Chapter 40 — Waving the White Flag

_August 23, 1989, Columbus, Ohio_

{psc} Tom Kirkland smiled, then turned, "Sure, Arthur."

They walked away and went into a room.

"White flag," Lara said. "They're going to offer some kind of agreement equivalent to a plea bargain."

"You think?" I asked.

"There's no other reason for Greenberg's counsel to speak to mine. Just wait."

About five minutes later, they emerged from the room, and Mr. Kirkland asked Lara and Angie's parents to join him, which they did.

"Not you?" Clarissa asked.

"I'm not party to the suit, even if I'm pulling the strings, so to speak. We did that on purpose.

About two minutes later, Lara came out and walked over.

"Greenberg will accept a ninety-day non-prejudicial suspension. Tom Kirkland thinks he's looking at a year if we go to the end of the hearing, but, as he warns, we can never be sure how the board will vote. They could let him off the hook completely, or with a reprimand."

"What do the Stephens think?" I asked.

"Same as me — it's up to you."

"What does 'non-prejudicial' mean?"

"He gets his license back automatically. If the board imposes a suspension, it can be either prejudicial, which means he has to apply for reinstatement, or non-prejudicial, which means he only has to refrain from seeing patients for ninety days, then can resume. Tom doesn't think they'd give him a prejudicial suspension based on a single incident with this fact pattern."

"Take it," I said. "We thought he might not even receive a reprimand when we started."

"OK. I'll right back."

She walked away, leaving me alone with Clarissa.

"That was wise," Clarissa observed.

"I achieved my goal," I said. "He paid a settlement to the Stephens for Angela's future care in the malpractice suit, and he's admitting an error before the State Medical Board."

"Lara didn't say he was admitting error," Clarissa objected.

"No, but by accepting the suspension, he has to admit the allegations were true. I'm sure he'll be permitted to make some kind of statement, and he'll admit that, in hindsight, he made an error in judgment. That will satisfy everyone. Heck, that admission without a suspension would be enough for me."

"That was what you insisted Doctor Mercer do."

I nodded, "Admit your error, learn from it, and move on. Call it medical «metanoia». Which, by the way, is the point of our M & M conferences. Identify the error, learn from it, and move on. Nothing developed or said in those conferences can be used in any way, shape, or form against the treating physician. They're almost as sacrosanct as the confessional, and hence, the parallel I drew by using «metanoia»."

"An interesting parallel" Clarissa declared. "I hadn't considered, but then again, I haven't been immersed in Orthodox Christianity from my first breath."

Lara and the Stephens returned, and Mr. Braun went into the room where Tom Kirkland had remained. They emerged two minutes later and went back into the hearing room. We followed them and took our seats. About five minutes later, the Chairman reconvened the meeting.

"Mr. Chairman," Arthur Braun said. "My client will accept, and the complainant will not object to, a ninety-day non-prejudicial suspension."

"Will Doctor Greenberg be sworn and admit to the complaint?"

"Again, with agreement from the complainant, he will admit to an error in judgment based on a negative outcome."

The Chairman turned off the mics and conferred with his colleagues, and by their nods and facial expressions, I knew the answer before he announced it.

"The Board will accept your offer. Doctor Greenberg, come forward, please."

He did and was sworn in.

"Members of the Committee," Doctor Greenberg said, "after carefully considering my actions and the negative outcome in this case, I admit that I made an error in judgment in my choice of treatment methods for Angela Stephens. I did not assign sufficient weight to her observed behavior, which led me to follow the usual standard of care, which turned out, in this case, to not be appropriate. I apologize to Angie, her parents, her friends, and this Board, and will accept a ninety-day suspension. Thank you."

"Thank you, Doctor Greenberg," Doctor Brewer said. "Your license is suspended as of this moment, and will automatically be reinstated on the ninety-first calendar day from today. You are prohibited from practicing medicine in any form, and from having any contact with your patients. You're instructed to turn over their care temporarily to another licensed physician. You may, of course, discuss the cases with this physician, but treatment decisions are up to them. Any violation will result in an immediate, indeterminate, prejudicial suspension and you would be referred to the local prosecutor for practicing medicine without a license. Do you understand?"

"I do," Doctor Greenberg said.

"You'll receive a letter outlining what I've just said. Do you have any questions?"

"No."

"Then this hearing is adjourned."

