Chapter 64 — Challenges

_November 30, 1989, McKinley, Ohio_

{psc} "You asked to see me, Lor?" I said from the door to her office on Thursday afternoon.

"I wanted to discuss your evaluations of your students."

I closed the door and sat down.

"Problems?"

"Red tape. Because of the situation with Krista Sandberg, Mr. Crowe asked to see the evaluations you wrote and I want to go over them with you before I send them to him."

"As if I'd change a single word because of an attorney's input?"

"Don't get defensive, Mike," Doctor Gibbs said. "It's just about ensuring our i's are dotted and our t's are crossed."

"Again, my evaluations speak for themselves, and the prose expresses my opinions accurately. It's not as if I used epithets or racially or sexually derogatory words or phrases!"

Doctor Gibbs sighed, "Can't _anything_ be easy with you?"

"Apparently not," I replied. "Look, Krista, and others, have been assigned to me because they were clinically or attitudinally challenged in some way. I've helped most of them, with only Tim and Krista having negative outcomes. If my evaluations are such a concern, then don't assign me reclamation projects."

"Damn it, Mike!" Doctor Gibbs growled. "Will you just stop?!"

"If the bureaucrats and lawyers would stop, I wouldn't have any reason to respond this way. Next time you have a reclamation project, assign them to someone else."

"Mike…"

"All I've ever done is try to do what's right, try to do what's best for patients, and try to do what's best for medicine. And at every turn, some bureaucrat or lawyer or dinosaur gets in my way and slaps me down. I just want to be the best doctor I can be and provide the best possible care for my patients. I have ZERO time for bullshit. Zero. Everyone else seems to have infinite time for it, while at the same time bemoaning a lack of resources to care for patients. And this conversation is bullshit and you know it."

"What is it you think I should do?"

"Push back. Say what I said, but use whatever you feel are politically acceptable words."

"Why do you assume I didn't push back?"

"Because you would have led with that; you didn't, so you didn't."

"I did, but I was told to do this. And, despite your holier than thou act, YOU know the hospital has to protect itself from lawsuits and damage awards, otherwise there wouldn't BE a hospital. So, get off your damned high horse and CUT ME SOME FUCKING SLACK! Now, are you ready to go over these evaluations?"

"Sure," I said flatly.

"For fuck's sake, Mike!" Doctor Gibbs exclaimed in exasperation. "I didn't find anything that I felt needed to be changed. Why are you doubting yourself?"

"I'm not! I'm doubting the ability of the administration to be more concerned about medicine and medical training than covering their asses."

"Listen to yourself! Every single time you make a note on a chart beyond the vitals and orders, you're covering your ass! That's what all your notebooks are about. Yes, you portray it as improving patient care, but it could easily be seen as ass-covering. It all depends on which perspective you take.

"You're so anti-bureaucracy and so anti-administration, you can't see that what they're actually doing DOES improve the provision of medical care. Someone has to collect the taxes, someone has to run the business, and yes, the hospital IS a business, someone has to do all the bullshit that you sure as hell don't want to do!

"Even if we eliminated bullshit lawsuits and Federal bureaucracy, someone STILL has to pay the utility bills, staff the cafeteria, ensure the floors are mopped, order supplies, and on and on. What I don't get is why YOU don't understand that! You're the one who makes the point that medical care requires the concerted effort of doctors, nurses, medical students, nursing students, and clerks. SOMEONE has to do the scut. That's true on the business side too!

"So, bottom line, cut the attitude, face reality, and quit being an extreme idealist who looks down on anyone who doesn't live up to his own standards. Maybe THIS will get through your thick skull…"

She opened her desk drawer and pulled out a Bible and opened to a page she had marked.

{_ Judge not, that you be not judged. For with what judgment you judge, you will be judged; and with the measure you use, it will be measured back to you. And why do you look at the speck in your brother's eye, but do not consider the plank in your own eye? Or how can you say to your brother, 'Let me remove the speck from your eye'; and look, a plank is in your own eye? Hypocrite! First, remove the plank from your own eye, and then you will see clearly to remove the speck from your brother's eye. _}

"Now, can we STOP with the bullshit?" Doctor Gibbs asked, closing the bible and putting it back into the drawer.

