Chapter 16 — Defeated

_July 6, 1989, McKinley, Ohio_

{psc} "A heart attack?" Mrs. Valerio gasped.

"Yes. Your cardiac enzymes show you had a mild heart attack."

"But you didn't see it on the machine!" her husband protested.

"Not every arrhythmia, that is an irregular heartbeat, shows on an EKG, and women often don't have the classic symptoms that men have. And the enzymes show that it was mild. I'm going to call for a cardiologist to see you. He or she and I will discuss what we do next, but for now, I'm going to give you some nitroglycerin, which will relieve the heavy feeling in your chest and bring down your blood pressure. Wendy, sub-lingual nitroglycerin tab, please. Len, call for a cardiology consult, please."

The nitroglycerin reduced Mrs. Valerio's chest pain, and brought down her blood pressure. About ten minutes later, Doctor Javadi came into the room with her student.

"Morning, Mike," Doctor Javadi said.

"Morning, Leila," I replied. "Mrs. Valerio, this is Doctor Leila Javadi, from Cardiology."

"Good morning, Mrs. Valerio," Doctor Javadi said.

"Good morning, Doctor."

"What do we have, Mike?" Doctor Javadi asked.

"Mary Valerio, seventy-eight, presented dizzy, weak, with mild chest pain, mild hypertension, and slight tachycardia. EKG showed no arrhythmia. Cardiac enzymes are slightly elevated. Nitroglycerin sublingual resolved the chest pain and hypertension. Len, the test results, please, for Doctor Javadi.”

He handed them to her.

"Thanks, Mike,” Doctor Javadi said. “Mrs. Valerio, I'd like to examine you, please."

Doctor Javadi reviewed the test results Len handed her, then performed her exam.

"Mrs. Valerio, I'm going to admit you to cardiology for an echocardiogram, which is an ultrasound of your heart. Mike, we'll need a portable EKG. Janelle, call for an orderly, please."

"Right away, Doctor," her student said.

"Len, you'll go with them. Cardiac patients are always accompanied by three."

"Will do," Len confirmed.

"Mrs. Valerio," I said, "Doctor Javadi will take good care of you."

"Thank you, Doctor."

I made notes on the chart, signed it, then left the room and went back to the admit desk.

"Who's next?" I asked Bob.

"Er, I thought you decided."

"Yes, but you tell me what you have and which patient you think I should take."

"Seventeen-year-old female with a sprained knee; twenty-nine-year-old male with a week-long productive cough; sixty-five-year-old with a minor forehead lac and contusion. I would take the cough, as the forehead contusion shows no neurological symptoms."

"Did you mask the cough?" I asked.

"Yes. That's on the standard procedure list."

"I agree that’s who I should take first. Do a second neuro check on the contusion in ten minutes, please."

"Will do!"

He handed me the chart, and I went to the door and called out, "Mr. Kennedy?"

"Me!" came the muffled reply through the mask

He stood up and walked over to me.

"I'm Doctor Mike; follow me, please."

I led him to Exam 5, then asked Ellie for a nurse. She assigned Julie, who accompanied me to the exam room.

"How long have you had your cough, Mr. Kennedy?" I asked.

"About a week," he replied.

"OK, we'll get your vitals and I'd like to listen to your heart and lungs. Julie, we should mask."

"What do you think I have?" Mr. Kennedy asked.

"I don't know," I replied. "The mask is simply a precaution. I’ll put one on because I'll need to have you remove your mask to check your breathing and look in your mouth and nose."

Julie and I both washed our hands, put on gloves and masks, and she took Mr. Kennedy's vitals. Once she'd done that, and written the results on the chart, I had Mr. Kennedy remove his mask and performed a basic exam. The only thing that stood out was that he had significant crackles in his lungs, along with slight tachycardia. I had him put his mask back on before I continued.

"Does your chest hurt?" I asked.

"Yeah," he replied.

"While you're coughing, after you cough, or all the time?"

"At first just when I was coughing, but now it feels tight and aches."

"Do you sweat at night?"

"Yes."

"Is that new or something that's been true for some time?"

"It started about the time the cough got bad."

"When, specifically, was that?"

"Let's see, it was after I came back from Mexico. I was coughing a bit after the flight, but figured I'd picked up a bug in Acapulco. So, maybe ten days."

"Have you been sick recently? Besides the cough?"

"No."

"Any other problems? Diarrhea? Fever?"

"No."

"Are you on any medication?"

"No."

"Any history of trouble with your immune system?"