He banged the gavel and everyone left the hearing room.

"Mike?" Doctor Mercer called out.

I stopped and walked back to her.

"Should I call you 'Doctor Loucks'?"

"Mike is fine," I replied. "I go by Doctor Mike professionally, but colleagues call me Mike."

"And I'm a colleague?"

"I don't hold grudges," I replied.

"Now that this is behind us, I'd like to restore our relationship, if you think it's possible."

"Doctor Paulus really got on your case, didn't she?"

"Not just about this," Doctor Mercer admitted.

"Kitten?"

"Yes. I'm not surprised you knew that."

"Elizaveta being sixteen was a hobby horse you wanted to ride into the sunset," I said.

"I think you're mixing your metaphors!" Doctor Mercer countered.

"Could be, but it fits," I replied with a smile.

"Call me in the next few weeks; I'd like to get together and catch up."

"I will. And thank you."

"You're welcome."

"Dinner?" Lara asked after Doctor Mercer had walked away.

"I don't think I should. I need to rescue my daughter from her crazy French aunt, then meet Kris at home so we can have dinner and go to Vespers at the Cathedral. We'll see you and Nathan on Sunday for Rachel's birthday party."

"Crazy French aunt?"

"My fifteen-year-old sister-in-law, who is teaching my daughter French and otherwise being a serious troublemaker!"

Both Clarissa and Lara laughed, we hugged, and after speaking briefly to the Stephens, I went over to Mr. Kirkland and thanked him. After shaking his hand, I hurried to my car for the drive to the Korolyovs' house.

_August 24, 1989, McKinley, Ohio_

"How did it go yesterday?" Doctor Gibbs asked when I arrived in the ED on Thursday morning.

"Ninety-day non-prejudicial suspension with an admission of an error in judgment."

"Wow! What happened?"

"Doctor Greenberg and his counsel felt the risk of a longer suspension was too great after the Chairman ruled in our favor on some key issues. Lawson and Forth were there, but in the end, they couldn't testify."

"What could they have testified to?"

"That in the course of my psych rotations, I had admitted that no doctor should be punished for a judgment call on treatment. But the Board refused to allow that testimony because they didn't want to set a precedent that might deter med students from asking questions or giving their opinions. They limited all testimony by me or about me to my relationship with Angie and her observed behavior."

"So the rumors that Lawson was gunning for you were true."

"They weren't rumors," I replied. "He actually threatened me, but in a way that had plausible deniability. Ultimately, though, he was boxed in by information I had about him failing to Match for surgery despite applying to eight programs and having to Scramble for psych, and that his hospital in Detroit wouldn't hire him as an Attending.

"Add in the fact that he actually called you for me to make a consult as a med student, and allowed me to do intakes as a Third Year, and he had nothing. The Board did hear about 'Mr. Alien Encounter' and the Chairman said I hadn't violated any principles of emergency medicine, so even that was defanged. In the end, rather than take the risk, and have Lawson publicly exposed as being driven by personal animosity, they chose the least risky course of action."

"I think I'd avoid Lawson and Forth for a while."

"I certainly won't go out of my way to see them, and consults are always Fourth Years or Residents. And it's not like there's any love lost between Psych and the ED. And I had support from the surgical team."

"I'm not surprised. How is Krista doing?"

"Average work," I replied. "I'd rate her a three at this point, up from a two. She has a Medicine Sub-I next, so they'll make or break her, as that's her choice for the Match. If she survives that, she'll have her surgical Sub-I, and you know how that works for Fourth Years. It's sink or swim."

"Which will she do?"

"Scrape by, unless she picks up the pace. There's no way she'll Match here, because Shelly Lindsay and Owen Roth will see the same things I have in her procedure book and her attitude. She was smart enough to stop being bitchy around me, but Libby reported that she has a bad attitude at the triage desk."

"Every med student does!"

"Not every."

"OK, not the one who might actually be the alien that 'Mr. Alien Encounter' was concerned about!"

"Which would explain my approach to treating him, now wouldn't it?" I asked with a grin.

Doctor Gibbs laughed, "Hiding in plain sight!"

There was a knock at the door and Ellie opened it and stuck her head in.

"Multi-victim MVA," she said. "At least three victims. First one three minutes out."

"What's free?" Doctor Gibbs asked.

