the x-ray room."

"Why?"

"Because only the patient, the x-ray tech, and medical staff are permitted in the room. And we'll leave when the x-rays are taken. The x-ray tech stands behind a lead screen to take the x-ray."

"I won't leave John alone!" she protested.

"I understand," I replied, "But hospital rules and government regulations for the use of x-ray equipment cannot be waived."

"Then I'll take him somewhere else!"

In this case, I could actually prevent that, unlike with Mary. While it was true Mrs. Tyler could sign an AMA form, Social Services would take immediate emergency custody of John based on his injuries.

"Mrs. Tyler, I don't want to be confrontational, but John has a potentially serious injury and we can't let you leave without diagnosis and treatment."

"I'm his mother!"

"Yes, you are, but once you brought him in, we're obligated by law to treat him."

"Not without my permission!"

"You signed the permission form," I countered.

"Then I revoke that!"

"It's not that simple," I said. "For a minor, I'd be required to call Family Services to evaluate your decision."

"You have no right!" she protested.

"It's not about having the right," I replied. "It's about having the legal obligation. May I suggest you allow us to take the x-rays and not escalate the situation?"

"I won't leave him alone!"

"Nurse Lisa and I will be with him the entire time except about five minutes in the x-ray room, and the tech will be with him the entire time."

"That's not good enough!"

"Lisa, call the on-duty social worker, please."

"I'm taking him!" Mrs. Tyler declared.

"I can't allow you to do that," I said. "Lisa, call security first, then call the social worker."

"Right away, Doctor!"

Mrs. Tyler moved to try to get John from the wheelchair, but I stood in her way. She tried to shove me out of the way, but I was five inches taller and had at least sixty pounds on her, not to mention understanding from karate how to keep my balance.

"Code Yellow, ED!" came over the PA system. "Code Yellow, ED!"

It was a matter of seconds before a uniformed security guard hurried into the ED and I signaled him.

"Social Services has been called for this patient," I said. "His mother is combative and trying to take him. She shoved me."

"Ma'am, step away from the doctor and the wheelchair," the security guard said.

"I won't! And no rent-a-cop is going to tell ME what to do!"

He might be a rent-a-cop, but I knew he was a special, limited deputy, and could arrest her.

"Ma'am, step away or I'll place you under arrest."

"I know my rights! No rent-a-cop can arrest anyone!"

"Ma'am, last warning."

She didn't budge.

"Ma'am, under the authority of the Sheriff of Hayes County, I'm placing you under arrest. You need to come with me."

She refused, which didn't surprise me. A second security guard arrived and together they escorted a now screaming Mrs. Tyler away from us.

"It's OK, John," I said. "Your mom is just upset about your wrist."

Lisa returned and together we walked down the hall, with me pushing the wheelchair. I now had more time to talk to John, though I decided to wait until after he had his x-ray. We arrived in Radiology and the tech took over, leaving Lisa and me in the anteroom.

"I'd say she knows we figured out he's battered," Lisa said quietly.

"For sure," I confirmed. "Was she combative before I came in?"

"Only in the sense she refused to let John out of her sight. That's pretty common for frantic moms, but she wasn't frantic."

"How did the injury happen?"

"We only have her word that he was playing outside and came into the house crying. Neither Naveen nor I think that's the truth. Obviously nothing was said, but I could tell from Naveen's body language and the tone of his voice."

"Did John say anything?"

"No. His mom answered every question put to him. Other than wincing when his arm was examined, he's been non-responsive."

"This probably exceeds my skill set," I replied. "Let's call for a pediatric consult. They have a pair of Residents with child psych certification."

"I'll make the call."

She went to the phone just as Jeanne Wilders came into the ante room. I filled her in and she concurred with the pediatric consult.

"Doctor Olson is on his way down," Lisa announced. "I'll stay with John because he knows me."

"Thanks," I said. "I'll leave this in both your capable hands."

"Thanks, Mike," Ms. Wilders said.

I left Radiology and returned to the ED where Naveen was speaking to Doctor Gibbs.

"Where's the patient?" Doctor Gibbs asked.

"Radiology. Jeanne Wilders is with Lisa, and Matt Olson is on his way down. They need a psych-certified pediatrician for this one. It's beyond 'Kid Whisperer' territory. How's the mom?"

"Threatening to sue anyone and everyone," Doctor Gibbs said. "Security called for a Sheriff's Deputy. I was hoping she'd calm down and we could simply let it go, assuming you don't want to file a complaint."

"I don't. It would serve no purpose. Jeanne Wilders will initiate the necessary process for taking emergency custody of what I'm positive Naveen's exam notes will show is a battered child."

"Absolutely," he confirmed. "I wrote on the chart that he needs a complete series of x-rays to look for other broken bones. Nate found two other visits in the past eighteen months in his computer. I sent Kim to search the charts."

"Mom?" Doctor Gibbs inquired. "Or is she covering for the dad?"

"I think it has to be her," Naveen said. "She said her husband travels for business and is away."

"Stress," I proposed. "Not that that excuses her."

"I agree," Naveen said. "She seemed stressed when she came in, though initially I attributed it to her son being injured."

"A natural inference," Doctor Gibbs confirmed. "Both of you fill out the paperwork, please."

"The bane of every doctor's existence!" Naveen declared.

"Preach it, Brother!" I declared.

"You won't hear an objection from me to that sentiment," Doctor Gibbs said. "Paperwork, then go heal the sick!"

I filled out the necessary form and took it to Doctor Gibbs, then my medical students and I took a hand lac walk-in. I debated with myself who should suture, and decided it had to be Al, as suturing was basically the only procedure a Third Year could perform without permission from an Attending. We had just finished with that patient when Deputy Kenseth came up to me.

"I need a statement from you, Doc."

I nodded, "I'll give one, but I'm not going to press charges. She's in enough trouble as it is."

"I'll make a note, but that's up to the County Prosecutor."

"I know all about 'stacked charges' and how they're used to effectively force plea deals," I replied. "

"That's between you and the Prosecutor! I just take the reports and arrest the perps! What happened?"

I explained the situation, minimizing her pushing me by describing it as bumping and trying to move past me.

"That's really what happened, Doc?" he asked.

"It's how I perceived it," I replied.

"OK. I'll speak to the nurse who was with you as well. McKinley PD is talking to the mom now, because they live in the city limits."

"OK."

My students and I handled another walk-in, this time a bee sting, which I allowed Krista to treat, and when we left the exam room, Detective Louise Rehling from the McKinley PD was waiting for me. At her request, we went to the consultation room.

"You're the second doctor on this case, with Doctor Varma being primary, right?" Detective Rehling asked

"Yes."

"Is it normal to involve another Intern for a broken wrist?"

"It's not typical, but also not out of the ordinary. Doctor Varma felt I have better rapport with toddlers."

She smirked, "Given most men are simply toddlers with more body mass..."

"Yeah, yeah," I chuckled.

"Describe what happened, please."

I described the series of events, beginning with Naveen calling me for what he'd referred to as a 'surgical consult', a subterfuge for bringing me into the exam room to speak to John. I concluded with leaving John with Lisa and the tech in Radiology.

"I don't think it was the mom," Detective Rehling said after I made that observation.

"Dad's on a business trip, right?"

"Yes, but Jeanne got John to talk to her and discovered Mom has a boyfriend. John said that the boyfriend was at the house this morning and that he's 'mean'."

"Wonderful," I sighed. "Mom is cheating AND covering for an abusive boyfriend."

"That's how it looks, Doc. I've seen this once before. We almost always like stepdads or boyfriends who aren't biological dads in these cases. Nine times out of ten, it's them. Add in the cheating aspect, and it's almost a lock."

"You arresting the boyfriend?"

"That's the plan," Detective Rehling said. "Detective Tremaine is swearing out the warrant now, based on what Doctor Naveen and Jeanne Wilders reported. I take it you'll confirm everything you just said to me."

"Yes. It's all in the report I wrote for Doctor Gibbs and on the chart."

"What about the battery? You left that out."

"I'm not interested in pressing charges for what amounted to a bump."

"Lisa Kent said," Detective Rehling flipped back in her notebook, "'then Mrs. Tyler shoved Doctor Mike to try to grab her son and Doctor Mike asked me to call security'."

"Her perception and mine differ," I replied. "Lisa was turning to go to the desk to call the social worker, so her perspective would be different."

"If you say so, Doc."

"I do. Mrs. Tyler has already hit the Daily Double on cheating and protecting an abuser. I don't see a need for a Trifecta."

"The Prosecutor will talk to you."

"That's what Deputy Kenseth said. I'll tell the same story, and I don't want to press charges. I figure she has enough trouble when Mr. Tyler finds out."

"Yeah, cheating with an abuser is the jackpot, for sure. Thanks, Doc. I'll let you get back to your job. Come by .38 Special and I'll buy you a beer and we can swap stories."

"I'm not allowed to drink twelve hours before a shift, which means I basically can never drink," I replied.

"One beer?"

"Not a single drink, even a beer. I follow the rules for the surgical service. When I finish my Intern year, there might be a few short windows where I could have a beer, but not now, for sure."

"Then ginger ale! There isn't a safer place to drink in the county."

I chuckled, "It's a cop bar, so I think that all depends on your perspective!"

She laughed, "Nobody is armed because it's against regs to carry while we're drinking. It's the one place a perp could count on NOT being shot!"

"You do remember I'm married, right?"

"I said swap stories, Doc, not spit! I'll leave that desire to Jill Kleist and Ellie Green! Your friend Clarissa is more to my taste, though she's taken."

"Ah, OK."

"Seriously, Doc, you've fixed up several Deputies and patrol officers, so you won't ever have to buy a drink at .38 Special."

"I'll keep that in mind. If I did come, I'd bring my wife, who's eighteen."

"Nobody is going to card her in a cop bar! Robbing the cradle?"

"I suspect she's still more mature than I am!" I said with a grin.

"Men...toddlers...yep!" Detective Rehling agreed.

"I have patients to attend to," I said with faux annoyance.

"Thanks, Doc. And do come by for a ginger ale or root beer."

"Thanks for the offer."

"You're welcome."

She left, and I went back to find my students. Al was alone and let me know that Krista had gone to see Doctor Northrup, so I asked him to get the next chart in the rack, ask a nurse to join him if the patient was female, and I'd come find him in ten minutes. He left. I went to the restroom, ate a granola bar, and drank a cup of coffee before I went to find him. The board showed him in Exam 6, so I went there.

"Doctor Mike, this is Dave Thomas, fifty-eight, who presents with numbness in his right arm. BP 120/70; pulse 72; PO₂ 99% on room air; temp 36.8°C. I didn't hear anything obvious on auscultation."

"Hi, Mr. Thomas. I'm Doctor Mike. If you weren't aware, this is a teaching hospital, so I'm going to ask my student some questions. Please don't be alarmed."

"I'm a science teacher at the High School, Doc," he said. "I know how it works."

"Good," I replied. "Al, were those pulse and BP numbers taken on his left arm?"

"Yes. I wanted to make sure I had a clear reading."

"Take them on the right arm, please."

Al nodded and did as I asked.

"Pulse is still 72, as I'd expect; BP is 90/60; PO₂ is 93%."

"What would account for that?" I asked.

"I'd only be guessing if I answered that."

"Don't guess, reason from what you know and what you've learned."

"Use the scientific method, Kid!" Mr. Thomas said with a smile.

"Well," Al said, "I'd surmise something is blocking or limiting blood flow in his right arm, but I have no idea what would cause these specific readings."

"In a younger person, we'd suspect some kind of musculo-skeletal condition first," I said. "In a person over forty, we look at atherosclerosis, peripheral artery disease, or some other cardiovascular condition. How would you proceed?"

"CBC and Chem-20, plus cardiac enzymes."

"You also want D-dimer levels, given we might be looking at something like deep vein thrombosis. Mr. Thomas, I'd like to listen to your heart and lungs and check your peripheral pulses. Then we'll draw some blood and likely call for a cardiac consult."

"How much danger am I in, Doc?" he asked. "I know everything you just mentioned from biochem in college, and I teach the anatomy class at Hayes County High."

"The main risk is a clot migrating to your heart, lungs, or brain," I replied. "Any history of kidney troubles?"

"No."

"Then, after I examine you, I'll order heparin, which is an anticoagulant. That'll reduce the risk until a cardiologist and vascular surgeon examine you. They'll most likely order a full-body CAT scan."

"Maybe I'll get lucky and be bitten by a spider who was subjected to the x-rays!"

"And change your name to Peter Parker?" I asked.

"Comic book fan?"

"Occasionally growing up, but I was more into Douglas Adams, Heinlein, and Asimov."

I washed my hands, put on gloves, then listened to his heart and lungs. I didn't hear anything concerning, so I had him lie down so I could check his peripheral pulses. His pulse was fine in his legs and his left arm, indicating that most likely the problem was limited to his right arm.

"Mr. Thomas, just relax and we'll get the blood drawn and get you some heparin. Al, draw blood and I'll get a nurse to bring in the heparin."

I updated the chart, then left the room and went to find an Attending to whom I could present. Doctor Nielson was available, so I went to him.

"Approved," he said once I'd described the presentation and my proposed treatment.

He signed the chart, I asked Kellie to administer the heparin, and then returned to the room. Al left with the tubes of blood and Kellie came in with the vial and syringe. She administered the drug, and I decided to call for a cardiology consult before the blood work came back, as I was positive he would be admitted to Cardiology. I walked over to the phone and dialed the correct number.

"Patty, Cardiology," the nurse who answered said.

"Hi, Patty; Doctor Mike in the ED. I have a patient with significant differences in blood pressure between his arms, lower PO₂ in one arm, and a weak pulse. I need a consult, please."

"I'll page Doctor Shore for you."

"Thanks."

I hung up and let Mr. Thomas know that a cardiologist was on his way down.

"Do you know Laura Bragg?" I asked.

"The math teacher?"

"Yes. She's a close friend."

"Great girl," he said. "Very, very smart, though I question her taste in men!"

"Oh?"

He laughed, "No, not really, I'm just jealous of Nathan Burke! Of course, I'm twice her age and married, so you know how it goes."

"The age difference isn't the problem there."

He laughed, "Mrs. Thomas would NOT be amused."

"Neither would Ms. Korolyov! That's my wife, who goes by her maiden name."

"Another Russian?"

"Despite my Dutch last name, I'm half Russian and attend the same church as Laura, who I usually call Lara, which is short for Larisa, which is her actual given name."

"Shore, Cardiology," Doctor Patrick Shore announced as he came into the room with a student.

"Hi, Pat," I said. "Dave Thomas, fifty-eight presents with differential BP and PO₂ in his right and left arms. Complaints of numbness in his right arm; BP differential is 120/70 versus 90/60; PO₂ differential is 99% versus 93%. Heparin administered prophylactically. CBC, Chem-20, and D-Dimer ordered."

"Thanks, Mike. Mr. Thomas, I'm Doctor Patrick Shore from Cardiology. I'd like to examine you, please."

"Go for it," Mr. Thomas said.

Doctor Shore repeated the examination I'd done, including peripheral pulses and repeat blood pressure checks.

"I'll take him," Doctor Shore said to me. "Ned, call Radiology and tell them we have a stat CAT scan."

"Radiology for a stat CAT scan," his student replied, then moved to the phone.

"We're going to admit you, Mr. Thomas," Doctor Shore said. "First thing we'll do is get a full-body CAT scan, then, between that and the lab test results, figure out our next steps."

"Ten minutes on the CAT scan," Ned announced. "Another patient is just finishing."

"Get a wheelchair and take Mr. Thomas there," Doctor Shore commanded.

Ned did as he was instructed, I completed my portion of the chart, then handed it to Doctor Shore who wrote the admission order, gave me the carbonless copy for our files, then left to head to Radiology. I handed the form to Nate, saw there were no charts in the rack, so I sent Al on his meal break.

"Mike," Nate called out a few seconds later. "Doctor Northrup would like to see you in his office."

I suppressed a sigh, because I was positive it was about Krista.

"Right away?" I asked.

"He said 'as soon as convenient'. There are no walk-ins waiting, and no EMS runs incoming, so I don't think you can avoid it."

"Me, either," I replied.

I left and headed upstairs to Doctor Northup's office. I felt he should be in the ED proper, but that wasn't how things were. That said, that is how they would be once the new ED wing opened in 1991.

"Good morning, Doctor," Carly, Doctor Northrup's new assistant said when I walked up. "Are you Doctor Loucks?"

"One and the same," I replied. "But I go by Doctor Mike."

"OK. Go right in."

"Thanks."

I went into Doctor Northrup's office and in response to a hand gesture, I closed the door behind me.

"You asked to see me," I said.

"Krista Sandberg came to see me this morning. I gather from what she said, that was your doing."

"Only in the sense that I couldn't do anything about her request and suggested she had to go to either Doctor Gibbs or you. She chose you, and I suspect she told you why."

"She thinks Loretta is treating her unfairly," Doctor Northrup said. "Do you?"

"As I said to Krista, I can't speak to anything that happens when Krista is assigned to other doctors. I've done my best to train her."

"Relax, Mike. This isn't an inquisition. I understand from Loretta that you sought out Doctor Javadi for insight into Krista Sandberg. Why?"