"I don't think so. I don't get sick very often."

"OK. Julie, CBC and sputum sample. Mr. Kennedy, I'm going to order a chest x-ray."

"Chest x-ray?" he asked.

"You have fluid in your lungs," I said. "It's a standard test to rule out any number of respiratory diseases."

And would give me strong evidence that my preliminary diagnosis was correct. I wouldn't bet the farm on it, but my suspicion was that he had infectious tuberculosis. I wrote my orders on the chart, excused myself while Julie drew blood and obtained the sputum sample. I went to find Doctor Williams and made my report.

"Good precautions," he said once I'd reviewed the case with him. "Make sure he stays masked and come find me when you have the x-ray. If it shows what you think it will, we'll need Mark Hammond to examine him."

Doctor Mark Hammond was the hospital's infectious disease specialist.

"And report to the CDC and County Health Department," I added.

"What's the lab test for TB?" Doctor Williams asked.

"Initial test is for acid-fast bacilli, but definitive diagnosis requires sputum cultures, but that can take weeks as MTB is very slow growing."

"That’s correct. Get the x-ray and lab tests and we'll take it from there. Chart?"

I handed him the chart, he made a few notes, then signed it and handed it back. I went to the nurses' station and called Radiology to set up the x-ray, then returned to the exam room.

"Someone from Radiology will come get you in about ten minutes," I said. "Just relax and I'll come see you when you're back."

"Thanks, Doc. What do you think it is?"

"Right now, all I can say definitively is either a viral or bacterial infection. The x-ray, blood tests, and sputum sample will point us in the right direction."

"Something I picked up in Mexico?"

"Possibly," I replied. "I'll see you in a few minutes."

I washed my hands, left the room, then disposed of the mask in the appropriate waste bin. As I went back to the admit desk, Len returned from Cardiology.

"Patient transferred," he said. "Nothing to report."

"Good. Bob, any change on the contusion?"

"No neurological signs."

"Then I'll take the sprained knee."

He handed me the chart, and I laughed, "First Kennedy, now Nixon!"

"I know, right?" he replied.

"Len, get a wheelchair, please."

He did, and we went out to the waiting room where a young woman with an ice pack on her knee was sitting. She looked vaguely familiar, and with her last name, I realized she might be related to Sheila, who I hadn't seen since my wedding.

"Cynthia Nixon? I'm Doctor Mike, and this is Len, my student. Let's get you into the wheelchair. Is this your mom?"

"My softball coach, Mrs. Paul," she said.

"Mrs. Paul, you can wait here while I examine Cynthia. We'll update you once we complete the exam."

She nodded and Len and I helped Cynthia into the wheelchair and pushed her into the ED, where I asked Ellie for a nurse and was assigned Becky, who followed us into Exam 3. We helped Cynthia onto the table and I began taking her history while Becky took her vitals.

"Any previous injuries to your leg?" I asked.

"I had a hamstring pull on my other leg last year, but that's it."

"How bad would you say the pain is?"

"It aches, but the ice helps."

"We're going to need to do an x-ray. Is there any chance you might be pregnant?"

"Only if my name were Mary and you're the Angel Gabriel!"

Len, Becky, and I all laughed.

"'Angel' is probably the last word anyone would use for me!" I said. "Len, call Radiology and arrange for a knee series."

"Right away!" he replied.

I filled out the chart, then handed it to Becky.

"Cynthia," I said, "I'll update your coach. Do you want her to come in? It might be as much as an hour before we get the x-ray results."

"Sure."

I left the room and went out to the waiting room.

"Coach Paul? The sprain doesn't appear to be severe, but you can't always tell with an exam, so we're going to get an x-ray of Cynthia's knee before we decide how to proceed. She'd like you to come back and sit with her."

"Thanks, Doctor."

I escorted her to the exam room, then had Len come with me back to the admit desk where I asked for the chart for the forehead contusion.

"Mr. Abrams?" I said, walking up to him. "I'm Doctor Mike. Are you OK to walk?"

"Yeah, I just banged my head on the cabinet and my wife insisted I come have it checked out."

"Because you collapsed!" she said.

That was not noted on the chart, which concerned me.

"Mrs. Abrams, you can come back with us if it's OK with your husband."

"If I say 'no', I'll probably need a surgeon," he said.

The four of us went to Exam 1 where I washed my hands and put on gloves.

"When you collapsed, were you unconscious?"

"No. It hurt like a motherf…hell. I saw stars for a few seconds, but that's it."

