Chapter 49 — What's the Protocol?

_September 13, 1989, McKinley, Ohio_

{psc} After lunch with Doctor Mertens, I returned to the Free Clinic and my next patient was a sixteen-year-old girl seeking an abortion. Per protocol, I performed a rapid pregnancy test which came back positive, and an ultrasound, which showed a properly developed eight-week fetus.

"You are absolutely pregnant," I confirmed. "Have you considered having the baby and putting him or her up for adoption?"

"I can't have a baby," Tracy, the young woman, said, close to tears. "My parents would freak out! And I'm only sixteen!"

"Have you told the boy?" I inquired.

"We broke up after we…you know. I think he just wanted that and when he got it, he started acting like a jerk."

A story I'd heard a number of times over the years. I didn't understand that behavior because in High School I'd have become a body slave to any girl who'd have gone to bed with me!

"OK," I replied. "I'm going to have you speak with Doctor Turner, who'll perform the procedure. Michelle will wait with you while I speak to him. Give me a few minutes and he'll see you."

"You don't do it?" Tracy asked.

"No. I'm morally opposed to abortion, so I won't perform the procedure, but as a physician, I have an obligation to provide you with the medical care you want and need."

"You're Pro-Life?"

"I am. But I'm not the one who is pregnant at sixteen. It has to be your decision, not mine."

She nodded, and I left the exam room. I walked down the hall to Doctor Turner's office and rapped lightly on the open door.

"What's up, Mike?" he asked.

"Sixteen-year-old prima gravida seeking an abortion. RPT was positive, and ultrasound shows a properly developed eight-week fetus. I asked about adoption, but she rejected the suggestion to consider it, and would like to schedule a procedure."

"As I've said, you're an odd duck, Mike. You can bring her in."

"I have an unwavering duty to my patients," I replied. "My personal concerns cannot interfere with their choices, though, as you know, I won't participate in the procedure."

"As I said, an odd duck."

I nodded, went back to the exam room, then escorted Tracy to see Doctor Turner where I introduced them. Nurse Michell and I stood near the closed door while Doctor Turner counseled Tracy. After about ten minutes of discussion, Doctor Turner scheduled the procedure for the following day and we left his office.

Over the course of the rest of the afternoon I saw seven additional patients with a mix of complaints. At 5:00pm I headed home for dinner with Kris and Rachel, and then the three of us attended Vespers at the Cathedral.

_September 14, 1989, McKinley, Ohio_

On Thursday, Antonne and the other members of the study group came to the hospital to have lunch with me. To make Conchita happy, I retrieved Rachel from daycare and brought her with me to the cafeteria.

"Hi, «amorcita»! Conchita said when I helped Rachel into a booster seat in a chair next to Conchita."

"Hi!" Rachel exclaimed. "Daddy? Hot dog?"

"And fries?" I asked, knowing the answer.

"Yes! Fries!" Rachel exclaimed giddily.

"I take it those are a treat?" Conchita asked.

"Yes, because my darling daughter would live on a diet of hot dogs and French fries if I allowed it."

I bought lunch for Rachel and myself, though I chose healthier options. Rachel could have 'junk' food once a week, but that was the limit. Otherwise, she ate as healthily as Kris and I did.

"How are things going?" I asked the group once I'd sat down with my food and given Rachel hers to eat, because as a 'big girl' she insisted on doing everything she could by herself.

"We're back into the swing of things after the Summer," Antonne replied. "Everyone is in the honors program and while we're only three weeks into the semester, we're on course for straight A's."

"Excellent."

"How are things going for you, Doctor Mike?" Jordan asked.

"Just 'Mike' is fine," I replied. "I'm enjoying the clinical work and hating the politics, which is not news to anyone who knows me."

"That bad?" Julius asked.

"Yes. I'm sure Danika can tell you stories if her dad has shared."

"That's the one thing Dad constantly complains about at home," Danika replied. "He hates hospital politics because they get in the way of excellent patient care."

"Like what?" Conchita asked.

"The Medical Director at Moore Memorial is retiring at the end of the year, and the competition for his job has created more than a bit of trouble."

"For you personally?" Paul inquired.

"Especially me because I'm on the surgical service but assigned to the ED, and the battle for supremacy is between the two department heads — the Chief of Emergency Medicine and the Chief Surgeon."

"Do you have an opinion?" Danika asked.