"Krista's procedure book was light, to the point where she had perhaps half the procedures of a typical Fourth Year on their second Sub-Internship. That concerned me, so I went to speak to Leila about it, as Cardiology was Krista's most recent rotation."

"What did Doctor Javadi say?"

"The short version is that Krista is academically talented but clinically challenged."

"And your thoughts on that?" Doctor Northrup asked.

"Off the record?" I asked.

"Consider this entire conversation off the record until I say otherwise."

"Off the record," I said, "I think we failed as teachers. Either Krista wasn't taught well, which is on us; or she received passing grades which she shouldn't have, which is also on us. The root cause of the problem, if you will, is exactly what you heard me say at the White Coat Ceremony. Nobody told her that until I did four weeks ago."

"Did anyone have to tell you?"

"It was said, but it was also something I figured out fairly early on because I had some poor teachers who are, by the way, excellent doctors."

"Any who are poor teachers and not excellent doctors?"

"Only one who isn't our problem at this point."

"Mo Rafiq, right?"

"He was competent, but a terrible teacher, and had a poor attitude, especially towards women."

"According to Loretta, 'competent' is your way of saying a doctor isn't up to snuff."

"That's her interpretation of my use of 'competent'. I used that about Doctor Varma, and I'd have no qualms about him treating me. Are there doctors who are better? Yes. But that doesn't detract from the fact that he does a good job and is someone I enjoy working with."

"Unlike Isabella Mastriano?"

"She and I have resolved our contention," I replied.

And I was positive it was really Doctor Rosenbaum, and given the rumors were that she'd broken off the affair, I doubted she and I would have problems.

"OK. Back to Ms. Sandburg. She expressly requested to work the same shifts as you."

"She did say she was going to do that," I confirmed. "My position is neutral, the same as it would be for any other student assignments."

"But I'm sure you have an opinion."

"I do, and that is that she, like everyone else, deserves a chance to succeed and our job as teachers is to provide her with every opportunity to do so. That means right up to the last day of her rotation."

"I deduce from what you've just said, you think Doctor Gibbs is wrong."

"No, I think Doctor Gibbs is probably right, but that doesn't change my belief that unless and until Krista shows she is unwilling or unable to learn, we give her the opportunity to do so."

"I'm going to ask a direct, off-the-record question, and I don't mean it to cause offense, but I have to ask -- are you involved with her in any way?"

"Other than as her teacher, no, I am not. I'm going to draw a conclusion from your question that's how she passed at least one rotation."

"I have no first-hand proof, but that has been said."

Which tracked with Doctor Javadi's express warning about being alone with Krista.

"All I can say is that she has never once behaved in an unprofessional, unethical manner with regard to me."

"Has anyone?"

"Only if you count nurses or LEOs flirting with me!"

"Do you?"

"No. It's all harmless, and I don't find it offensive, so long as they understand I am happily married and would never violate my wife's trust in that way."

"OK. With regard to Ms. Sandburg, in ten to fifteen years, this chair will be yours, if you want it. Tell me what you would do in my place, given the facts as we find them?"

"Going solely on what we know to be true, not what we theorize, I wouldn't dismiss her complaint out of hand, and I'd give her request proper consideration. The things which weigh against it are that we expressly do not allow students to request specific doctors as teachers, and students have to be able to learn from the doctor to whom they're assigned, even if they don't get along well.

"The challenge in Krista's case is that, so far as I can tell, I'm the outlier, so if she is assigned to anyone else, I suspect she'll be relegated to pure scut for a month unless either you, Doctor Gibbs, or Doctor Gabriel force the issue, and I wouldn't expect either of them to do so."

"Why should I listen to you, an Intern who's just completed his second month, over more experienced doctors? What do you know that they don't?"

"It's not about what I know," I replied. "It's about my philosophy that everyone deserves the same respect. In this case, respect means doing our level best to teach, until we conclude that a student is unable or unwilling to learn, or they demonstrate a complete inability to safely or ethically practice medicine."

"And when there are limited resources and we have to properly allocate them?"

"That's your job, and one I don't envy. Limited resources are my number one complaint."

"Mine, too," Doctor Nortrup agreed. "With regard to Ms. Sandburg, I'll give her request due consideration, and decide by the end of the day."

XLIV. Feelings of Guilt

August 31, 1989, McKinley, Ohio

I met Clarissa for lunch just after noon.

"I can't even leave you in the ED without you finding a way to get into trouble!" she said, shaking her head.

"Right, because saying I want to teach my medical student is 'getting into trouble'?"

"Even there you find a way to rock the boat or stir up a hornets' nest!"

"Gee, Lissa, did you give up on me Freshman year?"

"I'd argue that was different, but you won't accept that argument, no matter how well I make it."

"My point is not about specifics, but about giving up too soon. Nobody has given Krista a failing grade, and I honestly don't believe she deserves one now. Right now, I'd give her between a 2 and 3 for her rotation, with a 3 being likely if she continues to improve. A 3 won't end things for her, though it'll make it tough for her to Match to a top program and she'll very likely Scramble to a third-tier program in a rural area, similar to what happened with Melissa Bush."

"How is Melissa doing?"

"I haven't spoken to her again, though I will call her sometime in September to catch up."

"You're a strange guy, Petrovich."

"You have heard that it was said, 'You shall love your neighbor and hate your enemy.' But I say to you, love your enemies, bless those who curse you, do good to those who hate you, and pray for those who spitefully use you and persecute you, that you may be sons of your Father in heaven; for He makes His sun rise on the evil and on the good, and sends rain on the just and on the unjust. For if you love those who love you, what reward have you? Do not even the tax collectors do the same? And if you greet your brethren only, what do you do more than others? Do not even the tax collectors do so? Therefore you shall be perfect, just as your Father in heaven is perfect."

"Matthew's Gospel, right?"

"Yes. I figure if I can't take Jesus at His word, well, to paraphrase Paul, I've run a race in vain."

"I noticed you memorize things Jesus said and the Psalms, but not much else."

"David was a man after God's own heart, and Jesus is God. Paul and I have very different ideas on a number of topics, but that's OK because his letters are akin to the canons -- specific advice for specific situations, not meant to be generalized. I'm also partial to James and John.

"But coming back to our topic. I don't think it's right to give up on a student like Krista. She's not Tim, who failed rotations. That said, there is an accusation that she used sex to pass a rotation, but barring either confession or the doctor coming forward, it's just rumor. I mention it only because Doctor Northrup brought it up, and it does track with what I told you Leila Javadi said."

"She's never come on to you?"

"No. Ellie and Detective Kleist have actively flirted and want to have a fling; Kellie is absolutely interested, but wisely won't sleep with a married man. And a few med students have flirted or made rare suggestive comments, but Krista never has."

"Who is she assigned to as of now?" Clarissa asked.

"Mostly Paul Lincoln, given the schedule," I replied. "He works more or less opposite shifts to me now and also will next month."

"What do you think Northrup will do?"

"It's an interesting dilemma. He can't really allow students to select their Residents, but I'm likely the only Resident who would give Krista a chance. Think about a formal complaint and how it would work out when she pointed that out AND he denied her request."

"So she's found a way to force his hand?"

"In his position, under the current circumstances, that is what I would do, but I'm not sure what he would do. I believe he sees it as a situation where he's damned if he does and damned if he doesn't. On one hand, set a precedent where students are allowed to influence or even select their Residents, which creates a serious problem as students will gravitate to the best teachers through word of mouth; or, on the other hand, have her lodge a complaint that might actually succeed in some kind of formal proceeding."

"Why does this sound almost like the 'wine in front of you' bit from the movie?"

"Because he's basically screwed either way. I think he'll come down on not changing her schedule because, as I've been told time and again, no medical school or hospital has ever lost a lawsuit with regard to training medical students."

"Melissa Bush?" Clarissa suggested.

"I don't think she would have won in the end, but they chose not to take the risk, and to save the time and effort of defending themselves. The fact that she got her act together says the exercise was a success for both sides."

"What will you say if she does make some kind of formal complaint?"

"The truth, and only what I have personally observed. I did that with Doctor Northrup, even after he declared our conversation to be off the record."

"So you'd tell him what you thought versus what you were willing to say if asked?"

"Yes. As Residents, and especially during our Intern year, we're only provisional members of the guild. Doctor Northrup didn't want me to say anything on the record that might cause either of us a problem, and you know who comes out on top in that situation."

"It sounds as if you think she's going to get screwed," Clarissa observed.

"I think she put herself into a position where it was possible, and given she doesn't compare favorably with the other med students assigned to the ED, she's going to receive a sub-par evaluation, and might even fail. I'll object to failing her, but the thing is, this will be her second sub-par evaluation, and that's the kiss of death for any program other than the kind Melissa found in her second attempt."

"What would it take to fail in your mind?"

"Tim Burg deserved to fail; Krista doesn't, at least at this point. Someone, somewhere along the way, decided she wasn't worth teaching, and that started a downward spiral."

"Or, the rumor about her sleeping with an Attending to get a passing grade is true, and that is why she's being treated the way she is."

"I have no way of knowing, and as such, I won't consider it as material to anything."

"But if it were true..."

"Then she'd deserve to fail and the Attending ought to be suspended."

"Fat chance," Clarissa replied.

"I know."

We finished our lunch, and I returned to the ED, and had Krista take her meal break while I supervised Al suturing a leg lac. The rest of the afternoon was quiet, and, as promised, Doctor Northrup asked to see me just before 6:00pm. I checked with Doctor Gibbs, then went up to Doctor Northrup's office. As he had earlier, he signaled me to shut the door.

"I spoke to John Cutter, Ron Getty, and Tim Baker to get their input. The consensus is we can't, at this late date, change the schedule, especially for a sub-par student. And before you object, you did say she was clinically challenged. Are we going to have a problem?"

"No," I replied. "I understand your decision, and will obviously abide by it, and not publicly contradict it, but I don't agree."

"I understand. You'll find, in the course of your career, many instances where you don't agree with decisions that are made. How you respond is key -- it's OK to disagree, but it's not OK to stir up dissension."

"I understand."

"I will instruct Paul Lincoln to give Ms. Sandburg the benefit of the doubt, and not simply assign her scut. She is also free to attempt to trade shifts, but I suspect she won't meet with much success."

I was positive that wouldn't happen, as there was no chance Jake Green would switch with her.

"OK. I consider this matter closed."

"But you're unhappy," Doctor Northrup observed.

I nodded, "Yes, but I'm not in charge, and I'm not the one who has to make those calls. I've given my feedback. If this were a medical question, I'd be much more forceful."

"As I would not only expect, but demand. All reports I have are that you're doing an excellent job. Keep it up."

"Thank you."

I knew I was dismissed, so I left his office and returned to the ED, meeting Krista, who had obviously been summoned, on the stairs. I acknowledged her, but didn't say anything, as it wasn't my place. There was nothing pressing, so I was able to take my dinner break and meet Kris and Rachel in the cafeteria.

"How did your test go today?" I asked once we had our food and had sat down.

"It was easy," Kris replied. "You know I can read, speak, and write English, so that wasn't even a challenge. And I only had to answer ten questions from the list they provided and I am positive I answered all ten correctly. I should hear sometime in the next three weeks, then I simply need to appear to take the oath at a scheduled ceremony."

"When are those?"

"At varied times. Once my application is approved, I'll do my best to work around your schedule."

"I'm curious, but will you take the standard oath?"

"No. I'll say 'solemnly affirm' rather than swear, and I won't say 'so help me God'."

"What about bearing arms in defense of the US?"

"I can use the modified version which says that I will perform non-combatant services, which I am sure you would insist on if you were drafted."

"Well, I'd certainly be a doctor, but before I graduated, I'd have asked to be a corpsman or something similar, rather than carry or use a firearm. I take it your parents will apply once you're approved?"

"Not until after I take the oath, according to Mr. Burge."

"Daddy?" Rachel said.

"Yes?"

"Home?"

"Not tonight," I replied. "Daddy has to take care of sick people. Daddy will be home tomorrow night. One more sleep and one more nap."

"I think your idea that we shift her bedtime is exactly right," Kris said. "She really misses you."

"As we said, she didn't sign up for this the way we did, and at two, she doesn't understand. Fortunately, I'll have at least two months of the new schedule, and that will take us a third of the way through my Intern year."

"Maybe have lunch with her more often when she's in daycare here?" Kris suggested.

"I think I'll do that. I just hate that for two years she's paid the price for a decision I made seventeen years ago."

"She enjoys visiting Abi one day a week and being with Serafima another day, and she has her friends in daycare."

"I know, but she clearly wants her dad."

"And if you continue to beat yourself up for a decision you made when you were ten, where will that leave you? And where will it leave her?"

"You're right, of course. That doesn't make it any easier."

"And yet, as they say, the die is cast. The Rubicon was crossed long before she was born."

It was more complicated than that, but I couldn't say it out loud. My original plan had been to marry after my Intern year, which would have avoided the situation, but saying that would convey regret that I had Rachel, something I could never do. Nor could I say anything that would convey regret that I had Kris, despite the circumstances that had led to our marriage.

"I promise not to obsess about it," I said. "It's just that she tugs at my heartstrings."

"That's how it should be, shouldn't it?"

"Yes, of course. It's just that her little life has been difficult."

"Has it? Or do you think it's been difficult? She is a very happy toddler, with lots of friends. She doesn't know what happened. Her life is what it is, and you should be proud of what you've accomplished as a dad, despite all the adversity with which you've had to deal."

"You're right, of course."

"Keep saying that!" Kris said with a smile. "I like hearing it!"

"I'm sure!" I chuckled.

"How was your day?"

"Routine, and not too busy, though we lost a seventeen-year-old who wrecked his car early this morning."

"What is it with boys driving fast?"

"Don't ask me! I've never had a single traffic ticket. I left those to Jocelyn, who collected them like kids collect baseball cards!"

"How is your medical student?"

"She tried a Hail Mary today and didn't connect?"

"A 'Hail Mary'? The prayer?"

I chuckled, "Good thing American football wasn't on your citizenship test! It's a last-minute attempt to score by throwing a long pass into the end zone in the hopes one of your team will catch it, or the defenders will commit a penalty."

"Such a silly sport! You should play proper football! Or at least rugby football! And stop calling cars going around in circles 'racing'!"

"Ovals," I chuckled. "Ovals. But NASCAR does race on road courses a few times each season, I think."

"Formula One is proper racing."

"Listen to the Euro-snob!" I teased.

"There is no city in Ohio which even comes close to Paris!"

"Most people here would take that as a compliment!"

Kris laughed, "Of course they would! They're mostly Germans, after all!"

"As an Ohioan, I do have to point out that there are no Skyline Chili restaurants in Paris!"

"You say that like it's a bad thing!" Kris teased.

"Those are fighting words, Missy!" I growled.

Kris laughed, winked, and we continued eating. When we finished our meal, took a short walk with Rachel, and then my wife and daughter headed home. I walked back to the ED and found Serenity and Al waiting for me. About two minutes later, Joyce, a new clerk, let us know EMS was bringing in an MI. Serenity, Walt, and I gowned, gloved, and headed for the ambulance bay, along with Nurse Alice. The patient arrived in full arrest, and despite our best efforts, we couldn't revive him.

"Time of death, 19:17," I announced.

My students and I left the trauma room while Alice began the death kit. I asked Joyce if the patient had any next of kin and she said his wife and son were in the waiting room. I asked Serenity to bring them to the consultation room, and once she had, I relayed the news.

I realized I was becoming anesthetized to death, and I wasn't sure I liked it, despite it being necessary to be able to do my job. Each death weighed less and less, though I understood that the family and friends of each patient who died felt the full weight of their loved-one's passing, and I had to show empathy while remaining detached, which was no easy task.

Once I left the family in the hands of the chaplain, I completed the chart and filled out the physician's portion of the death certificate. I needed Doctor Taylor to sign the chart and the certificate, which he did, then I took the chart to Joyce, who would ensure it was recorded in the computer and then given to whichever Attending was responsible for the chart review.

The rest of the evening was relatively quiet, and I managed to sack out in the on-call room just before midnight.

September 1, 1989, McKinley, Ohio

"How was your day?" Kris asked when Rachel and I arrived home on Friday evening.

"Calm, actually. I managed to get about four hours of sleep, and Rachel and I had lunch together today."

"I'll take her so you can go change. We're staying home, right?"

"Yes. I don't want to foist Rachel off on anyone, given she clearly wants to spend time with me. Not to mention you and I have some business to take care of!"

Kris laughed softly, "So, making love to me is work?"

"No! But I'm concerned about the 'tape recording' feature that someone seems to have installed in our daughter!"

Kris laughed again, and went upstairs to change into shorts and a t-shirt, then went down to the kitchen to help with the final preparations for dinner. I helped Kris finish making dinner, then the three of us ate. After Kris and I cleaned up, I read two books to Rachel, then played my guitar for her. We said our evening prayers together, and then I gave Rachel a bath and put her to bed.

"I think I need a bath," Kris said invitingly.

"Before or after?" I asked.

"Before, I think, so we can just fall asleep after we make love."

We went to our room, I drew a bath, added bubble bath, and then Kris and I undressed and got into the tub.

"Did having lunch with Rachel help you feel better?" Kris asked as we lounged in the warm, sudsy water.

"Yes, and it did assuage some of the guilt, but it's only a partial solution."