"OK. Let me take a look, then we'll get your vitals, and I'll do an exam."

"The doc and nurse out front did three exams!"

"Which I asked them to do to ensure I could safely ask you to wait while I treated patients who had arrived before you."

I looked at his forehead and I felt it didn't even need a butterfly bandage, let alone sutures, and he showed no neurological deficits on exam.

"Len, clean the wound and apply a gauze dressing. 600mg ibuprofen PO. Monitor for an hour with neuro checks every fifteen minutes."

"Will do, Doctor!"

"Mr. Abrams, you don't appear to have suffered anything more than a minor abrasion and a headache, so we'll get you some ibuprofen, then monitor you for an hour. If there are no signs of concussion or other problems, we'll send you home."

"I told you, Mildred!" he said to his wife.

"Better safe than sorry, Max!" she countered.

I filled out the chart, signed it, and went to check on Mr. Kennedy, who hadn't returned from Radiology. I took the charts for Ms. Nixon and Mr. Abrams and went to see Doctor Williams. He reviewed both charts, made notes, and signed them.

"Kick the contusion as soon as you're happy. Let me know if you call an ortho consult on the knee."

"I'll want you to look at the film with me," I said.

He nodded, "Bring that to me when it's ready. Anything on the possible TB case?"

"He's not back from Radiology."

"We're keeping them busy this morning! This is four now. Varma had two and you've had two."

I left his office and almost ran into Ghost, who was moving quickly to the ambulance bay.

"Mike, I have a hot MI being transported in full arrest. Varma and Lincoln have traumas, and Nielson is on break. Can you assist?"

I was basically waiting, so I could.

"Yes."

I grabbed a gown and a fresh set of gloves and followed him, his Fourth Year, Jack, and Nurse Alice into the ambulance bay.

"Jack," Ghost said, "EKG and monitor, then Foley; Mike, intubation; Alice, trauma panel with stat cardiac enzymes."

A full arrest meant a fireman and paramedic performing CPR and a less than ten percent chance the patient would make it, and that was being optimistic. Two minutes later, the EMS squad pulled up, a paramedic jumped out and called out the vitals, which were basically non-existent, and moved to the back of the squad. There was a bit of shuffling as the gurney was moved out, and the fireman got on, straddling the patient, performing chest compressions as the second paramedic bagged.

"Trauma 1!" Ghost ordered.

The team performed the choreographed routine efficiently, and five minutes later the patient was on a respirator, but despite two amps of epi, an amp of bicarb, and continual chest compressions, we couldn't bring him back. With no heart sounds, no signs of electrical activity, and his pupils fixed and dilated, there was nothing left to do.

"Time of death, 08:19," Ghost said. "Alice, death kit, please."

We left the trauma room and stripped off our gowns and gloves.

"He was very likely dead when the paramedics got to him," I observed. "If you figure best-case response time, he was down ten minutes before they showed up."

"You know they prefer to bring everyone in because all it takes is my signature here, whereas it's a four-page triplicate form if he's declared dead on scene."

"Oh, I know," I replied. "I know this is going to sound crass, but that's a lot of resources expended to avoid paperwork."

"And if that were you? Would you want the paramedics to say 'fuck it'?"

"No, of course not! It was just an observation."

"You make some strange observations!"

"Maybe, but what is our number one problem here?"

"Besides people smoking, drinking to excess, and not seeing a doctor once a year?" Ghost asked.

I chuckled, "Yeah, other than those."

“Know-it-all Interns.”

I chuckled, “Yes, yes! Besides that?”

"Lack of resources, of course, followed closely by ODs. I get your point, but your answer to my question points out the reality of the situation. Frankly, between you and me, if I had to conserve resources, I'd start with 'save my ninety-five-year-old grandma at all costs'."

I nodded, "And as crass as that sounds, as much as 80% of all healthcare expenditures are made in the last five years of life. I already have an agreement with Kris that if either of us is in a situation where there will be zero quality of life, we'll end any heroic measures. When we get older, that will apply in general. The last thing I want to do is spend the final years of my life confined to a hospital bed on a vent."

"You and me both," Ghost said.

"I need to check on my patients."

"Then hop to it! Thanks for the assist."

I nodded and went to check on Mr. Abrams, who was showing no neural deficits or signs of concussion, and Cynthia, who was being helped into a wheelchair for her x-rays. Ellie called out to let me know that Radiology had the films on Mr. Kennedy, so I sent Len to get them.

"What did you see?" I asked when he returned.