"Fighting dirty, are we?" I asked.

"Hitting you where you live is good tactics, not fighting dirty."

"I smell a rat!" I said with a smile. "I'd like to see that bible, please."

"Admitting nothing, what makes you smell a rat?"

"You don't go to church, and Bobby is Catholic, so any bible you had at home would be either the New American Bible or the New Jerusalem Bible, and you quoted the New King James, which is the one the Orthodox Church uses. That means you consulted with either Ghost or Clarissa, and they gave you the correct version. My money is on Clarissa, but Ghost wouldn't surprise me."

"You are a ROYAL pain in the ass, Loucks!"

"Don't bring a knife to a gunfight! I concede that I had my back up, and that bureaucracy annoys me. I shouldn't automatically take it out on you. I apologize."

"Accepted. But does that mean you'll coöperate?"

"I reserve the right to object in the future."

"Object away. Come in and bend my ear. But don't blame ME for the system and absolutely don't take it out on me. Hell, you're Cutter's guy, give HIM both barrels starting in January! Now, let's discuss Nicole, Sophia, and Marv."

"Is there any concern at all?"

"You tell me. Anything I need to know?"

"You'd only ask that if you knew something. If I had to guess, you somehow know that Sophia and I dated casually and briefly during my Sophomore year at Taft. And that had NO effect on my evaluation of her. She's married to my best guy friend and has been for two years."

"Don't you think you should have disclosed that beforehand?"

"I didn't see the need. If we'd dated recently, then I could see it, but she's a friend and I had disclosed that I had an outside relationship with her."

"Friends is different from dating."

"It is. Friendship is more likely to create problems than a past dating relationship that ended amicably. What, pray tell, happens when Nora Mertens convinces five of the six members of the study group I'm mentoring to attend McKinley Medical School? Or when Jenny Leonard attends? Would it be fair to them to exclude me from training them because I mentored them beforehand? Or if someone I mentored as a third year who became friends with me is assigned to me?

"Or, what happens when an ED Resident takes a shine to a promising young student during his Preceptorship, then mentors and guides him during his Clerkship and multiple Sub-Is AND writes his evaluations? And recommends him for the Match after having dinner at his house, attending parties at his house, and inviting him for pizza in her apartment? You know darn well that NONE of those are considered ethical violations, so there is no need to belabor the fact that Sophia and I dated briefly when our close friendship is more important."

"Circumstances."

"Does anyone but you know the additional information?"

"I don't believe so."

"Then let it be. There is no way that Krista Sandberg is going to try to use that against me. I'm her best witness! And nobody can point to favoritism with Sophia. Her evaluation is accurate, and was confirmed by Doctor Baxter and Doctor Billings."

"Are there any other potential landmines?"

"Sophia is not a landmine. There are no landmines. As I said in my deposition, I have not engaged in any inappropriate relationships during medical school or Residency. I'll extend that and say that I've _never_ engaged in any inappropriate relationships as defined by my ethics or state law."

"Your ethics?"

"The hospital's ethical rules were no limit, as we've seen clearly demonstrated. Neither were the medical school rules, as we've also seen demonstrated. So yes, mine. I have friends, and yes, I have had sex with girls who were just friends. But _never_ anyone subordinate to me or supervising me while I was in medical school."

"Interesting qualification."

"No comment. Please just drop the Sophia thing. There's zero risk to the hospital and I'm positive the evaluation is unbiased and based solely on her work during her Sub-I."

"I don't disagree, but I'm positive you're aware of how it might be spun."

"Had it been after Elizaveta reposed, it would have been a different story, but it was seven years ago. And, as I said, someone could spin our relationship into false claims of favoritism."

"Given nobody has said anything, and you disclosed a friendship, I agree that's the way to handle it."

"Thanks. I'll deliver the reviews tomorrow."

"Go heal the sick."

_December 1, 1989, McKinley, Ohio_

"Did you turn in your evaluation at the medical school?" I asked Nicole when we met on Friday morning.

