Chapter 11 — 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 EMT called out. "Through-and-through small caliber gunshot wound to the upper right arm; tachy at 110; BP 110/60; PO₂ 99% on three liters by 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 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 want a neuro consult."

"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, 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 CT 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 CT and take him on our service," she said. "He'll come in once the CT 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."