"Trauma 1, 2 and 4," Ellie replied.

"Let's go, Mike. Ellie, ask Doctor Varma to join us and we'll need nurses."

"Already assigned. You have Wendy and Jamie, Mike has Kellie, and Naveen has Angela."

"If there's a fourth victim, give them to Ghost; Ron will have to handle walk-ins."

"Got it!"

I went to the lounge to get my students, and we gowned, gloved, and met the team in the ambulance bay to await the paramedics.

"I'll take the first, Mike the second, Naveen, the third," Doctor Gibbs directed.

Two EMS squads turned into the driveway, then pulled up in front of us. I focused on the second patient, who was being bagged by a firefighter.

"Female, late twenties; unbelted passenger; crush injuries to the chest; fractured arm; forehead lac and contusion; tachy at 120; BP 70 palp; PO₂ 92%; difficult to bag; LOC on site, IV saline TKO; cervical collar and backboard."

That PO₂ was sufficient that I felt I could give Krista her shot at intubation, but only one shot.

"Trauma 2!" I ordered. "Al, monitor then Foley; Krista, bag and I'll walk you through an intubation; Kellie, hang a unit of plasma, type and cross match, CBC, and rapid pregnancy test!"

"EKG?" Al asked.

"Let's see what we have first!"

We quickly moved the gurney, and I called out to Ellie for another nurse, and she came into the room herself. With concerted effort, we moved the patient to the trauma table.

"Ellie, 24 French and intubation tray to Krista!" I ordered.

I saw the questioning look in her eyes, and I didn't disagree, but I had to give Krista the chance. I began my primary exam by auscultation, and immediately found decreased breath sounds from the left lung.

"Tension pneumo! Ellie, I'll need a chest tube tray. Krista, hold off on intubation until I get the tube in, but keep bagging."

"PO₂ 90%, pulse 130, BP 60/20!" Al announced as he moved to insert the Foley catheter.

"She's bleeding internally," I said. "But we need to get the lung re-inflated first."

I slung my stethoscope around my neck and began the thoracostomy necessary for the chest tube. As soon as I cut through the subcutaneous tissue muscle, a gush of blood ran out and the patient's BP bottomed out.

"Ellie, two units on the rapid infuser!" I ordered.

I got the chest tube in and sewed it in place, but didn't worry about taping it.

"Easier to bag?" I asked Krista?

"Yes."

"Where's that blood?" I asked.

"Large bore in," Ellie announced. "Units running in now!"

The patient's BP came up a bit, so I could move on.

"Al, five-lead," I ordered as I cleared the patient's C-spine so I could remove the cervical collar.

"Krista," I said as moved to examine the patient's abdomen, "stop bagging and put the patient in the 'sniffing position'."

"What?" she asked.

That meant she hadn't read the textbook, and it was my fault for not checking first.

"I'll need to do it," I said. "Get me a portable ultrasound, please. We'll discuss after."

She moved, and I quickly inserted the tube, had Ellie bag, and listened. Once I heard good breath sounds," I instructed Ellie to hook up the ventilator.

"Need help?" Ghost asked, coming in.

"I won't turn it down," I said. "Chest tube and vent, about to check the belly. Neuro survey, please."

"Got it."

"Al," I said. "Call upstairs; I'm positive she's surgical. Tell them sinus tach; needs an ex-lap; flail chest; blood in her urine; lost 400ccs during thoracostomy; three units in."

"Sinus tach; ex-lap; flail chest; blood in the urine; lost 400ccs during thoracostomy; three units in," he repeated.

Krista, who was obviously unhappy, pushed the ultrasound in and two minutes later, I confirmed what I had already known.

"Fluid in Morrison's; likely splenic lac; possible liver lac. Let's move! Ellie, portable vent; Kellie, disconnect the EKG and monitor. Al, get a gurney!"

Everyone did as instructed and we transferred the young woman to the gurney and quickly made our way towards the elevator, following right behind Doctor Gibbs and her patient. That meant that at least one scheduled surgery was going to be pushed, if not both, and I was going to get to scrub in.

"Al, stay with the patient; Krista with me up the stairs so they can share the elevator."

Three minutes later, we wheeled our patient into OR 3, where Doctor Burke was waiting with a Resident, three nurses, and a student. I called out the information as we moved the patient to the surgical table.