"Yesterday after my shift."

"You're the first to receive an evaluation from me with the new forms and the new grading system. As you know, we switch from 1–5 to 1–9 for our grading system to provide a bit more granularity. A grade of 1–3 is 'Below Expected Performance', a grade of 4–6 is 'Expected Performance' and a grade of 7–9 is 'Above Expected Performance'. The grading criteria have changed as well, with specific descriptions of each evaluation provided to the reviewing physician. Did you have any questions about the evaluation forms?"

"No."

"I'll cover the numbers, and you can read the prose at your leisure. Overall, you were professional, respectful, proactive, and honest. I found no deficiencies in your professionalism. Those aren't scored numerically on the form, but if they were, 3 out of 3 across the board. Any questions?"

"I believe this is where it serves my best interest to say nothing!" Nicole declared.

I chuckled, "A lesson I should learn one of these days! For the four 'Patient Care' items, you received 6s for History Taking, Physical Exam, and Medical Decision Making, and a 7 in Clinical Reasoning. That leads to an above-average score. Questions?"

"How do I get all the scores in the highest range?"

"You can read the prose, plus review the evaluation criteria, but the short version is you have to be much better than the average student. According to the evaluation manual, scores above 6 are to be used sparingly. Remember, too, on these new forms, there is an overall grade, which is what will be reported. We'll get to that at the end. OK?"

"Yes."

"You received an 8 in Medical Knowledge, and an 8 in Learning Skills. Your medical knowledge is above average for students at your stage of clinical rotations, and you ask all the right questions and make a serious effort to learn. Questions?"

"No."

"For the 'Communication Skills', skills category, you scored 6s on your communication with patient and their families as well as charts and notes. You scored 7 on oral presentation of cases. Questions?"

"No."

"And finally, you scored 8 on teamwork, yielding an overall score of 7, which is above average and in the 'exceeds expectations' range. Is there anything with which you disagree?"

"This isn't disagreement or a complaint, but is it possible for anyone to earn a 9 on the scale?"

"Officially, yes, but we were discouraged from assigning a 9 unless the student is so head-and-shoulders above every other student in that category."

"Would YOU have earned 9s?"

I chuckled, "I have no idea, but anything 7 or above is equivalent to a 5 on the old scale, given the criteria. The new system allows for more nuance than the old one. In any event, you did outstanding work, and absolutely deserved an 'exceeds expectations' overall rating."

"What is reported with my transcript?"

"The overall score for each rotation. In this case, it will be seven of nine, with the text 'exceeded expectations'."

"Great! Thanks."

"Any feedback you want to provide for me?" I asked.

"Do you get to see the individual evaluations?"

"No. If there's a shortcoming identified, it will be communicated to Doctor Roth. Otherwise, I'll see my overall rating in early June when classes move up. Is there anything you want to say?"

"Other than you're a great teacher and you gave me plenty of opportunity, no."

"I wish you the best on your next rotations, and I'll see you for your trauma Sub-I!"

We left the consultation room and, together with Sophia, handled four walk-ins before it was time for Sophia's review. As I had with Nicole, I reviewed her scores, all of which were in the 'exceeds expectation' range, and she did receive a single 9 for Medical Knowledge. Her overall grade was an 8, though the guidelines had been fairly clear that those should be as rare as snow in July.

"You did excellent work, Sophia. Anything you want to ask or add?"

"Just that having been graded with the old system and received 5s across the board, it feels like a letdown."

I nodded, "I would have felt the same way, but I actually prefer the finer granularity, which allows me to distinguish between students, and the narrower categories which allow for more effective evaluations. No other Fourth Year received an 8 as their overall rating for their trauma Sub-I this rotation. You're still on track to graduate first in your class!"

"Yes, but now I can't have perfect scores in my rotations!" she groused.

"Remember, according to Doctor Mertens, any grade of 7 or above is equivalent to a 5 using the old system. The 8 and 9 are basically the checkmark on the old form."

"I suppose it's wrong to bitch about it, given I had the highest score!"

"You know I'd have bitched about it!" I declared. "There is one thing I do want to mention, and this is unofficial between friends, OK?"

