Contents

1. Publication Info

2. Dedication

3. Other Books in This Series

4. Other Books by Michael Loucks

5. I. The Doctor is IN (or is he?)

6. II. Farewells

7. III. Field Work

8. IV. It's going to be a very busy year!

9. V. And That Makes ME Happy!

10. VI. I'm Sure You Can!

11. VII. Red Scrubs

12. VIII. What A Stupid Way to Die

13. IX. Three In One Day

14. X. Call On Line 3

15. XI. Get Out Of Here!

16. XII. The Patient Is Our Focus

17. XIII. A Long Night during a Long Shift

18. XIV. A Long Shift Finally Ends

19. XV. A Wise Man Listens to Those With Knowledge and Experience

20. XVI. Defeated

21. XVII. Air Ambulance

Copyright © 2015-2023 Michael P. Loucks

Сам Себя Издат

First publication date: TBD

First revision publication date: TBD

You may contact the author at: author@michaelloucks.com

https://a-well-lived-life.com/

Scripture taken from the New King James Version®. Copyright © 1982 by Thomas Nelson.

Used by permission. All rights reserved.

For Jennifer

Other Books in This Series

Freshman Year

Sophomore Year

Junior Year

Senior Year

Medical School I

Madical Shool II

Medical School III

Medical Schoo IV

Residency I (\)*

- Work in Progress

Other Books by Michael Loucks

A Well-Lived Life, Series I

Book 1 - Birgit

Book 2 - Jennifer

Book 3 - Pia

Book 4 - Bethany

Book 5 - Stephanie

Book 6 - Kara I

Book 7 - Kara II

Book 8 - Stephie

Book 9 - Anala

Book 10 - The Wife

A Well-Lived Life, Series 2

Book 1 - Bethany

Book 2 - Stephie

Book 3 - Jessica

Book 4 - Elyse

Book 5 - Michelle

Book 6 - Samantha

Book 7 - Sakurako

Book 8 - NIKA

Book 9 - Kami

Book 10 - Bridget

A Well-Lived Life Series 3

Book 1 - Suzanne

Book 2 - The Inner Circle

Book 3 - A New World

Book 4 - Coming of Age

Book 5 - The Pumpkin Patch (\)*

Cliimbing the Ladder

Book 01 - The First Rung

Book 02 - The Second Rung

Book 03 - Climbing Higher (\)*

From the Files of Doctor Fran Mercer (\+)*

A Sailor's Diary

Book 1 - The War Years (\+)*

- Work in Progress

+ Available exclusively on Patreon or BuyMeACoffee

I. The Doctor is IN (or is he?)

May 25, 1989, Graduation Day, McKinley, Ohio

I accepted the leather-bound diploma from Doctor Warren with my right hand, instead of the usual left, as Rachel was in my left arm and was snuggled against my chest. I tucked it under my arm and shook his hand.

"Congratulations, Mike," Doctor Warren said. "An excellent valedictory oration."

"Thanks."

"She's beautiful. And it was a nice touch to walk her across the stage."

I smiled and nodded, but had to move on, as Tom Meyer's name had been called and he was right behind me. I shook hands with the other deans, then the President of the Medical School Board, and then returned to my seat. Just under fifteen minutes later, Medical School Board President Thomas Abbott gave us our commission to serve our fellow men, and closed the ceremony.

"Dada? Eat?" Rachel asked.

"As soon as we get to Mama," I said. "She has some cookies and juice for you."

I found my extended family and friends, and went to give Rachel to Kris, but Grandma Borodin intercepted. I let her know Rachel was hungry, and Kris gave Rachel's bag to my grandmother. Kris gave me a quick hug, but protocol dictated what I did next. I turned and took two steps to where my bishop was standing.

"Congratulations, Mischa," Bishop JOHN said.

"Thank you, Vladyka."

"A very good speech, one worthy of publication in the church bulletin of every parish in our diocese. It's a message that applies to all Orthodox Christians."

"I'm honored," I said.

"Then with your agreement, I'll have it published."

"I agree."

"Your grandfather looks as if he's about to burst!" Vladyka said with a smile. "I think I've monopolized you long enough!"

"Master, bless," I said.

I turned my hands up, and he gave his blessing, then I turned and took a step over to my grandfather.

"Congratulations, Mike!" my grandfather said.

"This one will result in wearing white, not black," I replied with a smile.

"Speaking of that," he said with a smile.

He handed me a package and nodded that I should open it. I did and found a long white medical coat, signifying a physician, rather than the short one signifying a student. Embroidered in black above the pocket was 'Doctor Michael P. Loucks'.

"Thank you, «Дедушка»," I said.

"You're welcome, Mike! Stefan and I reserved the overflow room at the steak house in McKinley and everyone is invited, including Viktor. I spoke to His Grace and he'll join us, and per your mother, I cleared it with Kris. Your friends are welcome, of course, though I expect Svetlana Yakovovna will want to be with her parents."

I laughed, "I haven't called her that in ages! And yes, she's going to be with her parents and grandparents tonight. Maryam, Fran, Peter, and Nadine all have their parents and others here as well. We're having a get-together at the house on Sunday."

"Congratulations, Mike!" Stefan said, coming over to us.

That started a string of congratulations from everyone else who was there - my mom and dad, my two grandmothers, Paul and Liz, Holly, Jocelyn and Gene, José, Lara, the Korolyovs, Doctor Smith, Doctor Forsberg, Doctor Casper, Doctor Strong, Doctor Roth, and Doctor Gibbs, who looked about ready to pop.

"You should not be here!" I said, looking at her positively huge abdomen.

"My feet and my hemorrhoids agree with you!"

"TMI, Doc!" I chuckled. "You aren't a patient!"

"I'm losing patience with Bobby Junior right now! And with his dad!"

"I bet! Go home, Doc! Doctor's orders!"

"That didn't take long!" she said, laughing. "Did you get your schedule for next week?"

"Yes. I'm on Bobby's three twenty-four-hour shifts starting at 0700 on Monday, Thursday, and Sunday."

"When do you leave for your vacation?"

"The Monday following my last ride-along shift, so Kris will do most of the driving. It's only about six hours, so I'll get a two hour nap before we leave."

"Sorry about that."

"Don't apologize! I want to do this. It'll be instructive and interesting to see what happens before the guys roll the patients out of the squad. It's just too bad they're Squad 2!"

"There are only twelve in the county, so no 'Squad 51' for you!"

"The real bummer is that fire stations no longer have poles to slide down!" I declared.

Doctor Gibbs laughed, "True, but they do have the mandatory Dalmatian!"

"What's his or her name?"

"Brigid, because she's the Irish goddess of the hearth and sacred flame, as well as of water."

"That makes perfect sense."

"Bobby named her."

"I have one for you," I said with a smirk. "Cerberus, the hell-hound and guard dog of the Underworld, comes from the root Indo-European word '∗k̑érberos', which evolved into the Greek word kerberos, which changed to Cerberus when it went from Greek to Latin. That Indo-European root word '∗k̑érberos' means 'spotted'. That means that Hades, Lord of the Dead, literally named his pet dog Spot!"

Doctor Gibbs laughed, hard.

"Don't do that! You'll make me go into labor!"

"I think there might be a doctor or two here to assist," I chuckled.

"More like two hundred! But there is no way YOU are delivering my baby!"

"I'd say 'The Doctor is IN' and ask for 5¢, but the LAST thing I want to do is deliver your baby! Now go home!"

"Yes, Doctor," Doctor Gibbs smirked.

We exchanged a light hug, she left, and I spent a few minutes speaking with Anicka and Milena, then our entourage began filing out of the auditorium. As we were walking to the parking lot, Maryam called my name so she could introduce me to her parents, and more importantly to Matta, who I was sure would be her husband in less than a year. We shook hands, but really didn't have time to talk. He was heading back to Chicago with Maryam's parents, so wouldn't be at the house on Sunday.

"I should go home and change," I said to my grandfather. "We'll meet you there about fifteen minutes after you arrive."

"OK."

Kris took Rachel from my grandmother, and we got her settled in her car seat in the back of my Mustang, then got in so we could head home.

"How do you feel, Mike?" Kris asked as I pulled out of the parking lot.

"As I said to Doctor Casper and Doctor Gabriel, the most important thing was the Match. To me, the Match letter was a bigger deal than the diploma. Graduating without Matching would have been depressing, and graduation has been a done deal since I passed all my core rotations."

"You're not excited?"

"I am, just not as excited as I think you expect me to be!"

"How about later?" she asked in her sultry French accent.

"You always excite me!" I declared.

"Dada Mama kiss!" Rachel giggled.

"Dada is driving," I replied, laughing, then said, "OK, who taught her THAT?" I asked.

"My sister, I bet!" Kris replied. "Like most fifteen-year-olds, she's very curious about that part of life! And I could just see her teaching Rachel to say that to tease you."

"Me?"

"You! She knows better than to tease me!"

I laughed, "Hell hath no fury like the elder sister scorned?"

"You know we really don't torment each other the way you and your sister did, or even the way you and Jocelyn did."

"Or Clarissa?"

"That's more like, well, a married couple, than anything. I'm positive if she were straight, you two would have married long ago."

"You aren't wrong," I replied. "But I've known her orientation since Freshman year. Angie was around then, and you know how I felt...feel about her. Sorry."

"Don't apologize," Kris said. "There is literally nothing you can do to change the past, and I don't feel slighted because you care for Angie and want to help her. I want you to help her."

"Thanks. What did I do to deserve you?"

"You listened to my cousin!" Kris declared mirthfully. "We each now have the doctor best suited for us!"

"I'm curious..."

"Doctor Casper needs a devoted wife who will spend quiet, relaxing time at home with him; you need a partner in crime!"

I laughed, "Clarissa, Jocelyn, or both?"

"Both! And your mom."

"Of course," I chuckled. "The three women who basically ruled my life until Elizaveta and Rachel came along!"

"Clarissa still does, at least outside our house."

"But never in a way that would interfere with my relationship with you," I countered. "She helped shape me into the man I am today. You would not have liked me eight years ago!"

"Eight years ago I was ten!" Kris declared mirthfully.

"You know what I meant!" I countered.

"I do, of course."

"And inside our house?" I asked.

"We both know who's really in charge."

"Rach!" my daughter giggled.

"Uh oh," I said quietly. "We're so dead!"

"Dada?"

"Yes, Rachel?" I inquired.

"«Zha'tim»!"

"I'm not sure what you just said, Rachel," I replied.

Kris laughed softly, "I think she tried to say «Je t'aime»! My sister strikes again!"

"Rachel, «Je t'aime»!" I said.

"Mama! «Zha'tim»!" Rachel declared.

"«Je t'aime, mon petit lapin!»" ("I love you, little bunny rabbit.")

"So it would appear she's going to learn French after all," I said as I pulled into the driveway of our house.

"Is that a problem?" Kris asked.

"Not really," I replied. "We had decided not to teach her Russian, at least as a toddler, but I'm sure she'll pick up the odd phrase here and there from my grandparents or Clarissa, who will, no doubt, revel in teaching my daughter how to tease me in Russian!"

"Clarsa!" Rachel exclaimed. "Love Clarsa!"

"Ok, now I'm positive I'm doomed!" I declared.

"Poor baby," Kris teased.

"Yeah, yeah," I chuckled. "I will admit that I signed up for this willingly."

"Perhaps you just need some personal attention later, after Rachel goes to bed?"

"Perhaps I do!"

I parked, we got out of the car and went into the house. While I took off my graduation regalia, Kris changed Rachel's diaper and packed food in her bag, as there was no way Rachel could eat anything at the steakhouse except perhaps the warm breadsticks they served with the salads and some baked potato.

We had an enjoyable time at dinner with Bishop JOHN, my extended family, including the Korolyovs, José, Lara, and Jocelyn and Gene. After dinner, Kris, Rachel, and I headed home, and once Rachel was in bed, Kris supplied the personal attention she'd promised.

May 26, 1989, McKinley, Ohio

"What do you plan to do today?" Kris asked when we got out of bed on Friday morning and went to the bathroom to take a shower together.

"If they'd let me, I'd work in the Emergency Department, but I can't actually do that before June 1st, when the Residency position is officially available. They couldn't pay me until then, and I wouldn't be covered by malpractice insurance."

"That's such a foolish concept! The state should simply pay compensation to those who are truly harmed and dispense with the silly lawsuits."

"The problem there is that it turns it into a political fight as much as one about medicine. That said, going to court is a losing proposition because juries almost always find for the plaintiff."

"And you told me the insurance companies settle for that reason, so why even bother with insurance companies? You could even simply take the premiums and put them in a pool administered by the state. No more insurance companies and no more court battles."

I laughed, "Oh you poor, naïve French girl!"

"What?"

"Instead of suing the hospital and the insurance company, they'd sue the government or the board that made the decisions, or sue the doctors and hospitals, anyway. It's almost impossible to avoid a lawsuit, no matter what you do."

"But the government could make it so you couldn't go to court, right?"

"Yes, and then there would be lawsuits over that. But you'd never get a law like that passed. Every attempt to reform malpractice is fought tooth and nail by what are politely called 'plaintiff's attorneys' but which most people at the hospital call 'ambulance chasers'. They have serious political clout because they have serious money to donate."

"The entire system is corrupted by money!"

"Perhaps so, but the First Amendment guarantees a right to free speech and free press, and the courts generally include an individual spending their own money to advance a political cause as covered by the First Amendment. I read about a case going to the Supreme Court this year about corporations being able to spend money on politics, and the consensus appears to be that the Supreme Court will allow those restrictions because corporations aren't people."

"Well, obviously!"

"Actually, not so obviously under American law," I replied. "I learned in High School that there are two important points. First, a corporation is owned by individuals who cannot be forced to give up their Constitutional rights to gain some service or benefit from the government. Second, in some things, corporations are treated as individual persons. That's necessary fiction because if that fiction weren't maintained, a lawsuit against IBM or GE would, under our system, necessitate suing every individual stockholder as an owner, rather than suing the corporate entity."

"That's just silly!"

"Maybe so, but that's how things work in our Common Law system. Remember, the basis of our system is different from the French system. Well, except Louisiana, which is based on French Civil Law. All the other states are based on English Common Law."

"How can one state be different?"

"ALL states are different! The laws in Ohio are different from the laws in Indiana, Michigan, Pennsylvania, West Virginia, and Kentucky, even though the states are contiguous with Ohio."

"The system is far too complex, and it should be simple for the national government to pass any necessary laws!"

"The system is actually designed to prevent that," I chuckled. "You don't have to like it, but you do have to accept that's the way things are. Well, at least until the glorious people's revolution hoists the red and black flag over the White House!"

"Are you mocking me?" Kris asked, hands on her hips.

"Me? Would I do that?"

"YES!"

"Perhaps," I chuckled.

We finished our shower, dried off, and dressed.

"You never did answer as to what you planned to do today," Kris said when we went down the hall to get Rachel.

"I think the Tsarina and I will just have some daddy-daughter time. I'll see if I can deprogram her from the French cult your sister is trying to indoctrinate her into!"

"You like this French girl!"

"I also like French kissing her!"

"Of course you do!"

"But neither of those things make it any less vital to teach Rachel the truth about France!"

"And what is that, Michael? Hmm?"

"What's the first thing you teach a French soldier?"

"Uhm, how to march?"

"No. This!"

I raised my hands to the 'surrender' position.

"Oh, please!" Kris exclaimed, rolling her eyes.

"Did you hear about the new French battle tank?" I asked as I began changing Rachel's diaper.

"No."

"Five speeds -- four in reverse; one forward, in case the enemy gets behind them."

"Are you going to keep going?" she asked, tapping her foot.

"New French military rifles for sale! Never fired; dropped once!"

"Perhaps you would like to sleep on the couch?" Kris threatened.

"Why are French main roads lined with trees?" I asked.

"Don't even go there, Michael Loucks!"

"Because the German Army likes to march in the shade!"

"Are you quite through?"

"I'm all out of French military jokes," I said with a grin. "I mean, besides the French military itself!"

"Gilbert du Motier, Marquis de Lafayette, is rolling in his grave!"

"I actually never knew his name," I replied. "He was always referred to by his aristocratic title."

"So, this French girl taught you something!"

"More than one thing, and I've returned the favor."

"To your own advantage!" she said mirthfully.

"And to yours!"

"True!"

I finished changing Rachel's diaper and the three of us went downstairs for breakfast.

"I still don't understand why Americans make fun of the French! We were your allies and helped you defeat the British king and his German mercenaries!"

"I honestly don't know, but I strongly suspect it has to do with World War II and Vichy."

"An outrage, though worse was the «collaboration horizontale»."

"Survival often necessitates setting aside ones' principles in favor of food and shelter. I find it hard to judge someone at risk of starving to death for whatever they might do to obtain food, short of physically assaulting someone or killing them. I assume you've read Les Misérables? Do you think Jean Valjean should have been sentenced to hard labor for taking a loaf of bread when he was hungry?"

"Isn't theft always wrong?"

"Isn't refusing to feed the hungry also wrong? One begets the other, don't you think?"

"Yes, of course, but you're a capitalist!"

"And an Orthodox Christian. The two are not as incompatible as you think they are. I would never refuse to share what I had with someone in need, to the extent of my ability to do so. Remember, 'sell all you have and give to the poor' was about love of riches, NOT a command for everyone to live in abject poverty. And, as we've discussed, in Acts, where Marx cribbed 'from each according to his means; to each according to his needs', it was voluntary, as shown by the incident with Ananias and Sapphira.

"You and I will have two above-average incomes, and we'll happily pay our taxes, tithe, and give generously to charity. But that does not mean we shouldn't enjoy some of the fruits of our labor. After all, as Jesus said in Luke's Gospel -- 'the worker is worth his wages'. Paul repeats it in his letter to Timothy with reference to supporting individuals engaged in Christian ministry. I daresay if ministers are to be appropriately compensated, then so are doctors.

"In the Old Testament, in Fourth Kings, it makes the point that religious leaders were to be compensated by the people so they could dedicate their lives to service to the community. I think there's a clear parallel for physicians. And it's not as if I'm doing this for the money. You heard my 'call to arms' yesterday, and that's the important thing. The compensation comes second, and while I won't turn it down or be embarrassed by it, I will follow the same course with money as I do my medical skills."

Kris smiled, "For somebody who hates politics, you have very strong political convictions."

"I'm an American and I believe in capitalism, so sue me!"

Kris laughed, "Only Americans would use 'so sue me' to make a point! The phrase works because you run to court at the drop of a hat!"

"And, sadly, our justice system provides little justice and plenty of retribution."

"Do you still plan to visit the man who murdered Lee after we come back from our vacation?"

"I'm going to try. I have no idea if he'll see me. I do have to find out the rules for visiting him, because his sentence was life without parole. I know visiting death row inmates is very difficult, and he's in the same prison where they house them."

"The death penalty is barbaric!"

"I agree, and so are the conditions in most prisons in the US. Had I remained a deacon, eventually I would have become involved in prison ministry."

"There's no reason you can't do that as a lay person, is there?"

"With the caveat that I'd be able to bring the Eucharist if I was a deacon, yes. And it's something to consider in three or four years when things calm down with regard to my schedule at the hospital."

"When will you know your schedule?"

"Not long after we return from Tennessee, though the first week is technically orientation week, but I'll start my regular shifts immediately because I don't need orientation on the hospital."

"What do they do for that?"

"The first week is a series of ten, four-hour shifts in each department where the new Resident shadows a PGY2 to become familiar with the other services."

"All Residents?"

"From the Emergency Department, yes. But because I had time on all those services at Moore, I don't need to do it."

"What do the other services do?"

"Nothing at the moment. In the future, Residents from all the major services will spend three months of their first year in the Emergency Department. That way, when we have major incidents, everyone will have recent experience in trauma. The typical Resident outside of trauma almost never does intubation, for example. Neither do the paramedics, for that matter, which is going to change and is why they'll spend time training in the ED in the future."

We finished making our breakfast, ate, and then Kris left for her final day of High School. She had two exams, though she was at absolutely no risk of not having straight A's, and we'd attend her graduation ceremony on Saturday.

"What would you like to do?" I asked Rachel.

"Dada sing!"

"You really are learning a bunch of words!" I said. "I'll get my guitar and play for you."

Rachel was twenty-one-months old, and her vocabulary was growing by leaps and bounds, and she was able to express herself in simple ways, but that was far more than even three months previous. To satisfy her, I got my guitar and sheet music, then sat on the couch in the great room to play for her.

As she often did, Rachel sat on the couch and leaned against me while I played and surprised me by trying to hum along with the guitar. Many of the songs I knew she preferred I knew by heart, but I also took the opportunity to practice some of the newer songs. When I finished playing, I put the guitar and sheet music away, then decided Rachel and I should take a walk.

Instead of putting her in her stroller right away, I held her hand until we reached the end of the driveway. I picked her up and met immediate resistance.

"NO! RACH WALK!"

"We'll try it your way," I replied.

She was determined, and I saw so much of Elizaveta in her personality. It could only be genetic, as except for a few brief seconds, Elizaveta hadn't even held her. Of course, she could have inherited that through me from my mom and grandmother because she had a double dose of Russian X chromosomes! Her Borodin stubbornness lasted about a hundred yards and she plopped down, her little legs clearly tired. I picked her up, and this time she didn't resist going into her stroller.

After our forty-minute walk, I read to Rachel, played with her, and then we had lunch. After lunch, I called Viktor and as he and Yulia were home, I took Rachel to see them, as she hadn't been to see them for several weeks.

When we arrived, I left Rachel with Yulia and Viktor and I went into his study.

"Thank you," I said. "I wouldn't be where I am without your help."

"You're welcome. And thank you for bringing Rachel to see us. What are you doing before you begin your Residency?"

"Next week, I'm going on ride-alongs with EMS as part of the new program. Then Kris, Rachel, and I are going to Gatlinburg, Tennessee, for ten days."

"When you return, we'd like you to join us for dinner at the country club."

"We'd love to," I replied.

"How are things going other the medical school?"

"I'd say they're good. You saw Rachel, and she's healthy and happy, and developing at a slightly advanced pace."

"Elizaveta was like that as well. She was helping Yulia in the kitchen by age three."

"That doesn't surprise me in the least!"

"The anniversary is on a Saturday this year, and I planned to ask Father Nicholas to conduct a graveside memorial service in the morning."

"If you do that, we'll be there."

"May I ask about you leaving the parish?"

"You may, but Father Nicholas didn't tell you why?"

"No."

"We left because I spoke the truth and was taken to task for doing so."

"About?"

"Oksana and Greg Casper," I replied. "Ghost, as Doctor Casper prefers to be called, felt he was being pressured into converting, which, of course, he was. I pointed out that there is nothing in the canons which required him to be chrismated before the wedding. Oksana didn't have a problem with that, but Father Nicholas did, and confronted me about it. When I pushed back, he said he was tired of my attitude, so, in keeping with him being tired of me telling the truth and acting like a Christian, I announced we were transferring our membership to the cathedral."

Viktor sighed, "I do not understand why Father Nicholas feels it necessary to get into confrontations with you at every turn! Father Roman is your spiritual father and confessor, and if Father Nicholas had a problem with you, he should have taken it up with Father Roman, who, I daresay, would not reprimand you for telling the truth. What did His Grace say?"

"That he was happy to have us at the Cathedral. The incident wasn't even mentioned. The same was true for Father Luke. Of course, Kris is happy, because her parents and sister attend services at the Cathedral."

"Does anyone else know the reason for you transferring your membership?"

"I only spoke to Clarissa about it, and I believe Kris only informed her parents, but she didn't give a reason. I didn't want to put Subdeacon Mark in the middle of things, so I simply let him know Kris and I had talked it through and made the decision. I have no idea what Father Nicholas might have said to him, and I don't want to open a can of worms."

"Wise. Shall we spend some time with my granddaughter?"

"If you can wrest her away from her grandmother!"

Viktor did get a chance to hold Rachel and read a book to her before we left. We arrived home just before Kris, who had brought Lyudmila with her to watch Rachel while Kris and I were at the graduation banquet. About two hours later, with me in a suit and Kris in a formal dress, we left the house and headed to the Holiday Inn where the banquet was being held, a reprise of the banquet at the beginning of medical school.

For this one, we were at the head table because I was class valedictorian, though the downside was that meant sitting with the deans rather than with my classmates. On the positive side of the ledger, Matta had stayed, and I had a chance to speak with him for about ten minutes. After that talk, I was even more convinced that he and Maryam would marry, and very soon. Fran had Jason with her, of course, and Clarissa had Tessa, but both Peter and Nadine had come alone.

The banquet has, as most banquets did, had decent food, but nothing special, and the speeches were, for the most part, simply platitudes and congratulations. The one highlight was when Clarissa was given a special award for achieving the highest test score in the history of McKinley Medical School. Later, I received a certificate and plaque for being valedictorian, and Clarissa received a certificate for being salutatorian. Those awards ended the evening, and Kris and I headed home.

May 27, 1989, McKinley, Ohio

"Your turn today!" I declared when Kris and I got out of bed on Saturday morning.

"Yes, but I start school again in July."

"And when you receive your Master's degree in seven years, I'll still be a Resident!"

"Poor baby," Kris teased.

"Careful, young lady!" I said, trying to sound menacing.

"Or what? You'll throw me in bed and ravish me? Oh, darn!"

"Well, that would be punishment...for me!"

"We could stop doing it, if it's so terrible for you!"

"On second thought..."

"I thought as much!" Kris said mirthfully. "Let's take our shower."

We had our usual busy Saturday morning with band practice, grocery shopping, a trip to the bakery, and then lunch at home. After lunch, we put Rachel down for an early nap, and at 3:00pm, we were at the High School football stadium for Kris' graduation. Rachel and I sat with her parents and Lyudmila, and I thought back to my own High School graduation, when I'd finally had the courage to tell Jocelyn how I felt about her.

That had set off a sequence of events that nobody could have predicted, and our lives had been completely upended by a terrible accident that had nearly cost Jocelyn her life. So many things had happened since then, culminating with sitting in the stands watching my second wife graduate from High School.

After the graduation ceremony, we had a celebratory dinner at the Korolyovs, then went to the Cathedral for Vespers. After Vespers, Kris, Rachel, and I headed home. After we put Rachel to bed, Kris poured us each a glass of wine, and we sat together in the great room.

"To both our graduations!" she said.

"«Ваше здоровье»!" I declared. ("Cheers!")

"«Ваше здоровье»!" Kris replied.

We touched the crystal glasses, and each sipped the red wine.

"What class did you decide to take in July?"

"An English elective -- composition. Mom turned in the paperwork yesterday. They just need my final transcript."

"Did they waive the language requirement?"

"Yes, because I'm trilingual."

"I certainly appreciate your oral skills!"

Kris laughed softly, "I don't think you want me to demonstrate those at Ohio State!"

"Most decidedly not! On the other hand, there's tonight!"

"I will if you will!" Kris said mirthfully.

"You don't have to ask twice!" I replied.