"Mike, scrub in," he said. "Your Fourth Year can observe."

I'd have strongly preferred keeping Al as he intended to Match for surgery, but there was no reasonable way to make that substitution once Doctor Burke had made his decision.

"Al, go back downstairs and see Ghost," I said. "Krista, with me!"

We went to the scrub room, completed the process with the help of Millie, the scrub nurse, then, with my usual black surgical cap in place, returned to the OR.

"Mike, you're the third surgeon. Stand next to Rob to assist."

I acknowledged and moved, holding retractors, and suctioning as necessary, but mostly watching them work, which was typical for any Resident before PGY3. It took the best part of two hours to repair the abdominal injuries as well as the bleeder in her chest that had resulted in the blood loss during the thoracostomy. When the surgeons had closed the incisions, Krista and I were excused and the patient was taken to recovery, and would certainly go to the ICU and need attention from Ortho.

"Why didn't you let me intubate?" Krista asked as we entered the stairwell. "You said you'd talk me through it!"

"Let's wait until we're someplace more private," I said.

She was quiet, and I led her to the temporary Resident's office, but kept the door open.

"You didn't know the 'sniffing position'," I said. "That indicates you don't know the textbook steps, which is a prerequisite. I should have asked beforehand, but as a Fourth Year, you should have taken the initiative to learn. And that's particularly true given what happened with the EKGs. That alone should have clued you in."

"Oh, right! Like I'm supposed to magically know what I need to know and study?"

"The first thing I and my study group members did when we were starting a new rotation was find out what the standard procedures for that rotation were, and read the relevant textbook material. It's all in there, and if you read the optional material, which you should have known to do after I asked about Doctor Osler, it's all in there."

"You're not being fair!" she protested.

I wanted to say that life wasn't fair, and list Elizaveta, Lee, and Sandy as primary examples, not to mention the young patients who had died in my presence over the previous two years.

"Your lack of initiative, even when prompted, is the cause of your current complaint, not anything I've done."

"How can I learn, if you won't teach me?!"

"How can I teach you, if you won't learn?" I countered.

"What?! How can you say that?"

"Because your medical training is your responsibility. My job is to teach you, your job is to learn. But learning isn't limited to your shifts in the hospital. It means studying anatomy, studying your textbooks, and being proactive. I shouldn't have had to tell you to learn to read an EKG, you should have read your textbook _before_ your cardiology rotation and then asked Doctor Javadi to teach you further."

"I didn't know."

"Let's assume that's the case. I gave you an assignment to learn, then quizzed you. From that, you should have learned a lesson. On your surgical Preceptorship and Clerkship, you had to read about the procedures before they were performed to be able to answer the quizzes during surgery. From that, you should have learned a lesson. Finally, you should have known that learning to intubate is a standard trauma procedure for Fourth Years. You didn't read the textbook, which I know because it expressly describes the 'sniffing position' and calls it that."

"Mike," Ellie called out from the door. "Walk-ins are seriously backed up."

"Two minutes," I replied.

Ellie left, and I turned back to Krista.

"You have five weeks left in this rotation. If you don't have an intubation in your procedure book, you're going to have a tough time Matching for anything except dermatology or psych, and even those will be tough with the paucity of procedures in your book. I suggest you take a break, find your emergency medicine textbook, and learn the procedure. I'll give you a shot if you can tell me the procedure from memory. If not, no chance."

"Take a break?"

"Your call, but we have limited time."

"I'll go home and get my book."

"OK."

She left, and I went to find Al, but he was helping Ghost, so I asked Ellie for assistance from Kellie.

"Can't stay away from me?" Kellie teased.

"I know a good nurse when I see one!"

"I'd say flattery would get you everywhere, but I know you're more than a little married!"

"Being a little married is like being a little pregnant!"

Kellie laughed, and I grabbed the first chart from the rack.

"LOL, seventy-eight, weak and dizzy all over," I chuckled.

"Want to play the lottery and try slot two?" Nate asked.

"No. I'll take this one."

"Where are your students?" Kellie asked.

"I sent Krista to learn the procedure for intubation, and Al is with Ghost because I was in surgery."

"Mike Loucks, _Wunderkind_! Able to deliver babies one-handed, perform surgery with his eyes closed, and avoid Ellie's clutches!"

"Well, one out of three! Wheelchair, please.