"Of course."

"Doctor Gibbs discovered, somehow, that you and I dated when you were a Freshman at Taft and asked me about it."

"Because she thought you were biased?"

"She doesn't, but she was concerned about how it might play out if someone else accused me of favoritism because we were involved. As I pointed out to her, I disclosed our prior friendship, and nothing in the guidelines applies to anything that occurred before entering medical school."

"Everyone is freaked out because Krista Sandberg has a legitimate claim against the hospital and King from Medicine."

"That is the bottom line, and, honestly, despite me going off on Doctor Gibbs about it, it shows they're _finally_ starting to take the subject seriously. You know how bad things are, and this will improve them, even if it's uncomfortable at times."

"The next doctor who hits on me is going to find himself on the receiving end of a complaint."

"May I make a suggestion?"

"Of course."

"Give a firm 'no' that cannot be legitimately misinterpreted as playing hard to get and complain after the second time."

"I suppose that does make sense," Sophia agreed. "Tell them to get lost, and if they don't take 'no' for an answer, then complain."

"Exactly. And that goes for female doctors, too."

Sophia laughed, "I'm about as interested in that as you were in Lee!"

"So not!" I chuckled. "Do you have your interviews scheduled?"

"Yes. Five hospitals in the Bay Area — three in San Francisco, one in San Jose, and Berkeley. Of course, I want UC San Francisco, but any of the hospitals will be OK. Will you write a letter of recommendation for the Match?"

"At the risk of incurring the wrath of the OBs and surgeons here, yes, of course!"

"Thanks!"

We left the consultation room and treated an even dozen patients before lunch. After lunch, I stopped in to check on Nancy, then met with Marv to have his review. I explained everything as I had to Nicole and Sophia, then moved on to the details. His overall score was a six, which was above average, and at the high end of 'meets expectations'.

"All done?" Clarissa asked when Marv and I came out of the consultation room.

"Yes. Sadly, that also means tomorrow is your last day in the ED. And with you doing a Free Clinic shift on Thursdays, starting tomorrow, we have even less opportunity to see each other."

"We can try for dinner on Monday and Tuesday, and lunch on Saturday, because we won't be on the same service."

"Sounds good."

_December 4, 1989, McKinley, Ohio_

On Monday, I had found my new medical students, Jenny Brown, a Fourth Year, and Kelly Atkins, Sophia's flirty friend, who was a Third Year. At noon, when Jenny went off, John Abercrombie would come on.

"Good morning," I said. "May I see your procedure books?"

Both of them had entries appropriate for their station — the fourth rotation of their respective years. I'd reviewed their evaluations on Friday, and both had received average or above average evaluations for each rotation.

"It's sink or swim time," I said. "Your trauma Clerkship or Sub-I will be the most difficult of all your clinical rotations. This is where you prove you're qualified to be a physician. A sub-standard evaluation will make Matching for a good program difficult, if not impossible. Jenny, get the first chart in the walk-in rack, perform an H&P, then call me when you're ready to present. Kelly, observe, because you'll do one later today."

"Without you there?" Jenny asked.

"Without me there. I'll validate your findings, but this will be your first patient, and you'll suggest a course of treatment. Hop to it!"

"Right away, Doctor Mike!" she exclaimed.

They left, and I went to see Ghost, who was the senior doctor in the ED until 10:00am.

"I take it you turned your students loose on an unsuspecting patient?" he asked.

I nodded, "Baptism by fire, as they say, though it's not as if I sent them to receive an EMS run!"

"That might be a bit much! Your theory on how to teach is interesting. Not many Residents would throw newbies into the deep end this way."

"More like the kiddie pool," I chuckled. "I checked the charts before I went to see them and the first chart in the rack appears to be a severe ankle sprain from jogging. If they kill THAT patient, the patient wasn't going to survive if you and I were there with them!"

"True," Ghost agreed with a wry smile. "Loretta talked to me about the dustup you two had last Wednesday."

"Which confirms my rat is Clarissa," I said with a smile.