"I always have opinions," I chuckled. "And expressing them often lands me in hot water! In this case, I'd prefer the Chief Surgeon, who is the odds-on favorite. But I'm doing my best to stay out of the line of fire, though given my position, that's difficult."

"Why is that?" Conchita asked.

"I have two separate hierarchies over me with competing interests and differing opinions. The Chief of Emergency Medicine objects to the 'only surgeons supervise surgeons' rule."

"As if that will ever change!" Danika declared. "Even Dad, as a Senior Attending Cardiologist, is technically supervised by the Chief Surgeon for any invasive procedures, including catheterization."

"I know it's off topic," Jordan said, "but is there any way you can get us into your concert at Shaken Not Stirred?"

I shook my head, "Unfortunately, no. They card hard, and nobody under twenty-one is allowed into the club. The only exception they've made is for band members, and they have to stay on the stage or backstage. They can't be in the club proper. The club was busted about five years ago for underage drinking and they'll lose their license if they do it again. That applies to my wife, too."

"That sucks! Do you have any other gigs?"

"In October, we're playing a club in Newtown, just east of Cincinnati. They allow anyone over eighteen and use a bracelet system to serve drinks."

"How does that work?" Antonne asked.

"They put a color-coded bracelet on each person. The colors are randomized and dated, so you can't try to game the system, and one color allows you to order drinks. If you remove your bracelet, they kick you out, and they're made such that you have to tear them to remove them."

"That seems awfully complicated," Conchita observed.

"The State of Ohio is bound and determined to enforce the concept that young men can be drafted and sent to kill or be killed, but not legally able to have a beer."

"That's just about the dumbest thing I've heard of," Jordan said.

"You'll hear dumber," I replied. "Trust me."

We finished our lunches, I took Rachel back to daycare, then returned to the ED. The afternoon was busy but routine, and my students and I saw a dozen patients. As was typical for Thursdays, I had dinner with Kris and Rachel.

"Daddy? Hot dog?" Rachel asked sweetly.

"You had a hot dog and fries for lunch, young lady. You'll have chicken and steamed carrots."

She crossed her arms and gave me a death stare reminiscent of the ones I'd received from Elizaveta over the years, but I was immune.

"She can be petulant!" Kris observed.

"Just like every other Orthodox woman I know!" I replied with a smile.

Kris rolled her eyes and didn't say anything, which had become her usual response to my quips about Orthodox women. Fortunately, Rachel relented and was willing to eat her chicken, carrots, and dinner roll, washed down with milk. When we finished our meal, Kris took Rachel home, and I returned to the ED.

"Mike, there's a patient asking specifically for you," Trish, one of the triage nurses, said.

"Who?" I asked.

"A Michelle Latham."

I hadn't seen Michelle for well over a year.

"Complaint?"

"She said she'd only speak to you. Do you want me to insist?"

I wondered how she'd known I was at the hospital, given the last time I'd seen her was when I was a medical student, but in the end, it didn't matter. She might have simply asked for me, knowing I'd be a doctor by now.

"No," I replied, "just prepare a blank chart with her name and I'll see her. Both my evening students are male, so let me ask Becky to bring her in."

I found Becky in Exam 3 and asked if she was available. She was, so I asked her to bring Michelle in and meet me in Exam 6. I'd have done that myself, but the new protocol had doctors not going to the waiting room except in the case of a true medical emergency. I waited for Becky to escort Michelle in, then went into Exam 6.

"Hi, Michelle," I said.

"Hi, Mike. Or Doctor, uhm, I forget your last name."

"It's Loucks, but I go by Doctor Mike, and it's OK to just call me Mike as we knew each other before I received my MD. What brings you in today?"

"Can we talk alone?"

I shook my head, "No. Hospital policy mandates that I have a female staff member or student in the room at all times when I treat a female patient. There are no exceptions to that policy."

She frowned, but there wasn't really anything I could do about it, as violating that policy could not be defended, and the last thing I wanted to do was give Doctor Northrop any additional ammunition.

"I'm, uhm, afraid I might have AIDS."

"Why do you think that?" I asked, skeptical that was actually true, though knowing it was possible.

"I'm tired all the time, I have a fever, and the glands in my neck are swollen."

"Those symptoms could be caused by any number of things," I said reassuringly. "Let me ask you a few questions. First, are you or anyone you've had sex with an IV drug user?"

"Besides you, I've only been with Toby, and he doesn't do drugs."