May 28, 1989, Circleville, Ohio

On Sunday, Kris, Rachel, and I went to church, but left immediately following the services, taking Lyudmila with us, so we could get home to meet José, Lara, Subdeacon Mark, Alyssa, Elias, and Serafima to set up for a joint graduation party for Kris, Jocelyn, Clarissa, me, and the rest of our study group, as well as Mark and Alyssa, who were both graduating from Taft.

"It's been quite the month!" Subdeacon Mark observed as he and I set up the grill. "You, Clarissa, and Fran graduating from medical school, Robby finishing his Master's, Kris graduating from High School, and Alyssa and I both finishing our undergrad degrees."

"It has," I agreed. "And for me, the culmination of eight tumultuous years."

"I know there's more to your story from before Alyssa and I met you four years ago, but I've really only heard bits and pieces here and there."

"And depending on where you get your information, it may or may not be accurate."

"You're referring to Father Nicholas, aren't you?"

"I'd rather just leave the statement generic."

"You can tell me if I'm out of line for asking, but what happened?"

I considered my options, and the first and most important thing was that I wasn't clergy, and so was free to speak my mind, even if it contradicted something the bishop said, with the exception of specific points of dogmatic belief. I would, of course, be seen by Father Nicholas as a troublemaker, but evidence suggested he was going to see me that way no matter what I did. And I saw no point in hiding something which would be blatantly obvious when Ghost and Oksana married.

"Greg Casper, Oksana's fiancé, made a comment about being strong-armed into being chrismated, with the implication that it was absolutely necessary to be married. I explained to him that wasn't the case, and that so long as he agreed to allow any kids they have to be baptized, and wouldn't interfere with Oksana taking them to church, the priest could not object to the wedding on canonical grounds.

"I made it clear that the two people who had a say in the matter were Oksana and him -- his decision to be chrismated or not, and her decision to marry someone who wasn't chrismated. Because of that, I was called a 'troublemaker' and when I pointed out that I was following the teachings of the church and wasn't about to back down, Father Nicholas told me he was tired of my attitude. That was, as they say, the last straw.

"You most likely know, at least in a general way, all the other times he got on my case for something I did or said which was not actually problematic. Worse was when he got on my case for things I didn't say or didn't do that I was accused of saying or doing. I don't need to give you the details, but there were numerous instances, including the Nativity before last, that led me to not worship anywhere for a time, and then worship elsewhere for several months."

"Father Nicholas has not confided in me at all the way I believe he confided in you."

"And I suspect that's at least partly because we're friends, though much of the confiding was done after I became a deacon, so it's not directly comparable. How is your relationship with Bishop JOHN?"

"Fine, I guess. I mean, I don't see him nor talk to him as often as you did, but again, that was after you were made a deacon. I basically only see him when he visits or at the twice-a-year clergy meetings, of if I'm needed at the Cathedral for some reason."

"That's true for most deacons, too," I replied. "The only reason I had such close dealings with Vladyka JOHN was because of everything that had happened with Bishop ARKADY."

"Let's just say I'm glad I had nothing to do with any of that."

"I wish that had been the case for me," I said.

I lit the kindling under the coals, which I used so I didn't have to use lighter fluid, and then we went back into the house to join the others, with the number of guests eventually swelling to around fifty.

We had a nice afternoon and evening together, along with plenty of food and fellowship. Maryam and I had a chance to speak, and with a blessing from Kris, we walked to the furthest corner of the backyard to speak privately, but not out of sight of others, to maintain proper decorum.

"He's a great guy," I said. "When he asks, say 'yes'."

Maryam laughed softly, "As if I'd say 'no' to the guy I basically chose! I'm not fickle!"

"That is the last word I'd use for you," I replied. "Do you have a timeframe? I'd like to come to your wedding, if I can swing it."

"I'd guess September or October. Obviously, it has to be before Little Lent, and can't be during the Apostles' Fast or Dormition Fast. Would you drive up?"

"I think I'd fly simply because it would be a whirlwind trip where I'd arrive on Saturday and leave Sunday evening, if possible. And that would all depend on my schedule and if Kylie can take part or all of a shift. You know how tough it is during a PGY1 year."

"That's part of the problem for me, too. But I don't want to wait a whole year before..."

She left the word hanging in the air, and her eyes twinkled, make it absolutely clear to me what she was referring to.

"It is addictive!"

Maryam laughed softly, "Not when I was sixteen, but last year? Yes!"

"I wanted to be addicted at sixteen, but I couldn't find a supplier!"

Maryam laughed hard, "Cute! How are things going with Kris?"

"Very well. We have very different political views, but that has led to some very good conversations, rather than conflict."

"You appear to be very happy."

"I am," I replied. "I still miss Elizaveta, but as we discussed, I had to find a way forward, for Rachel's sake."

"And yours, Mike," Maryam said, touching my arm lightly. "It would have been too easy for you to withdraw and hide behind your cassock. As you've said, 'Monk Michael' was not outside the realm of possibilities, but that wouldn't have been good for you."

"No, it wouldn't."

"Especially for the reason given in Stripes!" she teased.

I laughed hard at the reference to a monk not being wildly fucked by teenage girls that I would never have expected from Maryam, though on second thought, in private, I should have expected it.

"Your private self is VERY different from your public self," I observed.

"As we discussed, for a very good reason," Maryam observed.

"True."

"And I haven't been a teenager for a long time!"

"And yet..." I chuckled. "But setting that aside, I'm going to miss you."

"And I'm going to miss you as well. We'll keep in touch. I let Matta know."

"And I let Kris know as well."

"I'll hug you when I leave, but I wanted to say 'goodbye' privately so I could express just how much I care for you."

"It's mutual."

"Then let's rejoin the others," Maryam suggested.

"Let's."

II. Farewells

May 28, 1989, Circleville, Ohio

"You have NO idea how badly I wanted to stick my tongue out at you at the banquet when I received my award," Clarissa declared when we stood next to each other at the snack table

"I saw the look on your face," I replied. "I can read you like a book!"

"And I can play her like a piano!" Tessa declared.

"Sassy as always!" I replied.

"High praise coming from a nut like you!" Tessa exclaimed.

"He may be a nut, but he's my nut!" Clarissa declared.

"You're lucky I share!" Kris said, coming over to the table.

"She's not interested in THAT!" Tessa teased.

"That I do NOT share!" Kris declared.

"Which works well for all involved, doesn't it?" I suggested.

"It does!" Kris declared. "At some point, the four of us need to talk."

"We do," Clarissa replied, turning serious. "But we have a few years before any decisions have to be made."

"When we come back from Tennessee and you two come back from California, we'll have you over for dinner," Kris said.

"That sounds good," Clarissa replied. "Ten days in Napa Valley is exactly what I need before I start my Residency. We'll bring you a couple of bottles of California wine."

"It's OK for cooking, but not drinking," Kris said with a silly smile.

"Funny," I chuckled, "you were drinking California white the other night."

"You're supposed to be on my side!" Kris protested.

"Good luck with THAT," Clarissa smirked. "Petrovich is going to give you more grief than he gives me, and that's saying something!"

"Who? Me?" I asked innocently.

"Yes, you!" Kris and Clarissa both said simultaneously.

"I think I'm going to go hang out with the guys," I said. "It's safer!"

All three girls laughed, and I made a point of joining Bobby, Ghost, Jason, Elias, Subdeacon Mark, Robby, Peter, Gene, Chris, and Pete.

"Be about twenty minutes early tomorrow morning," Bobby said. "I'll meet you there then and get you set up with a locker and rack, and check you out on your bunker gear and the squad."

"Mike Loucks as a fireman," Robby said, shaking his head.

"Mike Loucks is expressly prohibited from running into burning buildings!" I declared. "I have a provisional paramedic certificate based on my MD and passing the paramedic test, but I am NOT a firefighter!"

"Heck, I don't run into burning buildings," Bobby said. "That hero shit is not my gig!"

"But you would, right?" Ghost asked.

"To save someone if that was necessary?" Bobby responded. "Absolutely. That's why I had full firefighter training. But that's not my job any more than doing routine physicals is your job. That said, the rules expressly prohibit Mike from doing that. But to ride in the squad or on either truck, he has to be checked out in bunker gear. Just being near a fire can be dangerous, especially in farm country, where every fire is a potential explosion or chemical release."

"Bunker gear?" Peter asked.

"It's all the protective equipment we use," Bobby said, "including gloves, helmets, boots, trousers, and coats. Respirators aren't technically part of that, because they weren't traditionally kept in a fireman's bunk, but we generally refer to everything we wear on our person as 'bunker gear'. It's all designed to fit over our uniforms, and the uniforms are designed to be comfortable at the station, and eliminate the need for soft linings for the trousers and coats."

"Do you put them on for every response?" Peter asked.

"Paramedics usually don't. We keep our gear in the squad and put it on if we need it on site. The guys on the truck, except the engineers, all put on their turnout gear before they get on the truck. The engineers' gear is in the cab of their vehicle, and they put it on once we get to the site. We discovered it's safer for them to drive in their station uniforms than wearing all the heavy gear, especially their boots."

"How do you get water when you're out in the boonies?" Peter asked.

"Some we bring with. We have a pair of engines which carry the firefighting crew and all the equipment they need, including hoses, ladders, saws, hooks, the 'Jaws of Life', and all the respiration gear. Each engine carries a thousand gallons of water on board. After that, they draw from any available water source - a hydrant, pond, river, swimming pool, or other water source up to two hundred yards away. The county can also dispatch up to five water tenders that carry three thousand gallons of water.

"In addition to those two, we have our rescue squad, which is a combination ambulance and what you might have seen on Emergency. For a fire, MVA, or HazMat, we respond with all three vehicles; for rescue or medical emergency, we respond with two. In addition to the water, we have extinguishers on all three apparatuses."

"What if the water source is too far away?" Peter inquired.

"A water tender will drive to the water source, fill up, and return. It will deliver the water into what's called a drop tank from which the engines will draw. It's not ideal, but we do what we have to do. We can also draw from cisterns. Some of the big houses northeast of town that aren't on city water and either don't have a well or don't have a reliable well, have cisterns they fill with rainwater or have water delivered, and we can draw from those, too."

"What will you do, Mike?" Jason asked.

"Mostly observe," I replied, "but I'm allowed to do anything I could do as a medical student. That gives me one advantage over Bobby, which is that I'm able to intubate a patient. The paramedics will be trained to do that over the next two years. Me going on a ride-along is the first step in a complete rethinking of providing advanced life support, starting with EMS response. The name change - Emergency Medical Services -- finally acknowledged what paramedics do.

"We've come a long way in twenty years from 'scoop and run' ambulance service to paramedics being trained to do significant medical procedures. Eventually, we'll have trauma physicians available to respond to 'mass casualty' events. I'll be one of the first qualified to do that. They're still working out the malpractice and liability insurance problems."

"Problems?" Robby asked.

"Lawsuits," I replied. "Firefighters are indemnified against basically anything they do by state law, so long as they follow procedures or specific orders from county officials, or in the case of EMTs, from doctors. Doctors, on the other hand, are not, even if they respond to the scene of an accident. We can still be sued, and as such, the hospital has to negotiate with their insurance company for covering me when I'm outside the hospital grounds. I have some coverage if I happen upon an accident or illness, but specifically responding as part of a rescue isn't covered."

Ghost nodded and added, "If there is any topic where you'll find physicians in complete agreement, it's malpractice reform. You can't sue a firefighter for failing to rescue you, or for injuries sustained while rescuing you, but even the slightest adverse outcome can lead to a multi-million dollar settlement from a doctor or hospital, even if they weren't really at fault."

"There is," Doctor Gabriel interjected, "always a chance of adverse outcomes, no matter what we do. A perfect example is the drugs used for intubation. They are standard doses and have no significant contraindications. One person in a 100,000 will have an adverse reaction to them, and one percent of those who have a reaction will die. There is no way to know in advance, and no test we can run because intubation has to occur within ninety seconds for an airway obstruction. So we do it. And get sued if something goes wrong, even if it's beyond anyone's control."

"Has that happened?" Subdeacon Mark asked.

"Not since I've been at Moore," Doctor Gabriel replied. "We had one incident at Cook County, but it was never proved it was the intubation drugs. That said, we do have people who never come out of anesthesia, even with reversing drugs. And there's no way to know in advance. Ditto for pulmonary or cardiac arrest during anesthesia. Even testing can't tell you in advance when that will happen. Again, nobody is at fault, but we pay the price."

"So, what's the solution?" Subdeacon Mark asked.

I smiled, "My wife would say fully socialized medicine with the government paying all claims for actual injury."

"What about negligent doctors?" Elias asked.

"A different problem of a completely different character," Doctor Gabriel replied. "All of us, and I mean physicians and non-physicians, should work together to weed out negligent doctors. You don't need malpractice suits to do that, you need good oversight with a mix of physicians and regular citizens."

"And no lawyers!" Ghost added. "Shakespeare had it right!"

I shook my head, "When Shakespeare had Dick Butcher say 'The first thing we do is kill all the lawyers' he was speaking about how a tyrant establishes an autocracy. But I agree, no lawyers on any review board. And adherence to accepted best practices should be a complete and total defense to any claims of negligence or malpractice."

"What he said!" Doctor Gabriel replied. "Though Mike's idea that we currently have socialized medicine is non-conventional."

"Says the man who works for a government hospital which receives significant funding from taxes!" I countered. "Not to mention the very point of insurance of any kind is to pool funds to socialize the risk. I have State Farm for my auto and home, and it's a mutual insurance company, which means at the end of a year, any excess premiums collected over losses and operating costs are returned to the policy holders, minus any money retained for reserves."

"That's not socialism!" Subdeacon Mark protested.

"No, but it's what people here mean when they say 'socialized medicine'. Most proposals do not call for every doctor to be a government employee or for all hospitals to be publicly owned. The proposals are almost always about 'single payer' in the way Medicare and Medicaid operate -- insurance funded by premiums collected as taxes. True socialism is common ownership of the means of production. That's a VERY different thing. Volvo and Ericsson, despite being Swedish companies, are publicly traded on stock exchanges."

"When did YOU start discussing politics in a serious way?" Ghost asked, sounding surprised.

"When he married Kris!" Robby exclaimed. "She's the 'Red' in his bed!"

"She'd reject that nod to the Soviets," I said. "She and my grandfather have the exact same opinion of the USSR and the Communist Party, despite coming from basically opposite sides. He's a liberal, and she's a socialist, to put it in European terms."

Some of the guests began to leave, including Nadine, who was driving home before heading to California. I walked her to her car, where we exchanged a chaste hug.

"Thank you for everything," she said. "If you're ever in California, look me up at UCLA."

"Absolutely. I suspect you won't be coming back to Ohio anytime soon."

"If I'm going to fly for four hours, I'm going to Hawaii, which is only five hours away!"

"I hear you on that! I'll make it to Hawaii at some point, but that's probably ten years from now. As for California, after speaking with Clarissa and Tessa, Kris is interested in visiting Napa Valley, but that's what? Three hundred miles from LA?"

"Closer to four hundred, I think," Nadine replied.

"Let's keep in touch," I said. "You have my address and phone, so just call or write once you have yours. Fran, Clarissa, and I will all be in the area. I already have Peter's home address and phone number, as he plans to live with his parents for the first year. I have Maryam's apartment address and she'll get me her phone number as soon as she's in Chicago. I'll make sure you get all the information for everyone and be the one to keep up with all the addresses and phone numbers."

"Awesome. Thanks again, Mike. I hope to see you in my OR someday, but vertical, not horizontal!"

"The same for my trauma room!"

We hugged again, and she got into her car and drove away. The scenario repeated itself with Peter about ten minutes later, as he was flying home first thing in the morning.

"Thanks for being there for me for four years," I said.

"I was just about to say the same thing!" Peter replied.

"It was fortuitous that we met at the banquet and then were paired for CPR. I'm glad that happened, and I'm glad you were part of our study group."

"Again, I could say exactly the same thing. Come to Atlanta and I'll show you some real Southern hospitality!"

"It'll be at least a year, for obvious reasons. I'm going to miss you."

"I'm going to miss you as well," Peter replied.

We hugged and slapped each other's backs.

"Take care and stay in touch," I said.

"You, too."

He got into his car, which he'd agreed to sell to a Second Year, and as he drove away, Maryam came out of the house. We'd already said what we needed to say, so we hugged carefully, Maryam smiled, and kissed my cheek.

"I'll see you at your wedding, by hook or by crook," I said. "Have a safe trip."

"Enjoy your belated honeymoon!"

"We will."

Maryam got into her car, backed out of the driveway, and, with a wave, drove off. Once her car was out of sight, I went back into the house. The party wound down around 8:30pm, and several couples stayed to help us clean up. When we finished, they left, then Kris and I put Rachel to bed, and went to bed ourselves.

May 29, 1989, McKinley, Ohio

On Monday morning, even though she didn't have school, Kris had been up early with me for our usual joint shower, to say morning prayers with Rachel, and to have breakfast. I'd kissed them both, then headed to Fire Station #2, which was about two miles from Moore Memorial Hospital.

"Morning, Doc!" Bobby said with a grin when he met me in the small parking lot behind Fire Station. "Welcome to Station #2!"

"Also known as the Second People's Hospital for the Insane!" I said with a grin. "After all, only someone who was truly nuts would make a living by running into burning buildings!"

"You do realize we don't ACTUALLY do that very often, right?" a fireman said, coming over to us.

"Doctor Mike Loucks, Lieutenant Jim Greer."

"Lieutenant," I said, extending my hand.

"Doctor," he replied, shaking my extended hand. "Just call me Jim, please. Usually, only our captain is addressed with his rank."

"How many firefighters are on duty at any given time?" I asked.

"A captain, a lieutenant, two engineers, two firefighter-paramedics, and eight firefighters. There is a battalion commander, but he's responsible for three stations and only responds when multiple fire companies respond. He's based in Station #1."

"Let's get inside and get you settled," Bobby said. "A rack, a locker, and bunker gear. Did you get your steel-toed shoes?"

"UPS delivered them on Friday."

"Safety regs require you to wear those at all times, except in the shower or sleeping."

"Got it."

"Your uniforms are here, and ready for you."

We went into the station and Bobby was greeted by other firefighters, some coming on duty, some going off.

"What happens if a call comes in now? Or if the crews were on a call?"

"Until 7:00am sharp, the crew on duty would respond, and if they were out, they'd stay out until they finished the run or were relieved by another unit."

We went to the back of the station where the dormitory and showers were located, and Bobby showed me the rack and locker I'd been assigned.

"Let's get you into your turnout gear. Once I'm satisfied you know how to wear it, we'll store it in the squad with ours. Put your uniform on first."

I changed out of my 'street clothes' and put on the brand new uniform that was hanging in the locker. Once I had it on, I began to put on the bunker gear. I had reviewed my notes from the training class I had and mostly got things right. Bobby provided pointers as I put on the gear, especially about the flaps which covered the zippers on the turnout coat. Once he was satisfied I'd be able to put the gear on properly, I put on the new shoes I'd ordered. Once they were on, we took the gear to the squad and stored it behind the bench seat in the cab, along with my medical bag. Once we'd done that, he showed me where all the gear was stored in various compartments accessible from the outside, along with what was stored in the ambulance portion of the squad.

"One thing I wondered," I said, "is why you don't have the radio hookup they showed in Emergency where Doctor Bracket or Doctor Early would say 'send us a strip' to get an EKG."

"We didn't have the money LA County did when we started."

"What are your standards for defibrillating?"

"No pulse or no heartbeat. Basically, 'shock and see'. Our new ALS ambulance units will have EKG equipment, and the ability to transmit, but that's next year before they begin delivery, and Moore needs to install the new radio and telemetry equipment."

"And for compromised airways, all you can do is bag at the moment, right?"

"Yes. You brought your bag of tricks with you, right?"

"Yes. I have everything I need for intubation in my medical bag. Has your training been scheduled?"

"No. That starts in September, but they don't have individual schedules out. It's going to take some time to get eighty hours of training in."

"Not to mention the 'luck of the draw' with regard to patients needing intubation. You'll need to do six or eight before an Attending will sign off. Do you know how to read an EKG?"

"I think the correct answer is 'no', because other than what I learned in paramedic school, I have no experience."

"That'll take another chunk of time, probably ten hours to become proficient enough to know when administering a shock will work. That said, you pretty much can't hurt someone by shocking them. And CPR is always indicated, except for a suspected flail chest."

"Let's go meet the guys," he said.

"Any female firefighters? I know there is a female paramedic because I've met Julie."

"Only one female firefighter in the county so far, and she's at Station #1. Julie is at Station #3. Did you know that the first paid fire company was in Cincinnati, and was started in 1853, and while it was all men, there were women volunteers?"

"No, I didn't know that! Did you know the first Residency program in emergency medicine was at UC in 1972?"

Bobby introduced me to the other firefighters, some who I knew by sight from the hospital. I already knew Sam Collins, his partner who I saw regularly at the hospital, and who was one of the few African American members of the Fire Department.

"You know, I never asked, but what do you guys do when you aren't on a run?"

"Depends on the time and the person. Some guys play chess, some play bridge, some read, and some watch TV or tapes. We also have a ping-pong table, free weights, and a treadmill."

"How do you handle meals?"

"Each shift is responsible for their own food. In the galley you'll see cabinets labeled by shift, and we make a grocery run when we need to restock."

"How does that work?"

"Usually an engine crew goes to Kroger. The engineer stays in the truck and the four firefighters and the officer go into the store and do the shopping. If there's a call, the guys in the store are called by walkie-talkie and basically drop everything and respond from there."

"Come to think of it, I've seen that on occasion at Kroger. What now?"

"Relax and wait for the call, exactly as you do in the ER! The only difference is you're coming with us, instead of us coming to you."

"OK. I brought medical journals, so at least for this morning, I'll read. What's the scoop on sleeping?"

"Quiet hours are from 10:00pm to 6:00am, so it's up to you. Did you bring an eye mask?"

"I did. I'm used to sleeping when other people are moving around. I bet it's actually quieter here than in the on-call room at the hospital."

"The guys are pretty good about keeping quiet. Use any of the recliners, couches, or chairs. There aren't any assigned spots except for wherever Brigid decides she wants to sit. You move if she wants the recliner or spot on the couch."

"Does she go on runs?"

"Usually with Lieutenant Greer on the second engine."

"I meant to ask before, but why respond with an engine and the squad for purely medical calls?"

"We learned when we first started that having two extra guys is necessary in moving some patients out of second or third floors, and sometimes we have to remove doors. Having an engine crew along allows us to focus on the victim while the other guys deal with any obstacles, or assist in getting someone out of difficult spots. Think about some of the narrow staircases and how well a stretcher would work. In those cases, we'll use a ladder and take someone out a window in a Stokes basket."

"So Emergency wasn't fiction?"

"It was pretty accurate in most cases. Did you know that engineer Mike Stoker was actually an active LA County Firefighter at Station #69 in Topanga Canyon?"

"No, I didn't."

"Basically, they needed someone who could drive and operate an engine and other apparatus and he held a Screen Actors Guild card. The dispatcher for the series, who you mostly heard over the radio, was LA County Dispatcher Samuel Lanier, and the captain in the first season was LA County Fire Captain Richard 'Dick' Hammer."

"You seem to have had more luck with doctors than Johnny did with nurses!" I chuckled. "How was she this morning?"

"Cranky! But I think that's as much not being able to work as it is Bobby Junior being stubborn."

"I was hoping he'd be born before Kris, Rachel, and I leave on vacation."

"I think Lor is as well!"

A klaxon sounded, followed by a loudspeaker call.

"Station 2; structure fire; County Route 25-A at Ferry Market Road."

Some other details were given in jargon I didn't comprehend, and it certainly wasn't time to ask.

"That's us!" he declared, and I followed him towards the squad while Lieutenant Greer acknowledged the dispatcher.

I chuckled to myself that the only thing missing from his radio acknowledgment was 'KMG-365'. We were first out of the station, as we didn't need to put on bunker gear. I had a general idea of where we were headed, and if memory served, it was a farm, which meant it could be a house, barn, or, more dangerously, a silo. It would, at the speed we were moving, take about eight to ten minutes to get there.

"What's the drill when we arrive?" I asked Sam, who was sitting to my right on the bench seat.

"Assess and treat any victims and wait for the engines for anything else. If there's a need for immediate rescue, we'll gear up and go in; you stay by the squad until we come out or you're directed to do something by the Captain or Lieutenant."

"Got it."

"The only exception," Bobby said as he slowed for an unguarded railroad crossing, "is a simple kitchen fire, where we can use extinguishers. But it's usually too late for that by the time we arrive when we respond to the boonies."

"You have to figure," Sam continued, "that by the time someone calls it in, we're dispatched, and arrive for one of these remote runs, it's twenty minutes. At that point, either the fire is out or fully involved. Old barns and farmhouses go like kindling. Remember, keep your helmet on at all times, even if you aren't wearing the rest of your gear."

"Got it."

As we turned west, I could clearly see smoke rising, and when we reached the crossroads, I saw, true to Sam's prediction, a barn that was fully involved. We stopped about fifty yards away, I grabbed my helmet and medical bag and followed SAm out the right-hand side of the squad.

"Where's the fire engine?" a man of about sixty asked.

"About a minute behind us," Bobby replied. "Anyone in the barn?"

"No, and we got the cows and horses out."

"Anyone hurt?"

"Don't think so. None of my hands were in the barn, and my wife and I got the animals out into the pasture."

The two engines pulled up behind us and the crews set to work. Fortunately, there was a large pond next to the barn that appeared to be fed by a well to draw extra water from. Hoses were deployed and water was directed onto the barn, which I was positive was a total loss. Twenty minutes later, there was no longer any black smoke and fifteen minutes after that, Captain Brinker declared the fire out. He sent one engine back to the station while the other crew checked for any hot spots using axes and hooks.

"Squad 2, County Dispatch! Squad 2, County Dispatch!" the radio chirped.

"Squad 2!" Sam answered.

"MVA; County Road 25-A and Thompson Road; Engine 22 responding with you, ETA eight minutes."

Engine 22 was the second engine, which the captain had ordered back to the station, keeping Engine 21 at the scene of the fire.

Sam acknowledge the radio call and, then said "Let's go! That's about two miles from here."

We clambered back into the squad and five minutes later climbed out at the scene of a single-car accident with the car upside down in a drainage ditch. A Sheriff's cruiser was blocking the road, and we pulled up behind it.

"Two victims; no fire!" the Deputy called out.

"Mike, stay by the squad!" Bobby ordered as he and Sam jumped out and ran over to the vehicle.

I put on my helmet and stood next to the squad while they went over to the car.

"Gear up!" Bobby called back. "We're going to need cervical collars and IVs right away."

I got into my gear, grabbed my medical bag, and then followed Bobby and Sam back to the overturned late 60s Ford LTD. I watched as they quickly assessed the patients, inserted IVs, and cervical collars. The engine pulled up just then and the four firefighters and Lieutenant Greer hopped out and came over to us, while the engineer, Carl Voline, stood by the engine.

"Mike, move back," Lieutenant Greer ordered. "We'll get 'em out for you."