Kellie retrieved a wheelchair, and we went out to the waiting room.

"Mrs. Olson?" I called out.

"Over here," a young woman in her twenties called out.

Kellie and I moved over to where the young woman was sitting with an older woman who looked confused.

"Hi, I'm Doctor Mike," I said.

"Hi, I'm Tracey Copeland and this is my grandma, Alice Olson. She didn't get out of bed this morning, won't talk, and I can't get her to eat."

"Mrs. Olson?" I said and when she didn't respond, I tried again with slightly more volume.

"When did this happen?" I asked Tracey.

"She was fine last night when she went to bed. Normally she's up around 7:00am, but when she wasn't up by 8:00am, I went to check on her. I tried to get her to eat, and when she wouldn't, and wouldn't talk, I dressed her and brought her here."

"You did the right thing," I replied. "Kellie, let's help Mrs. Olson into the wheelchair and take her to Exam 3."

"Can I come with her?" Tracey asked.

"Yes, of course."

Kellie and I helped Mrs. Olson into the wheelchair, then Kellie pushed, and both Tracey and I followed. In the exam room, Kellie and I helped Mrs. Olson onto the exam table. She could walk and stand, but had a blank look on her face, and wasn't communicating.

"Kellie, let's put her on a nasal canula then get a CBC, Chem-20, ABG, cardiac enzymes, and glucose panel," I said. "Tracey, I'm going to examine your grandmother, we'll draw blood, we'll put her on an EKG, and give her oxygen as a precaution. You can sit in the chair next to the treatment bed."

Tracey sat down and Kellie and I began the procedures I'd specified, each of us telling Mrs. Olson what we were doing, but other than a slight moan, when Kellie drew blood, Mrs. Olson didn't react. The EKG showed normal sinus rhythm, though her pulse was a bit low at 60, while her BP was 130/80, which was OK, and her PO₂ was 98% on the canula. I detected no physical signs, and she had proper reflexes. Kellie gave the blood to a student nurse to take to the lab.

"Kellie, let's get her a liter of D5 Ringer's, please. Tracey, we're going to give your grandmother an IV with glucose and electrolytes, because you said she hasn't had anything to eat or drink."

"What do you think is wrong?"

"Right now, I don't know. Other than being non-responsive, nothing is obviously wrong. The EKG shows her heart is beating normally, her blood pressure is fine, and her pulse is a bit low."

"I think that's normal. She used to run marathons."

"That would explain it. How long ago?"

"She ran half marathons after she turned forty-five and only stopped about six years ago."

"Has she been sick at all?"

"No."

"And she's active and eats properly?"

"Yes."

"Are you her caregiver?"

"She doesn't need one. Mom and Dad work, and grandma lives with us. I'm in college, and I work at Kroger during the Summer."

"Taft?"

"Yes. I'm a Junior."

"Is there any history of diabetes in your family?"

"No."

"OK. I don't believe your grandmother is in any immediate danger, so we'll wait to see what the lab results show. We'll send a nursing student in to sit with you until the lab results come back."

"OK. Can I call my mom?"

"Yes. Kellie, my students are busy, so would you get a student nurse to come in, then take Ms. Copeland to the consultation room?"

"Right away, Mike!"

I updated the chart, and Kellie brought Rose, a nursing student, into the room, then escorted Tracey to make her phone call.

"Rose, please keep an eye on the monitor. If she comes around, there are any alarms, or her blood pressure drops below 50 diastolic, call me."

"Yes, Doctor."

I left the room, and Kellie walked over to me.

"What are you thinking, Mike?"

"It doesn't fit anything other than asymptomatic cerebral infarction — no symptoms other than cognitive functions. It could also be the after effects of a Transient Ischemic Attack. If the labs don't show some kind of electrolyte imbalance, elevated cardiac enzymes, or hypoglycemia, then we'll call neuro and get a CAT scan."

"No thrombolytics?"

"If it is a stroke, it could be hemorrhagic, in fact, it likely is, and thrombolytics would make it worse. We have thirty minutes before the labs are back, so let's see what we have next in our game of walk-in roulette."

"Doctor Mike?" Al said, coming up to me. "Doctor Casper released me."

"What did you do?"

"Sutured an arm lac; he signed my procedure book."

"Good. Let's see what's next in the walk-in lottery! Get a chart, please, and bring the patient into Exam 1."