I saw Becky smirk out of the corner of my eye, but I had to simply go with the flow.

"And he's not bisexual?"

"No."

"Have either of you had a blood transfusion?"

"I haven't, and I don't think he has 'cause he said he's never been in the hospital."

"Do you have a sore throat, or did you have one recently?"

"Last week, but it mostly went away.

"OK. I need to do an exam, get your medical history, and run some tests, but it's far more likely you have infectious mononucleosis, or 'mono', than AIDS. I mean, a thousand times more likely. And it might not be that, either."

I performed my exam, noting pharyngitis and enlarged tonsils, then palpated her neck, noting enlarged lymph nodes, all of which were signs of mononucleosis.

"Becky, let's draw for a CBC, a heterophile antibody test, a throat culture, and a full-spectrum STD panel, please."

Becky drew the blood and called for a student nurse to take the vials to the lab.

"The test for mono takes about a day," I said. "We'll have the other results in about an hour. Has Toby had any symptoms?"

"He says he's tired, but that's it."

"I'm going to recommend that he go to the McKinley Free Clinic and have a mono test, and he should do that right away. Or you can send him here."

"He's in the waiting room."

"OK. Hang tight."

I left the room and went to the door of the waiting room, saw the nerdy guy I vaguely remembered, called him in, and escorted him to Exam 6. I explained the situation, and he consented to an exam.

"Becky, would you start a second chart, please? Then draw blood for identical tests for Toby?"

"Right away, Doctor," she replied.

She did as I asked, then I performed the same exams on Toby I had on Michelle, though the only symptom I noted for him was mild pharyngitis.

"At this point, I think you can both go back to campus," I said. "I'll receive the results of the throat culture and mono test late tomorrow afternoon, and I'll call you with the results."

"What prescription?" Toby asked.

I shook my head, "It's a virus, so antibiotics wouldn't have any effect, and there is no vaccine. You can use Tylenol or Advil, or generic acetaminophen or ibuprofen, for fever and discomfort, but the only cure is time. You should both rest, drink plenty of fluids, take Tylenol or Advil for pain, and refrain from kissing or any other activity that would share saliva, including oral sex, drinking from the same glass, or sharing a toothbrush."

"No antibiotics?" Michelle asked. "Really?"

"Really. They simply don't work against viral infections. If your throat cultures happen to be positive, then we'll prescribe antibiotics, because that would mean strep, rather than mono, though I think that's unlikely. Let me complete the charts, fill out the discharge forms, and you can go. We'll give you a pamphlet that explains everything, and if any of your friends have similar symptoms, they should go to the Free Clinic or come here for an exam. You should both see a primary care physician, a GP, as well. If you don't have one, we can provide you with a referral."

Fifteen minutes later, they were discharged and left the room.

Becky raised her eyebrow and smirked, "It appears you had fun with that one!"

"I don't kiss and tell, Mom!" I replied with a grin.

"She already told! And we agreed 'older sister'!"

"You're the one who brought up the late 50s!"

"Me and my big mouth!" Becky said with a soft laugh. "And I say you had fun!"

"Whatever!" I chuckled. "It was eighteen months ago, and before I remarried."

"I suppose you could say that 'The Doctor Is In'! ALL the way in!"

I laughed hard, "I didn't charge her 5¢!"

"I think the early 80s were WAY more fun than the late 50s!"

"Not to hear my mom tell it," I chuckled. "This conversation is entertaining, but I do need to see if there are other walk-ins."

"You realize I'm just teasing you, right?" Becky asked.

"Yes, of course! I have a very good sense of humor and I didn't take it in any way, but humorous. I'm not upset in any way, shape, or form. That said, it does have the chance of going beyond what is wise, so I chose to extricate myself before I said something that might actually get me into trouble!"

Becky nodded, and we left the room. I asked Al to bring in the next patient. The remaining ninety minutes was busy, and I saw five patients before I left for home at 9:00pm.

_September 15, 1989, McKinley, Ohio_

"We need to speak privately," Kellie said when she arrived in the ED just before 6:00am on Friday.

"About?" I asked.

"Privately," Kellie insisted.

"Exam 3 is open," I suggested.

We went to Exam 3, and Kellie shut the door behind us.

"What's up?" I asked.

"Rumor has it that you went to bat for Krista Sandberg," Kellie said.

"I did, though I have to ask who's talking."