I moved about ten feet away, and Bobby and Sam joined me while the firemen assessed the vehicle. I saw Bobby and Sam removing their gear, so I followed suit. The firefighters pried open the driver's door with a crowbar, but couldn't get the passenger door open, so they extracted both victims via the driver's door.

Bobby, Sam, and I went to check on the victims and neither of them had compromised airways, so I simply observed while the paramedics assessed them. The firefighters brought the two transport gurneys from the squad and carefully transferred the victims, one conscious and one unconscious, to them, then rushed them into the back of the squad.

"With me, Mike!" Sam called out.

I followed him into the back with the patients while Bobby got into the cab. One of the firemen shut the door behind us and pounded on it three times to signal to Bobby to go.

"Assess the patient by you, Mike."

I connected the PulseOx sensor to the teenage male and turned on the monitor, then auscultated the patient's chest and abdomen. He clearly needed oxygen, so I hooked up a mask and set the flow to five liters per minute, then checked his BP. The patient had an obvious broken arm, as well as a serious contusion to his temple, likely responsible for his lack of consciousness, but his belly wasn't rigid and his ribs did not appear to be broken. I got my penlight from my bag and checked his pupils and the right one was blown and the left one sluggish.

"How are your patient's pupils?" I asked.

"Sluggish, major contusion to the chest from the steering wheel. No other apparent injuries. Yours?"

"GCS 6; one pupil blown, the other sluggish. Bobby?" I called out.

"Yeah?"

"Call in and ask for neuro to be standing by."

"Got it!"

He made the radio call and about three minutes later, we pulled into the hospital driveway.

"How do we report vitals?" I asked Sam.

"You and I will do it, otherwise I'd give Bobby the most critical patient bullet."

"Mine goes first," I said.

"You got it, Doc!"

A few seconds later, the squad stopped, Bobby jumped out and hurried to the back of the squad to open the door. I disconnected the PulseOx monitor and Bobby and I got my patient out first.

"Late teen male," I called out. "MVA restrained by lap belt; severe contusion and laceration to the right temple; GCS 6; right pupil blown, left sluggish; BP 80 palp; tachy at 110; PO₂ 93% on five liters; IV saline TKO."

"Trauma 1!" Doctor Gabriel replied. "Neuro consult is waiting for us."

He, Felicity, Jamie, and I rushed the patient into the trauma room and I was about to begin hooking up monitors.

"Mike," Bobby said, "You're a paramedic today. Get the oxygen bottle and we're out of here."

I nodded, and as soon as Jamie had the hospital oxygen hooked up, I grabbed the portable bottle and we left the trauma room.

"Sorry," I said.

"Don't be," Bobby replied. "Those trauma rooms are your natural element, and I expect you to go on autopilot."

"If you need the john, use it now in case we get a call on our way back to the station," Bobby advised.

I took his advice and started to go to the locker room, but realized I wasn't acting as doctor or medical student, so I used the public restroom. When I came out the door, I nearly ran into Ellie.

"I see you decided to join the Fire Department instead of being a doctor?" she teased. "Good!"

"That sounds like sour grapes!" I chuckled. "Can't have it, so I don't want it, and I want it out of my sight?"

"Oh, I want it alright!" she said sexily. "But I know better."

I smiled and nodded, then found Bobby and we headed back to the squad where we met Sam. The three of us got into the cab and headed back to the fire station.

"How long do you usually stay on site for a fire?" I asked.

"Until we're released by the officer in command of the site," Bobby replied. "At that point, we're released for dispatch."

"Out of curiosity, what were you expressly told about what I can and can't do?"

"You're officially an observer unless Sam or I expressly assign you a task, and we're only supposed to do that if we're shorthanded, or like today when we have two patients in the squad."

Which was what I had expected to be the case. That meant barring a mass-casualty event or a need for intubation, I was going to be doing a lot of standing around watching, which was not all that different from my Preceptorships. What I was doing really was just observation, and the real involvement would come in training the paramedics to do additional procedures.

"I figured that was the case," I replied. "The main rationale is for me to get used to Fire Department procedures so I can train you guys to do intubations, hook up EKGs, and perform other procedures when that program starts in the fall."

"That's basically what Captain Brinker said to us," Bobby confirmed.

"I'm curious why you guys didn't try to pry open the doors of the car."

"We do have pry bars and other light equipment in the squad, but by the time he had the cervical collars on and the IVs in, the engine was only about two minutes away. If the car had been on fire, we'd have done the extraction. Otherwise, unless we need to perform immediate CPR, we wait for the firefighters."

"That delay could be sufficient for a victim to die," I countered.

"It's a balancing act," Sam interjected. "We do risk our lives, but it's always a calculated risk. In this case, with that ancient LTD, prying open the door gave complete access. But with a compact car we'd likely have had to cut away parts of the frame to extract the victims, and we simply don't have those tools."

"That makes sense," I replied. "I'm just thinking about the Golden Hour and how much of it elapsed while we were on the scene before we transported the victims."

"I hear you," Sam replied. "But even in the city, it's probably about thirty minutes from the call to the dispatch center until the responding unit arrives at the door of the ambulance bay. You figure six minutes transit time, roughly, each way, so twelve minutes is gone right there. Then assessment, initial treatment, and loading into the squad are at least five minutes, often closer to ten. That's a third of the Golden Hour right there, in perfect conditions. I'm not sure there's much we can reasonably do to speed things up."

"Being able to do more procedures on arrival is the key," I replied. "But some things, like clot-busting drugs, are risky, even in the ED."

"Incremental progress," Bobby said. "You made the point that just over a decade ago, it was still 'scoop and run' ambulance service. Soon we'll add intubation to our repertoire, but the biggest problem, and one for which there isn't a solution beyond saline IV, is blood loss."

"That's a tough problem to solve given the requirements for storing blood and blood products like plasma. I haven't seen any articles on pre-hospital transfusions, but I know the military used them successfully in Korea and Vietnam in aid stations. What do you carry in your drug box?"

"Atropine, albuterol, epinephrine, insulin, morphine, naloxone, and nitroglycerin. We also carry Tylenol, aspirin, and of course saline and lactated Ringer's. We'll add a few drugs when we convert to ALS units, but I'm not sure what those will be."

"I'd speculate at least lidocaine as an anti-arrhythmic plus succinylcholine and etomidate for intubation. Those are the obvious ones. Maybe something like Haldol or midazolam. I'll look into it, actually, because we'll need to know to properly train you guys."

We arrived back at the station and had five more runs before quiet time began, none of which were exciting -- two MIs, two MVAs, and a broken limb. I observed on all of them, as without a proper EKG or drugs, there really wasn't anything I could contribute, and Bobby and Sam knew their job. I quietly said abbreviated evening prayers, put on my mask, and turned in for the night just after 11:00pm.

May 30, 1989, McKinley, Ohio

We had one overnight run, just after 2:00am, for an elderly man who had fallen down the stairs at home and had broken his hip. I managed about six hours' sleep, which was more than I'd get in the hospital. At 7:00am, I left the station and headed home.

"Morning!" Kris exclaimed when I walked in, coming to greet me with a kiss.

"Dada!" Rachel exclaimed, toddling over for her own hug and kiss.

"Breakfast in about fifteen minutes," Kris said.

"OK. I'm going to take a quick shower and put on shorts and a t-shirt."

I did that and was back downstairs in ten minutes.

"How was it?" Kris asked.

"Interesting, as far as it goes. I'm an observer, with the main point being to understand how the guys work and what they encounter, so I'm equipped to train them in the Fall."

"Did you get any sleep?"

"About six hours total. We had a run just after 2:00am and were back at the station about 3:15am. I don't plan to nap or anything today."

"OK. I planned to take Rachel to the park. We'll meet Abigail and her nanny there."

"That sounds like a great plan! Mind if I tag along?"

"Of course not!"

Breakfast was ready a few minutes later, and after we ate, we cleaned up, then said morning prayers. At 9:45am we left for the park, where Rachel and Abigail had a great time playing together for an hour, then we returned home for lunch, and after that, we had a lazy day at home.

III. Field Work

May 31, 1989, Columbus, Ohio

On Tuesday, I joined Bishop JOHN for lunch at the Cathedral at his request.

"Thank you for joining me for lunch," he said after I received his blessing.

"It's my pleasure, Vladyka."

We sat down in the comfortable wingback chairs in his office, he said the prayer of blessing, and we began to eat.

"Was there a specific agenda you had in mind?" I asked.

"No, though I would, if you're willing, like to discuss Father Nicholas."

"I'm not sure I'm the best person to give an opinion."

"I've heard from several people, and without naming names, I'm sure you can deduce who, that they are unhappy that he, in effect, ran you out of the parish."

Viktor was almost a certainty, and it wouldn't surprise me if Subdeacon Mark had spoken with Bishop JOHN. Serafima was also a possibility, as she could no longer see her goddaughter regularly at church. It also wouldn't surprise me if Oksana had not said something given Kris was her cousin and given Doctor Casper -- Ghost -- and I were friends and colleagues.

"I think," I said carefully, "that the last four years have been so stressful for the entire diocese, and Saint Michael specifically, that it's difficult to lay blame at the feet of anyone, except perhaps the deposed Robert Langley. Everything stemmed from his behavior. I am not excusing the response of retired Bishop ARKADY, nor of anyone else, simply pointing to the origins of the problem."

There were also the unproven allegations of sexual impropriety against Bishop ARKADY, which privately I believed, but as they had not been investigated nor had they been proven, I kept that opinion completely to myself.

"You have," Kris said, "on a number of occasions, made the point that while we can't control what others do, we're responsible for our own actions."

"Me and my big mouth!" I chuckled.

"You also have a history of being reluctant to assign blame to others, even when they are clearly at fault."

"Because of my own failings," I replied. "For the most part, I'm too busy trying to remove the log from my own eye. I figure when I achieve complete theosis, and thus synergistic perfection, that's the time to worry about other's faults."

"A Christian attitude with which I cannot find fault, and yet, as episkopos, I have a duty to oversee my diocese and to care for the wellbeing of individuals, parishes, and the diocese as a whole. I appreciate your desire to, in effect, shake the dust from your shoes and move on, but I have no such luxury."

"Permission to speak freely?"

Bishop JOHN laughed softly, then said, "As if I could prevent that! I might as well tell the mountain to go cast itself into the sea!"

"My Residents and Attendings at the hospital would agree with you!"

"You are always free to speak your mind and your heart to me, Misha."

"I'm sure you're well aware of the false allegations and that I don't need to rehash them."

"I'm curious as to why you think Father Nicholas would have considered those allegations valid; if you're willing to share."

"I think the best answer to that is, that at times when I was neither betrothed, married, nor a deacon, celibacy was not my strong suit, something of which Father Nicholas, Father Herman, Father Stephen, and Father Roman are all aware."

"I surmise, then, that you confessed and received absolution for your failing in that regard, and that no transgressions of your marital or diaconal vows occurred."

"That's accurate. And it's that history, along with the whisper campaign about Rachel's caregivers, which led Father Nicholas to not give me the benefit of the doubt, so to speak. The most recent incident had to do with Doctor Greg Casper and his upcoming marriage to Oksana Ivashko.

"Had I remained a deacon and that same situation had been brought to my attention, I'd have spoken to Father Nicholas directly, or to you. But as a layman, I felt it was my place to correct a misunderstanding he had, one which, in my opinion, was created intentionally by Father Nicholas. In my mind, something I heard back in High School when studying the Spanish Inquisition..."

"Which nobody expects, right?" Bishop JOHN interrupted with a twinkle in his eye.

I couldn't help but laugh.

"Well," I replied, "I am sitting in a comfy chair!"

"Sorry to interrupt. Please continue."

"No apology necessary! That's exactly the kind of thing I would do myself! In any event, what was said was 'A man converted against his will is of the same opinion still', and I think that's exactly right. Doctor Casper is attending services regularly, and has no objections of any kind to having his children with Oksana baptized, and has many views which align with the Church.

"The problem, at its root, is he felt compelled to convert. It's my firm belief that had Father Nicholas not adamantly insisted he be chrismated, he might well have chosen to do so voluntarily before the wedding. The pressure bothered him, and, to be honest, was completely inappropriate. It would be one thing if Oksana had made that a requirement, as I did for any girl with whom I was serious; it's a different thing when the priest makes it a condition, when the canons require no such thing."

"You did have a habit of what my protestant friends would call 'missionary dating'."

"So sue me," I chuckled. "But to be honest, it worked with Angie, and if not for her illness, my life would have turned out significantly different. The same is true with regard to Kimiko, where the deciding factor for her was not a rejection of Orthodox, but of American culture, such as it is."

"I can see how, from the perspective of a young Japanese woman, our culture would be too chaotic and foreign. Some of our brethren in Russia would certainly agree."

"The elections in Poland this weekend may well be a major turning point in history," I replied. "If the Communist Party loses power, I would say that the Kremlin wall might bear the prophetic phrase 'mene mene tekel upharsin'. My grandfather certainly thinks this will be the crack in the dam, and that nothing will stop the water from bursting through. The fear, of course, is that the CPSU decides to go out with a bang, not a whimper, and the world is destroyed with fire."

"Lord have mercy that is not the case," Bishop JOHN said. "But returning to your thoughts, are you making an accusation against Father Nicholas?"

"Not formally," I replied. "But it is the case that, from what I can tell from my conversations with Doctor Casper, that Father Nicholas misrepresented the canons and teachings of the Church, if not directly, then by omission. But in the end, the problem was not a disagreement about the approach, or even about the canons, but when he said, and I quote, 'this attitude of yours is very tiring'."

"Said in response to what statement?"

"He asked, after I answered his question about Doctor Casper deciding not to be chrismated before his crowning, why it appeared I was bent on causing trouble."

"I responded in my usual fashion, and concluded with a statement that if my behavior was such a problem, Kris, Rachel, and I would worship at the Cathedral in the future. He said I was being overly dramatic, and I replied that he was being overly critical, as he had been for years. That's when he made the 'very tiring attitude' comment. At that point, I said we were going to transfer our membership."

"By 'usual fashion', I'm going to guess a reference to the canons and the Scriptures?'

"I'd covered the canons before, when I'd raised Doctor Casper's concerns. As for the Scriptures, I pointed out that the established clergy of the day called Jesus a troublemaker and that the secular governments called Saint John Chrysostom a troublemaker. I also mentioned Socrates for good measure. I made it clear I wouldn't apologize for speaking the truth, and that's when I said we'd worship at the Cathedral and the conversation proceeded as described."

"You are not afraid to speak truth to power, which is a positive trait, so long as it's done in love. Was their animosity in your heart when you spoke to Father Nicholas?"

"Probably some," I replied. "I planned to discuss that in detail with Father Roman when I see him on the 24th."

"Good. Then I'll leave that in his capable hands. Do you think Father Nicholas is a good pastor?"

"Generally speaking, yes," I replied. "My one objection was him not quashing the rumors, backbiting, and whisper campaign, which required you to step in."

"Yes, and confidentially, I addressed that privately with Father Nicholas. Do you think he should remain as pastor of Saint Michael?"

"I have two responses, first, that's a decision that is WAY above my pay grade! Second, our tradition is that priests serve the same parish for their entire career, if possible."

"A careful answer, as usual. In your mind, what would be sufficient cause to break with that tradition?"

"If the needs of the diocese were such that the priest's unique skills could be put to better use, or, more rarely, if conditions in a parish necessitated a reassignment. What happened at Holy Transfiguration rose to that level."

"But not Saint Michael?"

"Honestly, I believe more harm than good would be done by transferring Father Nicholas, if that's what you're considering. I am a unique, difficult case, perhaps impossible for a parish priest to manage. Possibly for a bishop as well."

Bishop JOHN laughed heartily, "You are not even close to the most difficult! And that is NOT an invitation to try!"

"Darn," I said flatly.

"In all seriousness, Misha, a parish full of outspoken individuals who promoted love, joy, peace, patience, kindness, goodness, gentleness, and self-control would be far preferable to a quiet parish which did not exemplify Christian morals and ethics. Nobody, even those who might object to your methods, could level an accusation against you for not living your life as a Christian should."

"And yet, I'm a sinner."

"What's the saying?" Bishop JOHN asked with a smile. "Join the club? Not to excuse your sin, but you know as well as I do that the Christian life is not an easy one, and we all miss the mark. The joy of our faith is that God loves us and is there to give us a hand up when we stumble every single time, no matter how often we make a misstep."

I nodded, "Something for which I am eternally grateful. Are you considering moving Father Nicholas?"

"On that, I have to keep my own counsel, though you're a wise man, Misha."

"If I may offer advice..."

"Of course."

"See how things are over the next year with the thorn removed from Father Nicholas' side."

"And instead in Father Luke's?" Bishop JOHN asked mirthfully.

"Because I'm not involved in teaching, almsgiving, serving at the altar, or on the council, I doubt there will be any concerns. I say that as the Dimitrijevics have greeted me cordially, and if anyone has a right to complain, it would be them."

"If I understand correctly, it was Danijela's decision not to move forward."

"It's complicated," I replied. "We had agreed on a decision after the one-year memorial of Elizaveta's repose, and Danijela pushed me to decide before then, mainly because I was still seeing Danika Kurian. It's my belief that either Danijela's grandmother, or mine, pushed her to 'close the deal', as it were, and when I demurred, she broke things off. I did speak to Danijela before I had my second date with Kris, and Danijela rejected my overtures, which I felt left me free to continue with Kris."

"Quite a few words to say 'yes'," Bishop JOHN replied with a smile.

"I know," I replied. "But you also know I'm reluctant to place blame solely on anyone else when I've been involved in the matter."

"Something I wish more people would do."

"I typically have a forest in my eye compared to other's splinters."

"A proper attitude, but one which can be taken too far. Should I, never, as a sinful man, correct a member of my flock who strays?"

"Far be it from me to teach theology to a bishop..."

"So, you're changing then?" Bishop JOHN asked with a sly smile, interrupting me.

I laughed, "OK, so I do have a history of doing that! It's not about being sinless, but about being cognizant of one's own sins, and not holding others to a higher standard than the one to which we hold ourselves."

"Quite so. I know your availability is extremely limited over the next year, but would you have time to be involved in the Orthodox Prison Ministry project?"

That made me suspect Subdeacon Mark had been one of the individuals to speak to Vladyka JOHN, though he and I had discussed the topic back in April.

"I believe back in April you said I should take two years before I became involved in anything like that."

"The topic arose recently," he replied, confirming my thought.

"I intend to visit Frank Bush, if he'll see me, sometime after I return from Tennessee."

"If you're willing, I could commission you as a lay chaplain, which would give you more access. No pressure, and if you say 'no', I'll completely understand. I wouldn't make the commission public, though I would need to inform the Metropolitan. It would also let you, if you chose, serve as a chaplain at the hospital."

"That I cannot do," I replied. "The roles are completely separate for a reason, and need to stay that way. I can minister, when appropriate, but being a chaplain at the hospital would interfere with my role as a trauma physician. The division of labor is a critical component of how the hospital functions."

"Ah, OK. It was only a thought."

"Let me confer with Kris," I replied, "but I'm inclined to accept a commission expressly for prison ministry."

"Good. I take it all is well between Kris and you and Kris and Rachel?"

"Other than my wife being a card-carrying socialist, yes!"

Bishop JOHN laughed, "So, divergent politics aside, there are no concerns?"

"None. Our plan is to have a brother or sister for Rachel in June or July of next year."

"God willing, I look forward to that! Children are a blessing for their parents and for the Church."

"I question that when my little tsarina gets her back up about something!"

"What would you have said in the past? That she's a Russian woman?"

"Oh, that she is! She takes after her mother; both, actually. Though my Franco-Russian wife has a different way of applying her Russianness."

"She's a wonderful young woman."

"She is, and I'm fortunate to be her partner. Or, as she put it, when discussing the difference between Doctor Casper and me, he needed a devoted, loving wife to greet him when he arrives home and I need a partner in crime!"

"She's not wrong!" Bishop JOHN said mirthfully.

"This kind of abuse I can get from Clarissa!" I chuckled. "And soon enough from my daughter!"

"And if them, why not your bishop?"

"I'm not even going to try to answer that!"

"What? Michael Loucks lost for words? Now I can die happy, having seen everything!"

I laughed hard, "This is a side of you I haven't seen before."

"You know the reason why, of course."

I sighed, "Because certain people would get their noses out of joint, similar to how they did with me with regard to Rachel's caregivers and my close female friends."

"It's our cross to bear, Misha. But with you I can, as they used to say, let my hair down."

"It's longer than mine! As is your beard!"

"In all seriousness, you need to trim yours for your masks, right?"

"It helps, but I could let it grow out further. It's only in surgery that I wear a special mask with a beard pocket. In the Emergency Department that's not necessary, and we don't generally mask because it's not a sterile environment in the first place, the way an Operating Room is."

"What about your surgical cap?"

"I wear one designed for women with long hair, but they're all the same color and basic design, so it's not something that makes me stand out. Once I finish my first year of surgical Residency, I can choose my own design. That said, we mostly don't wear surgical caps in trauma."

"What color do you wear?"

"Light blue in the Emergency Department. After my second year, when I start my surgical rotation, I'll wear red to distinguish me from the other doctors in the Emergency Department. Attending surgeons usually wear Dark Blue, but Doctor Cutter wants to distinguish trauma surgeons."

"Doctor Cutter? A surgeon?"

"Not just a surgeon, but the Chief of Surgery! A perfect name! It would be like the Navy having a Doctor McCoy as a ship's physician or a ship's captain named Kirk!"

"Unfortunately, our time is almost up," Vladyka said. "I have a 1:00pm meeting that I simply cannot delay. Please let me know if you'll accept the commission, and I'll send you a proclamation as well as inform the Ohio Bureau of Prisons and the Hayes County Sheriff."

"I'll let you know before I leave for Tennessee."

"Excellent."

We finished our lunch, I received his blessing, then headed home.

May 31, 1989, Circleville, Ohio

"This isn't a backhanded attempt to lure you into accepting ordination, is it?" Kris asked after I explained the bishop's offer.

"No. It's actually neutral in that regard, but after today's meeting, I would wager that Vladyka will elect not to offer to ordain me in three years."

"Why is that?"

"I saw a very different side of him today, one he cannot show anyone who is clergy, and possibly not even his brother bishops."

"How so?"

"What I'm about to say is not something that can be shared with anyone."

"OK," Kris agreed.

"Vladyka treated me like a friend," I replied. "Joking, teasing, and generally being irreverent without being ungodly."

"And that makes you certain he won't ask?"

"Certain? No. Reasonably confident? Yes. Even as close as he and I were when I was a deacon, he was never this way with me. There is a protocol for such conversations, and this is the first one that didn't even come close to following the protocol. If you think about it, who can the bishop have as a true friend? With his brother bishops, he has to follow protocol; the same is true of his behavior when he's with his clergy. And most of the laity would never be willing, or possibly even able, to see His Grace as a man."

"But you, the most spiritual person I know, can?" Kris inquired.

"Actually, that's part of why I can," I replied. "Along with knowing the canons and traditions, I also understand the theology. It also helps that I have an understanding of my own sinful nature, and that is my primary focus."

"I'm sure Rachel will appreciate that when she's a teenager!" Kris teased.

"I may revise my views at that point!" I chuckled.

"I doubt you would do that."

"Of course not," I replied. "We'll teach her the ideal, and do our best to help her make wise choices, but in the end, she has to make her own decisions, just as you and I did, and we'll love her unreservedly. And the same is true for the kids we have in the future. In any event, back to the original question -- do you have any objection to me accepting a commission as a lay chaplain?"

"No. I think it's something you'll be very good at, and I know it's important to you to find a way to serve the Church."

"Then I'll inform him tomorrow. That will help when I try to see Frank Bush after our vacation."

"How do you think that will go?"

"Badly, but I have to try."

June 1, 1989, McKinley, Ohio

On Thursday, the first two hours at the fire station were quiet, but just after 9:00am the station was called to a house fire which required a rescue, with three victims brought out suffering from smoke inhalation.

"Mike, I think this one might have a compromised airway," Rob, one of the firefighters, said carefully setting down an unconscious young girl in front of me. "Soot around her mouth and nose."

I put an oxygen mask on her and turned the flow to maximum, which was ten liters, then quickly auscultated to her lungs. She was moving very little air, so I opened my medical bag and took out my equipment to intubate. I moved so I was in the correct spot, then tilted her head. I saw a lot of mucous.

"Bobby," I called out, "do you have suction?"

"No. It's not something we carry on the rig."

I replaced the mask and quickly considered my options. I had an idea and went to the supply box, got an irrigation syringe as well as an IV tube. Connecting the tube to the hypo was a challenged, but I solved that with a hemostat from my bag. My makeshift suction device worked well enough to clear some of the mucous, which allowed me to visualize the vocal cords and pass the endotracheal tube properly. I connected an Ambu-bag to the tube and held it with one hand while I held the diaphragm of my stethoscope to the young girl's chest. I squeezed the bag a few times and had good breath sounds. Given she had only minor burns and no other obvious injuries, I simply bagged her until Sam was finished assessing his patient, a young boy.

"Bag her while I finish my assessment, please," I requested.

I did that and quickly confirmed that her only immediate problem was smoke inhalation, which bagging would help improve. I connected a PulseOx monitor to her finger and saw that her PO₂ was 88%. A minute later it was 92%, which meant she was in relatively good shape, though she might have lung damage.

"She goes first," I said. "And right away."

"OK," Sam said. "Let's load her and go. The other two are conscious and breathing OK with only minor burns. We'll have the Sheriff bring them in."

We got the girl, who I guess was about thirteen or fourteen, onto the gurney, and loaded her into the squad. Bobby hopped into the front seat, I got into the back, Sam closed the doors, then pounded on them, signaling Bobby to go. As we pulled away, I continued bagging.

"Neat trick with the suction," Bobby called back. "I'll have to remember that."

"Hopefully, your new ALS units will have suction in the kit. Actually, do you have an equipment list?"

"We don't, but somebody in the department has to because the orders were placed at the end of last year."

"Could you get me a copy? It would help with planning your training for later this year if I knew what equipment you'll have."

"I'll speak to Captain Brinker and see what I can do."

I began giving him the vitals, and four minutes later we were at the hospital.

"Approximately fourteen-year-old girl," Bobby called out. "Unconscious at the scene of a structure fire; smoke inhalation with soot in her nose and mouth; intubated; PO₂ 94% with bagging; pulse tachy at 110; BP 130/80; first-degree burns on both arms. Two more with first-degree burns but conscious coming in by Sheriff's cruiser."

We unloaded the girl from the squad and I continued bagging as we moved to Trauma 2.

"Trauma 2!" Doctor Casper said. "You did this, Mike?"

"Yes. I had to rig up suction with an irrigation syringe, an IV tube, and a hemostat to clear mucus to visualize the cords, but then the tube went right in, and I had good bilateral breath sounds. Her PO₂ came up from 88% to 92% bagging and improved from there during transport."

"Excellent work, Doctor!"

"Thanks."

As was the case with every transport, once we were in the trauma room, the doctors, nurses, and medical students took over, and Bobby and I left, meeting Sam who had come in with the Sheriff and the two other victims in the corridor. Once they were both in the capable hands of the medical staff, we paramedics headed back to the station.