He took the first chart from the rack, looked it over, and went to the waiting room.

"I'm going to get some coffee," I said. "Then confer with Doctor Gibbs."

I went to the lounge, poured myself a cup of coffee, then went to the see Doctor Gibbs. I presented my patient and my plan.

"You're comfortable waiting?" Doctor Gibbs asked.

"No, but Neuro will want to rule out other causes before they'll authorize a CAT scan, and my patient isn't showing any signs other than aphasia, which could have non-neurological causes. We'll have the blood test results in about twenty-five minutes, I have her on a D5LR IV, an EKG, and oxygen prophylactically, and a student nurse is sitting with the patient and her granddaughter. Given how the patient presents, would you authorize the CAT scan without Neuro?"

"No, but I'm not you!"

"I'd need your signature, and a certification that we can't wait for Neuro, which I don't believe you would give."

"Speak freely, Mike."

"Honestly? It's a toss-up. If we don't find anything, there's a good chance Medicare kicks it back, and too many of those would lead to significant risks to our reimbursement rates. I think it's BS, but, unfortunately, he who pays the piper calls the tune. I _want_ to do it, but I can't justify it under the hospital guidelines."

"Listen to you sounding like an Attending! Or a Chief!"

"I blame you, Shelly, and Carl!" I chuckled. "But in all seriousness, I know we have limited resources and we have to manage them. It sucks, but in this case, 'wait for the labs' is the answer. With more funding, we could do it. But I also wouldn't take money away from the new ED, which will save more lives than paying for a few extra CAT scans."

"Mike Loucks, socialist! The needs of the many outweigh the needs of the few! Or the one!"

"OK, Doctor Spock! And I don't mean the baby doctor! But triage isn't socialist, at least the way you mean — it's a reasonable application of limited resources. Every system, capitalist or socialist, has to do that. The 'all or none' thinking is simply wrong, because it is literally impossible to supply everything to everyone, no matter what we're talking about. Heck, even _Star Trek_ deals with resource limitations in their supposedly perfect socialist, egalitarian world."

"Your thinking has evolved."

"More like my idealism has run head-on into the brick wall of reality. I have more patients to see."

"Go heal the sick!"

I left the office, returned my coffee mug to the lounge, then went to Exam 1 where Al was with a young woman and Nurse Lisa, conforming to the rules about male doctors being alone with female patients.

"Julie, this is Doctor Mike."

"Hi, Julie," I said.

"Hi."

"Julie Perez, twenty-six," Al said. "Presents with a complaint of numbness and tingling in her left foot. Pulse 76; BP 110/70; temp 36.7°C. No other complaints."

"Julie, this is a teaching hospital," I said. "If you're amenable, I'll have Al take your medical history and examine you. I'll be right here the whole way."

"That's fine," she said

Al sat down on the stool and asked Julie about her medical history, any drugs, recent injuries, medications, and so on. Nothing stood out, so with a look to me, he began his exam, which included asking Julie to walk several steps, as well as checking her reflexes.

"No motor or reflex impairment," Al said.

"So, what do you want to do?" I asked.

"I don't know," he admitted.

"A perfectly legitimate answer for a student. Your next step is a neuropathy test. Have you seen one performed?"

"No."

"OK. Observe, and you'll know how to do one in the future. Becky, neuropathy probe, please."

I washed my hands, put on gloves, then accepted the small metal probe.

"Julie, I'm going to touch this to your skin on your feet, ankles, and calves, then on your hands, wrists, and lower arm. You tell me each time you feel it, OK?"

"Yes."

I began with the leg that wasn't bothering her and she had no trouble detecting each touch of the probe. I repeated the test on her left leg, and she missed five touches, three on her big toe, and two on the ball of her foot. I repeated the test with both hands and arms, and she had no trouble detecting them.

"No back pain of any kind?" I asked.

"None."

"OK. We'll draw some blood, and once we see the results, I'll have a specialist examine you."

"What do you think is wrong?" she asked.

"Right now, all I can say is that you're exhibiting peripheral neuropathy, that is, loss of sensation in your foot. There are numerous causes, most of which are easily treatable. Becky, CBC and glucose panel, please."

Becky acknowledged my orders, and Al wrote them on the chart, which I signed.

"What are those tests?" Julie asked.