"Mike, you need to forgive yourself the way you forgive others. What you're doing isn't sinful, so it should be even easier."

"As the saying goes, 'easier said than done', but I understand. I think I'll feel better starting Sunday because I'll have time for her every day. And equally important, time with you every day."

"And I will be happy to have you home more."

"When would your period normally start?"

"Around the 16th," Kris replied. "Are you expecting me to be pregnant?"

"If you aren't, it won't be for lack of trying!"

Kris laughed softly, "And we should try three times tonight to improve our chances?"

"I certainly got enough sleep last night that we can do that."

"Great!"

September 2, 1989, McKinley, Ohio

Kris, Rachel, and I had our usual Saturday morning -- band practice, shopping, the bakery, and lunch together. I left my wife and daughter about 11:40am, and headed to the hospital for my final shift of the August rotation, even though it was September on the calendar.

"Doctor Mike, do you have a moment?" Jake asked after I'd done my handover with Kylie.

I acknowledged Jake's request, and after checking in with Ghost, Jake and I went to the temporary Resident's office.

"What can I do for you?" I asked.

"Krista Sandberg asked me to switch shift schedules with her," Jake said. "She indicated she had your approval."

"Only to ask," I replied. "I'm neutral on who's assigned to me because I have to be."

"I don't want to switch, but she strongly implied that's what you wanted."

I shook my head, "You need to do what best suits you, just as she does. I need to teach whoever is assigned to me, and I'm not supposed to play favorites, though I do provide students who show aptitude and skill with more opportunities, as is the norm."

"OK. Then I'm going to tell her 'no'."

"As is your prerogative. Shall we go see some patients?"

"Yes," Jake replied.

"Get the first chart in the rack, take Heather with you, and do an H & P, please."

"Right away, Doctor."

I went to speak to Ghost, and about ten minutes later, Heather came to let me know that Jake had finished his exam. That began a busy shift which saw us treat ten walk-ins and handle two EMS runs before I finally took a dinner break just before 8:00pm. Because Clarissa had more flexibility, she delayed her meal break to match mine. For the next month or two, our shifts would only overlap on occasion, and that meant we'd have to make time to see each other outside the hospital, something which was difficult given my situation.

I was paged right at the end of my meal break as there were three simultaneous EMS transports inbound. Clarissa handled returning my tray, and I moved as quickly as possible without running the full length of the corridor, managing to glove and gown and join my students and Nurse Terry in the ambulance bay just as the third squad arrived.

"Stan Lowe, forty-nine; gunshot wounds to the abdomen and leg with no exit wounds; pulse 110 and thready; BP 60 palp; resps slow and PO₂ 92% on five liters; unit of plasma and IV saline; 5 megs morphine."

"Trauma 3!" I ordered. "Terry, another unit of plasma and type and cross-match; Jake, Foley; Heather, EKG and monitor. Move!"

We quickly moved the patient to Trauma 3 and the six of us moved him to the treatment table. The patient would need to be intubated before surgery, but his PO₂ was high enough that I could worry about other concerns, and his slow resps were likely related to the morphine, though significant blood in his abdominal cavity could put pressure on his diaphragm. He'd absolutely need an ex-lap, but I had to get his blood pressure up if he was to have any chance of surviving surgery. I found no other wounds.

"Blood in the bag!" Jake announced, which was no surprise.

"Jake, call upstairs to surgery; he needs an ex-lap to see what kind of damage the bullet did."

"Right away!" he exclaimed.

"Tachy at 125," Heather announced. "BP 70/30; PO₂ 93%."

"He needs more volume," I said. "Squeeze in the rest of that unit of plasma! Terry, set up the rapid infuser for that second unit."

"They need to call in a surgeon," Jake reported. "The other two transports need surgery as well."

"This guy won't live if he has to wait. Once the second unit is in, we're taking him up."

An alarm blared.

"BP just bottomed out!" Heather declared, then a second later announced, "Asystole!"

I had good money on traumatic rupture of his aorta, and even if he were open on a surgical table, mortality was north of ninety percent.

"He's hypovolemic," I said. "CPR and let's hang two more units on the rapid infuser."

As we sprang into action, Doctor Mastriano came in and I quickly gave her my assessment. We worked together, but the situation was hopeless, as we couldn't replace the blood loss quickly enough.

"Ruptured aorta," Doctor Mastriano observed about ten minutes after she'd come into the room. "Call it, Mike."

"Time of death, 21:12," I declared. "Do we know what happened?"

"Deputies were servicing a warrant," she said.

That surprised me, given no Deputy had come into the trauma room. That almost guaranteed that the other victims weren't Sheriff's Deputies.

"The first two victims?" I inquired.

"Unrelated MVA."

"Which Deputy is here?"

"None, yet," Doctor Mastriano replied. "The report is that the man's son has them in a standoff."

I updated the chart while Nurse Terry began the death kit. Once the chart was completed, my students and I left the room and immediately encountered Deputy McCallum.

"He didn't make it?" he asked.

"No. McKnight will tell us definitively, but he bled out, likely due to a ruptured aorta."

"Well, shit," he sighed.

"Problem?"

"I can't talk about it right now," he said. "Let me call it in. OK to use the consultation room?"

"Yes."

I had a feeling from his reaction, combined with what Doctor Mastriano had said, that it was what law enforcement called a 'bad shoot'. He went to the consultation room, and I took the chart to Joyce.

"Report is he was coming out of the house unarmed and a Deputy fired on him," she said quietly.

I nodded, "That fits Deputy McCallum's reaction."

"There are three charts in the walk-in rack. Doctor Varma has two already."

I instructed Jake and Heather to take the next chart and went to the lounge to use the restroom and get a drink of water, then joined them in Exam 3 for a patient with blurred vision and a headache. Thirty minutes and a neuro consult later, the patient was admitted for testing and observation with what I suspected was a brain tumor.

The rest of the evening was uneventful, and just after midnight, I headed home.

September 3, 1989, Columbus, Ohio

The events which had led to the patient who'd died of the gunshot wound appeared in the Sunday edition of the McKinley Times. The Sheriff's Department had, together with the FBI, gone to serve a warrant on a 'fugitive from justice' -- a twenty-year-old college kid accused of two kidnapping rapes in Boston. The man who died in the ED was his father, and had come out of the house unarmed as law enforcement was arriving, and a Deputy had, for some reason, fired on him.

"What will happen to the Deputy who fired the shots that killed him?" Kris asked as I pulled out of the driveway for the drive to church.

"It'll depend on the outcome of the investigation, but usually the police are exonerated of criminal charges. Usually the most that happens is the Deputy would lose his job."

"Even if he shot an unarmed man for no reason?"

"He'll give some reason, and most of the time, prosecutors defer to the judgment of the officer involved. Not always, but that is the norm."

"The police here are too free with their use of guns."

"I don't disagree," I replied.

"Changing subjects, what time do you need to leave tomorrow morning?"

"By about 4:30am," I replied. "That gives me enough time to get to the hospital, change, and get to the ED by 5:00am. I'll set my alarm for 4:10am, shower, dress, and be on my way. I'll say my morning prayers in the car on the way to the hospital."

"OK. Rachel's schedule is matched to yours. Serafima will pick her up tomorrow before I leave for class, and I'll drop Rachel at Abi's on Tuesday morning on my way. Wednesday, you'll take her to the hospital daycare. Thursday she's at Serafima's again, and then Friday you'll take her to the hospital daycare."

"Thanks for making those arrangements."

"The plan is to say evening prayers together around 9:30pm, right?"

"Yes. We'll keep that consistent every day to accommodate Rachel having a regular schedule. We can say morning prayers together on Wednesday, but that's the only day."

"Unless you object, I'm going to stay in bed when you get up, but I'd like you to kiss me goodbye."

"Where?" I asked with a sly smile.

Kris laughed, "You'll be late to work if it's anywhere but my lips!"

"That is the downside."

"Did your student switch shifts?"

"No. The student she asked to switch with her declined, which I expected him to do. There was literally nothing in it for him, and it wasn't anything like the situation I had with Kylie, where it was compassionate on my part, but also created a situation where I could attend services."

"That was the nasty doctor who tried to prevent you, right?"

"Yes. But fortunately, he's on another service and I have literally nothing to do with him unless he comes down for a consult."

"And the psychiatrist?"

"That entire service dislikes me, but, in the end, my interactions with them are limited, and they can't initiate them."

"Changing topics, I think Rachel might be ready to be toilet trained."

"Probably. We'll need to get a potty chair for her. The current thinking is to put her on it for a few minutes every few hours, telling her that pee goes in the potty, and so on. Do you want me to bring home the brochure from pediatrics?"

"I have zero experience with teaching toddlers to use the toilet, so that's probably a good idea."

"I'll get one tomorrow. I have zero experience in that area as well!"

"You've done a very good job with Rachel despite having no experience raising children."

"And you've done a very good job with sex despite having no experience!"

Kris laughed, "And that is a topic for a drive to church?"

"Well, if poo is an OK topic, I believe making love should be as well!"

Kris and I shared a laugh, though we did begin to focus on our destination, and five minutes later, with the levity behind us, I pulled into the parking lot across the street from the Cathedral. When we entered the nave, we lit candles as we usually did, and I let Subdeacon Nathanial know that I wanted Father Luke to hear my confession. Immediately after Matins started, Father Luke came out to hear my confession during the changing of the Psalms.

"What is on your heart, Michael?" he asked.

"A feeling of guilt that I'm neglecting Rachel," I replied. "She's starting to vocalize that she misses me when I'm working my thirty-six-hour shifts."

"You knew about those before she was born, did you not?"

"Yes, I did, and I signed up for them; Rachel didn't."

"Is it your thinking that what you're doing is somehow sinful?"

"I'd say it misses the mark of what I believe would be good parenting."

"Do you believe any parent is ever perfect?" Father Luke asked.

"I'd say it's doubtful."

"And you're doing your best, given your circumstances?"

"I think so; Rachel doesn't."

Father Luke laughed softly, "One thing you'll discover throughout your life is that your children are very good at pointing out your failings in as much detail as you can stand, and then some! I believe the rubber will meet the road in about twelve years when you do not feel at all guilty for acting in a way with which she disagrees."

"I can wait," I replied. "I suppose the true source of the problem is feeling guilty."

"And that's a good thing, Michael, in that you're aware of the impact of your calling on your family."

"I made a point of discussing it with Elizaveta before we married and Kris before we married, and they both had a choice."

"Don't get me wrong, Michael; I understand why you feel the way you do. Let me ask this -- would you be a better parent if you gave up medicine?"

"Probably not, because I'd be denying my calling."

"Things change in the future, right?"

"It'll be better after this first year and get progressively better to where I'll work an average of fifty to sixty hours per week."

"How is your prayer life?"

"I'm consistently following the rule Father Roman gave me."

"And fasting?"

"To the extent possible, given my crazy schedule and ensuring proper nutrition."

"Is there anything else on your heart?"

"No, Father."

"When will you see Father Roman again?"

"Next Sunday."

"Good."

He prayed the prayer of absolution, and I returned to my spot next to Kris and Rachel. When Matins and the Divine Liturgy ended, Kris and I chose to head home so we could spend time together as a family.

September 4, 1989, McKinley, Ohio

On Monday morning, I arrived at the hospital at 4:50am, went to the surgical locker room to change into scrubs, then reported to the ED for my shift.

"Morning!" Kellie exclaimed. "I matched my schedule to yours as much as possible."

"People are going to talk," I replied with a smile.

"Let 'em. You and I both know the score."

"Let me see Paul for the handoff," I said.

I walked over to where Paul Lincoln was standing near the board.

"Two waiting on Medicine," he said. "They'll go up around 6:00am. Exam 2 is gastro, IV rehydration underway; Exam 4 is an adrenal mass. Krista is coordinating with Medicine."

"Thanks. Did Doctor Northrup speak to you about her?"

"Yes."

"Just give her a fair shot, please."

Paul nodded, "I will. Anything else?"

"You can take off. I've got it, thanks."

He left, and I went to check in with Doctor Boyd, who'd be going off shift at 6:00am when Doctor Gibbs would come on. Doctor Boyd had no special instructions, so I reviewed the charts for the two patients, then confirmed with Krista she had things under control. The next hour was quiet, and Krista managed to send both patients upstairs before the end of her shift.

Jake and Heather started their shifts, and for the first time since I'd begun my clinical rotations, no medical students were sitting at the triage desk. It was now fully staffed by nurses, and we'd be starting to train paramedics. In addition, Residents from Medicine would be assigned to the ED for eight-week stints. Starting in January, the same would be true of surgical Residents.

The other big change was the EMS/Police radio system was being installed at the Clerk's desk, though it wouldn't be live for a few weeks. And, longer term, each of the ten-year-old EMS squads was being replaced with new Advance Life Support squads, which would have more equipment and supplies, and allow the new procedures we were teaching to be performed.

Changes were coming fast and furious, and the biggest one was yet to come -- the new trauma wing, which was taking shape just across the driveway from the ambulance bay. It would have six dedicated trauma rooms, fourteen beds in an open ward separated by curtains, two private exam rooms, a dedicated suture room which would double as a treatment room, a centralized nurses' station, and a waiting room that would be twice as big as the current one. All the trauma rooms and six of the ward beds would be 'telemetry' beds, which would allow a nurse at the nurses' station to monitor a dozen patients' vital signs simultaneously.

All of that, though, was at least eighteen months away. In the here and now, Jake, Heather, and I had patients in the waiting room. As was my usual practice, I had them retrieve the first chart, bring the patient in, and notify me when they were ready.

"Carol Klein," Jake announced after introducing me, "sixty-eight; fell during her morning walk and struck her head; minor contusion on her right temple; complains of dizziness and nausea; pupils slightly sluggish; pulse 68; BP 120/70; PO₂ 98% on room air. General good health; no recent ailments; uses naproxen for mild rheumatoid arthritis."

I acknowledged him, spoke to Mrs. Klein, performed a basic exam, then stepped into the corridor with my students.

"Proposed diagnosis?"

"Concussion," Jake replied.

"Proposed treatment plan?"

"Monitor and release if symptoms don't worsen; advise to follow-up with personal physician."

"Heather, is there anything you'd add or do differently?"

"Given her age, perhaps a baseline EKG? That was suggested in our Practice of Medicine course for anyone over sixty-five who shows signs of possible subdural hematoma."

I nodded, "Solid, defensive medicine, and easy enough to do. Jake, deliver your diagnosis. Heather, set up the EKG and attach a strip to the chart. No need for continuous monitoring."

I updated the chart, signed the order, then we went back into the exam room. Jake delivered his diagnosis, and explained that Heather would take an EKG. Mrs. Klein didn't ask any questions, so I left my students to accomplish the EKG, and about ten minutes later, they came to report no anomalies. I examined the strip and agreed.

"Ask Ellie for a nursing student to sit with Mrs. Klein," I said. "Do we know who brought her in?"

"Her husband is in the waiting room."

"Check with her and if she's amenable, you can bring him in. Let me know if they have any questions."

Jake acknowledged my instructions, they left to carry them out, and I went to see Doctor Gibbs to present the case.

"You had Jake do the workup," she said. "Why not have him present to me?"

"He's bringing in the patient's husband and arranging for a student nurse to sit with her. I'll have him present in the future."

"Treatment plan approved. Good call on the baseline EKG."

"That was Heather. I hadn't planned to do it, but she suggested it based on something that was said in her Practice of Medicine course. It makes sense, obviously, and it's good defensive medicine."

"Make sure she knows that."

I smiled, "I complimented her on suggesting it and used 'defensive medicine' when I did."

"Go heal the sick!"

XLV. Oh, Stop!

September 6, 1989, McKinley, Ohio

"Good morning," I said to the pretty blonde receptionist at the McKinley Free Clinic just before 7:45am on Wednesday morning. "I'm Doctor Mike Loucks."

"I remember you," she said with a smile. "But you were a medical student when you were here two-and-a-half years ago. Doctor Turner is waiting for you in his office."

"Thanks, Tamara. I remember where it is."

"Great! If you need anything, just ask!"

"I will," I replied.

I walked through the door and turned right, then walked down the short hallway to Doctor Turner's office.

"Good morning, Mike," he said.

"Good morning, Doctor Turner."

"Gale, please," he said, extending his hand.

We shook.

"Do you have your prescription pad?" he asked.

"I do. Doctor Gibbs reminded me yesterday that your rules are different from the hospital's."

"No pain medication and no controlled substances; generally, you'll only write scripts for birth control pills or antibiotics. Trina will write any scripts for diaphragms because they need to be fitted. You're authorized to do any of the procedures we do here, though I know you won't participate in an elective abortion."

"Correct."

"But you don't have a problem with our counseling policy, right?"

"Sure I do, but I'll still follow it."

"You're an odd duck, Mike."

"You are not the first person to say something like that! What's the drill?"

"See patients, assist the Nurse-Practitioners with procedures that require an MD, and generally be a doctor. That frees me for the things about which you have reservations. Use the small office next door, Nurse Michelle is assigned to you, and Exam 1 is all yours. Misty, at the front desk, will assign patients. Any questions?"

"I think I recall the procedures, but if I forget, I'll ask Trina."

"She's looking forward to seeing you. Let me know if you need anything."

"Thanks, Gale."

"Can I ask..."

"Why am I wearing a shirt and tie rather than my clerical robes?"