"I didn't know I was supposed to look," he replied.

"I was always curious and couldn't help but look. Go ahead."

We moved to a light board, and he put them up and I saw some dark areas that might well be indicative of TB.

"I have no idea what I'm looking for," Len said.

"I'm pretty sure this dark spot supports a diagnosis of TB," I said. "What does the wet read report say?"

He looked it over, "TB indicated and calls for further testing."

"Did we get the lab results?" I asked.

"Yes. Everything was normal except elevated white count. The sputum sample was positive for acid-fast bacilli."

"TB, almost certainly, but we have to wait for the culture to know for sure. And that takes weeks."

"So what do we do?"

"Call the infectious disease specialist," I replied. "He'll take Mr. Kennedy to Medicine, put him in isolation, and begin treatment, even before the results come back. It’s a six-month course of an antibiotic cocktail. The CDC and County Health Department will be notified as well.”

“Contact tracing?”

“Yes. Let’s go see Doctor Williams.”

We went to the Attendings’ office, and I handed the chest film to him. He put them on the light board and looked them over.

“What do you see?” he asked.

“A dark area here,” I said, pointing. “I’d say that’s indicative of TB, and the Radiologist agrees. The sputum sample was positive for acid-fast bacilli.”

“Let me call Mark Hammond,” he said. “Keep everyone away from Mr. Kennedy except you two and the nurse. Just wait here while I make the call.”

He picked up the phone, dialed, and then explained the situation.

“He’ll be right down,” Doctor Williams said.

Five minutes later, Doctor Hammond came into the office, looked at the film, looked at the chart and lab results, and nodded.

“I’ll take him,” he said, then turned to me, “Let’s go see your patient, Doctor.”

The three of us went to see Mr. Kennedy, putting on masks before we entered the room to which Julie had attached a ‘quarantine’ sign.

“Mr. Kennedy,” Doctor Hammond said, “I’m Mark Hammond, an infectious disease specialist. I’ve reviewed your case, including the x-rays and lab test results, and discussed it with Doctor Loucks and his supervisor, and we all agree you most likely have active tuberculosis.”

“TB?!” he exclaimed.

“You have all the classic signs, though a definitive diagnosis requires a culture, and that takes anywhere from two weeks to two months. We’re going to admit you to our isolation ward, and we’ll notify the County Health Department.”

“Doctor,” I said, “he was on a flight about two weeks ago.”

“The County Health Department and CDC will deal with that. Mr. Kennedy, is there anyone you spend a lot of time with?”

“My girlfriend, my parents, and work, of course.”

“Everyone will need to come in for a TB test,” he said. “But the Health Officer will take care of that. Doctor Loucks, please arrange for transport. Mr. Kennedy, I’ll see you upstairs momentarily.”

He left, I had Len place the call for an orderly along with the instructions that they mask before they came into the room.

“How bad is it?” Mr. Kennedy asked.

“A course of antibiotics usually clears it up," I said.

About ten minutes later, he was on his way to the isolation ward, and after carefully washing my hands, I went to check on Mr. Abrams, who I felt was ready for discharge. I filled out the paperwork, signed the forms, and then directed him and his wife to Patient Services. A few minutes later, the films for Cynthia Nixon came back, and Len and I went to see Doctor Williams again.

"What do you see, Mike?"

"No tears or obvious damage," I said. "So a low-grade sprain."

"Athlete, right?" he asked.

"Yes."

"Refer her to a sports physiologist; there's no need for an ortho consult."

"Wrap the knee, ice, and ibuprofen?" I asked.

"That's the textbook treatment."

I acknowledged him, then Len and I went to see Cynthia and explain the diagnosis.

"How long do I have to stay off it?" she asked.

"At least until you see the sports physiologist," I replied. "We'll get you a set of crutches. We'll wrap it in an Ace bandage, and you should keep it wrapped except when you're in the shower, and use ice and ibuprofen for pain and swelling."

"I know someone you can see," her coach said. "And I think I can get him to see you today."

"Thanks, Coach."

"I'll write out the referral just in case," I said. "Len, an Ace bandage, please."

He retrieved one from the cabinet, and after getting permission, I wrapped Cynthia's knee. Len got her crutches, we showed her how to use them, and then, with discharge papers and the referral in hand, Len escorted them to Patient Services. I grabbed a quick cup of coffee, then Len and I went to see Bob.

"Nothing at the moment," he said.

"OK. I'll be in the lounge."

