Chapter 43 — .38 Special

_August 31, 1989, McKinley, Ohio_

{psc} "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."