"Yes."

"You know what happened two years ago, right?"

"Yes."

"I chose to remarry, and the Orthodox Church doesn't allow clergy to marry. My options were to ask for release or take a vow of chastity."

"Say no more. Thanks for answering."

I left his office and walked down the hall to the small break room where Trina was sitting.

"Doctor Loucks, I presume?" she said when I walked in.

"I introduce myself and go by Doctor Mike. Everyone except patients and med students simply calls me Mike. How are you?"

"Good! You?"

"Good."

"No clerical robes?"

I gave her the same explanation I'd given Doctor Turner and then recapped what had happened in the thirty months since I'd trained at the clinic. A short, thin redhead came into the break room and Trina introduced her as Nurse Michelle.

"Trina," Misty announced, coming into the break room. "Your 8:00am is here. Doctor Mike, we have a walk-in."

"I'll bring the patient to Exam 1, Doctor," Michelle interjected.

She left, and five minutes later, to give her time to take the patient's vitals, I knocked and entered Exam 1.

"John Atkins, nineteen," Nurse Michelle said. "Vitals normal."

She handed me the intake form, and I quickly scanned it.

"Hi, John," I said. "I'm Doctor Mike. What brings you to see us today?"

"I have a strange bump on my Johnson."

"Michelle," I said, "specific vitals?"

"Pulse 73; BP 120/60; temp 98.4°F."

"John," I said. "I'd like to start with a basic exam, then I'll examine your genitals."

He agreed, so I washed my hands, put on gloves, and ran through a basic exam, calling out the results to Michelle to add to the chart. I found nothing remarkable in my exam, and then asked John to drop his jeans and briefs, after confirming he was OK with Michelle staying in the room. Once I'd completed the exam, I had him pull up his briefs and jeans.

I had spent my free moments at the hospital on Tuesday reviewing my OB/GYN flashcards, as well as those on virology, and sexually transmitted diseases, and at home on Tuesday evening, I'd reviewed the plates of STD images to refresh my memory. This diagnosis was fairly easy.

"You have a genital wart," I said. "It's a relatively mild form of sexually transmitted disease, caused by a virus, specifically Human Papilloma Virus, also called HPV. Something like half the population in your age group has it, and the vast majority of cases show no sign and have no symptoms.

"There is no vaccine or other treatment that will eliminate the virus, and in most cases, your body will simply clear the infection on its own. When symptoms do appear, such as genital warts, we generally use a drug called Podofilox, which is a topic cream. It will help clear the wart. I'll apply the first treatment and write you a prescription for it."

"My girlfriend gave me VD?!" he asked in surprise.

"Technically, yes, but HPV is in a different class from other so-called social diseases, such as syphilis, herpes, chlamydia, or gonorrhea. It's also possible you contracted it years ago, and there is evidence that it can be transmitted from mother to child when giving birth. It can also be transmitted via hands or objects. It might be transmissible by blood, but the jury is still out on that.

"The only action you can take at this point is regular use of condoms, otherwise you'll simply pass the virus back and forth with your partner. Your girlfriend is likely infected, even if she has no symptoms, which she might never have. You need to encourage her to see her gynecologist and have regular Pap smears. If she doesn't have a gynecologist, or can't afford to see one, she can make an appointment here."

"OK, he replied.

"Michelle, I need a tube of Podofilox, please, and an HPV pamphlet."

"Right away, Doctor!"

Fifteen minutes later, with the cream applied and instructions on how to use it, I handed John a prescription for another tube if the wart didn't clear with the first tube, the HPV pamphlet, and instructions to see his primary care physician for follow-up. Once he left, I asked Michelle to step back into the treatment room before our next patient.

"My preference is for vital signs to be expressly stated, please. Also, when we're not with a patient, just 'Mike' is fine. No need for the formal title."

"Sorry," she said.

"No need to apologize. Every physician has their own style."

"I'll go see what Misty has for us."

"I'll use my office to complete the chart and come back in about five minutes."

I removed my gloves, tossed them in the hazardous waste bin, and then went to the small office and completed the chart, putting it on the credenza behind me. One of Doctor Turner's duties was to review all the charts, and he'd take them home with him. That was one thing I appreciated about the ED -- Attendings did all chart reviews, so I wouldn't have to worry about that for several years.

When five minutes had passed, I joined Michelle and a female patient in Exam 1.

"Katy Brooks, sixteen, seeking birth control pills," Michelle said. "Pulse 70, BP 110/60, temp 98.3°F."

"Hi, Katy," I said. "I'm Doctor Mike. Let's start with some basics. Are you sexually active?"

"I haven't, you know, gone all the way."

I looked over the intake form and saw she'd checked the box next to oral sex, and had written in '2' next to number of partners.

"Let me ask a different way," I said with a smile. "Have you done things which your dad would consider 'sexually active'?"

"Uh, yeah," she replied, blushing slightly.

"And have you ever had a test for sexually transmitted diseases? What you might have heard called VD?"

"No."

"Do you see a gynecologist regularly?"

"Every year since I got my period when I was thirteen."

"And a regular physician?"

"I saw a pediatrician until I was twelve, now I just see my gynecologist."

"May I ask why you're here rather than speaking to him or her?"

"Her. She's my mom's gynecologist and if I make an appointment, my mom could find out. I, uhm, don't want to wait until my next appointment in May."

"You could tell them not to inform your mom," I said. "And they're required by medical ethics to honor that request."

"I couldn't afford to pay for the exam," Katy countered. "I don't work."

"And that's why we're here. What I'd like to do is perform a basic exam, which means listening to your heart and lungs, and checking your eyes, ears, nose, and throat, and check for swollen lymph nodes. You won't need to undress; just untuck your blouse and unbutton the top two buttons."

She did that I and checked her heart and lungs, then used the otoscope to check her ears, eyes, nose, mouth, and throat. That completed, I checked her distal pulses and then felt for enlarged lymph nodes in her neck.

"I don't find anything that would preclude a prescription for birth control pills," I said. "I would like to have the nurse draw blood for an STD test, given you've had multiple partners with whom you've engaged in oral sex."

"Uhm, neither of them has gone all the way."

"Fellatio or cunnilingus are pathways for the transmission of STDs," I replied gently.

"Er, what do those words mean?"

"Oral sex. Fellatio is what you do; cunnilingus is what he does. Either way, you exchange bodily fluid, which is how STDs are transmitted. I'm not implying you have one, and I can't force you to have the test, but it would be a good idea. It's completely anonymous and we'll give you a code number so you can call without identifying yourself, and nobody could get your name by calling the number."

"Uhm, sure."

"Michelle will draw a tube of blood and I'll write your Prescription. I'll also give you a three-month supply, and after that, if you can't afford them, you can continue to return here for another three-month supply at little or no cost. Also, you should inform your gynecologist or primary care physician that you're taking birth control pills and you should begin having Pap smears each year."

"Wait! I have to tell the gynecologist?! I came here, so I didn't have to."

"Ethically, she can't say anything to your parents. That said, the Free Clinic does provide gynecological services. You can make an appointment with the desk, and in your situation, there would be little or no cost. The challenge there would be not seeing your mom's gynecologist, which would raise questions. It's my opinion you should continue to see the gynecologist and make it clear you do not want her to share anything at all with your parents. If she did, she could lose her medical license."

"You're sure?"

"Positive. Michelle, you can draw the blood, please."

She did that, properly labeling the tubes.

"Do you have any questions?" I asked. "Either Nurse Michelle or I can answer pretty much anything you can ask."

"I had health class," Katy said.

I smiled, "I suspect that was similar to mine and the amount of information conveyed was actually minimal. Let me ask you a question, which you can decline to answer if you choose. OK?"

"Yes."

"Do you expect your first time to hurt and do you expect to bleed?"

"Obviously."

"Actually, not so obvious. Do you play any sports?"

"Softball and soccer. Why?"

"Then the odds of you having an intact hymen are very small. By age sixteen, it usually either atrophies or is ruptured by athletic activity."

"WAIT! I'm not a virgin?!"

"A misconception perpetrated by ignorant people," I said. "If you haven't had intercourse, you're a virgin. But in the end, that's nobody's business except yours. It's literally impossible to tell if a woman has had sex or not. Anyone who tells you differently has no idea what they're talking about. There are outliers, of course, but even in those cases, the barrier is thin and mostly open, as otherwise you couldn't have a menstrual period."

Katy laughed nervously, "I didn't even think about that!"

"Most people don't," I replied. "As for it being painful, in girls who are over fourteen, that is nearly always because of lack of foreplay, nerves, or some other thing that inhibits lubrication. In addition to the birth control pills, I'll give you a pamphlet which explains all of this in non-medical terms, as well as a tube of lubricant. You apply that to your partner's erection and there should be no pain at all."

"You're sure?" Katy asked skeptically.

I looked to Michelle to confirm.

"He's telling the truth," Michelle said. "I was sixteen my first time, and we took our time and it was wonderful. There was no pain, and I didn't bleed. My friends who rushed, or who did it in the back seat of a car, had somewhat different experiences. Find someplace private, where you won't be disturbed, take your time, engage in foreplay, and use the lubricant, and everything will be wonderful."

"The only other consideration," I said, "is that birth control pills don't prevent STDs. Rubbers are the only effective way to reduce your risk, though having only one regular partner can limit your risk, assuming he also only has you as his partner."

"If my boyfriend cheats on me, the last thing he'll need to worry about is VD!" Katy growled.

"A sentiment I've heard expressed by various girlfriends over the years," I chuckled. "That said, you wrote on the form you had two partners."

"Uhm, the first one was at a party where we played 'Truth or Dare' when I was fifteen. That was before I started going out with Don."

"OK. Let me get your pills, the pamphlet, and the lubrication, and you'll be all set."

"You need to take the pills religiously," Michelle said. "Every day at the same time, and if you miss one, you double the next day, but you have to use a condom until after your next period."

"Seriously? Why?"

Michelle looked to me to answer.

"The Pill works by regulating hormone levels, and even a period as short as twenty-four-hours can result in enough variation to allow pregnancy. The other thing to remember, and this is in the brochure, is that antibiotics and some herbal supplements can reduce the effectiveness of birth control pills."

"This is WAY more complicated than what they explained in health class!"

I nodded, "A common complaint. Any other questions?"

"No."

I left the room, got the pills, the lubricant, and the pamphlets, then returned to give them to Katy, along with the prescription and the form that would allow her to retrieve her tests results. She thanked us and Michelle walked her out. I returned to the small office to complete the chart, and Michelle came to the door.

"Someone just walked in, but they're filling out the intake form, so it'll be a few. You did a really good job with Katy."

"Thanks."

"I go home for lunch," she said with an inviting smile. "You're welcome to join me."

"I appreciate the offer, but if I did that, my wife would ensure nobody ever found my body!"

"Bummer, but I understand. The offer is there if you change your mind."

"Again, I appreciate it, but there is zero chance of that. And I'd appreciate it if we kept this professional and friendly, please."

"Sorry," she said. "I'll let you know when Misty lets me know the patient is ready to come in."

The rest of the day followed the pattern, and I saw a total of ten patients for a variety of sexual healthcare matters, with a break for lunch, which I ate alone in the break room. At 5:00pm, I handed the charts to Doctor Turner.

"How did things go?"

"No problems," I replied. "Michelle and I work well together, and Trina answered the one question I had."

"Great! Then we'll see you next Wednesday."

I left the clinic, headed to the hospital to retrieve Rachel from daycare, then headed home for dinner and Vespers at the Cathedral.

September 7, 1989, McKinley, Ohio

"How did things go yesterday?" Doctor Gibbs asked when she arrived in the ED at 6:00am.

"Other than a cute redheaded nurse propositioning me, just fine."

Doctor Gibbs laughed, "Nurses and doctors having affairs is so common that blatant requests to cheat are not out of the ordinary."

"Oh, I know. I declined and simply politely requested that we keep the relationship professional and friendly."

"Professional?" Doctor Gibbs smirked. "You're the last person I'd think needed to pay for it!"

"Oh, stop!" I chuckled. "I'd pay all right, and it's a price is too high.

"On a different topic, I'm sure it won't come as a surprise that Krista complained that she's not receiving enough procedures and isn't being given an opportunity to succeed."

"To whom?"

"Doctor Mertens. There's a meeting with her, Doctor Northrup, and me at 3:00pm."

"What did Paul Lincoln have to say?" I asked.

"That he reviewed her procedure book, and he's assigning her tasks appropriate with her training while looking for opportunities to expand her skills."

"That's the right approach," I said. "I suspect the crux of the complaint is that I take a more expansive view of what students can and should do. You know why."

"You've latched on to that Osler quote like a dog with a tasty bone."

"He wasn't, and isn't, wrong. You know my take."

"'I want more procedures!'" Doctor Gibbs said, trying to mimic my voice.

"The refrain of every medical student, and with good reason."

Ellie came to the door to the office, "Sorry to interrupt. Paramedics are four minutes out with an MI."

"Give it to Mike," Doctor Gibbs said. "Go heal the sick!"

I left her office, gathered my students and Kellie, and the four of us went to the ambulance bay to meet the EMS squad. I knew how it was going to turn out as soon as I heard from the squad driver that a fireman doing chest compressions -- at best a 5% chance of coming back. The four of us worked on the patient for fourteen minutes before I threw in the towel, as he'd been down ten minutes before he'd arrived in the ED. I had Heather bring his wife into the consultation room and presented the news and turned her over to the chaplain.

"I hate those," Heather declared as she, Jake, and I left the consultation room.

"Not the best part of my day, that's for sure," I replied. "This one was dead before he got here, but you know the EMS rule, right?"

"Not dead in the field unless there is obvious brain matter, obvious exsanguination, or the body is cold and not submerged in water."

"Decapitation is also on the list," Jake interjected.

"I dunno," Heather said with a sly smile, "most men seem to survive just fine without brains."

"Did you and Dale break up?" Jake asked.

"That obvious?" Heather asked.

"You usually don't get that down on men."

"He's been bitching about my hours."

"A girl from my former parish who I might have married made it clear she couldn't deal with the demands of medical training," I said. "It makes a complete mess out of relationships."

"How have you managed?" Heather asked.

"By finding the right woman," I replied. "One who could handle it."

"Guys do not accept it," she groused. "And you know how tough it is on women in medicine. I've heard you opine."

I nodded, "Medicine, and society as a whole, needs to get its head out of its butt. Look how long it took for even a tiny segment of the profession to admit that thirty-six-hour shifts are detrimental to patients AND to Residents. And there is serious pushback against the New York legislation as an 'overreaction' or 'political meddling'. But the situation was created by medicine, refusing to address the problem and take steps to fix it. The same thing will happen with the treatment of women, but unfortunately I might retire before things change in a significant way."

"Mike," Ellie called out. "There are five charts in the walk-in rack."

"Do your thing," I said to my students. "But this time, Heather, you do the assessment with Jake monitoring."

They went to get a chart, and I went to the lounge to get a drink of water. I sat down with Lancet and read for about ten minutes until Jake came to get me.

"How'd she do?" I asked.

"Fine. I didn't confirm her auscultation, though."

"That's OK at this point," I replied

We went into Exam 2 and after Heather introduced me, she presented.

"Heide Burdick, seventeen; syncopal episode in gym class; BP 100/60; pulse 76; PO₂ 99% on room air; brief LOC. No recent illnesses, no medication. Nothing remarkable on exam."

"Hi, Heide," I said. "How are you feeling?"

"Still a bit woozy."

"Can you tell me what happened right before you felt faint?"

"We were playing soccer, and I suddenly felt lightheaded. I sat down, my gym teacher said I passed out, but I'm not sure I did."

"They didn't call 9-1-1?"

"I insisted my friend could drive me, and the gym teacher didn't argue."

"Any tinnitus? That is, ringing in your ears?"

"Right before it happened."

"Did you happen to cough or sneeze?"

"I had a small sneezing fit. I have allergies."

"What did you have for breakfast this morning?"

"The usual -- a waffle, juice, and coffee."

"And dinner last night?"

"Steak, corn on the cob, and salad."

"Has your blood pressure been low?" I asked.

"My doctor says it's a bit low, but nothing to worry about."

"OK. I'm going to do a basic exam to check Heather's findings."

I did that, then excused the three of us so we could step out into the hall.

"Thoughts and next steps?" I asked Heather.

"Chem-20," Heather replied. "You ruled out blood glucose."

"Did I?" I asked.

"You asked about food and she ate, which means she shouldn't have hypoglycemia."

"Shouldn't," I replied. "Neither hypoglycemia nor hyperglycemia are ruled out, they're just unlikely. Continue."

"I don't have anything more."

"Jake?"

"OK to look in my book?"

"Yes."

He paged through his diagnostic handbook and, about a minute later, looked up.

"You suspect situational reflex syncope. That's why you asked about coughing."

"Yes. Keep going."

"She already has low blood pressure, she was exercising, and the sneeze triggered a syncopal event."

"So, what would you do?"

"Chem-20 to rule out some kind of electrolyte imbalance. If that's clear, then refer to neuro?"

"Check your book," I said. "One other test."

He looked in the diagnostic handbook.

"Hematocrit less than thirty. It also lists systolic less than 100."