It was typical to have peaks and valleys, where things were utter chaos and I'd have to juggle multiple patients or they were very quiet. The quiet times rarely lasted long, so I took my coffee, went to the lounge, sat in a recliner, and sipped my coffee. The quiet lasted all of about two minutes before Alice opened the door to the lounge.

"Multi-victim MVA. All hands on deck!"

"Thanks, Alice. Let's go, Len!"

There were a total of seven victims, none of whom were serious, but that kept us busy for over an hour before I could check with Bob on walk-ins, of which there were four. I juggled those and managed to meet Clarissa for lunch in the Cafeteria.

"Crazy morning," I said. "Seven walk-ins, a fatal MI, and a seven-injury MVA."

"I saw on the chart that you sent us the TB case."

"He was on a plane less than two weeks ago. That should be fun for the CDC and County Health Department."

"A contact tracer was meeting with him when I came down for lunch. Any of the other cases interesting?"

"Seventeen-year-old softball player with a sprained knee."

"Who just needed Doctor Mike's magic touch to be healed?" Clarissa teased.

"No, but when I asked her if there was any chance she might be pregnant because she needed an x-ray, she said only if her name was Mary and I was the Angel Gabriel."

Clarissa laughed, "Cute. And?"

"And nothing. She didn't flirt. I just found it amusing. She did resemble Sheila and had the same last name?"

"Cousin? Niece?"

"No idea. You know we're not allowed to ask questions such as that, especially given Sheila was also a patient."

"Who you 'probed' extensively!"

"No comment! Did they start Mr. Kennedy on the antibiotic cocktail?"

"Yes. He's my patient, with Doctor Hammond as the Attending."

"Just palliative besides the cocktail, right?"

"Yes. And you know the culture can take over a month because MTB grows so slowly. What made you order the acid-fast test?"

"He had the classic symptoms — productive cough, chest pain, and night sweats. And given it's a quick, inexpensive test with a staining agent, why not? If it had been negative, I'd have looked further for a diagnosis. What else do you have?"

"The usual collection of ailments; nothing exciting. How are things otherwise?"

"Rachel is unhappy she doesn't see me for long periods of time, but we're coping. She is happy to play with Abigail twice a week. And now that Viktoria Elizaveta is almost a year old, they're spending time together once a week."

"But avoiding little Viktor like the plague, right?"

"Yes. Both girls are very calm and he's hyper."

"Anything on the complaint about Angie's treatment?"

"Other than speaking to the attorney, no. I'm supposed to hear from him in the next few days to give a deposition. And to anticipate your next question, nothing on the citizenship application, but we don't expect that until next month, at the earliest. How are things with Tessa?"

"Great, except for not being able to see her during our long shifts."

"I'm having dinner with Kris and Rachel in the cafeteria again tonight. We're going to try to do that as often as possible during this first year."

"But cafeteria food…"

"Is irrelevant compared to seeing Kris and Rachel."

"Good point."

We finished our lunches, and both headed back to our respective services.

"Mike, can you take a patient so I can get lunch?" Paul Lincoln asked.

"What do you have?"

"Twenty-two-year-old presented with fever; abdominal pain; LMP six weeks; positive home pregnancy test; hCG levels consistent with reported LMP; white count normal; no distention or guarding. Waiting on OB to rule out an ectopic."

"Did you do an ultrasound?"

"No. I basically cowered in a corner during my OB rotation. Babies and I do not mix!"

"I'll take her. What room?"

"Exam 6."

He left, and I went to Exam 6 and checked the chart, then asked Becky to assist me, as Ellie wasn't at the desk.

"Let's get an ultrasound, please," I said.

"You're going to do the exam?" Becky asked.

"Yes. I know OB is coming down, but it'll be a bit because it's lunchtime. I'm trained to do the exam."

"Who'd you have for your OB rotation?"

"Doctor Leslie Cooper at Good Samaritan in Cincinnati. She's Chief of OB now."

"Catholic?"

"Russian Orthodox, but the same basic opinion on abortion, and before you get on your high horse, I believe it ought to be legal, I just won't participate in an elective one. Get the ultrasound, please."

Two minutes later, we went into the room.

"Good afternoon Ms. Blake," I said. "I'm Doctor Mike, and this is Nurse Becky. Doctor Lincoln asked me to check on you. I'm going to do an ultrasound."

"You're the OB?" she asked.

"Surgical Intern," I replied. "OK to examine you?"

"Yes, of course."

With Becky's help, I performed the ultrasound and saw what I hoped I'd see.

"There is a fetus in your womb," I said. "And a cyst on your ovary."