"Krista is telling people she has a guardian angel."

Which went against what I had advised Krista to do and made me suspicious.

"Drop the other shoe, Kellie," I requested.

"She's sleeping with a pair of doctors."

"I'm aware of that," I replied. "There's no rule against it, despite the objections I've voiced, so I'm not sure it matters. Ongoing?"

"Yes, and one of them is on our service. I have to tell you something important that you need to know — she wanted _you_, but Becky warned her off, saying you would not respond well."

"That's an understatement if there ever was one. Attending or Resident?"

"Resident."

"Well, she's mostly been assigned to me, Kylie Baxter, Kayla Billings, or Paul Lincoln. I'm positive it's not any of those three, and it's not me, so it's not someone who is evaluating her.

"How do you know it's not Paul?"

"Don't ask that question," I replied.

"Got it," Kellie said with a knowing look. "I won't say anything."

"There is a problem, though," I said. "Krista told me both 'flings' as she called them, were short-lived."

"They're ongoing, as I said. And there were others. It's Doctor Schmidt."

"If that's true," I replied, "then she lied to me about several things. She said it was two, that they were over, and neither of them were married. Schmidt is married, and you say the affair is ongoing, and that there were more than two. That presents a huge problem, because if she's lying to me about that, she could be lying about anything.

"The thing is, a medical student having a relationship with a doctor is not against the rules, even though it ought to be. As far as I can tell, there does not appear to be an appetite to change the policy, which means there isn't much I can do about it. What I can do something about is the lies. And that means I need to confront her, but I can't do it by myself. I need to think about the best way to handle it."

"Just be careful."

"As I said to Shelly Lindsay, I will be careful and only act after I speak to her, that is, Shelly. Thanks for the heads up."

"You're welcome, Mike."

We left the exam room, and I contemplated what I should do. While I took issue with Krista's behavior with doctors, my real concern was that she'd lied to me. Fortunately, I wouldn't see her before Monday morning, so I had some time to think about how best to proceed.

I had a fairly busy morning, though it was all routine, then joined Clarissa for lunch.

"Kellie believes Krista is lying about her relationships," I said when we sat down at a table for two, away from the other Residents.

"Marvelous," Clarissa said, her voice dripping with sarcasm. "What did she say?"

"That Krista is currently involved with two doctors, and one of them is a Resident in the ED. And she's had other relationships with doctors in the past."

"Oh, that's just fucking peachy! Now what?"

"I'm not sure, though it can't be about the relationships; it has to be about lying."

"I agree. You can't try to paint her as immoral, and she's not violating policy; well, unless YOU are the ED Resident she's sleeping with."

"I'd sleep with Mastriano before I'd sleep with Krista Sandberg."

"Interesting!"

"And you know there is zero chance I'd do that, too. There's only one person in this entire hospital I'd want to sleep with!"

"Ellie!" Clarissa smirked.

"Yeah, not happening! And before your mind races too far into the gutter, it's YOU!"

"Obviously. I know being lied to is a major problem, but is it any of your business?"

"If it affects her training, it is. That said, if she had said it was none of my business, I'd have left it. She volunteered the information after expressing offense that I'd even ask. And now it makes sense that she demurred when I suggested not being involved with anyone at the hospital."

"I think you're walking a tightrope between two skyscrapers, Petrovich. One false step and you're dead."

"I think, after having a few hours to ponder it, the best course of action is to let her know that I know, and basically put her on notice that I'm aware she lied, and if I ever catch her in a lie, she'll be before the ethics committee so fast it'll make her head spin. I'd already intended to grade her tough, and she did herself no favors by lying to me, which I believe she did."

"I think Leila Javadi's advice to not be alone with Krista still applies."

"With very few exceptions, I keep that rule. The exceptions are you, Kylie, Kellie, and any doctors, if I need a private conversation."

"I bet Kellie is a lot of fun!"

I chuckled, "I have no doubt, but I'll never find out first-hand."

"Obviously. Back to Krista, I think your heart was in the right place, but I hope you learned a lesson."

"Defending the weak, the downtrodden, and mistreated is never an error," I replied.

"I know you strive to follow the Christian ideal, but at some point, you have to guard your own reputation."

"But not at the cost of who I am. The only thing I objected to was Krista not receiving adequate training, and Doctor Northrup acknowledged that, though he did so half-heartedly. I'm not going into this with my eyes shut, but Krista should pass or fail based on her own skills and abilities, not due to a doctor being upset that she wouldn't put out."