"Yes. If either of those were the case, we'd admit her. If not, then she's not in immediate danger, so a better choice in my mind is to refer her to her primary care physician. He or she is a better choice to ensure continuity of care with a neurologist, cardiologist, or some other specialist. Not to mention the tests cost significantly less when ordered by the doctor outside the hospital."

"But she could pass out again, right?" Heather inquired.

"Yes, and I'll recommend she rest at home, which again is far more comfortable than here in the hospital. Let me ask you this -- what treatment would we give?"

"That would depend on the underlying condition, right?"

"Yes. And that's what her primary care physician will investigate. Shall we go back in?"

We went back into the room and I explained our suspicions and our plan to Heide, Heather drew the blood for the Chem-20 and hematocrit, and we excused ourselves until the labs came back. Heather put the tubes of blood in the rack, where they'd be picked up by a student nurse who would take them to the lab.

"Mike," Nate called out. "Your patient's mother is in the waiting room."

"Thanks, Nate. Heather, check with Heide and if she agrees, bring in her mom. You can repeat exactly what I said to Heide to her mom, but don't embellish. If they have questions, let me know. Then come join us to present."

She acknowledged me and went to the waiting room, while Jake and I went to the lounge to wait. Two minutes later, Heather joined us, and the three of us went to the Attending's office to present the case.

"Heather, present your case, please," I directed.

"Heide Burdick, seventeen; syncopal episode in gym class following a sneezing fit; BP 100/60; pulse 76; PO₂ 99% on room air; brief LOC. No recent illnesses, no medication. Nothing remarkable on exam. Chem-20 ordered. Suspect situational reflex syncope. If hematocrit is over thirty, refer to primary care physician."

"Did you make the diagnosis?" Doctor Gibbs asked.

"It was a team effort," Heather replied. "I had a lot of help."

"Approved. Chart, please."

Doctor Gibbs made notes on the chart, signed it, and handed it back. We left the office and Heather returned the chart to the rack just outside the door of the exam room.

"Get the next chart," I directed.

We handled another four walk-ins before lunch, and discharged all of them, including Heide Burdick. I took my meal break and saw Sophia and her friends in the cafeteria and went to sit with them. Kelly Atkins flirted shamelessly as she had the previous time, and I simply ignored all the innuendo and double-entendres. When I finished lunch, I returned to the ED and had Jake and Heather take their meal break while I handled a walk-in with a sprained wrist with Kellie.

"You know," I said, once the patient had been discharged, "I never asked, and tell me if it's none of my business, but are you seeing anyone?"

"What?" Kellie asked with a sly smile. "Cheat on my work husband?"

I chuckled, "You'll have to fight Clarissa Saunders for that role!"

"Last I checked, you have disqualifying anatomy! Otherwise, you two would have married ages ago."

"True," I replied.

"I've been dating, but nobody I'd say is 'Mr. Right', at least at this point. You took yourself off the market before I met you."

"I'm pretty sure the concept of 'Mr. Right' is a myth," I replied.

"How so?"

"Nobody is perfect," I replied. "That is, a perfect match for the Platonic ideal partner. It's hard work, and if you don't put in the hard work, it ends in tears."

"It sounds as if you've seen that."

"My parents divorced during my first year in medical school. I didn't realize it growing up, but they didn't put in the effort necessary to make it work."

"Twenty-two years? Well, more, I guess."

"If my inferences are correct, based on things that were said, the trouble started before they got married and was never resolved. And without intervention by several close friends, that very likely would have been me. I didn't really get my act together until my Junior year at Taft."

"Not uncommon, especially for guys," Kellie observed. "I joined the Navy right out of nursing school."

"Twenty-one, right?"

"Yes. And after a six-year stint, here I am."

"You were at sea the entire time?"

"About four years, total, out of six. I had some shore duty, and of course, the Nimitz was in port for part of the time. I left her when she arrived in Bremerton, Washington, last March. She had been based in Norfolk and now is based in Bremerton."

"I find it interesting that the carrier is named for Chester Nimitz, but you say 'her'."

"All ships are 'her'," Kellie replied. "I don't actually know why."

I thought about it for a moment, then smiled because I had an idea.

"In Latin, the word for 'ship' is navis, which is a feminine noun," I said.

"I've heard that, but the problem with that theory is that in the derivative languages, that is Spanish, French, and Italian, the noun is masculine."

"Oops," I chuckled. "So much for that theory!"

"I asked the Commander who was responsible for the nurses about it, and that's how I know about the problem with that theory. She had more than twenty years in when I showed up. She retired the same time I left the service."

"Mike?" Nate called out. "EMS three minutes out with a non-responsive toddler pulled from a swimming pool. Use Trauma 4."

"Lord have mercy," I said aloud.

Jake and Heather had returned, so the three of us, with Kellie, gowned and gloved and headed to the ambulance bay. The squad rolled to a stop, and Roy jumped out of the cab.

"Trey Washington, three, found in a swimming pool by his mom; CPR performed; pulse 120 and thready; BP 80/40; PO₂ 86% with bagging; GCS 4; vomited twice en route."

The fact that they'd got him to us with any kind of pulse was a good sign, but there was no way he was out of the woods. He might well have aspirated his vomitus, and was at risk for hypoxic ischemic brain injury, as well as acute lung injury or acute respiratory distress due to water in his lungs.

"Trauma 4! I'll intubate; Kellie, pediatric etomidate and succinylcholine, then stat ABG; Jake, five-lead and monitor; Heather, you bag until I'm ready to intubate!"

We moved quickly, and as we passed the nurses' station, I called out, "Ellie, I need a nurse!"

"Mary! Go!" Ellie ordered.

"Mary, pediatric intubation tray!" I instructed, as she joined us.

In the trauma room, we quickly transferred Trey to the treatment table and the orders I'd given were followed while I used bandage scissors I carried in my pocket to cut away Trey's shirt, then began a primary exam.

"Weak heart sounds," I reported. "Pulmonary edema, both lungs."

I moved into position to intubate, verified with Kellie that the etomidate and sux were in. She confirmed, and Heather stopped bagging and moved away. Kellie, having drawn the blood, left to have a nursing student carry it to the lab for immediate results.

"Sinus tach!" Jake reported. "PO₂ 85%."

"Do you feel confident you can insert a Foley in a toddler?" I asked.

"I can do it," he said.

He went to the cabinet to get the correct catheter as Mary was assisting me. Fortunately, I was able to pass the endotracheal without difficulty, and Mary hooked up the respirator while I checked for breath sounds.

"Bilateral sounds," I replied. "Now we wait and deal with any complications or symptoms."

"Foley is in; urine in the bag."

"Good job, Jake. What's the target PO₂ for drowning recovery?"

"Between 92% and 96% he replied."

"And the risks?"

"Severe brain injury due to hypoxia; pneumonia; long-term lung injury."

"Mike?" Ellie said. "His mom is having a meltdown in the waiting room."

"Bring her to the consultation room," I said. "I'll speak to her."

"Right away!" she acknowledged.

"Heather, you come with me; Kellie and Jake, stay with our patient."

Just then the phone rang and Mary answered it. She listened, then hung up.

"pH 7.30; PₐO₂ 55; PₐCO₂ 48; HCO⁻₃ 20."

"Put those on the chart, please. Jake? Interpretation?"

He shook his head, "I don't remember off the top of my head."

"He's slightly acidotic. Treatment?"

"For slight acidosis, oxygen via vent," he said.

"Good."

"How's it going?" Doctor Gibbs asked, coming into the room.

"Immediate CPR got him here with a pulse and respiration," I replied. "ABG shows slight acidosis; PO₂ 85%; sinus tach at 120; vented; being monitored. I was about to go talk to the frantic mom."

"I'll stay," she said.

"OK. Jake will stay here, and Heather will come with me."

Heather and I left the room and went to the consultation room where a clearly distraught woman in her twenties was waiting.

"Hi, Mrs. Washington; I'm Doctor Mike and this is my student Heather," I said. "We're treating Trey."

"How is he?" she asked frantically.

"His heart is beating, and he's breathing," I said. "We have him on a ventilator, and he's being closely monitored by my Chief and a nurse while I speak with you."

"Will he live?"

"I can't make any promises, but when a drowning victim arrives at the hospital with a heartbeat, the odds are very good."

"Can I see him?"

I considered how she might react to being told 'no', as well as how she might react to seeing him on a vent, with EKG leads on his chest. I decided that seeing him alive, even with life support and monitors, would be a good thing.

"Yes," I said. "I'll take you in, but you can only stay a minute."

"Thank you, Doctor."

I led her to Trauma 4, where her son was lying naked, with only a modesty cloth over his groin, a vent tube in his mouth, and EKG leads on his chest.

"My poor baby!" she gasped.

"PO₂ is up to 87%," Jake announced.

"That's a promising sign," I said to Mrs. Washington. "Heather, would you escort Mrs. Washington to the waiting room, please, and make sure she has coffee, water or whatever she needs to drink? Mrs. Washington, I'll update you as soon as I have more information."

"Mrs. Washington," Heather said. "If you'll come with me, please."

Heather left with Mrs. Washington and I performed a basic exam.

"Pupils are sluggish," I said. "But reactive. His sinus tach has resolved. I'd say the odds are he makes it, and might even have no deficits. Whoever performed CPR immediately saved this little boy's life."

"I'm going back to my office," Doctor Gibbs said. "Let me know when he wakes up and if you need a neuro or respiratory consult."

"Will do," I said. "Thanks, Loretta."

"Good job, Mike."

"Thanks," I replied. "As I said, it was the immediate CPR. You know the odds if they arrive without a pulse unless it's a hypothermic situation."

"Infinitesimal."

She left, and I instructed Jake to stay with Trey, while I left the room. Heather came back from the waiting room a minute later and walked over to where I was standing at the clerk's desk.

"How is Mrs. Washington?" I asked.

"She seems OK," Heather observed. "I got her a bottle of water from the lounge."

"Thanks."

"How do you stay so calm?" she asked. "You intubated a toddler like it was nothing."

"If you want trauma, you need ice water in your veins," I replied. "And you need supreme confidence. Remember what I asked Jake about the Foley?"

"If he could do it?"

"No," I said with a smile. "Think about the exact words I used."

"I don't remember."

"On that, you need to find a way to remember literally everything that happens in a trauma. You won't always have time to write things on the chart until later, and if there's ever an M & M, you'll be asked what you observed. What I asked Jake was if he felt confident about inserting the Foley. Not if he could do it, but was he confident he could do it. Confidence is even more important for intubation.

"That said, there's a fine line between confidence and arrogance. You have to be willing to admit you aren't confident in your skills or abilities, or that you don't know something. That's especially true for next year when you're a Sub-Intern, and it's true for me, too. The entire point of calling for consults is that we don't, and can't, know everything. Your task for the next twenty months is to ask questions, build knowledge, gain skills, and become confident."

"What if Jake had said 'no'?"

"In this case, I'd have instructed him to do it, because I was confident he could do it, or I wouldn't ask. The question was really a 'gut check' for him. But remember, too, there is no harm and no disgrace in saying you don't feel ready to do something. That's a clue to your teacher to up their game, and if they don't, for you to press them to help you."

"I hope I'm assigned to you for my trauma Sub-I. I learn more from you because you take the time to explain how to learn, not just what we need to do."

"Thanks. One thing I learned was something I've said many times -- you, and only you, are responsible for your medical training. Follow my prescription and you'll be successful. Get the next chart, please. We have more sick to heal."

XLVI. A Tireless Advocate

September 10, 1989, Monastery of the Dormition of the Mother of God, Rives Junction, Michigan

"Good morning, Michael," Father Roman said to me just before Matins on Sunday morning.

"Father, bless!" I replied.

He made the sign of the cross over my upturned palms and I kissed his hand.

"What time did you arrive?" he asked.

"Just after midnight," I replied. "I had a shift at the hospital until 5:00pm."

"Did you travel alone?"

"Reluctantly, but Kris and I agreed it made no sense to disrupt Rachel's schedule so badly. And it allows me to focus on the reason I'm here."

"We'll speak after Matins and Liturgy."

"I'd like you to hear my confession, please."

"Let's do that this afternoon, unless there is something so heavy on your heart that you need to confess before you receive the Eucharist."

"There is not."

"Good. Then worship in peace, and we'll have a private lunch after Liturgy."

"Yes, Father."

I moved to a spot just in front of the choir, cleared my mind, and for three hours and forty minutes, I allowed sights, sounds, and smells of Orthodox worship to draw me near to the Throne Room of God. As it had for my entire life, with very few exceptions, it created a sense of internal peace. I received the Eucharist, and once the Liturgy had ended, I joined Father Roman in a small private room for lunch.

"How have things been, Michael?" he asked after he gave the blessing.

"Overall, they are good," I replied. "I don't have enough time with Rachel, but that's a result of decisions I made long before she was born."

"Do you feel guilty?"

"I've thought quite a bit about it during the past week," I replied, "but I'm not sure that's the right word. I feel bad for Rachel, but I can't say I regret the course of action I chose when I was ten. Fundamentally, if Elizaveta hadn't reposed, I wouldn't have spent as much time with Rachel, and she wouldn't have been used to it. That said, the time I did have with her was amazing, and I'm not sure I'd be willing to give it up."

"You were feeling guilty?"

"I expressed to Kris that I felt guilty and she suggested that I needed to forgive myself the way I forgive others. I accepted that, though the more I think about it, I don't feel guilty, but I'm unhappy with how things worked out. The problem is, it's all because of my conscious decisions."

"So, is it, or is it not, weighing on your conscience?"

"Yes," I replied with a grin. "In another context, I made the point that the situation with Rachel is undesirable, but because I chose my course of action freely, the consequences aren't actually undesirable, because I knew about them and accepted them as a direct result of my own choice, a price, if you will. Kantian logic. What I didn't count on was Elizaveta's repose."

"And your marriage to Kris?"

"Is very different from my marriage to Elizaveta. Elizaveta planned to be a stay-at-home mom, at least until the kids started school. Kris is at Ohio State and has career plans."

"Do you have regrets?"

I shook my head, "No. Again, I signed up for this, and so did Kris. Rachel didn't."

"In layman's terms, you're beating yourself up for something over which you had no control -- the situation which occurred after Elizaveta's repose. In spiritual terms, you counted the cost at each stage and made a conscious decision. There's no sin here, Michael. Is your daughter healthy, fed, clothed, bathed, and loved?"

"Obviously," I replied.

"Not so obvious, Michael. I'm sure you've seen abused or battered children, or those who are malnourished or ill. Is Rachel any of those things?"

"No," I admitted.

"And are you doing the best you are able to do, given your circumstances?"

"I believe so."

"And are you a good father?"

"My friends and my wife seem to think so."

Father Roman smiled, "Well, as I see it, you've made logical decisions, none of which you regret or would change, your daughter is well cared for, your marriage is stable and successful, you appear to have the respect of your friends and colleagues, and you're serving God and your community as a physician. What advice would you give to someone in your situation if you were me?"

"When you put it that way..." I replied. "But it simply feels as if my daughter is suffering from my choices."

"How so? Because she wants more time with you?"

"Yes."

"Had Elizaveta not reposed, would you have had more time for Rachel?"

"Obviously not."

"Then I'm missing the problem, except for what appears to be a guilty conscience that seems to have no basis in fact. May I use a secular phrase?"

"Yes."

"Get over it!"

I laughed, because there was nothing else to do. He had a point, and I was beating myself up for things over which I had ceded control at age ten, and there was no going back.

"You do appear to have a propensity to obsess," Father Roman continued. "I suppose that trait is key to your success as a physician in the ER, but not in other areas of your life. The Scriptures, as I'm sure you know, contain admonitions about obsessing, and I would propose that such thinking is what leads to destructive behavior -- drinking, drug abuse, infidelity, and so on."

"I suspect you're right," I replied. "On that last one, for accountability, I should tell you that before I was betrothed to Elizaveta, and after I was returned to the order of the laity, but before I became betrothed to Kris, I was not chaste."

"That was confessed, and you received absolution?"

"Yes."

"And there was no infidelity, even emotional?"

"No. I do have a close female colleague, but Kris is fully aware, and the young woman and her partner are often guests in our home."

"You do realize that is how it starts, right?"

I nodded, "And both Clarissa and I are aware. I met her during my Freshman year at Taft, and she is one of the main people responsible for me being a doctor and a better man. It's similar to a relationship I had with a young woman from kindergarten until the Summer after I graduated from High School."

"What happened there?"

"Our relationship didn't survive a terrible automobile accident she was in, mainly because we were both too immature to handle what happened."

"Would you explain?"

I recounted Jocelyn's story from meeting her in kindergarten through the accident and her suicide attempt, as well as my bout of depression, our eventual reconciliation, and her marriage to Gene.

"Have you had a truly close male friend besides Dale?"

"During medical school, a fellow student, Peter, but he's in Georgia for his Residency, and Robby, whose the emcee for our band, but he and his wife are likely moving to San Francisco when she finishes medical school. I do have male doctors who are mentors and colleagues, but not close friends. My best friend has, as I've said, always been female."

"I won't belabor the point, as I'm sure you understand, but you need to be very, very careful, and should develop close male friends. Is there anything else specific on your heart?"

"Impatience with the medical establishment and their intransigence on making fundamental changes."

"Arrogance, too, if you think after such a short time as a physician that you know better than those who have practiced for decades," Father Roman countered.