"We all know that if we want to know exactly how you'll react to something, she's the one to ask. You tend to be a bit rabid when it comes to anything you feel interferes with patient care."

"I can't argue with that."

"My advice is to dial it back a notch. Save 'going to 11' for things that truly matter, such as sexual harassment of female medical students or racism. The other crap is mostly out of our hands, and we're at the mercy of politicians, lawyers, and bureaucrats, and you know as well as I do, they aren't going to cede control of anything nor allow any reforms that reduce their power, or in the case of attorneys, income. I agree with you on the topic, but pick your battles wisely, Don Quixote! Or, in terms you might relate to, more Picard than Kirk."

"Kirk won by breaking the rules," I chuckled. "Every single time! Including the _Kobayashi Maru_ scenario!"

"And Picard usually wins by finding a way to work within the rules, bending them about as far as possible without breaking them."

"At least you didn't compare me to Doctor Pulaski!"

"You're 'Bones' McCoy or BJ Honeycutt."

"Thank you again for not comparing me 'Hawkeye', who was a great surgeon but also the equivalent of the class clown. That said, I think Doctor Hunter 'Patch' Adams is on to something."

"Just remember, it could be worse — you could be at Cook County!"

"That would drive me nuts," I replied. "We don't have enough time to talk to patients here, and their workload per physician is almost double ours. According to Perry, that's a problem across their entire hospital."

"Let's hope it stays there, too!" Ghost declared.

"Sadly, our volumes are rising faster than they're going to increase staff," I observed. "And I don't think the county is in any mood for a property tax increase."

"I'd say you're right, given they already agreed to spend the money on the new ED and new Surgery wing. And we do get new staff to go along with that."

"But not enough, which is something that will probably be true for the rest of our careers."

"You could always switch to being a GP and do your 'old country doctor' routine, set your own hours and pick your own patients."

"I could, but it's not me."

"No, it's not."

"Doctor Mike?" Jenny said from the door to the Attending's office. "I'm ready to present."

"Then let's go," I said. "Later, Ghost!"

"Later!"

I followed Jenny to Exam 3, where Kelly was waiting with the patient.

"Doctor Mike, Marcus Shea; Marcus, this is Doctor Mike. Mr. Shea is twenty-nine and presents with an injured right ankle post stumble over a curb while jogging. Vitals normal, right ankle shows ecchymosis and swelling; no pain in the malleolar zone, nor any bone tenderness; able to bear weight with intense pain. Diagnose as an inversion sprain, most likely involving the anterior and calcaneofibular talofibular ligaments."

"Hi, Mr. Shea," I said. "My student has examined you, but I need to confirm her diagnosis. I'd like to listen to your heart and lungs and check your ankle."

"Sure, Doc."

I confirmed Jenny's results and felt x-rays were not warranted.

"You have a moderate sprain, Mr. Shea," I said. "We'll have a nurse wrap your ankle and get you a pair of crutches. Stay off the ankle for a week, then see your personal physician or return here for an exam. You can take Tylenol or Advil for pain and ice packs to reduce the swelling."

"It's OK to move around on the crutches?"

"Yes, though you'll want to elevate and ice your ankle as much as possible. Have you used crutches before?"

"In High School when I sprained my left knee playing football."

"OK. Give us a few minutes and a nurse will be in to wrap your ankle."

"Thanks, Doc."

I updated the chart, then motioned for Jenny and Kelly to follow me from the exam room. I found Kellie at the nurses' station and asked her to wrap Mr. Shea's right ankle, then took my students into the lounge.

"You did a good job, Jenny," I said. "One minor point — when you present, I want to hear the numbers for pulse and blood pressure, please, and if there's a monitor, PO₂ as well."

"Sorry," she said.

"No need to apologize," I replied. "Most trauma docs are happy with 'normal vitals'; I prefer the detail. Just remember for next time. Otherwise, an excellent job. This will be the pattern for the next two months. When we don't have a trauma, you'll bring the patients in, perform the H&P, evaluate their symptoms, and present. Kelly, starting next week, you'll have your chance."

"This beats chasing labs and other scut, for sure!" she exclaimed.