"How'd you come up with that idea?" Sam asked.

"In autopsy, when Doctor McKnight wanted to draw fluid from a body cavity, he used a device that is basically like what I put together. The difference is the tube is fitted to the syringe with a proper collar with a screw. The hemostat did the trick, and while I couldn't get a lot of suction, I got enough to allow me to visualize the girl's vocal cords so I could pass the endotracheal tube."

"Would she have made it to the hospital if you hadn't done what you did?"

"I'd say she probably would've, if you'd put her on hi-flow O₂ and transported her right away. Her PO₂ was low, but not dangerously low. In Denver, normal PO₂ would be around 92%, so she wasn't that much lower. There was no cyanosis, which is the key. If her lips or under her fingernails had been blue, that would be a different story. Another four or five points would make it dangerous, or if she was cyanotic from carbon monoxide, toxic fumes, or lung damage. The fact that her PO₂ came up with bagging indicates no serious lung damage. She'll cough up a lot of mucous over the next few days, but after that, she should be OK."

"Losing kids is the toughest," Bobby said.

"I agree," I replied.

"Squad 2, County Dispatch!" the radio squawked.

Sam answered, "Squad 2."

"Respond with Station #3, MVA, Route 50, mile marker 111."

"Squad 2, responding; ETA seven minutes."

"Lord have mercy," I said quietly.

"What?" Bobby asked.

"Jocelyn nearly died eight years ago on that stretch of Route 50."

"Who's that?" Sam asked.

"A close friend from the time I was in kindergarten. An elderly man had a stroke, crossed the center line, and hit her head-on. She was choppered direct to OSU."

"I remember you telling me about that," Bobby said.

"How is she?" Sam asked.

"Married, and she graduated from law school last Friday. She starts her job on Monday, and she and her husband will adopt a baby as soon as one is available."

"She's a really smart woman," Bobby said. "I spoke to her last Sunday. Her husband seems like a good guy."

"He is," I confirmed.

We arrived at the scene after Station #3 and three Sheriff's cruisers. The paramedics from Squad 3 were working on two victims and the firefighters were working to extract at least one other victim from a crushed Ford Escort that had collided with a minivan, which I couldn't identify.

"Is that the Doc?" Ralph, one of the paramedics, called out when I jumped out of our squad.

"Yes," Bobby replied loudly.

"You guys take the ones still in the Ford. Doc, come here!"

I hurried over and knelt down next to the patient.

"Male, mid-30s; unconscious restrained passenger; extracted about a minute ago; cervical collar and backboard; obvious tib/fib and forearm fractures; trouble breathing and difficult to bag; pulse thready, BP 80 palp."

I quickly auscultated the patient and was positive he had a tension pneumothorax and possibly a cardiac tamponade from broken ribs. The problem was, I couldn't put in a chest tube in the field and I couldn't do a pericardiocentesis as I'd only seen them done, never performed one.

"Get him into the squad and let's go. I can't do a chest tube or pericardiocentesis in the field. I'll ride with you and do a complete evaluation so the docs can do an immediate pericardiocentesis. We need someone with us to bag."

"John?!" Ralph called. "Let's load 'em and go!"

With assistance from two firefighters, we got the victims onto gurneys and into the squad. I hopped in and sat on the bench on the side with the patient, along with one of the firefighters from Station #3.

"Just bag as best you can," I instructed as I began my exam.

About two minutes after we pulled away, the patient's PO₂ had dropped to 85% and I detected cyanosis, which greatly concerned me.

"Ralph? ETA?"

"About four minutes, Doc!"

"I don't know that this guy has four minutes."

I felt the squad accelerate, but that wasn't going to cut more than a few seconds off the transit time. I could buy him some time with a needle decompression, but I didn't have the appropriate kit with me. I could improvise, though, as I'd read about how it had been done before specific needle-catheter systems had been developed.

"John, I'm going to try a needle decompression," I said.

"You're the doc, Doc!"

"I need a 12-gauge needle," I said.

"In the compartment to your left."

I opened the compartment and found the needle with the pale blue Luer taper, screwed it onto a syringe, removed the plunger, located the second intercostal space, and carefully pressed the needle into the patient's chest.

"Easier to bag," the firefighter announced

The victim's PO₂ reading came up to 89%. I listened and heard breath sounds on both sides of the patient's chest, and his pulse grew stronger. My solution was temporary at best, but it would ensure the patient at least made it to the hospital. By the time we reached Moore Memorial, the PO₂ reading was 91%.

When we stopped, Ralph hopped out of the cab and called out, "The Doc has the bullet!"

He opened the door, and I jumped out, giving the vitals as we moved the gurney out of the squad.

"Male, mid-30s; unconscious restrained passenger; cervical collar and backboard; tib/fib and forearm fractures; tension pneumo due to fractured ribs; emergency needle decompression performed after cyanosis was observed; pulse tachy at 110; BP 100/60."

"Trauma 3!" Doctor Nielson ordered. "Is that a syringe in his chest?"

"I didn't have a proper chest needle and catheter," I replied as we moved the patient into the hospital with the firefighter continuing to bag. "That was a technique described in JEM."

Doctor Nielson gave orders and, as was protocol, I left the trauma room with the firefighter and John.

"Great save, Doc," John said.

"That's on the list of procedures we'll teach you during your ALS certification. How do I get back?"

"2 is on their way here with the final victim," Ralph said, coming out of Trauma 2.

They left, and I went to the nurses' station to wait for Bobby and Sam. They arrived about four minutes later with the victim who'd been extracted from the Ford Escort by the firefighters, and who was obviously in bad shape as Sam was on the gurney doing chest compressions, and Rick, a firefighter, was bagging.

"That was probably futile," Bobby said when he, Sam, and Rick came out of the trauma room a minute later. "Arrested two minutes out. Major head trauma, plus both legs broken, one compound. The impact was on both driver's sides, obviously high speed, and the minivan driver had an airbag. How was your guy?"

"Tension pneumothorax, I resolved with a needle decompression."

"Good thing you were along. Let's head back to the station."

"Bobby!" Ellie called out. "Your wife just came into OB!"

"Sam, put us out of service for fifteen minutes while I check on Lor."

"Will do!"

"Mind if I tag along?" I asked Bobby.

"Not at all."

Sam made the radio call while I followed Bobby to the elevator that took us up to OB. We stopped at the nurses' station to find out which room Doctor Gibbs was in, then quickly walked there.

"I'm here to deliver your baby!" I announced when we walked in.

"Oh, HELL NO!" Doctor Gibbs replied.

"OK, maybe not," I chuckled as Bobby went over to kiss her.

"How are you, Lor?" he asked.

"Eight minutes apart, but my water broke, so I came in."

"Hi, Loretta," Doctor Alice Carmichael said, coming into the room. "Candace is aware and she'll be over in about an hour, and asked me to manage your delivery. OK with you?"

"So long as you keep the PGY1 in the paramedic getup there the hell away from me!"

"Hi, Mike," Doctor Carmichael said. "What's with the uniform?"

"Paramedic ride-alongs," I replied.

"I need to do an exam," Doctor Carmichael said.

"I'll step out," I announced, and went out into the corridor.

Five minutes later, Bobby came out into the corridor.

"Let's go. I'll come back when relief comes in. Shouldn't be a problem, as Doctor Carmichael thinks four to six hours most likely. Why'd you step out?"

"Because your wife is my mentor," I replied. "And I believe she'd prefer I wasn't in the room."

"You're a doctor!" Bobby protested.

"And yet, we only treat family in extremis and are very careful about treating friends. If you ask your wife, she'll agree with me. Anyway, how does this work for you?"

"Normally, I'd have to trade shifts, but cases like this, I can call the Chief's office and they'll find someone to cover the remainder of this shift."

"You know what I just realized?" I asked. "That you guys have it even worse than I do with regard to knowing what happened with a patient. I usually know if they're going to make it or not by the time we're done in the ED, but you guys drop them off and levae."

"Every once in a while someone stops by the station to thank us for a rescue, but otherwise, you're right -- we mostly don't know. Like you, we're just cogs in the healthcare machine!"

I chuckled, "It does seem like that at times!"

We met Sam in the ED, then headed back to the station where Bobby informed Captain Brinker that Doctor Gibbs was in labor, then called for a relief paramedic. About thirty minutes later, Gabe arrived and Bobby headed to the hospital.

June 2, 1989, Circleville, Ohio

The rest of the shift had been what Sam called routine -- minor injuries and possible heart attacks, and just after 6:00am on Friday morning, Bobby called to say that Bobby Junior had been born at 2:04am and both Doctor Gibbs and the baby were fine. At 7:00am, with the shift turnover, I had weighed visiting Doctor Gibbs, but was positive she'd be tired and cranky, so I'd headed home, where Kris and Rachel greeted me with kisses.

"Did you get any sleep?" Kris asked.

"About five hours total," I replied. "I'll be fine without a nap, though I could take one while Rachel takes hers."

"Go get your shower; breakfast will be ready in fifteen minutes."

I went upstairs, took a quick shower, then put on shorts and a t-shirt and went back down to the kitchen.

"Bobby and Loretta had their baby last night," I said. "Mom and Bobby Junior are both healthy."

"How typical! The man does two minutes of pleasurable work, then the woman carries the baby for nine months and labors and delivers, and the man gets equal credit!"

"Two minutes?! Excuse me?!" I protested.

"And another typical male reaction! Question their virility in even the slightest way and they lose their minds! What little they have of them, anyway!"

I rolled my eyes theatrically, then declared, "I have half a mind to prove you wrong!"

"Half a mind is right!" Kris teased. "But that's still more than most men!"

"Ah, then my decision is made," I said firmly. "Rather than demonstrate my prowess, I shall not bother, as, clearly, my efforts are not appreciated!"

"I didn't say that!" Kris countered. "It's just I want to needle you!"

"And what I have for you is bigger than a needle!"

Kris laughed, "You are a very virile and well-endowed man!"

"Thank you! Perhaps I'll relent and demonstrate after all!"

"In all seriousness, though, that doesn't seem like something you've ever had trouble with."

"No. My problem was one of a libido in overdrive."

"I don't mind," Kris replied with a smile.

"You don't mind?!" I asked with faux outrage.

"You are so easy to wind up, Mike!"

"Or," I said slyly, "I know you want to wind me up, so I play along to make you happy!"

"Wait!" Kris protested. "That's what you do with Clarissa, isn't it?"

"It is! And if you ever tell her, I'm going to be very unhappy!"

IV. It's going to be a very busy year!

June 5, 1989, On the Road to Gatlinburg, Tennessee

"What happens now that you've finished your time with the fire department?" Kris asked as she maneuvered her Tempo onto Ohio Route 23.

"Now I have a full twenty-five days off, and perhaps one or two more, depending on when I have my first shift."

"It doesn't start on the 1st?"

"Not necessarily. If I needed orientation, then it would. But I get paid starting the 1st no matter what."

"Do you know the other new doctors? I mean besides Kylie?"

"I know their names only, and where they're from. I haven't met any of them. Besides Kylie, there are four men and one woman, and one of the guys is from India, but went to medical school at UCLA."

"So, including you, five men and two women?"

"I'm technically not a trauma Resident," I replied. "So of the actual trauma Residents, it's four to two, which is an improvement, given there is only one female Resident, Doctor Billings, and only one female Attending, Doctor Gibbs."

"And you're OK with that?"

"I'll say the same thing I did when a similar question was asked about Taft -- you can only draw from the pool of applicants. My class was about two-to-one male over female, which was an improvement, and the ones behind us were less unbalanced. The most common Match for women in my class was pediatrics, followed by OB, and then going into general practice. Surgery, cardiology, and trauma combined had fewer Matches than pediatrics."

"Why?"

"Part history, part conditioning, part personality traits. And, yes, discrimination, especially in surgery."

"And you put up with that?"

"No, I simply acknowledge it to be true. I have spoken up when and where appropriate, just as I did at Taft. Things are changing, slowly, and the medical school is doing more outreach to women and minorities. But a smallish medical school in south-central Ohio is going to be more white and more male than, say, UCLA, simply because of the demographics. We don't have many Hispanics in the area, nor many Asians, just to identify two minority groups."

"What about what you call African Americans?"

"Not represented at the same percentage as they make up the population, but as Doctor Mertens said when I asked, it's an applicant problem, not an admissions problem. They admit a higher percentage of African American applicants than make up the applicant pool. Not to defend our system, but there must be discrimination in France."

"Mostly against immigrants from Africa, especially from Algeria. I believe the main cause is that many of them are Muslim, and do not agree with the absolute secularism which we maintain in French political life, called «Laïcité». It is very much like what you call 'separation of church and state'."

I shook my head, "I don't think so. In our system, the government is expressly forbidden from creating a national church, and that's it. That's been read to not allow it to favor one faith over the other, and I agree. But other than that, 'Free Exercise' means the government may not interfere with religious practice, but faith may not only be public, but openly influence public policy."

"But the 'wall of separation'?"

"That was Thomas Jefferson, and he's been seriously misinterpreted. In context, Jefferson's concern was being compelled to follow a specific religious practice by law, not that religious people expressed political opinions. And remember, at the time, there were still established churches in individual states, because the original Constitution did not prohibit state governments from having established churches, which they did into the 19th century."

"That make no sense at all!"

"It does if you understand the founding concept of the United States to treat every state similar to a country, albeit with a common foreign policy, a common national currency, a free trade zone, and no border controls. It's similar to the Schengen Agreement, with regard to borders, and the recently passed Single European Act with regard to a free trade zone. And I know there are proposals for a common currency, and there is quite a bit of common foreign policy."

"But you are one country!"

"We are fifty sovereign states," I replied. "And the Constitution delegates limited powers to the federal government. The main political argument in the US since 1789 is just how much power the national government ought to have."

"And what do you think?"

"I think the country is too large to be governed centrally with 'one-size-fits-all' policies. What concerns me in southern Ohio may not concern someone in southern California or in Alaska or in Texas. What we have in common is currency and foreign trade, and, in theory, the ethos of the American Dream, true or not."

"Do you believe in it?"

"My family, on my mom's side, lived it, and I'm a product of it. On my dad's side, they were well-to-do from the time they first arrived in Manhattan in the 17th century. My Russian grandparents came here with nothing except the clothes on their back, a few personal items, and a balalaika."

"The one you have, right?"

"Yes. My grandfather gave it to me about four years ago. It will be Rachel's, if she wants to learn to play, which I hope she will."

"She certainly loves sitting with you when you play!"

"Most girls did!" I said.

"Of course!" Kris said, laughing softly. "Boys who played the guitar attracted girls like bees to a flower!"

"I didn't learn to play until college."

"Poor baby," Kris said flatly. "But going back to Europe, I didn't realize you knew so much about European politics!"

"I've picked it up through reading the newspaper, mostly. Our civics classes here, at least when I was in High School, focused on the American system."

"My High School here didn't offer civics, but we did have a course in principles of government, which, of course, was so out of touch with reality that I couldn't stand it!"

"The usual American mischaracterization of socialism and a denial that we have programs which are, in their essence, socialist, by American definitions."

"Yes, of course! Not to mention treating Marx and Engels as 'class enemies' while denying 'class' theory!"

"Americans do tend to suffer cognitive dissonance on that topic. But I suppose I'm a class enemy because I believe the accumulation of capital is, overall, a good thing."

"We'll work on that!" Kris said lightly.

"And I say 'good luck to you in that endeavor'!"

"Changing subjects, we never really discussed what we'd do in Tennessee."

"I believe we should spend time with Rachel, hike, swim, and make love!"

"How do you think Rachel will respond to a brother or sister?" Kris asked.

"With a sister, I think if we make the point she's a 'big girl' and the 'big sister', she'll be fine. She's not keen on boys at the moment."

"That will change!"

"More than likely, but you know Clarissa, so you know that's not a given."

"And your response?" Kris asked.

"Will be to love my daughter," I said firmly, "no matter what."

"And speaking of Clarissa, we should probably discuss her request, so we're in full agreement before we have dinner with her and Tessa."

"I think, in the end, you have the master trump, and the right to play it."

"I'm not sure that's fair to you," Kris said. "To simply say 'no' without approaching it with an open mind, even if the result were to be the same. What is a partnership if one is a dictator? You do not want to be ruled by me any more than I want to be ruled by you, which is to say not at all!

"You know, because I've said it plainly, that there are only two absolutes -- absolutely no secrets and absolute sexual fidelity. And with regard to sex, I've promised to do anything you want, with you, with no limits and no restrictions, and you've made the same promise. Everything else is open to discussion.

"I reject completely all misogynistic practices, and it would therefore be completely out of line to turn the tables, so to speak. I know you like to tease about women controlling your life, but I hope you know that's not true about me, though I do reserve the right to give you guidance."

I laughed, "Guidance from a Russian woman is FAR more than just a suggestion!"

"Good advice ought to be followed, don't you think?"

"As much as it might sound as if I complain about women controlling my life, it's really not a complaint. As Mr. Sokolov told me before I married Elizaveta, God gives us wives to make us better men. I agree, and I don't feel controlled when you suggest a course of action or a change in behavior. My mom, Jocelyn, Clarissa, and Elizaveta never steered me wrong, even if I didn't always take their advice."

"You don't feel as if I'm trying to control you, do you?"

"No, I don't. You've made your views clear, but you've always been willing to hear my side, and consider my views, needs, and desires. I don't feel at all controlled or limited or restrained by our relationship, with the caveats about secrecy and fidelity, with which I wholeheartedly agree."

"I would hope so! I may not be jealous, but I do not share!"

"I learned to share in kindergarten," I replied with a silly smile.

"NOT THAT WAY!" Kris protested, though she laughed after she said it.

"Well, Jocelyn and I did hang our smocks on the same hook so they wouldn't be lonely at night!"

"You were five!"

"I grew up!"

"Allegedly!" Kris teased.

"Jocelyn and Clarissa would agree with you!"

"You know they're teasing, right?" Kris asked.

"Of course. That said, both of them were instrumental in making me the man I am today."

"So I owe them a debt of gratitude?"

"I don't know that 'owe' is the right term," I replied, "but you certainly should be grateful. There were others, too, especially Angie, who had a major impact as well, though mostly in terms of my views on the horrendous state of mental healthcare."

"That really is a focus for you."

"Some would call it an obsession," I replied. "How is it in France?"

"There are plenty of doctors and plenty of services, and they are covered by our health insurance system, but I cannot say how effective it is because I don't know. Have you decided what to do about the doctor who improperly treated her?"

"I spoke briefly to Lara at the graduation party and she and I will speak with Angie's mom later this month. In the end, it's up to her, as I don't want to put the Stephens through an ordeal they'd prefer to avoid. If she's OK, then we'll file a formal complaint with the Ohio Medical Licensing Board and use the malpractice settlement as proof something happened. We'll probably lose before the Licensing Board, but I think it's worth the time and effort, as does Lara."

"If he's a bad doctor, he ought to be identified as one."

"I agree. I'd prefer his license be yanked, but I've been told time and again that's not going to happen, and I'm going to tilt at that windmill despite being warned not to."

"By the psychiatrist at the hospital, right?"

"Among others. Basically, it would be Mrs. Stephens filing the complaint, and Lara bankrolling the attorney, and me providing guidance and input, but doing my best to stay out of the limelight."

"I'm curious whether you would choose to protect yourself or help Angie?"

"That's a difficult question to answer without understanding the exact risks, which I won't know until they occur. I think the best answer is I won't risk my future medical license, but I would risk alienating doctors and administrators."

"But wouldn't that harm your training?"

"Perhaps in some minor ways, but in the end, the literal worst-case scenario would be that I'd obtain my license as a GP and emulate Doctor Evgeni. But I don't see that happening. The psychiatrist absolutely failed to take Angie's best interest into account and literally ignored or discounted the indications that she might have been on the road to recovery, or, perhaps, stability at a level where she could regain her autonomy."

"I don't understand why that's no longer possible," Kris said.

"In part, because she has to be medicated, but in part because the psychiatrist's actions caused a mental breakdown and pushed Angie back to the exact place she had been at her lowest point. It took literally years of concerted effort to get her off the drugs, which is a prerequisite for obtaining a driving license and applying to have her right of self-determination restored. What happened means that task, which was already difficult, will now be impossible, as they'll point to that relapse as a reason to not release her from the guardianship orders."

"As I said when we first discussed this, that doctor is evil."

"Indeed he is."

June 5, 1989, Gatlinburg, Tennessee

Kris pulled into the drive of the Greystone Lodge in Gatlinburg just after 4:00pm, after an uneventful drive from McKinley. Rachel had slept a good portion of the way, as she often did on longer car rides. She parked, we got out, I took Rachel from her car seat, and we went into the lobby.

"We have a reservation under 'Loucks'," I said to the Reception clerk.

She flipped through cards and selected one.

"Doctor Michael Loucks?" she asked.

That was not how I'd made the reservation, and I smelled a rat, though I didn't know which rat it was.

"Yes, along with my wife and daughter."

"Welcome Doctor Loucks! We have you in one of our family suites for nine nights, departing on the 15th. I see the room rate has been paid. I'll need a credit card imprint for incidentals, please."

I handed over my MasterCard and the clerk took an imprint, then handed it back to me.

"Sign here, please," she said, sliding a registration card to me.

I signed and pushed the card back.

"Two keys?"

"Yes, please."

"Is your luggage in your car?"

"It is."

She tapped a bell, and the bellman came over.

"Doctor and Mrs. Loucks have luggage," she said, handing the bellman the room keys. "Doctor Loucks, we can park your car for you, if you like, and bring you the keys."

"Thank you," I replied.

"Enjoy your stay!"

I handed the car keys to the bellman, and we moved aside to wait for the bellman to retrieve our luggage.

"That American custom is annoying!" Kris said quietly. "As if I'm your property!"

"She could have said 'Doctor and Mrs. Michael Loucks' and made it sound worse," I chuckled. "But we're in the South, so you have to expect people to use traditional terms and make traditional assumptions."

"All that does is perpetuate the problem!"

"Maybe so, but we're on vacation, so just let it go and enjoy the hospitality, please."

The bellman retrieved our bags, then showed us to our suite, which had two bedrooms, one which had a bunk bed with side rails. The bathroom had a large tub and a large shower with a bench. And the main room had a 35" television and stereo system.

"We can move the trundle bed to the main bedroom if you wish," the bellman offered.

"Rachel will be fine in this room," I said.

I tipped the bellman, and he said someone would return with our car keys within ten minutes.

"Someone upgraded the room and paid?" Kris asked.

"Yes. Your parents?"

"No. They wouldn't do that without asking me. Viktor Kozlov?"

"I seriously doubt it," I replied. "If Yulia ever found out, she'd be upset."

"Lara?"

"She's one possible suspect, though, like your parents, she'd have said something. The thing is, the only people I told where we were staying were my mom and Clarissa. If I had to put money on it, either Stefan or my grandfather, or both."

"Does it upset you that they didn't tell you? I mean, whoever did it?"

"No. I'm OK with surprises and unexpected gifts. And that's why I don't think it was Lara, because she knows about your distaste for secrets and surprises. May I suggest you simply accept the gift graciously and let it go? I'll find a way to work your preference into a conversation so it doesn't sound critical but makes the point."

"You don't agree with me, do you?"

"I have a somewhat different opinion, but I support your desire to not have surprises or secrets. So, in the end, we'll do it your way because it's something that's important to you, but not particularly important to me."

"OK. What shall we do until dinner?"

"Well, given the Tsarina slept most of the way here, I'd say we should go to the pool."

"She'll be OK?"

"I don't plan to simply toss her in!" I chuckled. "Let me get her bathing suit on."

"What about her diaper?"

"My mom bought her something called a swimsuit diaper. It's basically plastic pants with a cotton liner and then a top."

I changed Rachel, then went to put on my bathing suit, and stopped dead in my tracks as I saw Kris in a pure white bikini.

"Wow!" I exclaimed.

"Thank you, but you've seen me naked!"

"I have, but sometimes leaving a bit to the imagination is sexy!"

"You don't have to imagine!" Kris protested.

"And yet, I stand by the fact that you look sexy in that bikini!"

There was a knock at the door and the bellman handed me the keys to our car. Once I put the keys with my wallet on the table in the bedroom, Kris, Rachel, and I went to the pool. Rachel didn't know what to make of the kiddie pool at first, but soon was splashing and enjoying the water. We spent about thirty minutes at the pool, and, as I didn't want Rachel to burn, we went back to the room and relaxed until dinner, which we ate in the hotel dining room.

"What do you make of the elections in Poland?" Kris asked as we watched the evening news on television after dinner.

"I think the genie is out of the bottle, so to speak, or Pandora's box has been opened. The repudiation of the Communist government is a major threat to the Kremlin, and Poland is a potential powder keg. All we can do is pray it ends relatively peacefully."

"You worry about the Soviet response?"

"I do. Hungary in 1956 and Prague in 1968 are precedents, though I don't think this would turn out the same way. And when it's obvious they will lose, what do the hard-liners in the Kremlin do? I hope they remember their humanity, but I fear they won't."

"I fear you're right," Kris confirmed.

Later in the evening, we said our evening prayers, and after Rachel went to sleep, Kris and I shared a warm bubble bath, then made love before falling asleep in each other's arms.

June 6, 1989, Gatlinburg, Tennessee

"Should we discuss Clarissa's request?" Kris asked as we cuddled in bed on Tuesday evening after a full-day hike and a nice dinner in Gatlinburg.

"It really does come down to your decision," I said. "I don't have any reason to say 'no'."

"Will you tell me why you want to do it?"

"During Junior year at Taft, when Clarissa and I had recognized we were basically soulmates, but with one glaring impediment, we discussed what kind of future we might have together. The obvious answer was going to medical school together, Matching at the same hospital for our Residencies, and then practicing together. Clarissa made the point that she did want to have a baby some day, and we discussed how that might work.

"Remember, at the time, there was no suggestion I would be a deacon, and my plans for marrying were for after my first year of Residency, at the earliest, with the most likely time being during my third year, given dating during my PGY1 year would be difficult at best, and given the amount of hours I'd be working. Had things gone the way we discussed, without Bishop ARKADY's desire to ordain me, it would have happened before I married, even possibly before I was engaged."

"But Clarissa has the same kind of schedule, right?"

"Yes, but there are ways around it, which Maryam considered when she and I discussed a possible future together. It's entirely possible to delay your Match for a year, which she would have done, but in the end, as you know, we decided that trying to raise a family when we both had eight or more years of Residency was a challenge that we both felt was too great.

"One option Clarissa has considered would be having the procedure done sometime midway through her PGY1 year, and then she could take off six weeks during her PGY2 year. Of course, we'd have had a nanny, but on two above-average salaries, we could have afforded that. Obviously, everything changed when Bishop ARKADY proposed ordaining me, and took everything off the table, as it would have been unacceptable for me to procreate outside of marriage as a deacon, even via artificial insemination."

"Did you discuss it with Elizaveta?"

"There really wasn't a point because it simply could not happen."