"Actually, my mentors, some of them very experienced, agree with me on those things, but inertia prevents needed changes from occurring in a timely fashion. A perfect example is Resident training hours, and the Libby Zion case."

"You'll have to explain."

I explained, concluding with, "If things don't change, then lawmakers will change them, and that's the last thing we need."

"I have no expertise in the area, but I believe your correct course of action is patience, which, I believe you know."

"I do."

"Is there anything else?"

"No."

"Are you keeping your prayer rule?"

"Religiously!"

"And you're using the Jesus Prayer to maintain internal quiet?"

"To the best that's possible in a busy Emergency Department. And I pray silently for every patient."

"Are you able to attend services?"

"When my schedule allows, which for the next two months is Vespers on Wednesdays and Saturdays, and Matins and the Divine Liturgy on Sundays."

"Fasting?"

"The basic relatively lax rule you assigned. We're trying to get pregnant, so, after discussing it with Kris, we think the rule about no red meat is probably the best."

"I would agree. Fish or chicken are acceptable for both of you. We'll revisit fasting after your baby is churched. How else can I help you?"

"For now, pray for me," I replied. "I'm sure I'll hit some kind of spiritual or secular brick wall and need spiritual surgery to correct it. That seems to be the pattern of my life."

"All our lives, Michael. I'm sure you know the saying -- we fall down, we get up, we love God, that is the Christian life. Continue to pray, fast, attend services, and love your family. I'm positive I don't have to remind you to care for your patients in a loving Christian manner."

"It never hurts to be reminded."

"Let's finish our lunch, and then you can be on your way home."

September 10, 1989, McKinley, Ohio

"DADDY!" Rachel squealed when I walked in the door.

I held out my arms, and she hurried to me so I could pick her up. She gave me a kiss on the cheek and I kissed her forehead.

"How's my big girl?"

"Good! I help mommy with dinner!"

"About fifteen minutes, Mike," Kris said, coming into the room. "I just put the spaghetti noodles in the pot."

She greeted me with a kiss.

"How was your day?" I asked.

"We spent the afternoon with my parents and sister, as we'd planned. How was your visit with Father Roman?"

"Mainly we discussed my discontent about the time I can spend with Rachel."

"And did Father Roman kick your butt and set you straight?" Kris asked with a smile.

"We had a good chat, and it's a work in progress. I need to stop obsessing over things long ago decided and which cannot be solved except by the passage of time."

"So long as you accept that."

"I do," I replied.

We sat down to dinner about ten minutes later, with Rachel in her chair, but close to me so I could help her with her spaghetti, which, as usual, left her hands and face painted red with tomato sauce.

"She's so insistent on feeding herself," Kris observed. "But what a mess!"

"How about I bathe her while you clean up?"

"I think she'll appreciate that."

Kris' observation was correct, as Rachel did appreciate me bathing her, and enjoyed splashing in the bubble bath. When I finished bathing her, we returned to the great room where I read her two books, and then we said our evening prayers together. Once Rachel was in bed, Kris and I went to bed to work on a sibling for Rachel.

September 11, 1989, McKinley, Ohio

"Do you have five minutes?" Krista asked when I arrived in the ED just before 5:00am on Monday morning.

"Let me finish do the handover with Ron, then I do."

There was only a single patient waiting on admission, and he was being handled by Al, so I got a cup of coffee in the lounge, and Krista and I went to stand in the ambulance bay as the consultation room was occupied.

"What's up?" I asked.

"Everyone except you has decided I should fail this rotation and they don't think I should be a doctor. It's totally unfair because I wasn't even given a chance to succeed."

I actually didn't completely disagree with her, as I didn't believe she was being given a proper chance. The challenge was what I could do about it. I didn't believe approaching Doctor Northrup would be successful, nor did I think going back to Doctor Gibbs would bear any fruit. The only thing I could think of was to speak with Doctor Mertens, who was Dean of Clinical Instruction.

"I know how this is going to sound, but I have to ask two questions. First, do you want to be a physician more than anything else?"

"Yes."

"Second, and I'm sorry for asking, and you need to be completely honest, but there are rumors you've slept with Attendings. Is that true?"

"Yes. There are no rules against it."

That made her situation much more difficult, and not only might a conversation not help, it might cause trouble for me.

"The rumor goes further, to say that you did that to pass a rotation."

"That never happened!" she protested. "Both times were doctors on different services from my rotation, and I wasn't assigned to them before or after."

"Just so we're clear, I believe there should be a firm rule against doctors sleeping with medical students, for what I think are obvious reasons. And now you can see why the rumors spread."

"Oh, please! I know girls who slept with their Attendings or Residents! I never did that."

"I understand, but people make all manner of inferences. That creates a serious potential problem, because it calls every rotation into question. I'm not saying there was ever an instance when you behaved improperly, but even the suggestion of impropriety is problematic. That's why I think there needs to be a rule."

"You think that's the problem?"

"I have no idea," I replied. "But had you not done that, then I could say definitively it wasn't. But what's done is done."

"Is there any way you can help?

"I have serious reservations, but if what you're saying is true, you didn't break any rules. All I can do is have a word with Doctor Mertens. I'll call her later this morning and see if she can come here to discuss the situation. That's all I can promise, given it's the Attendings and Doctor Northrup who have the final say."

"I know. You're basically my only hope."

"Is Doctor Lincoln giving you procedures?"

"Some, but not enough, and I honestly don't think it matters given everyone except you has concluded I don't belong here."

"You realize I'm neutral on that, right?"

"Yes, but you think I could make it; the others don't."

"OK. Let me see what Doctor Mertens has to say."

"Thanks, Doctor Mike."

"You're welcome."

About ninety minutes later, after handling two walk-ins, I placed a call to Doctor Mertens who, when I told her the reason, reluctantly agreed to meet me at 10:00am. I cleared that with Doctor Gibbs without mentioning the reason, and she agreed I could move my lunch break to 10:00am. I'd eat an apple and a granola bar in the ED, which would tide me over until my dinner break.

Doctor Mertens arrived as planned, and we went to a small conference room in the administrative wing.

"I think I want to approach this differently from how I first intended when I called you."

"Go on," Doctor Mertens said.

"I think it's high time for there to be a firm rule against doctors sleeping with medical students. I only have circumstantial evidence, but I have the feeling that someone is blackballing Krista because she slept with two different doctors, but never one who was on the same service or to whom she was ever assigned."

"Based on?"

"Nothing else makes sense," I replied. "The rumor is that she slept with an Attending for a grade, but she denies that, and I'm inclined to believe her. I don't condone that behavior, obviously, but it isn't against the rules."

"You don't appear to have all the relevant information," Doctor Mertens countered. "I have a specific report of an incident with an Attending from the service to which she was assigned."

"From whom, if I might ask? Position only, as I'm sure you cannot name names."

"A fellow medical student."

"As an eyewitness?" I asked.

"You're joking, right?"

"Well, with the pager incident, we actually DID have an eyewitness, so no, I'm not joking. May I ask what was said?"

"Simply that she was having an inappropriate relationship with her Attending."

"And did you verify that?"

"I asked and there was a flat denial."

"While I know that an Attending in that position has an incentive to lie, this smells more and more like someone blackballing Krista. The reason I'm saying that is because I was warned never to be alone with her AND to never leave her alone with a patient. Whatever the basis for those warnings might have been, I haven't seen a single thing that would indicate that either warning was prescient.

"Krista is not a rock star, but she's also not Tim Burg. She's competent, and, frankly, the world needs competent physicians. Is she a trauma physician? No way. But then again, neither are you, Doctor Forsberg, Doctor Baker, or Doctor Saunders. And no, I'm not saying they aren't very good, simply that not everyone is cut out for trauma. That said, she's competent at it, and she's not being graded appropriately, not being given the procedures an average student would be given. And I think it's because someone is blackballing her."

"Tell me your theory."

"There are a few possibilities -- first, it's innuendo and rumor, with no substance; second, it's retaliation either from a doctor she slept with or one she didn't sleep with; third, Krista and the Attending are both lying to cover up a quid pro quo. I honestly think that the last one is the least likely, unless you're prepared to name that Attending and bring them up on ethics charges.

"If that happens, Krista is just as likely the victim as she is the perpetrator. And that creates a massive problem because her complaint would be completely legitimate and easy for her to defend -- the Attending threatened to fail her if she didn't sleep with him. How could he, accused of sleeping with a medical student, defend against that claim? And that right there is exactly why we need a rule."

"Are you suggesting you'd advise her to say that?"

"No, but she's not an idiot, Nora! She had top marks in college, scored well on the MCAT, and scored well during her first two years. And I checked, her first rotation, Pedes, she received a grade of 4. Something happened, and evidence suggests that other than exercising poor judgment by sleeping with two Attendings, Krista didn't do anything wrong, and is, in my opinion, being held to a different standard than the doctors she's accused of screwing for a grade."

"This is going to sound bad, but I have to ask -- what would you say in an inquiry?"

"I would tell the truth about what I know and refuse to speculate about anything I don't know or can't deduce."

"And if asked for your opinion?"

"I'd point out the apparent double standard, and also point out that the entire thing would never have happened if the rule I'm proposing had been in place. I've made this point from the first time I set foot in the hospital. By not having the rule, medical students get...well, screwed. In various meanings of that term.

"I also want to point out that the next case might well involve a gay doctor being outed against his will. And that is going to cause, pardon the expression, a shitstorm. Nobody says much about Doctor Saunders, but the two gay doctors who are out are talked about behind their backs and with some of the worst slurs imaginable."

"You know I agree with you on the topic of sex between doctors and medical students."

"Then fix it. Make a rule. Will some doctors squeal like stuck pigs? Too bad for them. I'd also make it a student ethics violation to engage in sex during clinical rotation hours. Period. End of discussion."

"Morality police?"

"No. It's a concern about professionalism, period."

"I seriously doubt the administration is going to make that rule."

"Propose it anyway, and when this, or another incident, comes back to bite them, you point to the proposed rule and say it would have saved them the grief. And maybe you accept a half-measure. Propose the rule, and if there is pushback, which we know there will be, suggest that it apply to students on their current, previous, and next rotation. Everyone knows the schedule."

"I'll discuss it with Doctor Warren and Doctor Worth."

"What are you going to do about Krista?"

"I'm going to turn that around and ask, assuming what you've inferred is true, what you would do?"

"Is out of the box thinking OK?"

"Whatever it is would have to pass muster with Match committees."

"Assign her to me for the rest of the month, matching my schedule, all eighty hours, and I determine her grade."

"An Attending has to sign off."

"Doctor Casper," I replied. "I'll speak to Ghost and he'll give her a fair shot."

"What about your other students?"

"That's the tricky part, as Jake flat-out rejected switching shifts with Krista because he wants to work with me. I could handle two fourth years, which would allow me to see more patients, and give them both enough work, especially given Naveen and I are mostly doing walk-ins with the occasional EMS transport."

"Quite a few people would have to sign off on that -- Doctor Northrup, Doctor Gibbs, Doctor Gabriel, and Doctor Warren. And Doctor Turner at the Free Clinic."

"Gale won't be a problem," I replied. "That would free a nurse, and you know they're terribly short-staffed. And I can convince Doctor Gibbs and Doctor Gabriel. I'll leave the muckety-mucks to you!"

"And you'll evaluate her fairly and honestly?"

"Did you seriously just ask me if I'd lie or fudge a student's grade?" I asked indignantly.

"I had to ask, Mike, because I'll be asked."

"And you didn't know the answer to that question before you asked it such that you didn't actually need to ask it?"

"I honestly didn't mean to offend you."

"Then please do not question my integrity."

"Others may, given her reputation."

"I'll double-dog dare them to accuse me to my face. They won't, of course, because they'll know it's BS. There was a reason you asked me to serve on the ethics committee."

"Yes, there was. Let me talk to Doctor Warren and get his take before I stir up a hornet's nest."

"One is being stirred," I replied. "Maybe this isn't the one that stings, but eventually one will, and just as the medical establishment ceded control to the legislature in New York because they didn't respond to Libby Zion, they'll cede it to the legislature or courts because of situations such as this."

"We always win," Doctor Mertens replied.

"Until you don't. That's the lesson of Libby Zion."

"An interesting point."

"That's the question, Nora -- do we police ourselves or do we invite the legislature and courts to do it? I think medical professionals are best suited to make those decisions, not politicians."

"Let me see what I can do," Doctor Mertens replied. "I'm not sure I agree completely with you on your plan, but it's not unreasonable."

"I'm only unreasonable when someone is acting in a way that is not in the best interest of my patient or of medicine."

"Please do not say anything to Krista."

"Mum's the word. But we need an answer «tout de suite» as my wife would say, or 'toot sweet' as we provincials here in Ohio would say!"

"Does she really look down on typical Midwesterners?"

"You have no idea," I chuckled. "Parisian cultural arrogance knows no bounds! Nor does French socialism!"

"That must make for some interesting pillow talk!"

I chuckled, "We have had some lively debates."

"Is she teaching Rachel French?"

"No. Her trouble-making fifteen-year-old sister is doing that! Rachel is enamored with her «tante préférée»."

"Is anyone teaching her Russian?"

"No, My mother-in-law, that is Elizaveta's mom, did at first, but she more or less gave up."

"I'll let you go, and try to get back to you by the end of the day with Doctor Warren's views."

"She's salvageable," I said. "I'm positive she won't Match here because the well is poisoned, but there's no reason she can't be successful elsewhere. I'd also like to be the one to tell her, so I can lay down the law about how I expect her to perform."

"That makes sense. Thanks, Mike."

"Thank you, Nora."

We left, with Doctor Mertens returning to the medical school and with me returning to the ED. Fortunately, Krista's shift had ended at 6:00am, so she wasn't around and I didn't have to evade answering her questions. The same couldn't be said for Doctor Gibbs, who called me into her office.

"I promised Nora Mertens I'd refrain from discussing the topic of the meeting until she has a chance to discuss it with some other people."

"Krista Sandberg," Doctor Gibbs said, disgustedly.

"I promised I wouldn't reveal anything," I said. "And you know I keep my word. I will discuss the topic with you as soon as I hear from Nora that it's OK."

"Could we please have one day, just one, where you don't do or say something controversial?"

"According to Clarissa, she can't leave me unattended for two minutes without me getting into some kind of trouble."

"She's not wrong," Doctor Gibbs said flatly.

"I love you both," I replied.

"Go heal the sick, Mike."

"Right away, Doctor!"

Doctor Gibbs rolled her eyes, and I left the office.

Jake, Heather and I handled eight walk-in cases during the late morning and early afternoon, and I took a five-minute break to eat my apple and granola bar just after 11:00am. None of the cases were remarkable, so it was all routine. Just before 4:00pm, Nate let me know I had a call from Doctor Mertens. I went into the consultation room and closed the door for privacy.

"Mike," I said into the phone.

"Hi, Mike, it's Nora. Doctor Warren will sign off on your plan, assuming the medical staff at the hospital will agree. The rule change about doctors and students is likely a non-starter, at least in his opinion."

"As I said, we'll get away with it until we don't, and the results could be ugly. What about the sex while on shift ethics rule?"

"That one will be considered for the revised ethics rules for next year. I will push hard for it, and may bring you in if there is significant pushback."

"I'll speak to Doctor Gibbs now, and Doctor Gabriel first thing in the morning. Doctor Gibbs is not going to be happy."

"Doctor Warren wasn't happy, either, but he acknowledged your point about not wanting to cede control to the courts or the legislature."

"OK. Who will speak to Doctor Northrup?"

"I will, once you confirm that Doctor Gibbs and Doctor Gabriel are on board."

"Thanks. Let me go into the lion's den."

"Good luck, Dan!"

I chuckled, "I'd much rather be the Archangel Michael, wielding a sword than Daniel in the Lions' Den!"

We said 'goodbye' and I replaced the handset in the cradle, then went to find Doctor Gibbs, who was in a trauma. I let Nate know I needed to see her before she went home, then had Jake bring in another patient from the waiting room. I had just instructed Jake to begin suturing the small laceration on the six-year-old's temple when Doctor Gibbs came to the door of Exam 5.

"You needed to see me, Mike?"

"Yes. I can leave Jake to finish this. Jake, I won't be too long."

He acknowledged me and I left the exam room and followed Doctor Gibbs to her office, closing the door behind me.

"After a discussion with Nora Mertens and a review of the salient facts, I proposed a plan for Krista Sandberg. Doctor Mertens and Doctor Warren approved, but I also would need your agreement as Chief Attending and Doctor Gabriel's as Chief Resident."

"And Doctor Northrup's."

"Yes, but Doctor Mertens will speak to him if you and Pete agree."

"Tell me," Doctor Gibbs said impatiently.

"For the remainder of the month, Krista is assigned to me, according to my shift schedule, including at the Free Clinic, and I write her evaluation at the end of the month. It'll be fair and honest."

"Implying I'm not."

"No, saying that I won't write a review that extols her skills and abilities to simply prove that I'm right. I am neutral, as I've said from the beginning. I think she can be salvaged, but in the end, it's up to her."

"Why, Mike?"

"Honestly? Somebody is blackballing her. It could be one of the Attendings she allegedly slept with for some reason. It could be an Attending who disapproved or is a jilted lover. It could be an Attending who wanted to sleep with her but was rebuffed. Or some other reason. But nothing I was told has been borne out -- she is not dangerous to patients nor has she come on to me even in the slightest.