"There will be plenty of that, too," I replied. "So long as you show me you have the skills and knowledge, I'll ensure you have a chance to use them. Can either of you read an EKG?"

"I know the basics," Jenny replied. "Sinus rhythm, V-fib, tachycardia, and ST elevation."

"Good. Are you proficient in attaching leads for a five-lead and twelve-lead?"

"Five-lead for sure. I haven't had to do a twelve-lead, but I do know the mnemonics."

"Good. Kelly?"

"No," Kelly replied. "I haven't done my cardiology Clerkship."

"You may need to ask to learn. What about EKGs?"

"No."

I took my clinical notebook from my pocket and handed it to her.

"When we have a break, copy the diagrams from pages twelve and fourteen into your clinical notebook, along with the mnemonics on pages eleven and thirteen. For now, the two of you should get the next chart and complete the H&P. Come find me when you're ready."

That was the pattern for the morning, and Jenny did a great job. At noon, John Abercrombie arrived, and I knew his skills well, having worked with him in the past. After we spoke a bit, I had lunch with Vince Taylor then returned to the ER. The afternoon was filled with walk-ins until just after 6:00pm when Nate called out to me.

"EMS two minutes out with a stabbing victim," he said. "Ghost asked for you."

"Thanks, Nate. John, Kelly, let's go! It's your first trauma!"

We headed to the ambulance bay, grabbing gowns, gloves, and the newly mandated goggles. I understood why Risk Management had insisted on a mandate, rather than simply encouraging use, because the risks were real. I was happy they hadn't chosen the alternative that some had suggested — face shields — which I was positive would be off-putting for patients. Masks, on the other hand, were optional, and I chose not to use one except in the OR or with an airborne infectious disease.

"Mike," Ghost said, "EMS said it's a bad one. Your priority is controlling bleeding."

"We need a _real_ surgeon," I said.

"You're what I have for now. Nate called for an Attending. Someone has to come in."

If we were a Level I trauma center, an Attending surgeon would have to be in the hospital twenty-four-hours a day, every day of the year. I said an additional prayer, not just for the patient, but for myself, as I was easily going to find myself out of my depth. That would be true for any surgical Resident before PGY3, and those were the Residents who provided consults and emergency procedures. Bob Hodges was upstairs, but he, like me, was a PGY1. I wasn't sure who was on call, but they had fifteen minutes to arrive, and in that fifteen minutes, we could easily lose the patient.

"You OK, Mike?" Kellie asked quietly.

I nodded, "There are limits to what I can do."

"Then work right up to them, and do what you can."

"Yes," I agreed as the EMS squad turned into the driveway.

Ten seconds later, it pulled up in front of us and Bobby jumped out.

"Deborah Bailee, twenty-three; multiple stab wounds chest and stomach; lacerations on arms and hands; pressure bandages; BP 70/30; pulse 120 and thready; PO₂ 90% on ten liters by mask; unit of plasma in and unit of saline on large-bore IV."

Ghost began barking orders, and I turned to Kellie, "I need a central line kit; she's going to need volume and I can't fix the bleeders. Go!"

Kellie sprinted ahead of the rest of us as we moved towards Trauma 1 with the young woman who was barely clinging to life. A few seconds later, we burst into the trauma room and quickly moved Ms. Bailee to the treatment table. While she was intubated and hooked to a vent, I inserted the central line without sonography and without lidocaine. It was a risky procedure done that way, but if we didn't get blood into her quickly, everything else would be for naught.

"Line is in!" I announced. "Hang a unit on the rapid infuser!"

"Serious resistance on the vent!" Julie, a Fourth Year, announced.

"Chest tube, Mike," Ghost directed.

"I'm concerned that the pressure dressings are causing blood volume to tamponade and if I make an incision, she might bleed out before I can get the chest tube in."

"PO₂ 86%," John announced. "And dropping!"

"Do it, Mike!" Ghost ordered. "Her PO₂ is dropping and we can't increase vent pressure."

"Chest tube tray!" I requested.

Kellie brought the tray to me and I grabbed the scalpel and quickly made the incision with an immediate gush of blood.