"The other doctor thought I had an ectopic pregnancy."

"He called OB to rule it out, but I can confidently say you have a cyst and, so far, a successful pregnancy."

"What's the treatment?"

"Your cyst isn't large enough to warrant treatment at this time. Cysts usually resolve on their own, so my recommendation is that you take Advil for the pain and follow up with your gynecologist. When the doctor from OB arrives, we'll get you on your way."

The door opened and Doctor Carmichael came in.

"Hi, Mike. I thought this was Doctor Lincoln's case."

"He's having lunch. Sorry to steal your thunder, but Ms. Blake has an ovarian cyst and, as far as I can see, a successful pregnancy."

"Mind if I confirm?"

"Not at all."

Doctor Carmichael examined Ms. Blake, then we stepped out.

"You did an OB Sub-Internship?" Doctor Carmichael asked.

"No, but I basically insisted on being taught during my Clerkship. I did internal exams, and was trained on rape kits."

"Who taught you?"

"Doctor Mary Kelly at Good Samaritan in Cincinnati, who's now an Attending. I had a case very similar to this, and as in that case, I suggested Advil and following up with her gynecologist."

"Exactly right. Want me to sign the chart?"

"The hospital runs on paperwork, and once Paul called you, somebody will look for an OB signature. Honestly, though, everyone here should be able to do what I did."

"I don't disagree, but those red scrubs give you a bit more freedom than most trauma PGY1s. Let's go speak to Ms. Blake."

We went back into the room, and after I reiterated my diagnosis, Doctor Carmichael signed the chart, and I went over the discharge instructions with Ms. Blake. Once I'd done that, I left her in Becky's care and went to the admit desk.

"What do you have, Phil?" I asked the Fourth year who was filling in for Bob so Bob could have lunch.

"Probable broken ankle on a fifty-year-old; possible strep on a thirteen-year-old; and hammer versus hand on a twenty-three-year-old."

"I'll take the possible strep case first."

The afternoon was busy, and I saw all of those patients, and four more. The possible strep case was actually a case of infectious mononucleosis; the ankle was broken, and actually needed surgical repair by orthopedics; the hammer versus hand also needed ortho, as the patient's distal phalange was shattered. The other patients were a case of poison ivy, food poisoning, and heat stroke. I finished with the last patient just in time to be able to meet Kris and Rachel for dinner.

I hugged and kissed them both, and carried Rachel into the cafeteria.

"How has your day been?" Kris asked.

"Busy. Just under twenty patients, including two I sent to Clarissa — TB and mono."

"Tuberculosis? Here?"

"Tuberculosis. Here."

"All of your patients made it, then?"

"I assisted Ghost on an MI, but the patient was in full arrest when the paramedics got to him, so he was basically dead before we saw him."

"Then why bring him in?"

"If someone was with him and performed CPR, there would have been a remote chance of saving him, but the main reason is that Ghost or I could sign the death certificate, and it's a one-page form. For the paramedics, it would be a four-page form in triplicate. It would also require a Coroner's Inquest to decide why he died. In our case, it would just be an autopsy, and those aren't required if a patient dies in the presence of a doctor and there's no suspicion of foul play."

"How do they decide?"

"The rule is basically if there is so much blood that the patient has clearly exsanguinated or there is obvious brain matter or a decapitation, then they aren't brought in. It's a judgment call on everything else, and usually they default to transporting the person. As I said to Ghost, it consumes resources, but I think it's usually the right thing to do."

"You know my thinking on that!"

"I do, but there are not unlimited resources, and before you point to military spending, that's federal, and hospitals and doctors are state and local. There aren't enough, and I use this term advisedly, socialists in the US to change that."

"Why put it that way?"

"Because both Democrats and Republicans prefer to spend money on defense, funneling money to their districts, than they do on Medicaid or Medicare."

"That's disgusting!"

"I don't disagree, though you know I agree with my grandfather on having a sufficiently strong military to keep the Soviet Union in check. As President Reagan called it — 'Peace through strength', which appears to be working. I pray that it ends relatively peacefully, but you know my fear."

Kris nodded, "A nuclear holocaust."

"Yes. How was your day?"

"Fine. My composition class is interesting, and you know my opinion of English! It's so silly!"

I chuckled, "You remember what I said about English, right?"

"Yes, of course! What you need is an authority like in France to designate the proper way to use it!"