"Out of curiosity, did Clarissa consider conceiving the usual way?"

"Considered, but once I married, that was out of the question, for obvious reasons. As she said at the time, the physiology works, even if the desire isn't there."

"And it's something you want?"

"It's something Clarissa wanted that I could do for her," I replied.

"But do you want a baby with her?"

"I'm not sure how to answer that," I replied. "I agreed because it was something I could do for her and with her, but it wasn't something I needed to do, as I obviously could have children with whomever I married. I guess what I'm trying to say is that this isn't something I'd put ahead of my marriage to you."

"Did you discuss how the baby would be raised?"

"Not really, other than I'd want to be involved in raising him or her, though my assumption was that the child would live with Clarissa and her partner, who at the time was unknown. When Clarissa starting dating Abby, the entire thing was called into question because Abby did not like me at all."

"Why?"

"Simply because I was a faithful, practicing Christian. Clarissa reminded her time and again that I was loving and supportive, but Abby could never get past the teachings of the Church on marriage and sexual relationships, even if I didn't try to hold her and Clarissa to those standards. In the end, they broke up and Clarissa started seeing Tessa, though by that time, I was married to Elizaveta and a deacon, so even though Tessa was open to the idea, it was a non-starter."

"So you'd be a dad, but your son or daughter would mostly be raised by Clarissa and Tessa?"

"I suppose," I replied. "As I said, we didn't discuss it in detail because of the things that happened to make it basically out of the question."

"I obviously don't have a problem with Clarissa and Tessa raising a child, either one they conceive with outside help or by adoption."

"Ohio would never let them adopt," I replied. "A stupid policy, but the state makes it tough even for single people to adopt, and gay and lesbian couples are basically refused any opportunity. That said, Clarissa wants to conceive, and I obviously support her desire. It really comes down to a question of whether you can accept the situation. If not, say so now, because otherwise, we'll find ourselves in a very bad place."

"I'm not saying 'yes', but I'm also not saying 'no'," Kris replied. "I think we do need to have our conversation with Clarissa and Tessa, then you and I will discuss what to do. Is that acceptable?"

"Yes, it is, so long as you don't feel compelled or pressured to agree."

"I don't. You know I'll speak my mind!"

"I have no doubt about that at all!"

"Perhaps you'd prefer I did something else with my mouth right now?"

"I would indeed!"

June 15, 1989, on the road to Circleville, Ohio

"Did you enjoy the ten days?" I asked as I pulled out of the Greystone Lodge parking lot.

"I did!" Kris exclaimed. "We probably won't have a vacation like this for a number of years because of your Residency, my work towards my degrees, and having two more children!"

"Charlotte Michelle or John Michael?" I asked.

"Those are the names on which we agreed. It's simply a matter of making one of them!"

"Well, we've had plenty of practice, so it's just a matter of lowering the shield!"

Kris rolled her eyes, "A Star Trek reference with regard to sex?"

"I am fully functional in every way, and capable of multiple techniques; a broad variety of pleasuring."

"Star Trek, again?"

"Commander Data from the first season episode The Naked Now, which was a riff on The Naked Time from the Original Series. Thankfully, I'm not like Wesley, who on a planet where they make love at the drop of a hat, gets arrested for trampling flowers!"

Kris laughed, "You seriously do not like the Wesley Crusher character!"

"He's annoying! Though I do love when Worf tells him how to get laid in the second season episode The Dauphin -- 'Go to her door, beg like a human'!"

"As opposed to?"

"Klingons, where the female roars and throws things while the man reads love poetry...and ducks a lot!"

"And how do you see me? Hmm?"

"You do make wonderful sounds when sufficiently motivated!"

Kris laughed, "«La petite mort» makes me feel SO good!"

"And me, as well!"

"Dada kiss Mama!" Rachel exclaimed from the back seat.

"Not right now, young lady! I'm driving!"

"Do you think she knows what we're talking about?" Kris asked.

"I think she detects the tone of voice we use, not the topic. And we do use a different tone when we're talking about sex. That said, she's pretty smart, and she has been in the room when we've fooled around!"

"Not recently!"

"True, but who knows what goes on in the mind of a toddler? They don't have the language to express themselves. Rachel is just beginning to string more than two words together into what passes for speaking in full sentences. That'll accelerate rapidly in the next few months, and by the time she's two, she'll have several hundred words in her vocabulary and understand how to create proper sentences. At that point, she will be able, as is true of every woman in my life, to tell me exactly what I'm doing wrong!"

Kris laughed, "What do you say? It's the Y chromosome?"

"Or as Jocelyn put it, when describing her boyfriend Karl, Dale, and me -- testosterone poisoning."

"There might be something to that! Men do not always consider the risks associated with their behavior."

"Which is why we pay higher premiums for auto insurance," I replied. "My premium dropped by nearly half when I turned twenty-five. Part of that was driving a muscle car, but most of it was being a male between sixteen and twenty-five."

"Speaking of insurance, I never asked, but how does that work for us with regard to medical care?"

"So long as we see doctors affiliated with the hospital, and receive all our care there, it's covered one hundred percent with a $5 copay on prescriptions and a $10 copay on office visits. If we have to go to a doctor outside the hospital who is not affiliated, or to another hospital, it's covered at 80% up to an out-of-pocket maximum of $1000 per person, or $2500 for the family. You should decline whatever insurance OSU offers students as it cannot be anywhere near as good."

"Then I need to find a primary physician affiliated with the hospital."

"Ask Doctor Forsberg when you see her before we begin trying to make a baby."

"Baby?" Rachel asked.

"Uh oh," I said quietly, and Kris laughed.

"A baby brother or sister for you," I then said aloud. "But not soon."

"No baby!" Rachel declared. "Rachel!"

"Well, that deteriorated quickly," I said quietly to Kris.

"Rachel," Kris said, "Mama and Dada love you lots, but they want to have a baby together."

"NO!" Rachel declared.

"You are not going to win this debate," I said quietly to Kris. "Do you know the difference between terrorists and toddlers?"

"No."

"You can negotiate with terrorists!"

Kris laughed hard, "I can't actually argue with that one, given our daughter's stubbornness!"

"She is a Borodin, through and through!" I declared.

"Stubbornness is OK in some things, not in others," Kris said.

"Determination versus stubbornness," I said. "Determination is good; stubbornness is often problematic."

"True.

"That said, I believe the Tsarina expects her wishes to be carried out!" I chuckled. "Maybe distract her with an Oreo and a juice box?"

Kris retrieved a cookie and a juice box from Rachel's bag and gave it to her, which had the usual effect of distracting Rachel from whatever it was that was annoying her. In the end, in about a year, Kris and I would have our first baby together and Rachel would just have to deal with it.

June 16, 1989, McKinley, Ohio

On Friday morning, Kris and I stayed in bed cuddling until Rachel woke up, then we had breakfast and said our morning prayers together. I called Viktor, and he suggested dinner that evening at the country club, though it wouldn't be in a private room. I checked with Kris, and she agreed, so we confirmed for 6:00pm.

"There's no fasting until after Sunday, right?" Kris asked, looking at the calendar.

"Correct. Even though the calendar shows fasting resumes at Ascension, the practice in our diocese is, as our bishop once put it, to 'party until Pentecost'. And then in two weeks we have an abbreviated Apostles' Fast. And, then, of course, the Dormition Fast for the first fourteen days of August."

"Should we do our shopping today?" Kris suggested. "That way, we won't have to rush tomorrow because of the wedding."

"That makes sense," I replied. "We can also stop at the hospital so I can check my schedule."

"Will it change every month?"

"No. It should be the same for six months, but, obviously, things can change if something were to happen with one of the doctors or they need to adjust staffing based on changes in patient loads. We can go whenever you're ready."

"Then let me dress Rachel and we can go."

Five minutes later, we were in my Mustang on our way to the hospital. I was totally not surprised when Rachel attracted all the attention she could handle, which was a lot. I went to the lounge to check my schedule, but I wasn't on it, then remembered I was officially on the surgical service. I went up to the surgical lounge, saw my name on the schedule, wrote the details in my notebook before returning downstairs. When I walked into the Emergency Department, I saw Kris at the nurses' station where Rachel was the center of attention.

"My first shift starts on Monday, July 3rd at 0600 and runs until 1800 on Tuesday," I said, using military time, which Kris was used to from having lived in Europe. "My next shift starts on Thursday morning, and runs until Friday evening, then I have a twelve-hour-hour shift on Saturday from noon until midnight. I'll be able to attend Vespers on Wednesday and the Divine Liturgy on Sunday, and Friday nights are free, too."

"That seems like the best possible outcome," Kris observed.

"I'm fairly certain Doctor Gibbs accommodated church. There was a note for me from Kylie that she'll cover for me on the afternoon of the 4th so I can play the concernt Code Blue has scheduled at the lake."

"You're going to be very tired!"

"Possibly, but I do want to play. And the fact that I have Friday evenings free means there's a good chance we can play gigs."

"Hi, Mike!" Kylie said, coming up to us. "Hi Kris! Hi Rachel!"

"Thanks for leaving a note about the 4th."

"You're welcome. I confirmed with Doctor Northrup that it's OK, because I'd only have about four hours between the end of my shift and when I have to be back for yours, but it'll work out OK. Did you hear about Tim?"

"No, I was happily completely incommunicado for the past ten days!"

"He failed his rotation and was given the option of dismissal or starting over."

"Rotations or coursework?"

"Coursework. He's a First Year again, as of August 1st."

"We'll see if he learned his lesson or not," I replied. "How does it feel to be a doctor?"

"Not all that different," Kylie replied. "Except I get to assign all the scut to the Third and Fourth Years! I don't get my own trauma cases, but I do get walk-ins to handle on my own. Well, obviously I have to clear things with an Attending, but you know what I mean."

"I do."

"How were your paramedic ride-alongs?"

"Mostly observation, but one intubation and one needle decompression for a pneumothorax."

"I heard about that! Just a large-bore needle and a syringe?"

"They don't carry the correct equipment to do that in the current EMS units. They will carry the necessary equipment in the new ones configured for ALS, which is why we'll train them in procedures starting in August."

"Doctor Baxter?" Nurse Kelly said to Kylie. "Four-year-old with a suspected broken wrist."

"Duty calls! See you in two weeks!"

She left to check on her patient, and I managed to rescue Rachel from the clutch of nurses so that she, Kris, and I could head to Kroger to do our grocery shopping. After Kroger, we stopped at the bakery for fresh bread, bagels, and croissants, then headed home for lunch and a quiet afternoon. Rachel had her nap, and then about 5:45pm we left the house for our dinner with Viktor, Yulia, Geno, Anna, and Viktor Gennadyevich. Little Viktor was his usual rambunctious self and Rachel gave him the evil eye throughout the meal.

"Cousin Viktor's behavior appears to not be to Rachel's liking," Viktor observed as dessert was served.

"I'm surprised she isn't rolling her eyes and saying 'Boys!' the way Elizaveta used to say 'Men!'," I replied. "But he's a healthy, active kid, and obviously would much rather be outside playing than sitting in a formal dining room."

"Just as his father and grandfather would!" Yulia interjected. "Except they'd be playing golf!"

"We'll get Mike out there with us again eventually, though I don't think his schedule as a Resident is conducive to playing golf!"

"It's not," I replied. "It should be better next year, and, of course, during my PGY3, I'll be on a surgical team, which means regular Thursday afternoon golf. The surgeons brook no interference with that tradition!"

"How will that work?" Geno asked. "I mean being what amounts to a surgical Intern but in your third year?"

"I'll participate in some scheduled surgeries for teaching purposes, but my main role will be surgical consults and emergency surgery. Basically, I'll identify surgical cases and then assist with the surgery. That frees up regular surgical Residents to participate in scheduled surgeries and to care for patients on their service. Longer term, that's what I and three other trauma surgeons will do. If the program is as successful as I expect it to be, that will be the norm, and there will be enough trauma surgeons, so no general surgeon has to cover trauma."

"And the new Emergency Medicine wing will be finished right about that time," Viktor said. "We break ground on April 16. The final surveys and permits were completed last week."

"I'm very much looking forward to the 'telemetry beds'," I said. "That, combined with the ALS certification for EMS, is going to make a world of difference in patient care. And being a Level I trauma center will make even more of a difference, though that certification has to wait for the new surgical wing, which won't be finished until 1995."

"We're hoping to advance that by a year, at least," Viktor said. "If we can complete everything by the end of next year, we'll start in early '91 instead of '92."

"How long will construction take for the new ER?" Anna asked.

"It will be about eighteen months until it opens," Viktor said. "They broke ground last week, but some of the equipment has a very long lead time and takes significant time to set up and install."

"What are you doing for the next two weeks, Mike?" Geno asked.

"As little as possible! We have a wedding in Cincinnati tomorrow, then next weekend we're going to the monastery so I can visit with Father Roman. Other than that, just resting and relaxing as a family before my Residency begins and Kris begins her degree work at OSU."

"It's going to be a very busy year!" Kris declared.

"That it is," I agreed.

V. And That Makes ME Happy!

June 17, 1989, Milford, Ohio

On Saturday afternoon, just before 1:00pm, I pulled into the parking lot behind Saint Andrew's Catholic Church in Milford. The lot was between Milford Main, the middle school, the church, and the parochial school attached to the church. Kris got out of the car, I got Rachel from the back seat, and the three of us went around to the front of the church, which faced Route 28.

An usher held the door for us and we walked into a traditional Roman Catholic church, complete with pews and an altar which was set so the priest faced the congregation, rather than facing liturgical east. There were statues, rather than icons, and the closest thing to an icon were the reliefs of the Stations of the Cross. Those reliefs were the only thing which adorned the walls and were austere compared to a typical Orthodox church where the walls were literally covered with icons.

We sat in pews on the groom's side, six rows back from the steps that led to the sanctuary, with me holding Rachel in my lap. Normally, she'd be allowed to crawl around the nave at Saint Michael, but that wasn't possible here with the pews and kneelers and a marble floor rather than rugs, though there was a wedding runner in the center aisle.

"Dada? Down!" Rachel demanded, seemingly reading my mind.

"You have to stay in either Mama's or Dada's lap," I said. "Or sit in the pew."

"NO!" Rachel declared. "DOWN!"

"Having fun, Petrovich?" Clarissa smirked from the aisle next to me.

"Maybe you can reason with my toddler! I certainly can't."

"Rachel, want to come to Aunt Clarissa?" she asked.

"YES! Clarsa!"

"I see where I rank!" I chuckled.

Clarissa took Rachel from me, then she and Tessa moved past to sit to the right of Kris. Rachel looked at me and scowled, and I just shook my head. She certainly had a mind of her own, and there was going to be a serious contest of wills, which, from everything I knew, was normal for the 'Terrible Twos', even though Rachel wasn't quite two.

The wedding service was typical of Roman Catholics, with a nuptial mass, with Father Robert Buschmiller as the celebrant. The Roman mass generally followed the same liturgical order as the Orthodox Divine Liturgy, though somewhat simplified, and they used an organ, which was something that was categorically prohibited in an Orthodox temple.

Sticks was acting as José's best man, and Sierra had only her maid of honor, and just the four of them stood at the altar once Sierra's dad had walked her up the aisle. When the service ended, we filed out of the church and a large group of our friends gathered in the parking lot to decide what to do before the reception. It wouldn't start until 4:00pm, which gave us about two hours to kill. It was in Loveland, about twenty minutes away.

"Is there anything close by to do?" Robby asked.

"The Cincinnati Nature Center is in Goshen," I said, "but by the time we get there, and if we allow for time to get to Loveland, we'd have maybe an hour to walk."

"Why don't we go to Frisch's?" Tessa suggested. "I saw it on Route 50 on the way here."

That was the consensus, though I wondered if they could handle close to two dozen people at once. We headed there, and they did manage to seat all of us, using two large booths and a number of tables pushed together. We couldn't all sit together but it did work, and we all ordered coffee, soft drinks, and a snack of some kind, which for Kris, Rachel, and me was a plate of French fries.

"Perhaps the French fries will improve Rachel's attitude towards you!" Kris suggested.

"Until I enforce the limit of how many she's allowed to have!" I said. "But then she's my mom's problem!"

"I wondered if you were bringing her to the reception," Clarissa said.

"My mom is meeting us at the banquet hall and will keep Rachel until we pick her up after the reception. Kris and I didn't think Rachel would do well sitting for four hours and unable to roam freely. Not to mention some adults do not tolerate toddlers at these kinds of events."

"Clarsa? Fry?" Rachel asked, causing everyone at our table to laugh.

"She knows who's boss," Sophia declared.

"Well, Petrovich?"

"I surrender. I mean, it fits, being married to a French woman!"

"«Придурок»!" Kris exclaimed.

"'Jerk'" Clarissa translated for everyone, resulting in laughter.

"«Je t'aime chérie!»," I said.

Kris smiled and kissed my cheek, knowing I was teasing her. Clarissa fed a very happy Rachel a stream of French fries, and about 3:20pm we all left Frisch's to head to Loveland for the reception.

June 17, 1989, Loveland, Ohio

"Congratulations!" I said to José when I finally had a chance to speak to him at the reception.

"Thanks!" he replied as we exchanged a hug.

"How was your vacation?" he asked.

"Relaxing. I never asked -- where are you two going?"

"We fly to Orlando tomorrow morning for six days at a Disney resort. Ever been?"

"No. I haven't been to many places in the US. In fact, I've been to more European countries than I have states! Ohio, Pennsylvania, Kentucky, Indiana, Illinois, and Michigan is it. How did you swing Disney on short notice?"

"Sierra and her parents had planned a vacation and her parents ceded the room to us. That's why we're going there."

"Cool. I noticed you crossed yourself in Orthodox fashion and I saw the priest raise an eyebrow the first time!"

"I may have been exposed to a bad influence!" José replied with a goofy smile. "It's really too bad you aren't in your «ryassa», because that would really have attracted attention!"

"Which is exactly the opposite of the intent, though you aren't wrong."

"I might even hold up my palm for a blessing!"

I laughed, "Not something a deacon can do, though had I'd been made a monk, there are circumstances where it's appropriate."

"That was about as likely as me being a monk!" José chuckled.

"Believe it or not, without Rachel, I'd have seriously considered it."

"You did take that calling seriously, even if it was your secondary calling."

"True. What I can say, though, is 'May God grant you many years'!"

"Thanks, Mike."

"You're welcome!"

We hugged, and he moved on to the next person he wanted to speak to while I returned to the table where Kris and a group of our friends were sitting. We had an enjoyable time, Kris and I danced, and with her blessing, I danced with Clarissa and Tessa, and when the reception ended, Kris and I headed to my mom's to collect our daughter and then head home.

June 19, 1989, Circleville, Ohio

"Did you have any plans at all for this week?" Kris asked at breakfast on Monday morning. "I mean, besides having dinner with Lara and Nathan tomorrow evening?"

"Nothing beyond spending time with you and Rachel. Well, I'll practice playing my guitar, of course, but that entertains the Tsarina, so it's something she and I can do together."

"What is the plan for the weekend?"

"Father Roman expects us for dinner at the monastery," I replied. "We'll leave just after lunch, which will get us there by 5:00pm. We'll have dinner, attend Vespers, and then I'll spend some time with him. On Sunday we'll attend Matins and the Divine Liturgy, then come home after lunch."

"My sister is looking forward to spending the weekend with Rachel!"

"So she can further corrupt her with French?" I asked.

"Oh, stop!" Kris commanded. "You like my French accent!"

"And you know I like to tease you about being French, even if I do like French kissing!"

"Feel free to demonstrate any time!"

"Dada kiss Mama!" Rachel giggled.

With my wife and daughter ganging up on me, there was only one thing to do! I got up, went around to the other side of the dinette table, and gave Kris a deep French kiss that tasted of maple syrup.

"You know, there's another place that needs a kiss like that!" Kris said sexily.

"I bet it doesn't taste like maple syrup!" I chuckled.

"It could!"

"Perhaps Rachel would like to visit your sister this morning!"

Kris smirked and mimicked picking up a telephone, "Hello, Lyudmila?! I want to have my husband cover my «minou» with maple syrup and lick it off! Could you please watch Rachel?"

I laughed, "And how would she respond to that?"

"She'd laugh, of course. It's not as if she's ignorant of such things! She is French, after all! And it's not as if she doesn't know we make love! I'll call her after we finish breakfast. We'll have to take Rachel to my parents' house, though, as Lyudmila can't drive and my parents are both at work."

"And then pick her up before dinner?"

"Perfect!" Kris agreed.

We finished breakfast, said morning prayers, and then Kris called Lyudmila, who was more than happy to take Rachel for the day. Rachel was happy to see Lyudmila, who was her second favorite after Clarissa, and when we were leaving, Lyudmila called out, "Have fun!".

And fun we had, spending the day either in bed or in the large tub, except for lunch. I preferred chocolate fudge to maple syrup, but that didn't detract from the enjoyment of licking maple syrup off my wife, nor hers from licking it off me, nor from the deep French kiss that followed my release which tasted of Kris, me, and maple syrup.

"Is there anything you want to do that we haven't done?" Kris asked as we lounged in a warm bubble bath late in the afternoon.

"Besides making a baby?" I asked.

"Soon!" Kris said happily. "Is there anything else?"

"No. I think you've noticed how I prefer to make love to you."

"Our sitting position?"

"Yes. And, of course, kissing you all over."

"Especially a very specific place!" Kris exclaimed.

"Yes," I agreed. "Are you asking the question because you want to be...more adventurous?"

"We are not inviting another girl into our bed!" Kris declared.

"Been there, done that!" I chuckled. "But you knew about that."

"I did. I just want you to be as physically satisfied as I am."

"I am sure I am," I replied. "Well, perhaps it's better to say I'm as physically satisfied as I could possibly be. That said, I do enjoy play time like we had today."

"You know, one thing I've never heard is how long into pregnancy you can make love."

"It's more about comfort and desire than anything medical," I replied. "At some point, you simply won't feel like doing it because you're tired, uncomfortable, or just don't want to. Medically, until your water breaks, there is no risk from having intercourse, unless you're in a high-risk situation."

"What would that be?"

"The most common one is elevated blood pressure. That's generally not a serious concern unless it spikes significantly. You'll also retain water, so your feet will swell, and in addition to the obvious weight gain and changes to your abdomen, your breasts may get larger, and will likely be more sensitive. I think the short answer to your question is that up through the second trimester. After that, it'll depend on how your pregnancy progresses, which is different for every woman and even for individual children from the same woman."

"That's not how our textbooks or teachers described it."

"They gave you the statistical norms, which are true for all women as a group, but as I say about diagnosing and treating patients, statistics are not determinative for an individual. All they can do is provide a baseline from which you have to develop an individualized treatment plan. The same is true for pregnancy. Doctor Forsberg will guide you through it."

"Not you?"

"I'm not an OB/GYN! I'm expert at making babies, beyond that, I'll send you to an expert in pre-natal care!"

Kris laughed, "I suppose Rachel is evidence that you are, indeed, able to make a baby!"

"Well, at a minimum, I know the correct physiological activities to create the chance of pregnancy."

Kris laughed again, "In other words, you know how to fuck?"

"Yes. But that's not exactly rocket science!"

"I do like your guided missile when it's in my silo!"

I chuckled, "The missile leaves the silo to function!"

"Oh, stop! I was trying to be silly!"

"And you know I am nothing if not pedantic, and I find that to be funny."

"Of course you do!"

June 20, 1989, Circleville, Ohio

"What's up with Rachel?" Lara asked when Rachel didn't want to be held.

"She's in a mood today," I said. "I think it might be that she hasn't seen any of her friends in daycare for three weeks, and her friend Abigail is in Spain."

"She's going back to daycare, right?"

"Yes. Kris starts classes at OSU in less than two weeks, and Rachel will go to daycare at least three days a week. The other days, at least for July and August, Lyudmila will help out. How is summer school?"

"I have the remedial kids who didn't pass math," Lara said. "Nathan has the ones who failed American government."

"That sounds like fun! Not!"

Nathan laughed, "I do have a few kids who are taking the classes as electives so they can participate in drama and speech, or band and choir, which each occupy one class period per quarter."

"Speaking of band, are you going to be able to play on July 4th?" Lara asked.

"Yes. Kylie is covering for me. It's already arranged with Doctor Northrup."

"I'm still shocked at the hours you have to work," Nathan observed. "Who knew?"

"I certainly didn't until I was at Taft working on my undergrad degree."

"What are you planning to study at OSU, Kris?" Nathan asked.

"Political science, and I'll go for a Master's in Public Administration."

"Where are things with your citizenship application?" Lara asked.

"The papers will be filed on July 5th. Then it's a matter of processing which can take months, though our attorney says that with our situation, it should go relatively quickly."

"The main thing is the investigation," I added. "They will want to ensure this isn't a sham marriage solely for citizenship purposes."

"We'll have to lie, of course!" Kris declared with a silly smile.

"Riiiggghhht!" Lara exclaimed. "As if Mike would do that!"

"I suppose it would depend on the emoluments," I chuckled. "Money and sex with a hot French girl in exchange for marriage to get citizenship? You never know!"

"Oh, please! As if I'd do that with anyone except a real husband!" Kris declared.

"Of course," I said slyly, "I am providing money and sex so Kris can get her citizenship! And that helps her parents, too!"

"As if you would trade sex for anything!" Kris retorted.

"Well, there are plenty of cute female medical students and nursing students!"

"I'll send to France for a guillotine, but it won't be the head above your neck which is chopped off!"

"Ouch!" Nathan said, wincing.

"A food processor was suggested by Elizaveta," Lara smirked.

"Remind me NEVER to piss off a Russian woman!" Nathan said, shaking his head.

"Something learned very quickly by anyone who encounters them," I chuckled. "And that started with my mom for me!"

"Oh, please!" Kris exclaimed. "You prefer Russian women!"

"Maybe," I replied with a sly smile.

"You married Elizaveta, and you considered Maryam, Lara, Oksana, Tasha, Danijela, and Danika, all before choosing me!"

"You might have a point," I chuckled.

There were actually a few more, but Oksana didn't know the extent of my relationships with Sara, Tami, Irina, or Susana, not to mention Sheila, though she'd become Orthodox after the fact. I heard the timer on the oven, so I excused myself and went to the kitchen to check the roast, which was ready, so I asked Kris to help get everything on the table, and a few minutes later, the five of us sat down to eat.

I continued to be impressed by Nathan, and really liked him, and I was reasonably certain he and Lara would marry, and probably soon. He'd been coming to church regularly with Lara, which was a good sign. Given her timeframe for kids, I expected them to marry within a year and start a family soon after.

Rachel didn't get out of her mood, so with agreement from Lara and Nathan, the five of us said evening prayers and we put Rachel to bed a bit earlier than usual.

"You say morning and evening prayers every day?" Nathan asked once Rachel was in bed.

"Mike's fastidious in his prayer life," Lara said before I could answer. "He's been that way since I first met him."

"And long before that," I replied. "My mom was fairly consistent, and my grandfather is like me."

"The only time I regularly prayed was when I was little and prayed the morbid 'Now I lay me down to sleep...' prayer. I mean, who teaches a kid to pray 'if I should die before I wake'?"