"Pressure bottomed out!" John announced, then declared, "Asystole!"

"At least a liter on the floor!" I announced as I continued to work.

"Two units!" Ghost ordered. "Pump them in!"

I worked quickly and got the tube in, then hooked up the ThoraSeal.

"Done!" I announced.

"Starting compressions!" Ghost announced as he started CPR.

"No pressure," John repeated. "No pulse."

"I think you can forget it, Ghost," I said quietly. "She's lost too much blood."

"One more unit and epi down the tube!" Ghost ordered.

I was sure it was futile, but the team complied with his orders and I said another prayer.

"Epi is in!" Nurse Amy announced.

"Blood is running in!" Kellie declared.

"No change," John announced.

"Call it, Ghost," I said quietly.

He stopped compressions, listened to her heart and checked her corneal reflex.

"Time of death 18:18," Ghost said.

"Lord have mercy," I said quietly.

"Ghost?" Nurse Becky said from the door. "There are police detectives here."

"Put them in the consultation room. Mike and I will be there in a minute."

She acknowledged and left.

"I'll get the death kit," Amy announced.

"Wait on that," Ghost ordered. "Let us speak with the detectives first."

I pulled my «chotki» from my pocket and began reciting the Jesus Prayer. What I'd done had directly caused her death, though inaction would have led to the same result. There would absolutely be an M & M conference on this patient, though I was positive even a fully trained trauma surgeon would not have been able to repair the damage before Ms. Bailee bled out.

"You OK, Mike?" Kellie asked.

"Yeah," I said quietly. "I count eleven abdominal stab wounds. She never had a chance."

"Ready, Mike?" Ghost asked.

"I believe the correct answer is that it doesn't matter if I'm ready," I said. "We need to do it."

"It's always OK to take a moment to compose yourself."

I nodded and held up my prayer rope, "That's what this is about."

"You didn't kill her," Ghost said.

"My brain knows that," I replied. "My heart doesn't."

"First time some direct action on your part ended this way, right?"

"Yes."

"Call your monk friend in Michigan," he counseled. "I believe that's part of what he's there for."

"True. I'm ready. Jack and Kelly, please stay here. I want you both to observe and assist with the death kit once we speak to the police."

They acknowledged my order, and Ghost and I left the trauma room and went to the consultation room where Detectives Tremaine and Kleist were waiting.

"Hi, Doc," Detective Kleist said with an inviting smile. "Did she make it?"

"Good evening, Detectives," I replied. "No."

Ghost and I sat down at the table with the detectives.

"What can you tell us about her injuries?" Detective Tremaine asked.

"Mike?" Ghost prompted.

"I counted at least eleven abdominal stab wounds," I said. "She also had lacerations on her arms and hands."

"Is there anything you can tell us about those?"

I shook my head, "No. You'll need an autopsy for that. We were focused on trying to save her life."

"Can you take us through what you did?" Detective Kleist asked.

"I'll take that," Ghost said. "She was transported by Hayes County EMS and was received with vitals and presentation which indicated hypovolemic shock, that is, shock due to blood loss. The paramedics had given her a unit of plasma by IV, and applied pressure bandages. Our first actions were to intubate and insert a central line, which is basically a large-bore IV in the jugular vein. While we were working on her, her heart stopped, most likely due to hypovolemia, that is, blood loss. I can't say more than that. You'll need to speak to Doctor McKnight once he completes the autopsy."

"So she has a breathing tube and IVs?"

"And a chest tube," I added, "which we inserted to try to relieve the pressure on her lungs."

"Will you allow us to take some photos before you move her?" Detective Tremaine asked.

"Yes," Doctor Casper replied. "I asked them to hold up on the death kit because I suspected you'd want to do that. Can you tell us what happened?"

"Only that we have her boyfriend in custody," Detective Kleist said. "Did you run a pregnancy test?"

"No. We didn't have time for any blood tests except ABG — arterial blood gas — and typing, both of which we can do in the trauma room. Doctor McKnight will be able to answer that for you. Mike will take you to the trauma room."