"I made the point with Nora that we need a rule against inappropriate relationships between doctors and students, and I am convinced if we don't make that rule, a rule will be imposed on us by the courts or the legislature. I know you agree with me. I also asked for having sex at the hospital while on a clinical rotation be made an ethics violation. Again, we need to act before something really bad happens and rules are imposed on us.

"But all that aside, whoever is out to get Krista is doing a damned good job, because they convinced Leila Javadi that Krista is some kind of seductress or succubus. I haven't spoken to her again, but I will, at some point. The thing is, Nora looked into the claim that Krista used sex to get her grade and the Attending denied it. Krista denied having sex with any Attending on the service to which she was assigned, or with any Attending who supervised her at any time."

"And you believe it?"

"If the Attending, and I don't know who it is, is lying, then somebody should do something about it. If he's telling the truth, then the scurrilous rumors should be quashed. Unless someone can prove it, she has to have the benefit of the doubt. And it appears I'm the only one willing to do so."

"Excuse me?!" Doctor Gibbs exclaimed, sounding just as indignant as I had with Doctor Mertens.

"You told me she was unqualified to be a physician, based on reports from other departments, and at odds with what I was reporting. It turns out that going to Leila was a mistake, because in the end it only confirmed in your mind that Krista didn't belong here. Something is, as they say, rotten in Denmark."

"I don't appreciate the accusation," Doctor Gibbs said.

"The source of this problem is we listened to what other people said. The difference is, I observed directly, day to day, you didn't. I changed my opinion based on that observation, an advantage you didn't have. If I have any complaint about you, it's that you dismissed what I was saying about Krista because of what had been said to you by other Attendings outside of the ED."

"What is this girl to you?"

"Someone who is not being treated fairly," I replied. "I think ALL of us were misled, including Doctor Javadi. Someone, somewhere, is out to get her for no good reason. She asked for my help because I am literally the only person who will take her seriously. Heck, I'm the only one who will actually listen to her. Even you have been dismissive, Lor."

"Will you admit that some people are simply not cut out to be doctors?"

"Yes. Show me any proof that applies to Krista. I don't believe you can because it's become a self-perpetuating thing. Someone decided they didn't want her in the program and systematically ruined her reputation and ensured she didn't learn. From what I can see, nobody tried to help her. And think about what would have happened had you, and a few others, not tried to help me. Or Felicity. Or countless others."

"And if we don't agree, you're going to back her if she files a formal complaint, aren't you?"

"Why the heck is EVERYONE so worried about that? Don't answer! I'll tell you -- you know the complaint is legitimate! You know if asked, I'll answer honestly and completely, and she might actually win. I'm going to repeat what I said to Nora -- we have to fix this ourselves or someone outside the medical profession is going to fix it for us, and we won't like the results.

"This isn't a slam dunk like Melissa Bush or Tim Burg, or like Jack Strickland or Gerald Kirby. Quite the opposite, this is a loser case, even if we win in court. Think about the bad press and the investigation that will follow. We can't point to a single thing -- not clownish behavior, not discrimination against patients, not missing a code, or being too arrogant. I thought that last one was the thing, but it's not. She wasn't taught and NOBODY intervened.

"We implemented the Resident hours limits with defined sleeping periods because of the Libby Zion case. We could, as most hospitals have done, ignore it, but that would have invited intervention by the legislature. Instead, we're out in front and we can define the best practices. And following best practices means not sleeping with your students. Would you sleep with a student?"

"I'm married."

"That doesn't appear to matter to many doctors," I replied. "I can name three who regularly cheat on their wives. That's their business, and their wives' business, not mine, but being married doesn't create the barrier you and I believe it does. But we also wouldn't do it because of the potential ethical problem. I bet you had opportunities as a student and Resident."

"I did," Doctor Gibbs confirmed, "and I turned them all down."

"Exactly. My challenge has been nurses who don't think wedding vows mean anything, mostly because there are very few female Attending physicians at the hospital. That's changing, quickly, as it should, and we're likely to see a situation with reversed roles blow up in our faces. Imagine, too, if Krista were a minority. Think how THAT would play out with a public complaint."

"You've made your point," Doctor Gibbs said flatly.

"It's your call as Chief Attending," I said. "What's it going to be?"

"You're still a pain in the ass, Loucks."

"It's who I am," I replied. "A tireless advocate for my patients, but also for the weak, the downtrodden, and the mistreated. And if that makes me a pain in the ass, I'm in very good company."

"Your personal hero, Martin Luther King, for one."

"A modern-day prophet, who, like many of those, if not most, who speak truth to power, was imprisoned and killed for it. I hope to escape that fate."

"Jesus and Socrates, right?"

"Among others. I still have to make my case to Pete, but I think I can. And if you sic Ghost on me, he'll get both barrels, too."

"Would I do that?"

"In a heartbeat!"

"Get out of here! Go heal the sick!"

I nodded and left her office. I'd put my butt on the line for Krista, and I could be burned by that, but I didn't think I would be. That said, I was absolutely going to lay down the law with her as I'd said to Doctor Mertens I would.

XLVII. The Woodshed

September 11, 1989, McKinley, Ohio

"Jesus, Petrovich!" Clarissa exclaimed while we were having just after 1:00pm on Monday afternoon.

"Tell me I'm wrong, or that anything I said to Doctor Mertens, Doctor Gibbs, and Doctor Gabriel was wrong."

"You probably aren't wrong, but you know people are going to assume you're sleeping with her."

"Let 'em," I replied. "I know it's not true, you know it's not true, and most importantly, Kris will know it's not true. If someone says it to me, I'll demand proof, and if teaching a student, even remedially, is 'proof', I'll get the new rule implemented before you can say 'Jack Robinson'."

"Where did that phrase come from?"

"No clue. It wasn't one of the ones Mr. Black took time to explain, which, I suspect, means there is no origin story of which we're aware."

"Back to your Quixotic quest -- what now?"

"Nora Mertens has a meeting with Doctor Northrup in about an hour. I don't see how he can reject the request without risking outside intervention. Krista isn't an idiot, and all she has to do is say that the doctors demanded she sleep with them or they'd blackball her, and someone she turned down is blackballing her."

"That's true?"

"Does it matter? It wins because it could be true. Think about a jury, told about doctors banging medical students, about the fact that she's being held accountable but the doctors aren't, and that she believes she's being punished for not having sex, or for having sex, or both, while the doctors all skate."

"Ugly."

"Exactly. This isn't an issue of medical training, and you know how I'll testify."

"That she's an average, but competent, clinician who appears to have been treated unfairly."

"And that I have no knowledge about her relationship with any other doctor except for me. What do you think happens if someone accuses me of sleeping with her at that point?"

"Scorched earth. But you'll screw yourself."

"Will I? What's Doctor Roth's position? And Doctor Strong's? And Doctor Gibbs'?"

"And if you're wrong about her?"

"Then I give her a substandard grade or fail her, and neither she nor anyone else can legitimately say a thing about it. Similarly, if I give her a passing grade, who could legitimately argue with it? Think about why they assigned Felicity and Tim to me. And, honestly, why they assigned Krista to me."

"There has to be some potential downside."

"Yes, if I'm wrong, it will harm my reputation and create impediments in the future. That said, I can mostly mitigate it by admitting I was wrong. The challenge would be if I'm wrong and then there's a future student who needs my help. It would harm them more than me. But you know I can't sit idly by and allow an injustice to occur."

"No, you couldn't. Isn't Jake going to be upset?"

"I'll have two Fourth Years. I'll simply see more patients, because I can have each of them do a workup, then see the patients in turn."

"You actually might be onto something to speed up how quickly patients are seen."

"Possibly, but that's not the main point."

"Obviously, but it might be part of the solution. Of course, there are a limited number of Fourth Years, though I know there are some who would like to have multiple trauma Sub-Is but who can't because of limited slots."

"The challenge, of course, is Residents who want to teach and are able to teach multiple students at a time. But we'll worry about that in the future."

We finished our coffee, and I returned to the ED while Clarissa returned to Internal Medicine. Jake, Heather, and I saw four patients and just after 3:00pm, Nate let me know that Doctor Northrup wanted to see me. I checked with Doctor Gibbs, then went to the administration wing.

"He's expecting you," Mrs. Andrews said.

I went into the office and saw Doctor Mertens and Doctor Warren as well. I greeted them, then sat down at a nod from Doctor Northrup.

"This entire situation is very irregular," Doctor Northrup said. "I'm concerned about significant disagreements amongst my Attending and Residents over a medical student, and the dissension it seems to be causing. I'm also concerned about the claims of unfair treatment and double standards. And I'm also concerned about the rumors that are flying. Doctor Loucks, you've put me, and the medical school, in a very tricky situation.

"I'm sure you're aware that the training program for medical students is far from perfect, but it does work. Can it be improved? Yes, of course. And you benefitted greatly from one of those improvements -- Preceptorships. That said, what we cannot have is a specialized training program targeted for a single medical student. That's simply not sustainable. In addition, it's also not practical or reasonable to assign two Fourth Year students to a Resident.

"I've listened to what everyone has to say, and off the record, I believe we've handled this situation poorly, and it reflects badly on the hospital. That said, there is no easy solution to the problem before us. I'm reluctant to support any plan which does not conform to our standard practices, because I do not want to set a precedent that either allows students to pick their Residents, or Residents to pick their students. That is a recipe for trouble similar to the issue at hand.

"Doctor Loucks, if we were to accept your proposed solution for Miss Sandberg, it would, of necessity, mean swapping her shifts with Mr. Green, something he expressly rejected. I don't believe it wise to, in effect, punish him to benefit the wishes of another student, or even of a Resident. What that means is, despite the agreement of Doctor Gibbs and Doctor Casper, I have to reject the proposed solution.

"Doctor Warren, Doctor Mertens, and I had a lengthy discussion on how to address the specific complaint. Doctor Mertens proposed a solution on which the three of us agree. Miss Sandberg will repeat her trauma rotation, starting in December, and her grade for that second rotation will be her grade for both rotations. No record of that specific grading standard will appear in her transcripts.

"Her next rotation is Internal Medicine, and I spoke with Tim Baker right before I called you upstairs, and he will instruct his Residents to treat her as they would any other Fourth Year. He's confident that will happen. This change would cause her to give up her rotation in Pedes, but that's the price she'll have to pay if she wants to attempt to improve what would be a sub-par or failing grade.

"As for assignment, I will ask, but not require, Doctor Gabriel to match Miss Sandberg's schedule to yours as best he can, provided it fits within the normal scheduling guidelines. Scheduling of student hours has always been delegated to the Chief Resident, and I'm not of a mind to change that, nor to undermine their final authority on the matter. We'll inform Miss Sandberg of her options, and Doctor Mertens will modify her schedule for December and January if Miss Sandberg agrees."

"OK," I replied, absolutely positive Doctor Northrup was not interested in a debate.

"Now, to you, Doctor Loucks. Everyone here believes you are an excellent clinician, but you are irreverent with regard to policies, intemperate with regard to demanding change, and impatient with the process. If you do not get control of those tendencies, you won't make it to an Attending position. We all see things that ought to change, and we all get frustrated from time to time, but that is not license to disrupt the operation of the Emergency Department. I'm going to ask Doctor Gibbs to closely mentor you on that, and your evaluation as a Resident will depend on it."

I was tempted to simply say 'bullshit' but held my tongue and silently repeated the Jesus Prayer forty times.

"OK," I said evenly.

"Go back to work, Doctor," Doctor Northrup said. "Doctor Mertens will speak to Miss Sandberg."

"Yes, Doctor," I replied.

I got up and left the office, more frustrated than I'd been in a long, long time. I decided to take advantage of being excused from the meeting to go to Internal Medicine to see Clarissa.

"Uh oh," she said as soon as she saw me. "18 is empty, so let's go there."

I nodded and followed her into the empty patient room.

"What happened?"

"I said the Jesus Prayer forty times to prevent me from saying 'bullshit' to Doctor Northrup when he basically told me to shut up and do my job and not rock the boat."

"I think before we discuss that, I need to ask what happened with regard to Krista Sandberg?"

"Swapping a pedes rotation for a second trauma rotation, with her grade on the second rotation being her grade for both rotations, and nothing in her record about that grading system. That'll be in December, but no guarantee she'll be assigned to me. Her next rotation is Internal Medicine, and Doctor Northrup said he'd call Doctor Baker and ensure Krista is treated the same as any other Fourth Year. I hope you'll keep an eye on that and let me know if that doesn't happen."

"Sure. Now, tell me how much trouble you're in."

"He said that I'm 'irreverent with regard to policies, intemperate with regard to demanding change, and impatient with the process'."

"He's not wrong."

"No, he's not. But it's what he said next that's the concern -- he said my frustration isn't license to disrupt the operation of the ED, and that he's instructed Doctor Gibbs to monitor me and my evaluation will depend on not doing that. It's, in effect, an order to shut up and do as I'm told."

"Or a request to back off in the only way you, who needs to occasionally be whacked on the nose with a rolled up newspaper, would understand and take to heart."

"Maybe," I admitted.

"There's no 'maybe' about it, Petrovich. You'd accept a reprimand or rebuke such as that from your bishop if it was accurate, and Doctor Northrup's description of you is accurate."

"Except what he's saying is that nothing is going to change. It's exactly the problem with the OB chief at Good Samaritan that Doctor Kelly and others identified -- an unwillingness to accept necessary changes for the overall benefit of the practice of medicine. In effect, he's saying he's OK with doctors sleeping with medical students AND is OK with sex in on-call rooms."

"I think you might be reading a bit too much into it."

I shook my head, "Why rebuke me as irreverent, intemperate, and impatient about policy and changes if that's not the case. Think about the things I asked for, and apply the response to those."

"We did say we would have to wait until we're Attendings to make real change. You pushing now would qualify as impatience."

"So we just ignore it? And what happens when the sexual harassment complaints are made, because you know they will be."

"The hospital quietly settles to keep it out of court."

"And doesn't change policy to avoid looking guilty."

"You're in one of your moods, Petrovich. What did you say?"

"Four words. I said 'OK' twice, then 'Yes, Doctor' when I was dismissed."

"What are you going to do?"

"Practice medicine. But this is going to blow up, and you know it. And someone is going to come to me, take a deposition, and all hell is going to break loose because I won't lie to cover their sorry butts. That said, I am going to push Doctor Mertens to make having sex in the hospital while on duty an ethics violation with dismissal recommended. She was receptive to that idea."

"Neatly cutting the Gordian knot."

"And I'll get grief for it, but Lissa, it has to stop before something really bad happens and courts or the legislature impose rules on us that are not conducive to good patient care. No judge and no politician has a freaking clue about it, unless they're medical doctors, and those are few and far between."

"Don't you think they got it right in New York?"

"Do you think a hard and fast rule, with potential civil and criminal liability, is in the best interest of patients? Or is flexibility a necessary component of good medical care? And what happens when they get it wrong, but the change sounds good to the public, yet needlessly makes medical care more difficult or more expensive? I'll answer -- the politicians blame the doctors and hospitals, and get zero blame for the problem they created.

"It's the same problem with shifting away from insurance to government programs -- there is no actual accountability. Yes, you could argue that insurance companies avoid accountability, but that only proves my point -- they use the courts and the regulations to escape responsibility and liability. A bureaucrat is going to be even MORE insulated from the public, because, as was made clear in Civics class, you can only sue the government with its permission, and the remedies, if there are any, are generally weaker than against a private company."

"You must be pissed! You're discussing politics and political theory."

"You're a safe ear," I replied. "I can rant to you without worrying that someone will rat me out. And Doctor Gibbs has been assigned to be Chief Rat, in addition to Chief Attending."

"Jesus, Petrovich."

"That was made clear by Doctor Northrup. Which means her butt will be in a sling if she doesn't rat on me. And that means I can no longer be honest and speak my mind to my first mentor. What was left unsaid is what Doctor Northrup is going to say to Doctor Cutter."

"Because you're officially on the Surgical Service. What about Doctor Lindsay? She seems sympathetic and I believe she agrees with you. And she's Doctor Roth's star pupil."

"I don't want to drag anyone else into this mess at the moment."

"Besides me?"

"You signed up for this when you decided to take me in as a stray and began whacking me on the nose with a rolled-up newspaper! Little did you know you were boarding a high-speed train to Crazy Town."

"I suppose that's better than a highway to hell!"

"Actually, I retract that, because of the implications with regard to mental health. Make it a 'highway to the danger zone'. Anyway, I need to get back to the ED."

"Dinner?"

"I'll call you when I'm free. If you don't hear by 7:00pm, assume I can't get away."

"OK."

We hugged, I left the room, and headed back to the ED. I found Jake and Heather, and we began seeing walk-in patients. I knew, at some point, before the end of the day, Doctor Gibbs would ask to see me, and that happened about 4:00pm.

"I warned you," she said firmly. "And so did Pete and Ghost."

"I just want you to answer one question with complete honesty," I said. "Off the record, do you, or do you not, think it's inappropriate for doctors to sleep with medical students?"

"That's neither here nor there," she countered.

"I'd like an answer, Doctor Gibbs," I said formally.

"Mike..."

"The only thing I have to say is that I'm happy this isn't the Soviet Union, where I'd be shot for pointing out the flaws of the Party."