"I agree," I replied. "That's the last thing I want Rachel to think about."

"Kris, did your family say regular daily prayers?" Nathan asked.

"Yes, very similar to what Mike and I do now with Rachel. I've done it since I was a baby, so it's normal for me. Lara had a different experience growing up."

"My biological dad and my step-mom generally say evening prayers," Lara said, "though not fastidiously. My stepdad, well, he's irreligious in the extreme."

"How are things with your stepdad?" I asked.

Lara shrugged, "He's convinced I've thrown away my life, but you know I don't see it that way. In the Fall I'll have an after-school club to encourage girls to pursue careers in science or technology."

"Then make sure you get in touch with Taft, and send anyone interested in a medical career to see someone at McKinley Medical school. Our incoming group of Residents in trauma is four guys and two girls, which is double the number in the previous two incoming groups. Only one matched for surgery, and Clarissa is one of two in Internal medicine out of six."

"It starts in grade school," Lara said. "I've been talking to the Superintendent about similar clubs in the elementary school. I also want to have women scientist, engineers, and doctors come in and talk to the kids. I already asked Clarissa."

"Cool. You should try to get in touch with Katy Malenkov. I know she's out in the Bay Area in California, but she comes home fairly often. She'd be a great resource."

"I'll do that. She's working for a company that makes computers, right?"

"Sun Microsystems," I said. "It was started by some guys from Stanford, so that got her an 'in' with them."

"I'll call her mom and get her phone number."

"Let me know if you need any introductions at the medical school or the hospital."

"I will!"

June 24, 1989, Monastery of the Dormition of the Mother of God, Rives Junction, Michigan

"How have you been Michael?" Father Roman asked.

"For the most part, very good."

"And the part that isn't?"

"My most recent interaction with Father Nicholas, which I called you about when it happened."

"First, I will say that comparing yourself to Socrates, Saint John Chrysostom, and Our Lord might actually qualify as overly dramatic, given the circumstances."

"I won't dispute that."

"You are not intemperate, or prone to wild swings of emotion, so I have a theory about why you felt it necessary to speak to your colleague and your response to Father Nicholas. I believe, based on how you described the conversation with Father Nicholas, it was your intent to provoke him so that you had an excuse to transfer to the Cathedral, and lay the blame at his feet."

"Except I didn't actually need a reason, given I'm no longer clergy."

"That's not true, Michael. Well, it's true you didn't need a reason for the bishop; on the other hand, you did need a reason for yourself. You had to justify your actions, and Father Nicholas has been your target of choice for six years. Was he actually being overcritical? Stop to think before you answer, and no self-justification or martyrdom, please."

I took a few moments to consider, and while I certainly agreed I had most likely intentionally provoked Father Nicholas during our conversation, I didn't feel I had spoken to Ghost with any sort of ill intent, though I had known it would create a potential conflict.

The question I was asking myself now was whether I had some personal motive in doing so. I didn't think so, but one of the points of having a «старец» was for him to conduct a deep, spiritual examination, much like a medical exam. Like a medical exam, it was diagnostic, with a goal of determining the root cause of «ἁμαρτία» -- 'missing the mark'.

"I would say that it was not unreasonable for me to challenge Father Nicholas for the way he responded to the false accusations against me."

"And, pray tell, Michael, what do the Scriptures, in which you are so well versed, have to say about that? Think carefully."

I was certain he had two points in mind -- how to respond to false accusers, and the standards for clergy. I carefully considered my response before I spoke.

"Two things come immediately to mind," I said. "First, the Holy Apostle Peter wrote:

Servants, be submissive to your masters with all fear, not only to the good and gentle but also to the harsh. For this is commendable, if because of conscience toward God one endures grief, suffering wrongfully. For what credit is it if, when you are beaten for your faults, you take it patiently? But when you do good and suffer, if you take it patiently, this is commendable before God. For to this you were called, because Christ also suffered for us, leaving us an example, that you should follow His steps:

"Who committed no sin, Nor was deceit found in His mouth";

who, when He was reviled, did not revile in return; when He suffered, He did not threaten, but committed Himself to Him who judges righteously; who Himself bore our sins in His own body on the tree, that we, having died to sins, might live for righteousness--by whose stripes you were healed. For you were like sheep going astray, but have now returned to the Shepherd and Overseer of your souls.

"How much of the Scriptures do you have memorized?" Father Roman asked, interrupting me.

"I don't know," I replied. "If I had to hazard a guess, about half the Psalms and about a third of the New Testament."

"I believe you follow the lectionary for your prayers, correct?"

"Yes. The daily Scripture readings as well as the appointed Psalms."

"Continue..."

"Second, the Holy Apostle Paul wrote to Timothy:

Likewise deacons must be reverent, not double-tongued, not given to much wine, not greedy for money, holding the mystery of the faith with a pure conscience. But let these also first be tested; then let them serve as deacons, being found blameless. Likewise, their wives must be reverent, not slanderers, temperate, faithful in all things. Let deacons be the husbands of one wife, ruling their children and their own houses well. For those who have served well as deacons obtain for themselves a good standing and great boldness in the faith which is in Christ Jesus.

Let no one despise your youth, but be an example to the believers in word, in conduct, in love, in spirit, in faith, in purity. Till I come, give attention to reading, to exhortation, to doctrine. Do not neglect the gift that is in you, which was given to you by prophecy with the laying on of the hands of the eldership.

"If I draw a conclusion from those two passages, I'd say you felt, and perhaps still feel, that you were being taken to task for things which you considered not just right, but righteous and holy."

"The accusations were patently false," I replied.

"I want to say something, and I understand that it, in effect, goes counter to the admonishment to 'have no further care' for any sins you confessed, but would you say that the accusations were patently false, or that they were premature?"

"Ouch," I said reflexively.

"As a student of the Scriptures," Father Roman said with a smile, "what would you say now?"

"I don't have them memorized, but Proverbs has several warnings against even walking past the door of the harlot's or the adulteress' house. Similarly, the Holy Apostle Paul wrote to the Ephesians:

Therefore be imitators of God as dear children. And walk in love, as Christ also has loved us and given Himself for us, an offering and a sacrifice to God for a sweet-smelling aroma.

But fornication and all uncleanness or covetousness, let it not even be named among you, as is fitting for saints; neither filthiness, nor foolish talking, nor coarse jesting, which are not fitting, but rather giving of thanks.

"Did you stop there for a specific reason?" Father Roman asked.

"Yes, I did," I replied. "The point I think you were trying to make is that my behavior, even if correct, called my character into question, something against which Paul warns. Also, despite your caveat about 'have no further care' in this instance, I place myself in God's hands, desiring mercy and love. Or, as Paul writes to the Romans, I know the law, and the law is good when it shows me my sin."

"No quote?"

"I could..."

"Not necessary. What I want to point out is that you were a self-admitted fornicator, and had ample warning, and yet..."

I nodded, "I know."

"Yes, Michael, you know, and yet, even after the false accusations, you were determined to prove them ultimately correct. It was, in fact, only a matter of timing. The question is, why, if you know the following verses, and you have the demonstrated ability to remain chaste, why did you fornicate?"

"Honestly? Because I wanted to."

"Thank you for being forthright. I have to ask, Michael, how you know that you won't simply decide you want to commit adultery?"

"Because, and I say this with the caveat that no specific sin is worse than any other, adultery is of a different character than fornication, because in addition to a sin against the body, it would be a sin against my wife, not to mention a complete betrayal of the commitments I made to her. It's also the case that being married provides an outlet for the desire."

"And you've never once been tempted while you were married?"

"No. And that includes both betrothal periods."

"To what do you attribute that?"

"That I could never countenance of such a breach of trust and violation of my word. And that applies across the board in all my endeavors."

"What would you say your primary philosophy is?"

"I think it can best be distilled into the vow physicians make -- 'first, do no harm'."

"And would you say your actions were harmless?"

"The Orthodox answer is an unequivocal 'no'."

"But you disagree?"

"We teach that all sin harms the sinner spiritually, but concepts of harm are also very personalized."

"In other words, it's how you feel that matters?" Father Roman asked.

"I think what I'm trying to say is that perception matters."

"Yes, it does, as you stated before. But whose perception?"

"God's, of course."

"I feel you were going to make some kind of argument that if your partners consented and didn't feel they had done anything wrong, that absolved you of your sin against them. Does it?"

"No, of course not."

"And does their opinion that it was not sinful actually matter?"

"No, it doesn't."

"So, when you confessed, what was it exactly you repented?"

"My inability to control my desire."

"But that's not true, is it?" Father Roman pressed.

"No," I admitted.

"So you see the source of my concern? You are able, when you choose, to suppress your desire to sin sexually. But you also, at times, have chosen to set aside your ability to remain chaste. I am sure Father Nicholas was aware of that propensity, and again, his comments were premature, but not his concern."

"Are you saying we should return to Saint Michael?"

"That is not my place," Father Roman said. "That's between you and Bishop JOHN. On the other hand, I do believe you should sit down with Father Nicholas and talk this out, but only if you can approach him non-confrontationally. You have a habit, when you are convinced you are right, of being extremely confrontational. I don't believe that's how you practice medicine."

"It's not," I replied. "Being a forceful advocate for my patients is not about confrontation, but collegiality. There is a time when confrontation becomes necessary, but it's a last resort, and only when there is imminent risk of death."

"I'll accept that exception, as I have little experience in emergency medicine. I doubt you believe any lives were at risk during your conversations with Father Nicholas."

"They weren't."

"Are you able to do what I've suggested?"

"Yes."

"Good. As for where you attend services, that is, as I said, between you and Bishop JOHN. My opinion, and it's only that, is you are probably best served spiritually at the cathedral. I'd like you to spend the rest of the evening praying and meditating in the chapel, and to keep the monastic hours overnight."

"Yes, Father."

June 25, 1989, Circleville, Ohio

"I'd like to hear your thinking about your desire to have a baby with Mike as the father," Kris said as she, Clarissa, Tessa, and I relaxed in the great room after dinner.

"I've always wanted to have a baby," Clarissa said. "But once I understood my orientation, I was faced with a serious challenge. Unlike Jocelyn and Gene, the state won't allow Tessa and me to adopt, and, honestly, I'd rather have a baby, if possible. After I met Mike, and came out to him, I considered the possibility that I might have one with Mike, given his stated timing on marriage, which was sometime during Residency.

"Your former bishop made a mess of that, and, despite my orientation, Mike and I actually discussed marriage, but, in the end, I couldn't act contrary to my nature. Mike and I discussed alternatives, and finally I asked if he'd be willing to help me conceive through artificial insemination at the time of my choosing, and he agreed. That was before he began seeing Elizaveta, of course. We had no formal plans at that time, and I wasn't contemplating having a baby before I finished Residency, so nothing was said. Of course, you know what happened after that."

"Alternatives? Besides artificial insemination and marriage?"

"Every possible option, including thinking outside the box," Clarissa said. "From conceiving naturally to some kind of setup where I was legally married to Mike and Tessa lived with us."

Kris laughed, "And Mike would be allowed to have sex with both of you, of course!"

"On occasion," Clarissa replied. "But rarely with me, and possibly only to conceive. And that was the thing that Mike couldn't countenance, besides the problems that it would cause at church. I absolutely could have sex with a guy to conceive, and Tessa is bisexual, but Mike needed, and needs, a traditional relationship. And that was something I couldn't ever give him, as much as I might have wanted to."

"Were you going to acknowledge Mike as the baby's father?" Kris asked.

"That's not something we had decided, but Mike was strongly in favor of not keeping it a secret. He would, I'm positive, have insisted on his name being on the birth certificate."

"What about baptism?"

"Without question," Clarissa replied. "I know how important that is to Mike, and you know Tessa and I attend regularly at Saint Michael, though we don't go every Sunday. Whatever other considerations we'd make, we'd raise a child I had by Mike in the Orthodox Church because I know he'd have it no other way."

"What about raising him or her?" Kris inquired.

"We didn't get deeply into that conversation, though we did agree that my partner and I would be the primary caregivers. That was before I met Tessa, by the way."

"Mike made me aware of that."

"What do you think?" Tessa asked, speaking up for the first time.

"As I said to Mike, we'd speak with you, then he and I would discuss it and come to a decision together. As I said to him, I haven't made up my mind one way or the other as yet. How would you see things developing over the years?"

"I'd imagine Mike would be involved," Tessa said, "and that a child Clarissa and I were raising would spend time with the two of you and Mike's other kids. They'd be half-siblings, and I think they should spend time together."

"Out of curiosity, would you have allowed Mike and Clarissa to conceive naturally?"

"Yes, because, and please don't take this the wrong way, it would be about facilitating a baby, not about pleasure, though physiology being what it is, that might end up as part of it. Well, for Mike it's basically necessary, but you know what I mean. And the agreement Clarissa and I have allows expressly for that one possibility, though with Mike being married, it's obviously out of the question for him."

"But not for you?"

"I don't have any specific moral objection to extramarital sex of any kind, so long as both partners consent, and it fits within whatever relationships the individuals have. In other words, who has sex with whom isn't my business, and if a married man has a 'hall pass', then that's between him and his wife. Mike, for practical purposes, has the same view."

"How so?" Kris asked.

"She's referring to my non-judgmental approach," I interjected. "In other words, even if I have specific moral objections to certain behaviors, I tend to mind my own business and not interfere. I won't violate my own firmly held beliefs, but I also won't impose them on anyone else. You and I have a very specific understanding of the boundaries and I not only agreed to them, I endorse them and believe they are correct. But they aren't the only answer to the question. Add to that my own behavior, and as the saying goes, people who live in glass houses shouldn't throw stones."

"Why not quote the Scripture?" Kris asked.

"I can answer," Clarissa said quickly. "Because he knows that they don't carry the same weight with Tessa and me that they do with you and others who are practicing Christians."

"Are you a Christian?" Kris asked.

"I suppose the best answer is that I was baptized in the name of the Trinity, and I believe the basic moral teachings of Jesus, but I'm not sure about anything else."

"She's an agnostic," I said. "Much as I am. The difference is, I default to what the Church teaches to be true, where Clarissa is skeptical."

"WAIT!" Kris protested. "You're agnostic?!"

I smiled, "The word means 'I do not know' and that is my philosophical position. Or, to put it in Scriptural terms -- I do believe, help my unbelief."

"So you have doubts?" Kris asked.

"I've always had doubts," I replied. "It stems from being a scientist at heart, and someone who approaches almost everything with rigorous logic."

"That's what makes Mike a great doctor," Clarissa said. "Single-minded, clear thinking, and not swayed by emotion. I think the parallel with Doubting Thomas is apt -- Mike needs to see the proof to say he 'knows' and until such time he'll say that he's agnostic."

"You never shared that with me, Mike," Kris said disapprovingly.

"I should have," I admitted. "That said, it has no practical effect on anything at all with regard to me being Orthodox, or faithfully praying and attending church."

"Yes, but it is very much about who you are," Kris said. "We can discuss this later."

"OK," I agreed.

"Clarissa, do you have anything else you want me to consider?" Kris asked.

"Just that I love Mike more than anyone on the planet, something of which Tessa is aware. He is, without question, my soul mate, but the universe played a cruel trick on us, if you will, in that I was born lesbian. Or, as Mike irreverently put it, I like pussy just as much as he does!"

"He does like it a lot!" Kris said lightly. "And that makes ME happy!"

VI. I'm Sure You Can!

June 25, 1989, Circleville, Ohio

"Why didn't you feel it necessary to share your true feelings with me?" Kris asked after Clarissa and Tessa left, and after we'd said evening prayers, and put Rachel to bed.

"Because I didn't feel they were particularly relevant, nor did I feel they affected our relationship in any way. I faithfully attend church, faithfully say daily prayers, was ordained a deacon, even though I was laicized, and I'm a catechist, even if I haven't taught in some time."

"Did Elizaveta know?"

"No. Only two people knew -- Clarissa and Lara; Clarissa, before I married Elizaveta; Lara after Elizaveta reposed. And Lara only knew because it came up in the context of a conversation where I referenced Jonah being swallowed by the whale. Lara asked me if I believed that happened and the discussion led to me comparing myself to Doubting Thomas. Clarissa knew because she knew literally everything."

"Because you believe you're soul mates?"

"That was the conclusion we came to, but there was an insurmountable obstacle."

"Just as there was with Angie, yes?"

"Yes. And you know what happened with Elizaveta."

"Are you trying to tell me something?" Kris asked with an arched eyebrow.

"Only that there has been adversity with every young woman with whom I had a deep relationship."

"But isn't that true of all deep relationships?" Kris asked. "Every couple encounters challenges or obstacles and has to overcome them."

"That's true, but I believe I have more baggage than the average spouse."

"If we assume that's true, it's still the case that you chose to be with me. I don't see it as some might, that I was some kind of consolation prize, rather that you saved the best for last, so to speak. You and I both knew immediately that we were meant to be together. And, I know something important which I didn't know then."

"What's that?"

"That you love me! You even said so! In French!"

"I did, though in context..."

Kris put her finger to my lips, "Did you mean it?"

"Yes."

"Then nothing else matters. I know you believe Angie is your one, true love, that you and Clarissa believe you are each other's soul mate, and that you loved Elizaveta. But none of that interferes with the fact that you chose me and that you love me. And I knew it before you said it."

"You're handling all of this very well," I said.

"If you expected differently, you wouldn't have married me."

"True."

"Is there anything about you that Clarissa knows that I don't know? I mean, besides things which are purely related to being doctors."

I considered, and I didn't think so, except for one very specific set of facts.

"Other than knowing most, if not all, of the girls I dated, no."

Kris smirked, "And by 'dated' you mean 'fucked'?"

I laughed, "No, there's a shorter list she knows of the young women with whom I was intimate. I didn't run to her with 'after action reports', but she was an astute observer."

"I know I've agreed not to ask this question, and I fully understand if you refuse to answer, but you and Angie?"

"A single serious kiss. That kiss was when I had the first inkling of her problem, but had zero context to understand what I was observing."

"When did you find out?"

"She wasn't definitively diagnosed until 1984, and that kiss was in Fall 1981. The first serious symptoms showed up in Spring 1982, but it took a long time, a couple of breakdowns, erratic behavior, and eventual hospitalization to definitively diagnose her. Looking back from 1985, the signs were obvious, starting in High School, though I didn't meet her until Freshman year at Taft."

"You hoped she'd recover?"

"Yes, though it was unlikely. That said, she did show signs of recovery until the «мудак» who was treating her decided to intentionally destroy her."

"And he's still practicing, right?"

"Yes. How we proceed will be discussed when we have dinner with the Stephens on Thursday. I'm positive Mrs. Stephens will agree to proceed with a malpractice claim to the State Medical Licensing Board."

"But you don't think you can win, do you?"

"I suppose it depends on what we consider a victory," I replied. "But we're off track from our conversation."

"I think," Kris said, "that Clarissa is what I've heard described as a 'work wife'."

I laughed, "I've never heard that phrase before!"

"My dad heard it at work, about two co-workers. He asked what it meant and then described it for us at dinner that evening as a platonic relationship between a male and female co-worker that takes on aspects of a marriage because they spend so much time working together."

"I'm sure Tessa will be amused that Clarissa has a 'work husband'. But you know it's deeper than that."

"I don't think there's a good description that works, because 'friends' or even 'dear friends' isn't sufficient. And she was one of your main sources of advice, even after you married Elizaveta. From what I can tell, she's been more circumspect about offering advice with regard to me. I surmise that's because I'm, and please do not take this the wrong way, older and more mature."

"Elizaveta was mature for her age," I countered. "What I would say is that she was naïve, not immature, and that her worldview was much, hmm, narrower, I suppose, than yours. We had some struggles at first due to that."

"I surmise that she was uncomfortable with your past behavior?"

"Yes, but that was partly my fault for soft-pedaling how extensive my experience was. That led her to look at all my female friends with a jaundiced eye."

Well, except for Clarissa, because that was something I couldn't reveal to Elizaveta.

Kris smiled and her eyes twinkled, "I simply assume you've fucked every single female you're friends with, and then some!"

"Seriously?" I asked, instantly concerned she might suspect I'd been with Clarissa.

"No, of course not!" Kris said, laughing. "But that's the behavior you just ascribed to Elizaveta, at least indirectly."

"I guess I did, didn't I?"

"Yes, you did. How did she deal with you treating female patients?"

"Not well, if it involved any kind of intimate exams. She had a difficult time differentiating between medical and sexual contexts, and was a bit prudish about sex, except with me in private. Well, after a few days of marriage."

Kris smirked, "What's the American phrase? Having your brains fucked out? That does change one's perspective!"

"You were NOT naïve!"

"No, but I also had zero experience."

"While that's true, you were far better educated and informed. But back to the original topic -- do you want to discuss my agnosticism or Clarissa's request?"

"I'm not sure which is more pressing, actually."

"Why? Nothing has changed in my practice or in my faith from the time you met me. And leaving aside the problems with Bishop ARKADY and the discord at Holy Transfiguration, I'm basically back to where I was before Elizaveta reposed. Fundamentally, saying 'I do not know' has no practical effect on the expression of my faith nor on my belief in an eschaton of union with God."

"Heaven?" Kris asked.

"If you mean in the way it's usually conceived as a place, no, I don't believe that. It's a state of being, and I think the ultimate proof of my point, which is a theologoumenon or private theological opinion, is found in the Icon of the Last Judgment where the same river of fire bathes the saved and the damned. There is no difference between their eternal states except that the saved love God and the damned do not. It is not a place, but the direct experience of the energies of God."

"That is not what the Church teaches," Kris protested.

"Which is why I said it's a theologoumenon. The church has no dogmatic opinion, and before you ask about the Creed, it says «τοὺς οὐρανούς» in Greek, which can be understood as 'the heavens', which makes sense given the Apostles reported that Christ ascended. You know, like a missile leaving a silo!"

"Oh, stop!" Kris said, laughing and shaking her head.

"Hey, I'm not the one who made that analogy! And you know how pedantic I am!"

"I do," Kris said, rolling her eyes. "But in all seriousness, do you have other theologoumenon?"

"More than you can shake a stick at!" I declared. "But as I've said to the few people with whom I've shared those, in any church-related context, I speak the party line. Lara once asked me about Jonah, and I said that in church, I will unequivocally state that Jonah was swallowed by a whale, and I believe that it literally happened. Outside of church, though, I will only state that it's a metaphor for being swallowed up by the world and allowing it to deter you from your ministry."

"How can you have it both ways?"

"That's basically the same question everyone I've expressed my thinking to asks. It depends on whether I am evaluating with the «nous», the eyes of the soul, or to use shorthand, as Mike the scientist and physician. The thing is, that's Orthodox, and we refer to things as 'mysteries', in the sense they are hidden from us, which is the original meaning of the word, not in the sense they are 'mysterious'."

"But if you don't believe..." Kris said, sounding confused.

"I do believe; help my unbelief! I honestly don't think we're going to resolve this tonight, because it's such a deep-seated philosophical position that I have only discussed with a few people, and even then, only in a cursory way."

"Father Roman doesn't know?"

"No. We're not there yet. He's doing triage, which has been true from the first time I met him."

"You didn't say what you two discussed."

"My inability to control my passions, to put it politely."

"Being a boy, to put it succinctly," Kris replied.

"Or, as numerous women said to me, mostly in jest, being a pig."

"Mostly in jest?"

"Yes. I did treat the young women with...let me start over. From a secular and social point of view, I always treated them with respect, I simply took advantage of the multitude of opportunities which presented themselves to a future doctor who played the guitar. Father Roman would, of course, disagree with that assessment that I treated them with respect."

"Because you tempted them into sin?"

"It was a two-way street," I replied. "And not much tempting was necessary on either side. Father Roman's point, and that of the Church, would be that the act of fornication is innately disrespectful to both participants. Father Roman's concern, and it's valid, is that I willfully engaged in fornication when I had the demonstrated ability to remain chaste."

"You were, as they say, a perfect gentleman during our betrothal. And a perfect lover afterwards."

"I was always a perfect gentleman," I replied. "That's what attracted the young women. Please be honest, were you thinking about sex before we married?"

"From the first second I met you!" Kris exclaimed.

"It was mutual! Shall we discuss Clarissa's request?"

"You realize she really wants to conceive naturally, right?"

I nodded, "That was the initial discussion, and had Bishop ARKADY not intervened, that is probably what would have happened. Obviously, that can't happen now."

"Obviously. I don't have a problem with her request, but I think you need to have a clear agreement about it."

"I can't imagine ever disagreeing with Clarissa on anything."

Kris smiled, "Unlike me?"

"Clarissa isn't a socialist!"

Kris smiled, "Nobody's perfect! But in all seriousness, it's not just Clarissa."

"Tessa?"

"And Clarissa's parents. It's not that I expect trouble, but you have to make sure everything is in order, similar to how you did with Rachel and me."

"I'll discuss it with Clarissa, and with Stefan."

"What will he say?"

"Who knows? But it'll be a few years down the road. I'm more interested in what Bishop JOHN will say."

"What do you think?"

"I have no idea, but it will be interesting like so much else in my life."

"I can think of something interesting to do now!"

"And whatever might that be?" I asked.

"As if you don't know!"

"Let's go upstairs and see if we can figure it out."

"I'm sure you can!"

June 27, Southern Ohio Correctional Facility, Lucasville, Ohio

"I'm here to see a prisoner, Frank Bush," I said to the guard at the gate to the prison.

"I'll need to see some identification, please."

I handed over my driver's license, along with the chaplaincy ID that I'd received in the mail on Saturday.

"Profession?" he asked.

"Medical doctor," I replied.

"Doctor and clergy?" he asked.

"Lay chaplain," I replied.

"Relation to the prisoner?"

"No blood relation," I replied. "He murdered my friend."

He raised an eyebrow but didn't say anything.

"Are you carrying any weapons, anything that could be used as a weapon, or any contraband?"

"No."

"When I buzz you through, walk straight up the path to the building and go inside. Don't dawdle or step off the path. When you enter the building, approach the desk and present your ID. Have a good day."

"Thank you."

I heard a buzz, pulled the gate door open, walked through, and walked briskly to the door of the building. When I entered, I removed my fedora and approached the Plexiglass window.

"Doctor Michael Loucks to see prisoner Frank Bush," I said, handing over my ID.

"Good morning. I have you on the visitors list. Have you visited a prisoner here in the past?"

"No."

"OK. I need to go through a series of questions with you, you'll need to be searched, and then pass through a metal detector. You'll meet the prisoner in the visitor's room; the usual thirty-minute limit is waived for chaplains. As a chaplain, you're permitted to see the prisoner's cell, and to use the chapel. First, state your complete name, spell your last name, and provide your date of birth, place of birth, your full address, and your phone number."

I was tempted to ask if he was unable to read the information on my driver's license, but given I actually wanted to get inside, being a smart ass was not the right approach.

"Michael Peter Loucks; L-O-U-C-K-S; born 02–02–1963 in Rutherford, Ohio," I said, then provided my address and phone number.

"Have you ever been convicted of a felony?"