The four of us stood, and I led Detectives Tremaine and Kleist to Trauma 1 where John, Kelly, and Nurse Amy were waiting with Ms. Bailee. Detective Kleist used a Polaroid camera to take several photos, including one of the pool of blood on the floor.

"Thanks, Doc," Detective Tremaine said. "She's going to autopsy?"

"Yes. Doctor McKnight will have gone home; we can page him if you feel it's necessary."

"Would you do that, please?"

"Absolutely. Amy, you can proceed with the death kit. John and Kelly, observe, please. Put some surgical sponges on that blood on the floor until maintenance can clean it up."

"Right away, Doctor," John said.

The detectives and I left the trauma room walked to the clerk's desk.

"Mal, would you page Doctor McKnight, please? The Detectives would like an autopsy performed on a crime victim right away."

"Will do!" she said, picking up the phone.

"Thanks, Doc," Detective Kleist said. "We'll head down there to wait."

"Nail whoever did this, please," I requested.

"You can count on it!" Detective Kleist declared.

They left, and I went to the now-empty consultation room and used my calling card to call the monastery. I identified myself and asked the young nun who had answered the phone if Father Roman was available. She put the phone down and I waited for about five minutes until she returned to tell me he would return the call after Vespers. I thanked her, then let Mallory know I was expecting the call.

"Grab your meal, Mike," Ghost suggested.

"Thanks. What happened to our surgeon?"

"Doctor Edmonds arrived while you were on the phone. He went back home."

"We can't be a Level I center soon enough," I observed.

"I agree, though in this case it wouldn't have mattered. Nobody could have saved her."

"I know," I replied. "At least intellectually."

"This isn't even the 'Trolly Problem'," Ghost said. "This was a damned if you do, damned if you don't situation. And in those cases, you do, because not doing guarantees the outcome, even if doing is ultimately futile."

"I know," I replied. "Thanks."

"Did you get hold of the monk?"

"He's going to call back sometime after 8:00pm."

"I'll make sure you have some free time."

"Thanks."

I left the ED and went to the cafeteria, happy to see that Carl Strong from Cardiology was in line. When I got my food, I joined him at his table, along with several other Residents.

"How are things going, Mike?" he asked.

"Overall, pretty good. We just had a twenty-three-year-old stabbing victim who didn't make it. Eleven abdominal wounds and defensive wounds on her hands and forearms."

"Jesus!" Doctor Leah Peterson from Medicine, breathed.

"McKinley PD has the boyfriend in custody," I said.

"That's some serious anger and aggression," Lucy Vanderberg observed. "Any idea on the trigger?"

"The cops asked if she was pregnant," I replied.

"She presented with vitals with those wounds?" Doctor Melissa Zander from Pediatrics asked.

I nodded, "In hypovolemic shock; she was breathing and tachy, though her BP and PO₂ were critically low. The paramedics did a great job getting her to us alive, but with those wounds and her chest cavity full of blood…"

I shook my head.

"With those wounds, even a full surgical team couldn't have prevented her from bleeding out," Carl observed.

"I hope they fry the bastard!" Leah declared.

"An eye for an eye results in the whole world being blind," I countered. "Lock him up for life."

"And then the taxpayers are on the hook for $20,000 a year for sixty years. No thanks."

"All life is sacred," I replied. "Killing in response to killing is not the answer."

"And if that were your loved one?" she asked.

"One of my best friends was murdered," I replied. "I opposed sentencing him to death. He's incarcerated for life without parole, and I visit him every month."

"What?! Why?!"

"Mike was, until the death of his wife, an ordained minister," Carl said. "And he takes the command to heal the sick, care for widows and orphans, and visit those in prison seriously."

"I don't know that I could do that," Leah said. "It's a bridge too far."

"As with many other commands given by Jesus, it's not easy, and it's not meant to be easy."

"Sorry, it just dawned on me what Carl said. Your wife died?"

"Just over two years ago, while I was a Third Year," I replied. "She suffered an intraparenchymal bleed due to a congenital arteriovenous malformation that developed into a nidus."

"My condolences, though they're late."

"Thanks."

We all finished our meals and returned to our respective services.