"Good luck with that!" I chuckled. "We have significant regional variations, and there isn't actually an 'official' version. The English here, using Peter Jennings as a standard, is, as I'm sure you know, different from that spoken in England, India, and Australia."

"Why a news presenter?"

"Anchorman," I countered with a smile.

Kris rolled her eyes, "As I said!"

"The funny thing is, he's Canadian, but he speaks US English in a standard, flat, Midwestern way that's acceptable across the entire country, where a strong Boston, New York, Philadelphia, or Southern accent wouldn't be. Basically, all the three major network anchors sound as if they're from Ohio, Michigan, or Indiana, as do most of the reporters. Anyway, what are you writing?"

"A short story about two teenagers in love."

"So, for you, pure fiction?" I asked.

Kris smiled, "Teenage romance is almost always silly."

"Because," I asked with a sly smile, "teenagers are not mature enough to handle relationships?"

"Not most American ones, that's for sure! But you know my view on romantic love — that it is more likely to interfere in a relationship than make it successful."

"I think it's more complicated," I said, "but I don't completely disagree with you. The divorce rate in a country where romantic love is the primary driver for marriage makes that point pretty well. What are your plans for this evening?"

"Put Rachel to bed, then work on my story with a glass of red wine! And tomorrow is Rachel's usual day with her cousin Viktoria. Did you want something special for dinner?"

"At the end of a thirty-six-hour shift, I'm not sure I'll care, so long as it's filling and nourishing."

"OK. There was a message from your mom asking when we could come to dinner. I'll arrange it, but when would be best?"

"Sunday after church, I think," I said. "That really is the only reasonable time."

"I'll ask if a week from Sunday will be good for them."

"Thanks."

We finished our meal, I walked Rachel and Kris to the car, and then headed back to the ED.

"Did you hear the great news?" Mary asked when I met her in the lounge, as Bob and Len had gone off shift just after I went for dinner.

"What's that?"

"Doctor Casper said that the Hospital Board approved the additional nursing staff to cover triage. The bad news is that it'll take until September 1st before the new nursing staff is hired and Fourth Years no longer have to do triage."

"I think that's good, obviously, but I also think triage is useful training. That said, if it's a choice between procedures and triage, I think procedures are overall better training."

"Out of curiosity, why do you think that?" Tom asked.

"Because at some point you may be called upon to do triage in a mass-casualty event and having done it when things are relatively calm helps you be ready for when they are chaotic. That happened with a school bus accident in my case."

"Doctor Mike?" Nurse Angela called out, "Paramedics three minutes out with a six-year-old choking victim. Use Trauma 2. Nancy will assist."

"Got it! Mary? Tom? Let's go!"

The three of us gowned, gloved, and hurried to the ambulance bay where Nurse Nancy joined us. I assigned tasks, and about a minute later the EMS squad pulled up. Tom jumped out of the cab and called out the vitals.

"Jeremy Lyons; age six; choked while eating; Heimlich maneuver performed when he began turning blue; airway clear; BP 120/70; pulse 88; resps strong; PO₂ 99% on nasal canula; GCS 15 and oriented times three."

"Trauma 2!" I ordered, and we began moving. "Nancy, ABG only."

"No trauma panel?" she asked to confirm.

"Correct."

"Jeremy, I'm doctor Mike and we're going to take good care of you," I said. "How do you feel?"

"OK. My brother squeezed me real hard, and the bread came out!"

"Tom, any LOC?" I asked.

"None reported. We elected to transport out of an abundance of caution."

"Smart. Parents?"

"Right behind us."

"Jeremy, how old is your brother?"

"Twelve."

That was impressive for a twelve-year-old, and that kid deserved some kind of recognition for saving his brother's life.

"Jeremy, do you think you can scoot from the rolling bed to the other bed?"

"Yes."

He did that with Tom ensuring the nasal canula stayed in place. Nancy switched the canula to the hospital system, though in my estimation it probably wasn't necessary. Once that was done, Tom and his partner left the trauma room.

"Jeremy, my friends Mary and Tom are going to put a monitor on you to let us see that your heart is OK, and I'm going to listen with my stethoscope. OK?"

"Yes."

"Tom, let's remove his t-shirt without cutting, please," I said. "It's OK to remove the nasal canula to do that."

Ten minutes later, with blood drawn, the EKG and pulse oximeter attached, and a primary exam performed, I was confident that Jeremy was OK, and instructed Tom to bring his parents in.

"What happened, Jeremy?" I asked.

"I was eating bread, and it got stuck in my throat. I couldn't talk and my brother Jimmy hugged me and squeezed hard and the bread popped out."