"No."

"Have you ever been arrested or charged with a felony offense?"

"No."

"Do you associate with known criminals, whether or not they've been convicted?"

"In my job, I treat anyone who presents at the Emergency Department, so I can't say. Outside of the hospital, I don't knowingly associate with anyone who has ever been arrested or who I would call a 'criminal'."

"I'll put down 'no'," he said. "Are you carrying with you any firearm, knife, or other weapon, or implement that could be used as a weapon?"

"The only thing in my pockets are my wallet and keys," I replied. "My stepdad is an attorney and advised me to carry nothing except those with me."

"Good advice. You will need to leave those in a locker. Are you carrying anything else with you? A bible, prayer book, or other religious items?"

"I wear my baptismal cross around my neck, but otherwise, no."

"OK. I'll keep your ID cards until you're ready to leave, and return them, along with your other property. I have a form you need to read and sign. The top part lists the prison rules. If you violate any of them, even in a minor way, you'll be asked to leave. The bottom part lists things which are considered criminal activity. If you violate any of those, you will immediately be arrested and charged. Please initial each line in both sections, then sign and date at the bottom."

I accepted the form and skimmed it, then read through it a second time more carefully. There was nothing in either part that concerned me, so I signed the form, dated it, initialed each line, then slid it back to the guard. The guard compared my signature with my driver's license, then used a paperclip to attach the ID cards to the form.

"When the buzzer sounds," he said, "pull open the door, step through, and wait. Once the first door closes, a second buzzer will sound. Pull open the door in front of you, and step through, then wait for the guard to give you instructions. Do not cross the red tape on the floor without being instructed to do so."

"I understand," I said, then moved over to the door.

The buzzer sounded, and I pulled open the heavy metal door, stepped through, then allowed it to shut behind me. I heard loud clicks as the locks reengaged, then waited for the buzzer to sound again. When it did, I pulled open the second door of the 'man trap', then stepped through, stopping before I crossed the red tape on the floor.

"Good morning, Sir," the guard said. "Please step to your right, away from the door, and wait."

I did as instructed, and he came over to me with a small basket. I put my wallet and keys in it, having left my watch in the glove compartment of my Mustang, along with my «chokti». He set the basket aside, then had me walk through a metal detector which pinged.

"What metal do you have on you?" he asked.

"My baptismal cross," I replied.

"Would you show me?"

I nodded, unbuttoned my polo shirt, and lifted the cross from beneath my undershirt.

"Just let it hang down, please," he said. "And hold your arms out."

I did, and he picked up a wand and swiped around me, with it triggering for both the cross and my belt buckle.

"I haven't seen a cross like that before," he said.

"It's a Russian soldier's cross," I replied.

"Loucks isn't Russian, is it?"

"No, it's Dutch. My mom is of Russian descent, and I'm a member of the Russian Orthodox Church."

"OK. I need to frisk you to check for anything which might not be detected by the machine or wand."

I nodded, and he frisked me quickly. I was tempted to say something about not buying me a drink before he ran his hands over my groin, but his job was, at least in that regard, similar to mine -- it had zero to do with sex, and everything to do with doing his job correctly.

"I'll put your wallet and keys in locker #4," he said.

He handed me a small cardboard disc with '4' imprinted on it, which I put in my pocket, then put my wallet and keys into a locker and closed the door, but didn't lock it. I was amused by the fact that he didn't lock it, but given where I was, it wasn't as if someone was going to break in and steal the thirty bucks or so I had in my wallet or my car keys.

"I'm going to escort you to the visitor's room. You have a bit more leeway as a chaplain, in that you're permitted to sit next to, rather than across from the prisoner, and can make physical contact for purposes of prayer, but you need to inform the guard on duty before you do that. Generally, your conversation needs to be audible, but you are permitted to speak quietly for a brief period for penitential purposes. Understood?"

"Yes, I understand," I replied.

"Then follow me, please."

He led me down a hall through another pair of doors configured as a 'man trap', which we were buzzed through, then down another hall to a heavy metal door, which he unlocked and ushered me through. A guard inside directed me to a simple metal stool on one side of a simple metal table, which was on a pedestal. I sat down and waited, and about five minutes later, Frank Bush, dressed in orange prison overalls, was led to the table.

"How are you?" I asked.

"How do you think I am?"

"I suppose that depends on how you mean. Are you getting enough to eat and getting exercise?"

"Yes."

"And you have sufficient reading material and access to a television?"

"Yes."

"Any medical problems?" I asked.

"No."

"Then I believe my answer would be 'as well as can be expected, given the circumstances'. And if any of those things were not acceptable, I'd do my best to rectify them."

"Why?"

"Because," I said, with a soft, friendly smile, "it's the Christian thing to do. I can do nothing else."

"I'm going to hell," he said firmly.

I shook my head, "That's only true if you want to go there. God does not send anyone to hell; we send ourselves. Does that mean you don't pray or attend services?"

"To what end? Nothing I can do can change my eternal fate, and I'm sure not getting out of here standing up."

"These facilities used to be called 'penitentiaries'," I said. "And with good reason. May I ask what you do all day?"

"My prison job is in the laundry, which is three hours every morning. I eat, watch TV, read, play chess, and, when it's nice enough, go out in the yard."

"I played competitive chess in High School, but haven't played much since."

Well, if you didn't count the 'strip chess' games with Grace Simmons!

"Do you have visitors?" I asked.

He shook his head, "No. My wife divorced me, which probably doesn't surprise you. I haven't seen my son or daughter since the trial."

"Melissa Matched, a year late, for internal medicine, at a regional medical center in eastern Kentucky."

"I didn't know that. Does that make you angry?"

"Why should it?" I asked. "She'll succeed or fail, and if she succeeds, it will be because she learned her lesson and reformed. You can do that, too."

"I was convicted of murder," he countered.

"I won't belabor the point, but I'll ask you to recall what Jesus said to Dismas, the penitent thief - 'this day, you will be with me in Paradise'."

"The Bible doesn't name him."

"No, it doesn't. It also doesn't contain a list of books to be included, which comes from tradition. I'm sure you remember the debate I had with Reverend Saddler."

"That fool had no grasp of the Scriptures," Frank Bush said, shaking his head.

"Do you want me to get in touch with Melissa?"

"I doubt she even cares," he replied.

"Well, I care."

"Why?"

"For the same reason I gave before," I replied. "It really is the Christian thing to do."

"Where did you Match?" he asked, changing the subject. "Moore Memorial?"

"Yes, for trauma surgery. My Residency begins on Saturday."

"Top of your class?"

"Yes."

"Melissa said you were extremely intelligent."

I shrugged, "That's only a small part of it. Hard work, dedication, and selfless service are the key to success. And that will determine if Melissa succeeds or fails. Do I have your permission to contact her on your behalf?"

"It won't do any good, but do it if you want to."

"Would you be OK with me visiting you each month?"

"Why?" he asked.

"To play chess, talk, and to give you hope."

"Hope for what? I'll never leave this place upright, and when I do, where I'm going is far worse than any punishment the State of Ohio can mete out."

"Then to talk and play chess."

"Again, why?"

"Because, whatever else may or may not be true, it's the right thing to do. One sinner to another."

"I suppose if we're going to spend eternity together in Hell, an hour a month is OK."

I wasn't going to take his bait.

"I'd like to see your cell and then visit the chapel with you."

"You don't stop, do you?"

"If you won't let me pray for you, then pray for me."

"The only one who would listen to my requests is the devil himself."

"The Scriptures say that God causes the rain to fall both for the just and the unjust. As I said, I'm as much a sinner as you are, so in one sense, we're in the same boat."

"One taking us directly to the gates of Hell without a return ticket."

"AC/DC might have been on a highway to hell, but there is an off ramp. Let me speak to the guard."

I got up and walked over to the guard, explained what I wanted, and after he used his radio to verify that I was, indeed, a chaplain, he escorted Frank and me to a cell in 'C Block'. It was, as I had expected, austere in the extreme, but it was what I didn't see on Frank's shelf that stood out -- he didn't have a Bible.

As I thought about it, that was actually a good thing at the moment, as the only thing he would find there would be condemnation. As a Five Point Calvinist, he'd find no solace and no refuge, despite the Scriptures being full of examples of God's love and mercy.

"Is there anything you need?" I asked. "Or that you want?"

"There's a new Tom Clancy novel that will be released in August. It takes forever for the prison to get new books."

"As soon as it's released, I'll get you a copy."

"You need to have it shipped directly from the bookstore," he said. "You can't carry it in."

"OK. I'll do that. Shall we go to the chapel?"

"You're bound and determined."

"As I said, if not for you, then for me."

The guard led us to the small chapel, which, thankfully, was empty.

"I'm going to say an abbreviated form of the Trisagion prayers, and then Psalm 50, which you know as Psalm 51."

"Why do you use a different numbering system?"

"Because we follow the numbering system in the most ancient texts, which are the Greek versions of the Jewish Scriptures used by Christians from the earliest times. Those differ from the later Hebrew manuscripts, which were never used by Christians before scholarship overrode tradition."

"What are those prayers you mentioned?"

"A formula," I replied. "Not all that different from the one you would have used in your Church, except that there are set petitions before the free-form ones."

I said the prayers while Frank Bush stood quietly next to me. Because he was silent, I gave the responses to the prayers and petitions, and when I completed the abbreviated set, I recited Psalm 50 from memory.

"Next time I visit," I said. "I'd like to play chess, if you're willing."

"Why not?" he asked. "It'll break up the monotony."

"May I leave you with one thought?"

"What's that?"

"If you ask for my forgiveness, I'll give it unreservedly."

"Why would you do that?"

"Because it's the right thing to do."

June 27, McKinley, Ohio

"Doctor," Clarissa said with a smirk when I walked into Frisch's after driving back to McKinley from my visit with Frank Bush.

"Doctor," I replied, then added, "all we need is a third for the Three Stooges routine!"

"True!"

The waitress seated us in a booth and we ordered right away.

"How did it go?" Clarissa asked after the waitress brought us our Cokes.

"Let's just say that it's not a place I'd like to spend a lot of time."

"No kidding! But I meant your conversation?"

"I'd say he's remorseful, but he's also convinced he's going directly to Hell, do not pass 'Go', do not collect $200."

"And you offered a 'Get Out of Hell Free' card?"

I shook my head, "He's not ready to hear the Gospel at this point. That'll take some time, and maybe it'll turn out to be a fruitless endeavor on my part, but that's not the point."

"You're a better person than I am, Petrovich," Clarissa said. "I couldn't do it."

"I'm not better than you, Lissa; we're all in the same boat. And while I know it's trite to say -- I can do all things through Christ who strengthens me."

"Speaking of that, how did things go with Kris after your surprise revelation about your interior life?"

"She was unhappy I hadn't shared that with her, but as I explained, it has no practical effect on the expression of my faith or of my belief in an eschaton of union with God. It did lead to a moment of sheer terror, though."

"How so?"

"Through a winding conversation, we discussed Elizaveta's insecurity based on my past partners and that she looked at all my female friends with a jaundiced eye."

"Except me!" Clarissa exclaimed. "She never even suspected."

"No, she didn't, and I had that thought when I made that comment. Kris' response nearly caused me to have a heart attack. She said, with her eyes twinkling, that she simply assumed that I'd fucked every single female I'm friends with, and then some!"

"WHOA!" Clarissa gasped. "She knows about us?"

"That was my concern, but when I asked if she was serious, she said she wasn't, and she said that was basically what I'd implied to Elizaveta."

"That's a relief. How do you think she'd respond?"

"Given how mature and open-minded she is, and the fact she called you my 'work wife', I'd say she'd have a serious problem with me not telling her, but not actually be surprised that it had happened. And that's the neat trap I've built for myself."

"Now that you know her well enough, you could tell her, but you can't tell her because she'd be very upset that you kept it from her, and that would create a serious problem."

"That is the trap. Damned if I do, potentially damned if I don't, because I didn't trust her enough to tell her at first. But the trap is even deeper."

"How so?"

"If she, at some point, decides that you and I have been together, and I haven't told her, then it'll be even worse than if I had told her after keeping it a secret. And I completely understand her 'no secrets' rule and why it makes so much sense. But, as I said, I'm trapped."

"I'm not sure what to advise, Petrovich. Did you discuss my request?"

"Kris said it was obvious you wanted to conceive naturally."

Clarissa laughed, "And she shut that down immediately, right?"

"Actually, I did, saying that I understood that was your preference but that it obviously couldn't happen now."

"I think she might suspect."

"I think if she did, she'd say something," I replied. "She's not one to stay silent or try to test me. With Kris, what you see is what you get."

"I bet!" Clarissa smirked. "She's hot! Tessa agrees!"

"There are no foursomes in our future, Lissa!"

"Darn," Clarissa replied flatly.

"Uh-huh."

"So, what did she say?"

"She's amenable to your request, but insisted I make sure we have a clear understanding of how things will work going forward."

"You mean with church?"

"That, and what you might call parental rights between an unmarried couple. Obviously, if, God forbid, something were to happen to you and Tessa, I'd want to ensure that legally nobody could interfere in my son or daughter being with Kris and me."

"Which is why you had Kris legally adopt Rachel."

"Exactly. Now, there is literally nothing that anyone could do if something happened to me."

"You mean Yulia?"

"She was the main reason, yes. And our joint wills appoint Elias and Serafima as guardians, with Subdeacon Mark and Alyssa being backups. My grandfather is our executor, with Jocelyn as backup."

"I don't have a problem with any of that."

"You need to discuss it with Tessa so that there aren't any questions. All four of us have to be on the same page and some of it has to be in legal documents. That said, we have plenty of time, right?"

"Yes. There's no point in trying before the end of PGY2. I'm thinking midway through PGY3 would be the right time to start, given it can take several attempts."

"That works for me. Discuss it with Tessa, especially how often you'll attend church, and if you're OK with Serafima and Elias as godparents, and once you two are of the same mind, the four of us will discuss it, and I'll have Stefan draw up the appropriate paperwork."

"Great!" Clarissa declared. "I'm excited!"

"Because you don't have to actually sleep with me to get it done!" I chuckled.

Clarissa rolled her eyes, "I enjoyed the closeness, if not the physical act, though that was pleasurable in it's own way. You know that making love with you was about being spiritually together, not you penetrating me."

"I do," I replied. "But I'm also not going to deny that I found it extremely physically pleasurable."

"Because you're a guy!" Clarissa smirked.

"Right, because you don't like orgasms at all!"

"You do admit it was a very different thing than your other lovers, right?"

"Of course. You're special to me in a way nobody else is."

"And yet, I can't hold a candle to Angie," Clarissa siad wistfully. "Nobody can."

"The universe is a truly fucked-up place," I sighed. "At times, I wonder if it's Loki who is running things rather than God."

"I can see that," Clarissa replied. "It does, at times, seem like a cruel joke -- Sandy, Lee, and Elizaveta."

"Yeah," I replied, thinking of my friends and my first wife.

The waitress brought our food, I said the blessing, and we began eating.

"Are you going to see Frank Bush again?"

"Yes. Once a month to play chess and talk. Nobody has been to see him since he was incarcerated."

"Does that surprise you?"

"Not really, when I think about it. His wife divorced him, neither of his kids has been to see him, and nobody from his church would visit because he's reprobate."

"I do NOT understand that."

"Sadly, I do. It's what happens when you give a French lawyer a copy of the Scriptures, he ignores the entire tradition of the Church, and comes up with his own private theology. His Institutes of the Christian Religion read more like a legal treatise than a theological text, which should come as no surprise, given Jehan Cauvin was a lawyer!"

"I take it that's his French name?"

"In Middle French," I replied. "It's Jean Calvin in modern French, and John Calvin in English. He published first in Latin, then later in French, which fit the notion that scholarly and theological work should be in Latin first, and one's mother tongue second. Luther's Disputation on the Power and Efficacy of Indulgences, better known as the Ninety-five Theses, was in Latin, and was later translated into German."

"Your instant recall of that kind of information is pretty amazing. It's no wonder you were an excellent student."

"We're still technically students, Doctor Saunders! Do you have a medical license? I don't."

"I'll get mine before you get yours!"

"True, given I need two years of surgical Residency before I can take my Boards, and I have two years of trauma before I begin that part."

"Ready for your first shift on Saturday?"

"Champing at the bit! I've enjoyed the time with Kris and Rachel, but I need to be back in the hospital and Rachel needs to see her friends. She's been in a mood and was asking for Abigail."

"They're in Spain, right?"

"Yes, though Joel could only stay two weeks. Milena, Abigail, Anicka, and Derek are there for a month or so."

"That was a fun visit."

"It was. Someday we'll do it again. With our kids."

"I like the sound of that."

"Me, too."

We finished our meal and walked out to the parking lot.

"I think I have to tell Kris," I said. "The risk of her finding out at some point in the future is too great. I'll take my lumps now, rather than risk something fatal to our marriage."

Clarissa was silent for a moment.

"Let me tell her. And tell her I swore you to absolute secrecy."

"She might change her mind," I said.

"Better now than a massive blowup at some point in the future, don't you think?"

"Let me think about it, OK? I'll tell you on Sunday at church."

"Sounds good."

We hugged, and once Clarissa had gotten into her car, I got into mine and headed home.

VII. Red Scrubs

June 29, 1989, Greater Cincinnati, Ohio

"Hi, Ang," I said when she greeted Kris, Rachel, and me at the door.

"Hi, Mike! May I hold Rachel?"

"That's up to her," I replied. "She's discovering her independence!"

"She's almost two, right?" Mrs. Stephens asked from behind Angie.

"At the end of August," I replied as I handed a willing Rachel to Angie.

Kris and I followed Angie as she carried Rachel into the living room, and once Angie was settled, I left the three girls and joined Mrs. Stephens in the kitchen. Mr. Stephens joined us a moment later.

"First," she said, "you should call us Marjorie and Ken."

"And you should continue to call me Mike," I replied. "Are you willing to proceed with the formal complaint to the medical board?"

"Yes," Ken replied firmly. "My only question is who'll be paying the attorney."

"A close friend who has the resources and wishes to remain anonymous," I replied. "I already spoke to my stepdad, and he recommended an attorney from his firm who specializes in malpractice. My friend will pay the bill directly."

"What do we need to do?" Marjorie asked.

"The attorney, Tom Kirkland, will call you in the next few days. He'll want to gather any records you have, and he'll likely subpoena files from Doctor Mercer and Doctor Greenberg. Stefan will provide him copies of the depositions and the settlement agreement."

"And that doesn't prevent us from doing this?" Ken asked.

"No. It says you won't take any legal action, and you aren't. The Ohio Medical Licensing Board is an administrative body, not a judicial one. Doctor Greenberg may try to make that argument, but according to Stefan it's a settled principle in Ohio courts that actions by licensing boards are administrative."

"Do you think he'll have his license revoked?" Marjorie asked.

"It's unlikely, according to everyone with whom I've spoken, but the complaint will go into his records, and that means any additional complaint would be given much greater weight, even if, in the end, he's not disciplined. That said, I think the argument I'm going to make is inescapable, and the board will have no choice but to, at a minimum, issue a reprimand. We'll go for more than that, of course, but sadly, that's the most probable outcome."

"Why?" Ken asked.

"Because he followed the standard treatment protocols, and that is almost invariably sufficient to defeat claims of malpractice. That said, I believe I can show he actually didn't do that, which will, I hope, force the Board to act."

"How do you plan to show that?"

"As I'm positive you know, one of the key symptoms of schizophrenia is not being able to process things long term -- literally everything is 'now'."

"Right," Marjorie said. "Angie wasn't able to think long term."

"And that right there is what Doctor Greenberg got so very wrong. When Angie decided she was going to do whatever was necessary to get to a point where she and I could marry, she was thinking about the future, outside the moment, had made a plan, and was successfully executing it. That is not a sign of someone who is suffering from full-blown schizophrenia and is a strong sign that something has changed. In my opinion, that's why the insurance company settled. They knew they would lose, not just on emotion, but on facts."

"And you saying that, as a doctor, carries weight?"

"They'll argue that I have insufficient experience, but I have the textbooks and peer-reviewed journal articles on my side, not to mention I believe, in the end, Doctor Mercer will confirm. I think she'll testify on our behalf, not Doctor Greenberg's."

"Angie really liked her."

"Me, too, until she listened to Doctor Greenberg instead of all of us. That said, I understand why she did, even if I don't agree. Anyway, I should spend some time with Angie before dinner."

"Thanks, Mike," Marjorie said.

"Yes, thanks, Mike," Ken added.

"You're welcome."

We went back to the living room where Angie had Rachel on her lap and I briefly flashed to an alternate universe where Rachel was mine and Angie's, though I suspected strongly she'd have had red, rather than black, hair. The source of Rachel's black hair could be either side of the family, as all of Elizaveta's family had black hair, as did my mom and grandfather, while I had my dad's sandy brown hair. The odd one out was my maternal grandmother, who had been blonde before her hair had turned white.

"How does it feel to be a doctor, Mike?" Angie asked.

"Not all that different, really. My final rotation in the Emergency Department was basically exactly what it will be like for the next few months, only I don't need close supervision and can work more independently. How are you doing?"

"OK, I guess. I'm working and going to Aikido."

Which was probably about the limit for her, given she was still taking psychoactive drugs, albeit at very low doses. I doubted she'd ever be able to go back to school, or get a better job than her data entry job, but it was something, when the alternative was nothing. I hated the situation and wished there was something I could do other than exacting a pound of flesh from the psychiatrist, but sadly, any last hope had been destroyed by his actions.

"That's good."

"Are you going to have more kids?"

"Angie..." her mom said firmly.

"It's OK," I said to Marjorie, then turned to look at Angie again, "Yes, Kris and I plan to have two more."

"What do you do, Kris?" Ken asked.

"I'm enrolled at Ohio State University in political science with a goal of an advanced degree in Public Administration."

"And you've been in the US how long?"

"Almost eighteen months," Kris replied.

"Her citizenship papers will be filed next week," I added.

"That's fast!" Ken declared.

"They were issued Green Cards based on her dad's job, and a Green Card holder can apply after eighteen months if they're married. Once Kris is approved, then her parents can apply early as well."

A timer rang, and Marjorie asked us all to go to the table while she brought the food to the table. She'd made oven fried chicken, home-style fries, bread, and coleslaw. I was asked to give the blessing, which I did, and then we dug in. The food was excellent, and I ate more than I probably should have, but it was so good that I simply couldn't resist. Dessert was apple pie and ice cream, along with coffee.

When we finished, I offered to help Marjorie with the dishes, which gave Angie more time with Rachel. After we finished the dishes, I spent a bit of time with Angie, and then Kris, Rachel, and I said 'good night' and headed home.

June 30, 1989, Circleville, Ohio

"What are we doing today?" Kris asked at breakfast on Friday morning. "You start your Residency tomorrow, and I start classes on Wednesday."

"I think we should do the grocery shopping today. We really won't have time tomorrow after band practice, and I can't skip that, given we have our concert on Tuesday."

"No, of course not! Grocery shopping today is fine. And a stop at the record store?"

"Yes. I also want to stop at Barnes & Noble and place a pre-order for the book I promised to buy for Frank Bush."

"We should obviously stop at the record store and bookstore before the grocery store, given how warm it is outside."

"Obviously," I agreed.

"What about tonight?"

"No plans, as most of the gang is gone and several others aren't available. You're OK with what Serafima and Alyssa suggested after Vespers on Wednesday evening -- that we restart in the fall with what we used to call Dinner Club, which would be them, us, and Ghost and Oksana, right?"

"Yes, of course! And, as you and I discussed, we'll find time to get together with José and Sierra, Gene and Jocelyn, and Clarissa and Tessa."

"Then let's just stay in, have a quiet family dinner, and once Rachel goes to bed, you and I can take a nice bubble bath."

"«C'est magnifique!»" Kris exclaimed happily. "And after the bubble bath?"

"Anything you want, of course!"

"As it should be!" Kris declared.

"Some day, Rachel will say that to YOU and I'll laugh!"

"She's much more likely to say it to you!"

"Dada? Want Abby!"

"She's in Spain, which is far, far away. She'll be home in about a week."

Rachel crossed her arms and stared at me, but there was really nothing I could do. She'd be back in hospital daycare on Wednesday, which I hoped would improve her mood. We needed more friends with daughters, but so far, except for Abigail, there were only boys, including my nephews. My half-sister and my adoptive niece lived too far away for Rachel to see her regularly.

"I think we need to find a few more girls for Rachel to play with," I said. "But the majority of the babies at Saint Michael, Holy Transfiguration, and the cathedral, and in my family, are boys. Anna has remarked a few times that we need more girls because Viktor Gennadyevich will need a wife!"

"It's a bit soon to worry about that, don't you think?" Kris asked.

"Specifically, yes, but the general problem is that when our young men marry outside the church, they usually leave and attend their wife's church. When our young women marry outside the church, their husbands usually attend our church. So if we have too many boys in the parishes, we have a long-term problem, unless the trend of which church mixed-faith couples attend is reversed."

"I never really paid close attention to that in Paris, but I've heard others here say that."

"In any event, Rachel will have her choice of boys in about thirteen years. But for now, she much prefers the company of girls."

"If I had to spend time with Viktor Gennadyevich, I would, too!"

I chuckled, "He is one hundred percent 'boy' and reminds me of his uncle, more than his dad."

"You mean Joe, not you, right?"

"I was more like Rachel when I was little, and you know I hung out with Jocelyn more than anyone else. And that was true even after Dale and I became friends in second grade, after I had some disagreement with Jocelyn. Whatever the source of our disagreement was, it's lost in the mists of time, but me hanging out with Dale caused Jocelyn to seek me out and that created a trio of fast friends."

"You do have some qualities which are more feminine."

"That's been said before, and I attribute it to a combination of my mom and Jocelyn."

"DADA! WANT ABBY!" Rachel demanded.

"I wish you could understand what it means to say she's in Spain," I said. "You'll see your friends in daycare on Wednesday."

"Why don't you take her on Monday?" Kris asked. "She really hasn't seen her friends in a month. I'll pick her up, and if you're able, we could have dinner together at the hospital."

"Let's give that a shot," I said. "I really do not want an unhappy toddler!"

"Think about my situation," Kris teased. "I have to raise two toddlers!"

"Oh, give me a break!" I chuckled. "I was already housebroken when you met me! You owe thanks to my mom, Jocelyn, Clarissa, and Elizaveta for that!"

"You are useful around the house," Kris observed. "Especially in the bedroom!"

"Gee, thanks," I replied with a grin.

"Would you prefer I said not in the bedroom?" Kris asked lightly.

"No."

We finished our breakfast, cleaned up the kitchen, then got ready to run our errands. Our first stop was Barnes & Noble, where I pre-ordered The Sum of All Fears for Frank Bush and arranged for it to be mailed to him at Southern Ohio Correctional Facility. Per the clerk, it would be shipped directly from their warehouse, rather than to the store first, as the warehouse was fully up to speed on the rules for sending things into prisons.

Our next stop was the record store, though it now carried more CDs and video games than vinyl albums.

"What's new I should listen to?" I asked Johnny.