"I understand your point, and I'm going to repeat my admonition to be careful."

"I will. See you and Tessa for dinner tonight?"

"Yes. I miss the larger group going out, but everyone's schedules are such a mess, and I know you want to spend time with Rachel. José and Sierra will join us, right?"

"Yes."

We finished our lunches, and I headed back to the ED. Just after 2:00pm, I received the results of Michelle's and Toby's tests, and they were positive for infectious mononucleosis. I called the number Michelle had left, and left a message for her to call me back, which she did just after 3:00pm. I relayed the news, and reminded her to see her regular physician, as well as get plenty of rest and not engage in any activities which might share bodily fluids.

I had checked the M & M schedule, and there wasn't a truly interesting case, nor was the lecture important enough for me to ask for time off in the ED. As Fridays were one of my short days, I left the ED at 5:00pm, picked up Rachel from daycare, and we went out to my car. We headed home by way of the Chinese restaurant to pick up dinner, and at 6:00pm, our friends joined us and we sat down to eat right away.

"Still on to practice on Sunday?" José asked.

"That really is the only time we have," I replied. "Rachel will visit her grandmother and cousins while we're practicing."

"How are you and Kris going to handle the fact Kris has to stay backstage?"

"She'll just hang out backstage with Kari for a short time so I can circulate."

"Those rules are SO stupid!" Sierra declared. "I'm not even allowed backstage because I'm only twenty and not part of the band!"

"At least next year, you'll be allowed in," Kris said. "It's more than two years before I can go into the bar area."

"Europe is far saner on their alcohol laws," I said.

"On most things!" Kris declared.

"If you'll pardon the change of subjects, I have some news," Tessa said. "I have a final interview on Tuesday to be Assistant Director for the 9-1-1 Dispatch Center for Columbus."

"Congratulations!" I declared. "You kept it quiet!"

"I wanted to wait to see if I made the final round, and when I did, they said I was the leading candidate. I'm meeting the Chief of Police and the Fire Chief and the Chief Paramedic. If they approve, I have the job."

"I take it you'll move?"

"Close to you, most likely," Clarissa interjected. "We'd have the same situation you and Kris have with Columbus and the hospital."

"Congratulations, Tessa," José said. "That's a big step up, right?"

"Yes. I'm the most senior shift supervisor in our center, and this role is over the whole center. The only downside is the Assistant works mostly evening and night shifts. The upside, of course, is that I'll have a great shot at the Director's job when he decides to retire."

"Mike, would you get a bottle of California sparkling wine, please?" Kris requested.

"They do call it champagne," I chuckled. "But that would offend you, wouldn't it?"

"Yes!" Kris declared. "And get a bottle of sparkling grape juice for you and Clarissa, please."

I got up and went to the basement and got the two bottles. I had never regularly kept alcohol in my house, with the exception of a bottle of vodka, but having married Kris, we'd adopted a more French attitude, and we had what she termed a 'small wine cellar'. Of course, I could rarely imbibe, and with my current schedule, I had to abstain completely. I retrieved the bottles, brought them up to the kitchen, opened them, and put them on a tray with six glasses. I carried that to the dining room table and poured for everyone.

"What about Rachel?" Kris asked.

"I think she could have some sparkling grape juice," I said. "I wouldn't give her alcohol at this point."

"That is what I meant! When I was seven, my parents began giving me watered-down wine, about one part wine of three. I didn't have it straight until age twelve. And, of course, only a very small amount."

"OK. Let me get a clean sippy cup for her."

I did that and poured some of the white sparkling grape juice. I made a toast to Tessa, and then we all drank. I watched closely as Rachel sipped her cup and laughed when she made a face and dropped the cup on the floor.

"Well, that received a negative review," I chuckled. "Have you or Lyusha given her pop?"

"I haven't, and I don't think my sister would without asking first. Rachel has had chocolate, strawberry, and vanilla shakes."

"Shake!" Rachel declared giddily.

"Now look what you've done," I said with a grin. "Rachel, no shake today."

She pouted, but went back to eating her chicken. We finished our meal, then José and I cleaned up while the women and Rachel went to the great room. When we finished, Sierra put in a tape of _Light of Day_, starring Michael J. Fox and Joan Jett. At best, it was passable, though the soundtrack was pretty good. Michael J. Fox didn't work well for me in a serious role, because I saw him as Alex P. Keaton or Marty McFly, and the others agreed.