"A CBC is a Complete Blood Count and is exactly what it sounds like — a count of each type of cell in your blood. The main thing we'll look for is an elevated white count, which is a sign of infection. A glucose panel measures your blood sugar. The reason for that test is that a high level of blood sugar is one common cause of peripheral neuropathy. Just relax, Becky will draw some blood, and I'll be back when we have more information."

"Thank you, Doctor."

"You're welcome! Al, with me, please."

We left and went to Exam 3 to check on Mrs. Olson. There had been no changes, and the lab results weren't back, so I asked Al to get the next chart. I took the opportunity to empty my bladder, then went to Exam 5, where Al was waiting with a male patient in his fifties.

"Joseph Nylander, fifty-six; complaining of severe indigestion; BP 130/90; Pulse 100."

I looked at the patient and made a snap decision.

"Hi, Mr. Nylander, I'm Doctor Mike. We're going to move to another room. Al, Trauma 2."

"What's wrong?" Mr. Nylander asked.

"I think you might be having a heart attack."

Al and I escorted Mr. Nylander to Trauma 2 and had him lie down on the treatment table, and I waved Kellie to join us.

"Al, monitor and five-lead," I ordered. "Kellie, nasal canula."

I quickly washed my hands, put on gloves, then did a quick exam. Once Al had the equipment hooked up, I looked up at the monitor that Al had turned on. There was no clear arrhythmia on the five-lead, but that only ruled out an ongoing ST-Elevation Myocardial Infarction, or STEMI.

"Kellie, nitro tab sub-lingual, then draw blood for Chem-20, lipid panel, and cardiac enzymes. Get the blood to the lab, stat."

"Sublingual nitro," she repeated. "Draw for Chem-20, lipids, and cardiac enzymes."

"We're going to give you medication which should relieve the pain," I said. "And we'll draw blood to check to see if you've had a heart attack."

"I thought the monitor would show it," he countered.

"Not always, and they only show what's happening right now, whereas blood tests will tell us what happened in the past four to six hours."

Kellie placed the nitroglycerin tablet under Mr. Nylander's tongue, drew the blood, then gave it to a student nurse to take to the lab.

"BP dropped," Al announced. "100/70."

"Why would that happen?" I asked.

"The nitroglycerin."

"Yes. Mr. Nylander, how does your chest feel?"

"It doesn't hurt nearly as bad," he said.

"When did the pain start?"

"Maybe an hour ago."

"What were you doing?"

"Sitting at my desk."

"Any exercise this morning?"

"I have a treadmill at home, but that was around 6:00am and the pain didn't start until much later."

Which was typical for unstable angina, but that didn't rule out a Non-STEMI.

"Have you had pain like this before?"

"After eating at Taco Bell," he replied.

I chuckled, "I hear you! Did you eat any spicy food last night or this morning?"

"No. I usually don't get indigestion except from Taco Bell. But I can't quit it!"

"Do you smoke or drink to excess?"

"Never smoked, and I'll have a shot of bourbon three or four times a week."

"How often do you exercise?"

"Thirty minutes on the treadmill three times per week; doctor's orders."

"For anything specific?"

"I had put on about fifteen pounds."

"Taco Bell will do that."

"That's what he said! But I took off the weight, so he doesn't give me too much grief about my addiction to really bad Mexican food."

That gave me another clue about what might be wrong — atherosclerosis.

"Kellie, IV saline and push 250mg ASA, please."

"Saline IV, push 250mg ASA," Kellie repeated, as Al wrote it on the chart.

"We're going to give you an IV, along with some additional medication," I said.

"What's got you worried, Doc?" he asked as Kellie inserted the IV.

"Atherosclerosis, which is a narrowing of your blood vessels. Your Taco Bell diet might be coming back to haunt you in other ways than gaining weight. How are you feeling?"

"Much better. Can I ask a question?"

"Sure."

"Everyone I saw coming in but you is wearing blue. Why are you wearing red?"

"I'm a trauma surgeon," I replied. "I work for the Chief of the surgical service, but I'm assigned to the emergency department."

"And they have you handling walk-in cases?"

"Everyone does, but I'm an Intern, which is the low man on the ladder, so I do more walk-ins than anything."

"You seem pretty smart for a brand-new doctor."

"He is _very_ smart," Kellie said. "You have the best doctor in the Emergency Department."

"I thought you guys always wore white coats."