"How do you feel?"

"Good! Firemen carried me out of the house and I got to ride in the fire truck!"

"Does anything hurt?"

"Just my arm where the nurse took my blood."

"Mary, you can turn off the EKG and remove the pads," I said. "Leave the pulse oximeter in place for now."

"Yes, Doctor," she said.

"Doctor Mike, Mr. and Mrs. Lyons," Tom said.

"Hi, Mr. and Mrs. Lyons," I said. "Jeremy is fine and you should be able to take him home soon. We just need the results of his blood test, which we should have in the next few minutes."

"I'm OK, Mom!" Jeremy said.

"I hear his brother was the quick thinker," I said.

"Yes," Mr. Lyons said. "He learned that at school last year, along with other first aid."

The door opened and Deputy Leslie Cowan stuck her head in.

"OK to come in, Doc?"

"Yes," I agreed.

"Mr. and Mrs. Lyons," Deputy Cowan said, "I just need to speak to one of you to complete my report. There's nothing wrong, and you aren't in any trouble, I just need some details."

"I'll answer," Mr. Lyons said. "Terry, you stay with Jeremy."

They left and Jeremy's mom asked if it was OK to hug him. I nodded, and she did so, then stayed by the treatment table. The lab called to say the results were ready, and I sent Tom to get them. He was back two minutes later.

"Everything is in range," he said.

I looked over the results and concurred.

"Mrs. Lyons, Jeremy is just fine, and if you'll give me ten minutes to do the paperwork, we'll get you on your way."

I updated the chart, filled out the discharge form, then went to see Doctor Williams, who signed off.

"No followup?" he asked tapping his pen on the discharge form.

"Only if he shows any impairment," I said. "His EKG was textbook, his PO₂ was 99% on room air at the end, his blood gasses were also textbook, and he's awake, alert, and oriented times three. No signs of abuse, and his story fits all the facts."

Doctor Williams laughed, "A simple 'no' would have sufficed."

"Sorry."

"Don't be. I had to ask, or I wouldn't be doing my job, because you're an Intern. For the most part we treat you as if you weren't, but you still do have a lot to learn. And I didn't see your response as defensive, simply factual, which is your way. One thing to learn when reporting is that it's possible to give _too_ much information. I know that sounds strange, but in this case, your med students could have handled it with their training. Save the details for important cases or when you're not sure."

"Yes, Doctor."

"Brent."

"Actually in this case, you're an instructor, not a colleague, so 'Doctor' seemed more appropriate."

"Formality from the guy who goes by 'Doctor Mike' to patients?"

"Totally awesome dude!" I said in a 'surfer voice'. "It's all casual!"

"OK, that might be going a bit TOO far! This isn't Malibu! Get out of here!"

"Right on, Brah!" I smirked.

Brent shook his head and pointed to the door and I left, returning to the trauma room. Mr. Lyons had returned, so I spoke to both parents, basically repeating what I'd said to Doctor Williams, and once Mrs. Lyons helped Jeremy put on his shirt, I did my usual thing.

"What's your favorite candy?" I asked Jeremy.

"Gummy bears!"

And with that, my perfect record was defeated.

"Second favorite?"

"Spree!"

I pulled a roll of Spree from my pack and handed it to him.

"For being a good patient," I said. "But you listen to your mom and dad about when you can have them, and you should probably share with your brother for helping you."

"Awww, do I have too?" he whined.

"No, you don't have to," I said. "But you should."

He gave me a look that said he'd reluctantly share, but that was between him and Jimmy.

"Thanks Doctor," Mrs. Lyons said. "Jeremy, you should say 'thank you'."

"Thank you, Doctor Mike!"

"You're welcome. Mr. and Mrs. Lyons, Tom will take you to Patient Services, and then you're free to take Jeremy home."

They both shook my hand, I said 'goodbye' to Jeremy, and Mary and I left the room.

"First time you didn't have what the kid wanted?" Mary asked.

"I only carry the ten most popular, and in the end, it had to happen. Was it that obvious?"

"You had a brief look on your face as if someone had killed your puppy, but you recovered quickly."

"I was lucky and his second choice was in the top ten. I might have been in real trouble after that!"

"Nah, just offer him a sucker from the jar at the nurses' station and pretend you aren't the 'Kid Whisperer'."

"I won't go down without a fight!" I declared.

"Doctor Mike?" Nurse Angela called out. "Ghost needs you in Trauma 2."

"Thanks! Mary, let's go!"