Our friends left when the movie finished, and Kris, Rachel, and I said our evening prayers, and then we put Rachel to bed. Kris and I went to bed right away, as I had to be at the hospital at 5:00am.

_September 16, 1989, McKinley, Ohio_

"What's up with you and Loretta?" Ghost asked when I walked into the lounge on Saturday morning.

"What did she tell you?" I asked.

"That you reacted badly to what amounted to mild correction."

"That is a serious mischaracterization of the conversation. But that's not the real problem. The real problem is basically being thrown under the bus."

"Loretta? No way."

"All she had to do was say the same thing to Doctor Northrup she's said to me on a number of occasions. She declined to do that and declined to back me. On the other hand, Doctors Lindsay, Roth, and Cutter did."

"I find that hard to believe," Ghost protested.

"Believe it, because it's true. Ask her."

"You need to find a way to patch things up with her."

"I don't have a problem working with her or taking clinical direction from her."

"You toss away a friendship so lightly?" Ghost asked.

"If a friend betrays you, can you simply continue as if nothing had happened?"

"What about forgiveness?"

"That requires «metanoia». When I tried to speak to her about it, she deflected and refused to engage on the substance, focusing on what she felt was my bad reaction to Doctor Northrup telling me not to speak my mind. That same statement from him, with Doctor Gibbs backing me up, would have been water off a duck's back."

"She said you refused to discuss it."

"Only after she refused to admit, even off the record, that she agreed with me. Something she'd done on several occasions in the past."

"Ghost?" Nurse Angela called from the door. "Paramedics are five minutes out with a beating victim."

"OK. Mike, we'll continue later."

"OK," I replied.

He left, and I got a cup of coffee. It was eerily quiet for the next ninety minutes, with only one walk-in handled by Doctor Varma. I handed off two patients who had been admitted overnight to Internal Medicine, read journals, and generally relaxed. Finally, just before 9:00am, I had my first new patient.

"What brings you in today, Detective Kleist?"

"You and your gorgeous eyes," she replied.

"Heather," I said, "what was Detective Kleist's complaint on presentation?"

"Tenderness and loss of motion in her right knee," Heather replied.

"When did that begin?" I asked.

"Upon waking this morning," Heather replied.

"What am I, invisible Doc?" Detective Kleist asked.

"No," I replied. "But I did need to know why you're here; medically I mean. How did you injure your knee?"

"I twisted it slightly last night during an arrest," she replied. "I kind of felt a pop, but it seemed fine other than being a little sore. I went to bed, and I woke up around 5:00am and it hurt like hell, and when I tried to walk, it was difficult."

"OK. I'll need to examine your knees," I said. "We'll step out and you can remove your sweat pants."

"I can undress in front of you, Doc!" Detective Kleist said.

"It's standard practice for medical staff to leave the room when a patient removes their clothing, unless the patient needs help, in which case a nurse would assist, or if it's a medical emergency."

"You're joking!"

"No, I'm not. We'll step out and come back in about two minutes."

Heather, Jake, and I stepped into the corridor.

"Let's not be TOO obvious!" Heather declared _sotto voce_ once the door had closed.

"What's the protocol for something like this?" Jake asked.

"You start the way I did — ignore the obvious flirting as if it hadn't happened. If the patient persists, you make a general comment, such as I did, about sticking to medical topics. If they persist, then you have to decide if you're comfortable treating the patient, or want to send in another physician."

"You're going to examine her?" Heather asked.

"Actually, you are, with me supervising. What's the differential for a knee pop, late pain onset, and reduced range of motion?"

"ACL injury."

"Good. What examination techniques would you use?"

"I don't know, and the way you asked that rules out an x-ray."

"First, you do a gross exam and compare the knees; the injured one will probably show some swelling. There are three main physical tests to perform — the Lachman test, a pivot-shift test, and an anterior drawer test. I'll walk you through them."

"Is she going to accept that?" Jake asked.

"We're a teaching hospital," I replied. "If she objects, then I'll call an Attending, which in this case is Doctor Mastriano, and she'll take the patient with help from her Fourth Year."

"That's something I wondered about," Heather interjected. "Why do Attendings only have Fourth Years?"

"Until last year, Attendings didn't have medical students at all, so to accommodate more Sub-Internships, they assigned Fourth Years who plan to Match for Trauma to Attendings. Let's go back in."