"You're being overly dramatic."

"Answer the question, then, Doctor."

"I'm not the enemy," Doctor Gibbs replied.

"No? Doctor Northrup made it clear that you're his «стукач»." ('stukach')

"Translation?"

"Stool pigeon or snitch. I was told to shut up and desist, and you were going to monitor me and base my evaluation on my fidelity to the Party."

"Mike, please..."

"Please what? Keep quiet when an injustice is being perpetrated? Look the other way when someone is blackballed either for taking advantage of the policy or for refusing to? I don't know which, but either one is wrong. And the Old Boys Club is closing ranks. Every single department head is male. You're the only female Chief Attending. Tell me how it looks to a neutral observer."

"Mike, I don't want to fight with you."

"Answer my question, please, Doctor, or allow me to go back to work."

"That's it? We're no longer friends?"

"Beyond this conversation, I can no longer speak my mind to you without risking it getting back to Doctor Northrup and ruining my career. We can discuss clinical issues, but that's it."

"What do you expect me to do?"

"Stand up for your Residents," I replied. "Look, let's be clear. I will follow the directive, and I won't cause trouble. But, you know as well as I do, at some point, this will blow up and someone will come to me and ask difficult questions, and I'll answer them truthfully. And if anyone instructs me or advises me to lie, obfuscate, or dissimulate, I'll make sure that's known publicly. Anyone who expects different doesn't know me."

"You realize you're putting your Residency at risk, don't you?"

"That's the same thing Doctor Lawson said when I backed my friend Angie against her psychiatrist. I was not only justified, but proven right when he accepted a suspension without putting up any real fight."

"You're putting me in the same category as him?!"

"If the shoe fits..."

"Go back to work, Mike. We'll discuss this when you calm down."

"I'm the very picture of serenity," I countered. "I'm calm, cool, and collected."

"Exterior? Yes. Interior? No."

"Believe what you will, Doctor," I said. "Unless you have some clinical matter to discuss, I'm going back to work."

"Shit," she swore under her breath.

I wasn't sure what that meant, but in the end, I was going to do my job, to the best of my ability, and within the guidelines. That was, in the end, the only way to not be dismissed from the program, which was the clear threat Doctor Northrup had made.

"Mike?" Nate called out. "Paramedics three minutes out with an MI. Trauma 2 is free."

"Thanks, Nate."

I gathered Jake, Heather, and Kellie, and the four of us went to the ambulance bay to wait for EMS to deliver the patient, which they did two minutes after we had entered the ambulance bay. The patient was having a non-STEMI, so after evaluation and a cardiology consult, he was admitted.

The rest of the early evening was routine, and I managed to get my meal break around 6:45pm, and Clarissa could join me, given her more relaxed routine in Medicine.

"Doctor Gibbs spoke to me," I said after Clarissa and I sat down away from other Residents.

"And?"

"I called her a «стукач». It went downhill from there."

"That is not good. Is she really the enemy?"

"I asked her to give me an honest, off-the-record answer to the question about the propriety of sex between doctors and medical students, and she avoided answering. That makes her part of the problem, not part of the solution."

"And if you cut off every doctor who doesn't accept your views, you're going to find yourself alone."

"It's worse, Lissa. She agreed with me on the topic until Doctor Northrup spoke to her this afternoon. Now she's basically quoting the party line like a good «аппаратчики» and doing the will of the Party." ('apparatchiki')

"You're back to Russian," Clarissa observed. "That tells me you are extremely upset."

"Shouldn't I be? Should I just 'follow orders' even when I know they're wrong?"

"No, but you have to be wise in how you do it."

"I was," I replied. "I wasn't overly strident, I simply pointed out something glaringly obvious that is impacting the situation I'm trying to remedy. The more I think about it, the closing ranks tells me I'm actually onto something."

"Coverup?"

"To protect someone, I suspect. I just don't know who."

"I know what you're thinking, Petrovich; don't do it."

"There's something more to this, Lissa."

"And if you try to find out, you'll risk being dismissed from the program."

"Doing nothing simply perpetuates the problem," I protested.

"Do you remember when we agreed we'd have to wait until we're Attendings to change things?" Clarissa asked.

"Nine years for me. When that time comes, I'll be an Attending who has no moral ground on which to stand after having kept my mouth shut for nearly a decade. Which is exactly what they want."

"They who?"

"The doctors who perpetuate the system and refuse to implement necessary changes."

"As you see them," Clarissa countered.

"Oh, for Pete's sake, Lissa! You agree. So did Doctor Gibbs, until Doctor Northrup turned her into a snitch! She's protecting her position, and THAT is how they protect themselves."

"So you'll throw away eight years of work just like that?"

"No. But I also won't simply ignore the problem. I will find a way."

"Even if it costs you everything? And leaves you in a position to not be able to care for your wife and daughter? It's not only your fate you're putting at risk."

"As I said, I will find a way."

"Don't do anything rash, Petrovich."

I simply nodded and ate, and about five minutes later, Doctor Lindsay came to the table.

"Hi, Mike," she said.

"Hi, Shelly. I assume Doctor Gibbs called you and you came back?"

"Yes. Doctor Saunders, would you excuse us, please?"

"I'll move to the table with the other Residents," Clarissa offered.

She got up and Shelly sat down.

"Doctor Gibbs is worried about you," she said. "She's afraid you might quit."

"Then she doesn't really know me," I replied. "Nobody who knows me would think I would quit."

"As pedantic as you are, that might well mean you won't quit, but you might well orchestrate a situation where you were dismissed."

"Then you don't know me, either," I replied. "Or did Doctor Gibbs put that thought in your head?"

"She suggested it."

"What else did she say?" I inquired.

"That you were extremely upset with how Doctor Northrup handled things."

"Again, she's missing the point, or purposefully avoiding it. I'm completely neutral on how Krista Sandberg's complaint about her training is addressed, so long as it's actually addressed. On the other hand, I am not neutral about the fact that she's been accused of sleeping with a doctor to get a grade, and literally nothing is being done about it."

"Did she sleep with a doctor to get a grade?"

"Both she and the doctor deny it; her to me, the doctor to Doctor Mertens. I was, in effect, told to shut up about it, and to not question any policies or procedures, and threatened with a negative evaluation if I don't toe the line exactly as Doctor Northrup demands."

"Doctor Roth is the one who'll sign your review."

"But not in a vacuum. And Doctor Northrup made Doctor Gibbs his...snitch."

"Why did you pause?"

"I was going to use a Russian word."

"You've decided she's the enemy?"

"Before I answer, will you, off the record, tell me if you think it's OK for doctors to sleep with medical students?"

"Is that your litmus test for friends now?"

"Before I respond to that question in response to my question, would you answer my question?"

"You know my answer," Doctor Lindsay said. "I think it's wrong, period, and I'm not afraid to say so."

"That isn't the litmus test," I replied. "Well, it is for allies, but for friends and mentors, the litmus test is not changing your position, or not speaking up when asked. Doctor Gibbs refused to speak up, despite having made unequivocal statements to me in the past. I'm positive she was told by Doctor Northrup not to agree with me, and she wouldn't, even off the record. Things might have been different had she, as Chief Attending, simply stated her opinion privately to Doctor Northrup."

"Ross and Cutter agree with you on that, and on the point about sex in on-call rooms."

"That, fortunately, is up to the medical school, not doctors. They can, as I suggested to Nora Mertens, make it a student ethics violation."

"They certainly could, and I hope they do."

"But that's a minor problem compared to sex between doctors and students, which I believe is behind the blackballing of Kista Sandberg."

"A bad breakup?" Shelly suggested.

"Or a refusal. I'm convinced Doctor Northrup knows more and is refusing to deal with it because of the Old Boys' Network that is Moore Memorial. You are the most senior female Resident, and Doctor Gibbs is the only female Chief Attending, there are no female Chief Residents, and no female Department heads. I daresay if there were more women in those positions, this topic would not be given short shrift."

"You don't think female doctors sleep with male medical students?"

"I'm sure they do, but I'm not aware of it happening, and don't care to know. All I know is of the female doctors I've worked for, not one has hit on me, either to try for an enticement to cheat, or when I was single. I can't say the same for nurses."

Shelly laughed, "Ellie still hasn't given up?"

"Ellie will never give up!" I chuckled. "But she also keeps it subtle and doesn't do anything that would give me cause to complain. I know it's available, I'm just not interested."

"You don't have to answer this, but after your wife passed, were you involved with any nurses or medical students?"

"A brief relationship with a nursing student, and two with medical students, both relatively brief, and both Fourth Years, so there was no teaching or supervisory relationship. I did my utmost to keep nurses who were on the same service at bay. I know you're single..."

"Now that I'm PGY5, I finally have enough time and a regular enough schedule to have a relationship. Doctors are out, for a host of reasons, and medical students are a non-starter."

"Out of curiosity..." I asked with a smirk and a raised eyebrow.

"You're high if you think I'll answer THAT question!" she declared mirthfully. "Even though I know you're just giving me a hard time. Or maybe wanted to!"

I chuckled, "Touché. The thought never crossed my mind because of my feelings on the matter, and I suspect that's true for you, too."

"Yes, it is," Doctor Lindsay confirmed.

"While not on the exact same topic, I suspect you and I agree on the improper treatment of women who choose the 'mommy track'. I bring that up because it's a function of the same male-centered Old Boys Network that defends and protects doctors who sleep with medical students."

"What do you intend to do?"

"Practice medicine to the best of my ability in the best interest of my patients. On the other matter, I'm going to keep my own counsel, but I won't sit idly by."

"Will you promise me one thing?" Shelly asked.

"What's that?"

"That before you do anything you'll speak to me? Please?"

"Before I do anything overt, I will."

"Implying you're going to do something covert."

"No, simply saying I won't act without speaking to you."

"What are you going to do about Doctor Gibbs?" Shelly inquired.

"Follow her directions on clinical matters. On anything else, I have no time for turncoats or cowards. It would be one thing if she was a Resident, but she's Chief Attending. Someone in that role has the duty to train and support their Residents, not agree to act as a stool pigeon on a topic on which she agreed with me before she was called into Doctor Northup's office. I certainly won't share any personal thoughts with her, because they might well be used against me."

"I think you might be overreacting."

"I don't think so," I replied, shaking my head. "Doctor Northrup was clear that I'm to shut up, toe the line, and follow orders, and Doctor Gibbs has to report me if I don't toe the line."

"Let me speak to Vince Taylor and Doctor Roth, please," Doctor Lindsay requested. "At least give me a day."

"OK," I agreed.

"Thanks."

We got up and left the cafeteria, but Clarissa came after me.

"Petrovich, wait up!" she called out.

I stopped to wait for Clarissa while Shelly continued towards the hospital lobby.

"Did she talk you off the ledge?" Clarissa asked.

"I wasn't on the ledge. I am suitably outraged, but I'm going to do my job. As for being quiet, well, Doctor Northrup does not have the last word."

"You're going to start an inter-service war?"

"I believe Doctor Northrup slapped me on the face with his glove, initiating the war."

"I'm not sure he'd see it that way."

"And yet, he's the one who threw down the gauntlet."

"Turn the other cheek?"

"I could go all Tolstoy and say that the only legitimate authority is God, not any human institution, but in order to practice medicine, I have to yield to the State Medical Board and the hospital administration."

"And you'll keep your promise not to do anything rash?"

"To you and to Shelly."

"OK."

I returned to the ED, completed my shift uneventfully, then headed home to say evening prayers with my wife and daughter, and work on a sibling for Rachel.

September 12, 1989, McKinley, Ohio

I wasn't surprised when Krista asked to speak to me first thing on Tuesday morning. I'd had the night to sleep on what I might do and had decided on a course of action. Whether it was the right way was unclear, but it was also something I could do without involving anyone except Krista. She followed me to the consultation room, which was empty.

"I wanted to thank you for going to bat for me," Krista said. "The solution isn't perfect, but given the alternatives, I'll take it."

"You're welcome," I replied. "I do have several things I want to say, and I hope you'll listen."

"It would be foolish not to!"

"Which does not mean you'll listen," I countered.

"I will."

"And, before I begin, everything we say here has to be completely confidential and cannot be shared with anyone. I mean that. If you reveal anything that is said here, you'll be done, because you'll have literally nobody who will care about you being given a chance to succeed."

"OK," Krista replied tentatively.

"Promise me, please."

"I promise."

"Good. First, on your upcoming rotation in Internal Medicine, if you have questions, need help, or need to learn something, ask Doctor Saunders, if at all possible. She and I are very close, and she won't steer you wrong. And she won't rat you out to anyone. That said, she will talk to me about pretty much everything."

"OK. Everyone knows you two are close."

"Second, and this is only advice -- stay out of relationships with anyone in the hospital."

"I have no real life outside the hospital!"

"A common lament," I replied. "But the trouble you're experiencing is, in my opinion, because someone is blackballing you."

"Seriously?"

"Seriously. I'm going to ask two questions, both of which you can refuse to answer. First, which doctors did you sleep with; second, which doctor did you refuse to sleep with?"

"I think I should be offended by those questions!"

"They are offensive, but necessary. I ask because it might provide a clue as to who is blackballing you. Obviously, you can refuse to answer both questions, but the answer to the second might be instructive."

"Rosenbaum in Pedes; the one I rejected."

Suddenly, things fell into place. Given how Rosenbaum had treated me simply for daring to wear my cassock at the hospital, I could see him blackballing Krista for refusing his advances. What I really needed to do was ask Doctor Mastriano about him, but I wasn't sure I could do that. It was something I'd have to think about, and something to discuss with Shelly Lindsay.

"I have a history with him," I said. "And that history makes me very suspicious. When did that happen?"

"During my Pedes rotation, which was in December and January. What happened with you?"

"He didn't come on to me," I replied with a smirk.

Krista laughed, which was what I had hoped would happen.

"The timing works," I continued. "Did you have bad breakups with either of the other two doctors?"

"No. Both were fairly short-lived, and they were just what you'd call flings with doctors who are single. Should I say something about Rosenbaum?"

Her comment about the doctors being single might well have been her rationale for turning down Rosenbaum, who was married, but I didn't feel it necessary to ask about it.

"No, you shouldn't. Right now, it could only go badly for both of us. This is a shitstorm, and I had my ass handed to me by Doctor Northrup."

"I didn't mean to get you into trouble."

"You didn't, at least not directly. I got me into trouble by rejecting the idea that it's OK for doctors to sleep with medical students. I'm not really tuned into the rumor mill or gossip circuit, but is there a doctor who you think is abusing his position with regard to female medical students?"

"I've heard some rumors and complaints," she said. "But I don't know anything more than the gossip."

"OK. I don't want you to repeat any gossip, nor engage in spreading rumors, so let's leave it there."

"What are you going to do?"

"For now? I'll do my job, and you should focus on your training. At some point, I'll take action, but I can't do that at the moment. I have to pocket the win with regard to your training, because if I did anything now, I'd put both our positions at risk."

"Thank you for believing in me."

"You're welcome. You've been given your chance; make good use of it. If you don't, you'll never be a physician."

We left the consultation room, and I began my day. When Doctor Gibbs arrived about an hour later, she called me into her office.

"Is there some clinical matter that we need to discuss, Doctor?" I asked.

"Not even a 'good morning'?" she inquired.

"Good morning," I said flatly.

"Mike," she sighed. "Can we just talk?"

"No. I have nothing to discuss because I cannot freely speak my mind without the risk of you running upstairs and snitching to Doctor Northrup if I deviate from the Party line on anything. I'm happy to discuss clinical matters, but that's all."

"You're blowing this completely out of proportion."

"No, I don't think so. We are where we are because you betrayed me, plain and simple. You've said you agree with me, but refused to back me with Doctor Northrup. One of two things must be true -- you lied to me, or you threw me under the bus."

Doctor Gibbs frowned, "I had hoped you would have calmed down."

"As I said yesterday, I'm the very picture of serenity. I'm calm, cool, and collected. My statements were carefully considered after practicing appropriate spiritual discipline so as not to be intemperate. I said exactly four words to Doctor Northrup, holding my tongue. I then went to discuss the situation with Clarissa Saunders in a calm fashion. I had a calm, reasoned conversation with Shelly Lindsay. I have no desire to continue this conversation because that will make it difficult to remain calm and peaceful and do my job."

"Can we fix this?"

"I can't because I was told in no uncertain terms I'd put my Residency at risk."

"That is not what Doctor Northrup said. If I understand correctly, he said to monitor for you being disruptive."

"Which he considers to be anything that goes against his views. And I'm allowing you to drag me into a conversation that can never be profitable. May I go treat patients, please, Doctor?"

"Mike..."

"May I be dismissed?"

"Go," Doctor Gibbs replied flatly.

I left the office, went to find Jake and Heather, and began seeing walk-ins. Just after 9:00am, Nate let me know I had a phone call. The consultation room was occupied, but Exam 6 was empty, so I went there to have some privacy for the call.

"Doctor Loucks," I said.

"Mike, It's Nora Mertens. Do you have time to get together outside the hospital?"

"It's tricky with my schedule, except Wednesdays. What about lunch tomorrow? I work at the Free Clinic, and there's a deli two doors down, next to the bakery. My lunch break is at noon."

"I'll meet you there at noon on Wednesday."

We ended the call, and I went back to work.