"It's optional for my service," I said. "We only wear medical coats on rounds, and always over a shirt and tie, not scrubs. Medical coats are standard on most services. In the Emergency Department, medical students always wear them, and most Attendings, that is, senior doctors, do as well. Surgeons don't wear them in the OR."

"Thanks for answering my questions."

"I'm going to go check on my other patients. Al will stay with you to watch the monitors. He's one of my best students."

Kellie and I left, and Nate signaled me to come to his desk. He let me know the lab had called with Mrs. Olson's results, and that a student nurse had chased them for me. I looked them over and saw nothing out of the ordinary for a woman of Mrs. Olson's age, though her blood sugar was a bit low. That wasn't surprising, given she hadn't eaten breakfast.

"Zilch on the labs on the aphasia," I said to Doctor Gibbs from the door to her office. "I'm going to call Neuro."

"What's your best guess?"

"Hemorrhagic stroke followed by a tumor. Given the sudden onset, I don't think it's neurological disease."

"I concur."

"Thanks."

I left and went to the nurses' station and used the phone to call for a neurological consult, then went into the room where Mrs. Olson and her granddaughter were.

"Your grandmother's blood tests came back normal, except for slightly low blood sugar, but I attribute that to eating nothing since last night. The IV we gave her should take care of that. I've called our neurology department to send someone to examine your grandmother, and they'll be here shortly."

"What do you think is wrong?"

I contemplated if I should demur, but decided I could answer.

"Most likely, she's had a very mild stroke, but we'll need to do a CAT scan to verify that. I'll confer with the neurologist once they complete their exam."

"Will she recover?"

"The answer to that question will have to wait until we complete further tests."

The door opened and Nate let me know that Mrs. Olson's daughter was in the waiting room.

"Rose, would you escort Mrs. Copeland in from the waiting room?"

"Right away, Doctor!" she said brightly.

She left and returned about a minute later.

"What happened?" Mrs. Copeland asked the moment she was in the room.

"Grandma didn't wake up at her usual time, so about 8:00am I went to check on her and she wasn't able to talk, so I dressed her and brought her here. This is Doctor Mike, who's trying to find out what's wrong."

"Hi, Mrs. Copeland," I said. "We've run several tests and in a few minutes, a specialist from neurology will examine your mom."

"What's wrong?"

"We don't know yet. Our next step is most likely a CAT scan to see if she's had a stroke."

"NO!" Mrs. Copeland gasped.

"We don't know for sure," I said trying to soothe her. "All the tests have come back normal so far, and her heart and lungs are in excellent condition for a woman of her age. Those are all positive signs."

"Vanderberg, Neuro," Lucy Vanderberg announced coming into the room with a male student.

"Hi, Lucy," I said. "Alice Olson, seventy-eight; presented with aphasia; blood work shows no anomalies except low blood sugar consistent with no food intake since last night; nasal canula and D5 Ringer's. Patient's granddaughter discovered the patient in this state about 8:00am and brought her in by private vehicle. No reported injuries, no reported illnesses. Recommend a diagnostic CT. This is Mrs. Copeland, Mrs. Olson's daughter, and this is Tracey, her granddaughter."

"Hello," Lucy said to all three women. "Mrs. Copeland, I'm going to examine your mom, and then we'll take her for a CAT scan. Mike, I'll admit her either way."

"OK. Tracey, Mrs. Copeland, you're in good hands with Doctor Vanderberg. She's an excellent neurosurgeon and will take good care of your mom and grandmother."

"Thanks so much!" Tracey gushed.

"You're welcome. Rose, you can go about your duties."

I updated the chart as Lucy began her exam, signed it, then filled out the admission form, which I also signed. I set the chart on the table, then left the exam room and went to check on Mr. Nylander, who was feeling OK, and had what appeared to be normal sinus rhythm on the monitor.

I got some coffee, then reviewed the lab results for Julie Perez, which were completely normal for a healthy young woman. Given that, I returned to the exam room where Lucy Vanderberg was completing her exam.

"Lucy, I have another one for you," I said.

"OK. Luke, call radiology and let them know we need a CAT scan stat, then call for an orderly with a wheel chair. Mrs. Copeland, I need to check another patient, but I'll be back shortly."

Lucy stepped out, and I presented my second case.

"Let's go see her," Lucy said