We stepped into the room and Detective Kleist was sitting on the exam table with her sweatpants next to her.

"Detective," I said, "We're a teaching hospital, so Heather, who's a medical student, will perform the physical exam under my supervision."

"Seriously, Doc?" Detective Kleist asked.

"That is a normal practice for routine cases," I replied. "That's why Jake and Heather brought you in and took your vitals. If you object, I can call Doctor Mastriano, but I really do need to teach my students."

"Go ahead."

"Heather, the first and most reliable test is the Lachman test. It's done with the patient supine. You flex the knee at about fifteen degrees, then place one hand behind the tibia and the other holding Detective Kleist's thigh, making sure your thumb is on the tibial tuberosity. Pull the tibia forward, and if the ACL is intact, there should be no forward translational movement. If, on the other hand, there is no firm resistance, and it feels 'mushy', that's a positive test. You then do the same with the 'good' knee to ensure there isn't some hereditary physiological anomaly. Go ahead."

With some additional guidance, Heather successfully performed the test, which was positive. Even so, I walked Heather through the other two tests, with the same results.

"It appears you have a Grade 3 injury to your anterior cruciate ligament, or in sports broadcaster terms, a torn ACL. The initial treatment is a knee brace, along with physical therapy. The physical therapist will evaluate you and recommend a course of treatment which might include arthroscopic repair. That said, a significant portion of this type of injury heals on its own."

"Is this something that will keep me off the job?"

"I'd avoid putting weight on it as much as possible until you see a physical therapist. I'll write you a referral, and Heather will take you to the Outpatient Center in a wheelchair. They'll set you up with an appointment and go over all the details with you. I'd strongly recommend waiting for that evaluation, but if you absolutely have to go to work, you could do so wearing the knee brace and use ibuprofen or acetaminophen to reduce the pain."

"I have some sick time."

"I'd suggest using it," I replied. "At least until you're evaluated for surgery."

"You can't do that?"

"I'm a trauma surgeon," I replied. "You just heard my entire knowledge with regard to knee injuries! We'll step out so you can dress. Do you need help?"

"No, I think I can pull on my sweats and my slippers."

"OK. Oh, before you go, can you tell me how Detective Townshend was shot? With my schedule, I don't get a chance to read the paper or see the news every day."

"He was serving an arrest warrant," she said. "Everything seemed OK, the suspect was being taken into custody peacefully, then the suspect's brother comes into the room and fires three shots, two hitting Bill, and the other going wide. Louise took the shooter down with two shots in his x-ring. DOA."

"What the hell?" Jake asked.

"You got me," Detective Kleist said. "It was for what they used to call statutory rape — a willing fifteen-year-old. He'd likely have only received probation on a plea. Now, he's in serious shit, even though the brother did the shooting. I doubt we'll ever know the full story, given the brother is in the County Morgue."

"Thanks, Detective," I said.

We stepped out, and then two minutes later, went back in. Jake and Heather helped Detective Kleist into the wheelchair.

"Thanks, Doc. I owe you a beer or two."

"You're welcome," I replied. "Good luck with your recovery."

Heather pushed the wheelchair from the room and I filled out the chart, then turned it into Nate, who updated the computer records. I was, despite my historical distaste for computers, looking forward to the new system we'd have when the new ED opened. I'd read some literature on the software from Epic Systems, which was based in Madison, Wisconsin, and it looked promising. Being able to easily look up patient records would be a huge benefit, though the telemetry beds were even more of a benefit.

"Doctor Mike?" Heather said when she returned from the Outpatient Cervices. "I have a question."

"What's that?"

"How do you remember everything without even pausing to think?"

"You know those flashcards you've seen me with? That's how. I still review some every day, and I'd say I'm working through the set of 3000 for the hundredth time in four years. Some more. It's the only way. Let me sign your procedure book, then go sit down and write out what you did. Bring it to me to review, and then when you go home, make flashcards for the anatomy, the diagnostic techniques, and the treatment. You, too, Jake."

Heather took out her procedure book, wrote in a brief description of what she'd done and I signed her book.

"Mike?" Nate called out. "EMS three minutes out with an MI."

"Game time!" I said to Jake and Heather. "The notes will have to wait."

She put her procedure book back into the pocket of her lab coat, we put on gowns and gloves, and headed to the ambulance bay to receive the patient.