"Bleach, by Nirvana. They're a grunge band from Seattle. I think they're going to be big."

"You've never steered me wrong. What else?"

"The End of the Innocence by Don Henley or Disintegration by The Cure, which returns to their early 80s style. And The Miracle by Queen."

"Decisions, decisions! How about the new group and Queen?"

"You got it! CDs, correct?"

"Yes."

He retrieved both CDs for me, put them in a bag, and rang up my purchase.

"I read in the paper that you graduated and are officially a doctor now."

"I am. I actually start my first official shift tomorrow."

"Cool. Your daughter is growing like a weed!" he said as I handed him three $10 bills.

"She is! You know, I've never asked, do you have kids?"

"A ten-year-old son."

"Business still good?"

"Being the only dedicated store in town helps, though I get undercut by K-Mart. But my selection is wider, and I do special orders, not to mention my regular customers. Adding video games helped, and I'm going to start carrying video game hardware, too. And I've expanded my used album business. I know you won't sell, but if you know anyone looking to unload vinyl or CDs, let them know."

"Will do."

Jonny handed me my change, I thanked him, and then Kris, Rachel, and I headed for Kroger. We completed our grocery shopping, stopped at the bakery, then headed home. After we put away the groceries, I put on the Nirvana album.

"You like this?" Kris asked.

"I have eclectic tastes," I replied. "Grunge isn't my preferred style, but I do appreciate the talent and artistry. I'd say Johnny is correct and Nirvana will be very popular."

After we listened to the album, we ate lunch, then put Rachel down for her nap. The rest of the day was quiet, and Kris and that evening, I had an enjoyable time in the bathtub and bed.

July 1, 1989, McKinley, Ohio

"How was Disney?" I asked José when he walked into the music room at Taft.

"You think the man even SAW the parks?" Sticks asked.

"I bet he did," I said.

"You'd win that bet," José replied. "Not that we didn't do what Sticks is implying! And yes, we had a great time."

"Shall we practice?" Kim asked. "We need to run through the two sets we're doing on Tuesday."

We did that, and Kim was happy with our practice. When we finished, we hurried to pick up Rachel at her grandparents' and then home for a shower. I dressed, put on the new long medical coat that my grandfather had given me, kissed my wife and daughter, then headed to Dorothea Rhodes Lummis Moore Memorial Hospital for my first shift of my PGY1.

Because I was assigned to the surgical staff, I reported to Doctor Vince Taylor in the Surgical Department at 11:30am.

"We'll dispense with the usual first-day Resident BS," he said. "I've been assigned as your mentor, but I don't think you'll need much mentoring from me for your first two years. Your mentor in the ED is Ghost, and you should go to him for anything related to trauma, and to me for anything else. Doctor Cutter wants you to wear red scrubs."

"Marking his territory, so to speak?" I asked with a grin.

Doctor Taylor laughed, "That's one way to put it, but yes, he wants to ensure that everyone knows you're officially a surgical intern. He feels it's better to differentiate the surgeons from the other doctors in the ED."

"OK. I'll take several sets down to the ED locker room with me, so I don't have to come up here if I need to change."

"Actually, your locker is here," Doctor Taylor said.

"Turf war, right?"

"Good guess. It started as soon as you Matched. I assumed you knew."

"I didn't. I thought there was a requirement for surgical Residents to be supervised by surgeons."

"There is, but you're in a gray area, at least for the next two years. In any event, Doctor Cutter prevailed, but that hasn't stopped Doctor Northrup."

"Wonderful," I sighed. "Day one, and it's already political."

"Just be a doctor and ignore the BS. You can do that as a PGY1. Let the senior Attendings fight it out with the Medical Director. In the end, you're going to be a Board certified surgeon, and that's the master trump."

"Trust me," I said with a smile, "I'll ignore it for as long as I possibly can!"

"See Penny at the nurses' station. She has your ID, your keys, and your pager."

"Keys?"

"We began locking all supply rooms as of last week. Too many consumables were disappearing. Everything has to be logged, not just drugs."

"More paperwork," I said, shaking my head.

"Unfortunately, I think we have to get used to it. Our patient load is up and our funding levels are stagnant."

"Same old story. I did see the construction equipment in what used to be the grassy field outside the ED, so that's something."

"It is, but they should have built the new surgical wing first."

"Well, being on the surgical service, I'm not going to disagree with you, but I disagree with you!"

Doctor Taylor laughed, "I hear you. You're not a surgeon at heart, even if you'll make a very good one."

"Thanks, Doctor Taylor."

"It's Vince, please. All surgical Residents address each other by their first name."

"Thanks, Vince."

"Go see Penny and let me know if you need anything. I can't imagine what it might be, given you've been here for four years, which is longer than I have!"

I shook his hand and went to the nurses' station to see Penny, who was new.

"Hi, Penny," I said. "You have my ID, pager, and keys."

"Doctor Loucks?"

"Mike, please," I said.

"Protocol is to call all doctors by their title," she said.

"Then Doctor Mike, please."

"OK. I understand you were a medical student here, so I'm sure you know about the pager."

"I do."

She handed me the ID, pager, and keys, I thanked her, then headed to the locker room to change. Using the surgical locker room was a minor inconvenience for working in the ED, but, in the end, I was a member of the surgical service, so it made sense. I found the locker with the tag 'M. Loucks' on it, and opened it, finding it empty as was to be expected.

I walked over to the cabinet which held the red scrubs, selected the correct size, changed into them, slung my stethoscope around my neck, clipped on my new photo ID which identified me as 'Doctor Michael P. Loucks' and had the red 'S' symbolizing the surgical service superimposed on the lower left of my photo, while the lower right had the standard Staff of Asclepius.

Normally, surgical Residents wore surgical caps while on duty, and I had several I'd ordered, as they were personalized, but they were not usually worn in the ED, so I simply left them in my locker. Last, I put on my medical coat, which surgeons wore when not in surgery, but which was generally dispensed with by doctors in the ED except when meeting with families.

Properly attired, I shut the locker, attached my combination lock, closed it, spun the dial, and then left the locker room to head to the ED. I took the stairs, something I had resolved to do to get that bit of extra exercise with my schedule, making regular exercise difficult, if not impossible.

"Good morning, Luisa," I said to the nurse at the nurses' station. "Doctor Mike Loucks."

She was new, having just graduated from nursing school in May.

"Good morning, Doctor!" she said brightly. "It's nice to meet you. Doctor Casper is in the lounge."

"Thank you."

I went to the lounge and saw Doctor Casper stretched out on the couch.

"Morning!" I said.

"Hi, Mike," he said, sitting up. "What's with the red scrubs?"

"Doctor Cutter's orders," I said.

"Proving, in his mind, that he has the bigger dick."

"Of all the things I could possibly care less about, I'm not sure there are many I care less about than the relative size of two Attendings' dicks."

"You and me both!"

"Who's the Attending?"

"A new-hire you haven't met - Doctor Isabella Mastriano."

"Italian?"

"Yes. She graduated from OSU and served her Residency in Texas. Loretta spoke to her, so she's been warned about you."

I chuckled, "Of course. Who are the med students?"

"You have Callie Newsom and Gabriella Martin today; Newsom is the Fourth Year. Also, Doctor Gibbs wants you to take the Preceptorship students on Tuesday afternoons."

"I know Callie. Preceptorships should be fun at the end of a thirty-six-hour shift."

"Welcome to PGY1! Anyway, you'll get mostly walk-ins today. See me if you have questions, and Doctor Mastriano will sign your charts."

"Sounds good."

"Hi, Mike!" Nurse Alice said, coming into the lounge.

"Hi, Alice."

"Doctor Casper, EMS four minutes out with a fall from a ladder."

"Thanks, Alice. Which room?"

"Trauma 3 is open."

He got up, and I went to the triage desk to check in with the medical student and nurse who were manning the desk.

"Hi, Doctor Loucks!" Nurse Billie said.

"Hi, Billie."

"Hi, Mik...Doctor," Fred Lawson said.

"Hi, Fred. I'm assigned to walk-ins. I just need to do the handover with Doctor Billings."

"OK. There are two waiting, so they're all yours."

"What do we have?"

"Two days of nausea and diarrhea and a minor arm lac."

"OK. I'll be right back."

"What's with the red scrubs?" he asked.

"As a trauma surgeon, I'm on the surgical service, but assigned to the ED. Surgeons wear red."

"Interesting."

I left the triage desk, checked the board, and went to see Doctor Billings.

"Hi, Doctor Billings," I said as I stepped into Exam 2.

"Hi, Mike. Call me Kayla, please. I'll be finished in two minutes. Meet in the lounge?"

"You got it."

I returned to the lounge and a few minutes later, Doctor Billings came in.

"Nothing to turn over," she said. "I just streeted that sprained ankle and my last admission went up fifteen minutes ago. Ready for your first shift?"

"It doesn't feel that way, actually."

"The golden-haired boy who did more procedures as a Fourth Year than I did as a PGY1! And why do you rate red scrubs?"

"Jackpot," I chuckled. "You and every other person I've spoken to has asked or commented! I'm officially on the surgical team though I'm assigned to the ED. Doctor Cutter wants me to wear red."

"Dick measuring contest between him and Northrup."

"So it would appear. I have two patients waiting on me, so unless there's something else..."

"Nope. I'm outta here!"

We both left the lounge with Kayla heading to the locker room while I went to find Callie and Gabriella, both of whom were standing in the ambulance bay, with Callie smoking.

"Don't you know those will kill you?" I asked Callie.

"It helps with the stress," she replied. "How are you, Doctor?"

"I'm fine. Who's your cohort in crime?"

"Doctor Mike Loucks, Gabriella Martin, Third Year. Gabby, meet Doctor Loucks, PGY1."

"Doctor Mike, please," I said. "Nice to meet you, Gabby. We're catching walk-ins. Come with me."

Callie stubbed out her cigarette and the two of them followed me inside.

"Callie, I'll have you do the H & P."

"Seriously?" she asked. "On your first shift?"

"Yes. My job, in addition to healing, is teaching. I know how to do an H & P. Now we'll see if you do. And Gabby, pay attention, because you'll do one as soon as I'm sure enough about Callie to turn her loose on her own."

"On her own?" Gabby asked. "Don't we have to be supervised?"

"Yes. My definition of supervision is allowing Callie to do an H & P on a walk-in on her own, then verifying her findings. That's how she'll learn."

"Rumor has it that you know everything," Gabby said.

I chuckled, "Let's assume for a moment that's true. It's what you learn after you know everything that counts!"

"Hang on! If you know everything, you can't...wait, Zen, right?"

"Of that same basic idea, but I heard it from a Russian Orthodox monk."

We arrived at the triage desk, so I switched out of friendly teacher mode into doctor mode.

"Who's first?" I asked Fred.

"I'd say nausea," he replied.

"Me, too," I agreed.

"Kaylee Jennings, nineteen; last vitals: pulse 92; BP 120/70; temp 38.6°; no cough or sore throat; ears clear."

"OK. Chart please."

He handed me the chart, and I went to the door to the waiting room and opened it.

"Kaylee Jennings?" I called out.

A pretty girl stood up, as did a woman who I suspected was her mom, and came to the door.

"Hi; I'm Doctor Mike. Ms. Jennings, if you'd follow me," I said to the young woman, then turned to the older woman, "Ma'am, you'll need to wait here, please."

"It's OK, Mom," Kaylee said.

I checked the board, saw that Exam 1 was open, and brought Ms. Jennings there, with Callie and Gabby following me.

"Go ahead, Callie," I said.

"Hi, Kaylee," she said. "What brings you here today?"

That was literally the by-the-book first question to ask and was intentionally open-ended to elicit as much as possible from the patient.

"I've been sick to my stomach and have the runs."

"When did those symptoms start?" Callie asked.

"Thursday night."

"What did you do on Wednesday and Thursday?" Callie asked.

"Not much. A picnic at the lake."

I made a mental bet with myself that she had salmonellosis, or, as it was more commonly known, food poisoning. I almost laughed, thinking back to carrying Lara from the dorm to the infirmary at Taft, but that would have been inappropriate. Callie obviously had the same thought as she asked what Kaylee had eaten, then went through a complete H & P, reporting her findings.

"Preliminary diagnosis is food poisoning," Callie announced.

"I concur," I said. "Kaylee, I need to do a quick exam to check Callie's findings."

"She's not a doctor?"

"No. She's a medical student. This is normal for training."

I did a quick exam, hearing no anomalies in her heart or with her breathing.

"Kaylee and I need to present your case to our Attending," I said. "That's a senior doctor. Gabby, you stay with her."

"OK," Gabby agreed.

Callie and I stepped into the corridor.

"You'll present," I said. "What's your proposed treatment?"

"The choices are oral or IV rehydration, and given she's nauseated, I recommend IV Ringer's."

"Good. Anything else?"

"Ceftriaxone."

I shook my head, "Studies show that has no positive effect on otherwise healthy patients who are not very young or very old. Overuse of antibiotics is a serious problem, so we don't use them unless we have to."

"Patients want them."

"And I want shorter shifts!" I chuckled. "I don't see anyone granting that wish simply because I want it!"

Callie laughed, "Good point!"

"Anything else?"

"Not that I can think of."

"Antiemetic?" I asked.

"Is her emesis sufficient to need that?"

"I asked you first!" I chuckled.

"She hasn't vomited since we brought her into the exam room, so I'd say she doesn't need it."

"Think about that for a second," I suggested.

"She said she couldn't keep anything down. So, in addition to the IV, we give her some juice and see what happens."

"Excellent. How do we confirm our diagnosis?"

"Stool sample or blood test. If I suggest a stool sample, are you going to make me collect it?"

"What do you think?" I asked with a goofy smile.

"I think she needs a blood test!" Callie declared.

I laughed, nodded, and we went to the Attendings' office and I knocked on the open door.

"Doctor Mastriano?"

"You must be Mike Loucks.

"I am."

"What's with the red scrubs?"

"Doctor Northrup's orders," I replied. "We have a patient to present."

"Go."

"Callie?"

"Kaylee Jennings, nineteen-year-old female; pulse 94; BP 124/72; temp 38.6°; nausea and diarrhea onset on Thursday after a picnic at the lake; no cough or sore throat; ears clear. My preliminary diagnosis is food poisoning, likely caused by salmonella. Recommend treatment with IV Ringer's for dehydration and blood test to confirm."

"Antibiotics?"

"Not indicated for healthy adults. She doesn't appear to need antiemetics at this point. Observe for two hours."

"Approved. Let me have the chart to sign."

Callie handed over the chart, Doctor Mastriano signed it, and then handed it back.

"Mike," Doctor Mastriano said, "come see me when you have a break, please."

"Will do."

Callie and I left the office and stopped outside the exam room.

"Thanks for the tip on antibiotics," Callie said.

"All part of the service!" I replied. "Do you know if Gabby has done IVs?"

"I haven't seen her do one, no."

"OK. Then you do it. I'll ask her about it, but not in front of the patient. Blood draw?"

"Same answer."

"OK. You do that, too, and have her take the blood sample to the lab."

"OK."

We went into the exam room and I nodded to Callie.

"Kaylee, we're going to give you IV fluids, and run a blood test to confirm our suspicion that you have salmonella-based food poisoning."

"No antibiotics?" Kaylee asked.

"No," Callie replied. "They're usually not necessary for otherwise healthy adults. We will keep you for a few hours to see how you're feeling, as well as get the results of the blood test. If you'll lie back down, I'll get the IV going and draw the blood."

Callie did a good job on the IV and the blood draw, and as we agreed, asked Gabby to take the blood to the lab. Once that was done, I sent Callie to bring in Kaylee's mom.

"She'll be fine," I said. "We're giving her IV fluids to counteract the dehydration caused by her vomiting and diarrhea while we wait for the blood tests to confirm food poisoning. You can wait here with her. If the tests do confirm it's food poisoning, you can take her home and have her eat broth until her stomach settles. We'll come back to check on her every twenty minutes or so."

"Thank you, Doctor!"

"You're welcome."

Callie and I left the exam room and went to the triage desk.

"Arm lac or migraine next?" Fred asked.

"How long as the arm lac been here?"

"About thirty minutes," he replied.

"How many sutures do you estimate?"

"Five or six at most."

"Callie, may I see your procedure book?" I asked.

She handed it to me and I counted five signed-off sutures during her current rotation.

"OK. I'll do a quick exam, you can suture, and I'll check your work. While you're doing that, I'll see the migraine. I'll ask a nurse to help you; I'll have Gabby help me."

"Great!" Callie declared. "I'm going to enjoy working under you!"

The stress on the word might have been my imagination, but I didn't think so. I elected to simply let it go.

"Fred, we'll take the arm lac chart, please."

"Jack King; forty-eight; vitals normal; five centimeter lac on right forearm."

He handed me the chart, and we went to the door, I called Mr. King, and Callie led him to the new suture room that used to be the Residents' office. I went to the nurses' station and ensure there was an experienced nurse to help Callie. I was assigned Nurse Julie, and she followed me to the suture room.

I did a quick exam saw no contraindications and asked Callie to proceed.

"Call me when you're finished, and I'll sign the discharge papers."

"Will do, Doctor," Callie said.

I left the room and saw Gabby returning from the lab, waved for her to follow me to the triage desk.

"Migraine," I said.

"Take two aspirin and call you in the morning?" Josh, the clerk asked.

"Sadly, that may be about as effective as most treatments we have for migraines. Vitals, Fred?"

"Stephanie Smith, twenty-six; pulse 88; BP 124/74; temp 37°; onset shortly after waking this morning; previous visits in January, March, and May."

"Frequent flyer," I said. "Did you pull her records?"

"No. I can't leave the triage desk."

"OK. Gabby, go to the records room and find me the file for Stephanie Smith. Birthdate..."

"March 22, 1963," Fred said.

"Be right back," Gabby said.

Five minutes later she returned.

"What does it say?" I asked.

"I didn't know I was allowed to look."

"Required, is more like it. Tell me what you see."

She opened the file and flipped through it."

"Each visit is about eight weeks apart, she was treated the first time with a 'migraine cocktail'. What's that?"

"Basically Excedrin, but with higher dosage -- 500mg acetaminophen, 300mg acetylsalicylic acid, and 100mg caffeine."

"The second time, with IV metoclopramide; the third time they added dexamethasone.

"Any red dot on the inside folder?"

"No. Why?"

"That would indicate a drug-seeker," I said. "Claiming migraines or back pain are the most common excuses for asking for opiates. This young woman hasn't done that, so we believe she actually has migraines. Let's bring her in."

Fred handed me the chart and Gabby and I went to the door and called Ms. Smith.

"Hi, I'm Doctor Mike and this is Gabby, a medical student. Let's get you into an exam room."

I checked the board and Exam 3 was open, so we led Ms. Smith there and she climbed onto the exam table.

"What brought you here today?" I asked.

"I have terrible migraines."

"When did they start?"

"The first one was probably about a year ago, and Excedrin knocked them down for the first six months. When that stopped working, I came here, and they gave me a higher dose of the same stuff. The next times I had an IV, but can't tell you what it was."

"Are you sensitive to light or noise?"

"Both," she replied.

"Your migraines seem cyclical," I said. "Do you have any idea what triggers them?"

"No."

"When was your last menstrual period?"

"It should start tomorrow or Monday."

"Is there any chance you're pregnant?"

"No. It's been a couple of months since the last time, and I've had my period."

I went over her medical history, then said, "I'd like to do a physical exam, please."

"Sure."

I started with heart and lungs, then eyes, ears, nose, and mouth, and finally palpation of her abdomen.

"Gabby, let's get a CBC, Chem-20, and a glucose panel," I said, writing those orders on the chart, along with a medication order. "Let's also start her with 500mg acetaminophen, 300mg acetylsalicylic acid, and 100mg caffeine. Ms. Smith, I'm going to check on two other patients and I'll come back after Gabby draws the blood."

"Do you need Doctor Mastriano to sign off?" Gabby asked.

"No," I replied. "Only for scheduled drugs."

"Why would you need approval?" Ms. Smith asked.

"That's normal for Interns," I replied. "That's someone in their first year of Residency."

"You're a brand new doctor?"

"First day, officially, though I've technically been a doctor for over a month."

"First day? Seriously?"

"Yes."

"You're in good hands, Ms. Smith!" Gabby said. "Mike graduated at the top of his class and aced his exams!"

"I wasn't concerned," Ms. Smith said. "I was impressed!"

"I'll be back shortly," I said.

I went to check on Kaylee who was feeling OK and resting comfortably, updated the board, which I'd failed to do earlier, then went to check on Callie, who was almost finished.

"Those stitches look good," I said. "When you finish, fill out the discharge form, bring it to me to sign, then take it to Doctor Mastriano. Discharge if she signs off."

"Will do!" Callie said.

I left and went to check if there were any other walk-ins, but there weren't, so I returned to Exam 3 where Gabby was completing the blood draw. Given it was just the two of us, I went to the drug locker, retrieved the oral tablets, then went to the nurses' station knowing I'd need someone in the exam room when Gabby ran the blood to the lab. Nurse Jessica walked to the exam room with me, and Gabby took the blood to the lab. I administered the medication.

"I'm going to speak to my Attending," I said to Ms. Smith. "Nurse Jessica will stay with you."

I left and went to see Doctor Mastriano. I described Ms. Smith's complaint and what I'd done so far.

"What do you want to do next?" Doctor Mastriano asked.

"IV metoclopramide and dexamethasone. Once the blood test results come back, I'll return with any additional treatment plan."

"OK. Do you have a moment now?"

"Yes."

"Shut the door and have a seat."

I did as she asked.

"First day, first patient, and you have a Fourth Year do the exam?"

"It was impressed on me that teaching is an important part of a Resident's job, and from experience, I found that many Residents don't give their Third Years and Fourth Years enough opportunities. It was the right decision."

"I wasn't challenging, you," Doctor Mastriano said. "I was surprised a PGY1 would do that their first day. You'll have every student clamoring to be assigned to you."

"I don't see that as MY problem!" I chuckled. "I was under the impression Doctor Gibbs had told you about me."

"She did, but that doesn't mean I'm not surprised."

"I believe she should have warned you, not told you about me," I chuckled.

"I believe you're right!"

VIII. What A Stupid Way to Die

July 1, 1989, McKinley, Ohio

"How was your first day?" Doctor Casper asked just before midnight.

"Routine, really. Fourteen walk-ins, with the only truly interesting case being the young woman with the migraines. I had mixed emotions about the MRI, hoping it would show something but dreading what it might show."

"That's a common reaction," Doctor Casper said. "You have a tentative diagnosis that you really hope doesn't pan out. I think you had a leukemia diagnosis in a college-age student."

"Yes. That sucked, though she recovered."

"How do you know that?"

"José married her best friend. It sucks that we don't have an answer for the migraines."

"Yes, but you asked Doctor Mastriano for a neurology consult and they took her, so you did your job. The last three times they simply sent her home after giving her analgesic cocktails."

"But the consult turned up nothing."

"Mike, what's your job? And don't give me any bullshit 'heal the sick' answer, either."

"That is my job," I replied.

"No, that's your calling," Doctor Casper countered. "What is your job?"

"First line emergency care."

"Did you do your job?"

"Yes."

"Then as shitty as this sounds, that's a good day. You cannot heal, cure, or whatever you want to call it, every single person who walks into the ED or is brought in by ambulance. And as shitty as it sounds, and feels, it's not your job. You job is to triage, treat or stabilize, then admit or discharge. You know the catchphrase."

"Treat 'em and street 'em. We've had this conversation before."

"And we're going to have it again until you get it through your thick head that the 'S' on your badge does not stand for 'Superman'!"

"I don't believe I'm Superman," I replied.

"Then don't try to be Superman. How many of your patients walked out of the ED happy today?"

"Thirteen out of fourteen."

"That's a damned good day. How many died?"

"None."

"That's an outstanding day. Days like that are right up there with the pilot's refrain that any landing you can walk away from is a good landing. Do you want to know my count for the past eighteen hours?"

"Go on."

"Eighteen treated, three of them resulted in a consult from McKnight. Want to trade days?"

That was another euphemism that was used in the ED to indicate a patient had died without saying it where other patients could hear.

"No."

"Then in ten minutes, let's get our showers, put on our street clothes, and go home. You're back on Monday, right?"

"0600 for a thirty-six-hour shift."

"You may be the last class of Residents who have those shifts."

"The Libby Zion case."

"Yes. Word is that the end result, when all the smoke clears, is eighty-hour weeks and no more than twenty-four-hour shifts, with at least eighteen hours between shifts. That's what New York is imposing, and I expect, eventually, the Accreditation Council for Graduate Medical Education will adopt the same standard."

"Fortunately, I mostly have eighteen hours between shifts, but I know some of the shifts work out to only twelve hours between thirty-six-hour stints."

"Hi, Mike!" Kylie said, coming into the ED.

"Hi, Kylie."

"How'd your first shift go?"

"I handled fourteen walk-ins. My board is clear."

"Excellent. I'll see you on Monday morning."

"See you then," I said.

July 2, 1989, McKinley, Circleville, and Columbus, Ohio

Just after midnight, Doctor Casper and I left the lounge and walked towards the locker room.

"I'm upstairs," I said.

"Cutter is really pushing the point, isn't he?"

"Yes," I agreed. "But so long as the turf war doesn't have any effect on my training, I can deal with the petty stuff."

He went into the locker room and I headed upstairs to the surgical locker room. I took a quick shower, dressed, then headed home, where Kris was waiting up for me.

"How was your first day being a doctor?" she asked after we exchanged a hug a kiss.

"Not all that different from my last day of being a Sub-Intern," I replied. "The main difference is I can do basic procedures without seeking permission every time, order tests, and prescribe non-schedule drugs."

"Narcotics, right?"

"Yes. Those I won't be able to prescribe until I actually have my medical license, which is after I pass my Boards, which is sometime after PGY4. In theory, I could do it in two parts, if Doctor Cutter would sign off on getting my basic license before I spend any time in the OR, but I'm not sure he will, given the turf war."

"Turf war?"

"A contest over who is actually in control of my schedule and decides the course of my training. Doctor Northrup tried to change things, and Doctor Cutter reacted. The only real effect of their little battle is that my locker is in the surgical locker room, and I wear red scrubs instead of pale blue ones. It's really no big deal from my perspective."

"So, now you have medical students to order around?" Kris asked lightly.

I chuckled, "Yes, but you know me. The key is teaching, not having someone to do scut."

"Male or female?"

"Today? Two females. I'm not sure who I'll have on Monday, but med students are limited to twenty-four-hour shifts, and mine are thirty-six, so I could have as many as six different students during that period, depending on the schedule."

"Any interesting patients?"

"I treated patients who walked in, which means mostly minor stuff. The only really interesting one was a young woman with migraines, but in the end, all I could do was refer her to neurology. The CAT scan we ran showed nothing, so they gave her some stronger medication than you can buy over the counter. I suspect she'll be back. How was Vespers?"

"The same as it's been for over a thousand years," Kris said lightly.

I laughed, "OK, I deserved that. Shall we go to bed? We have to leave for Matins in just over six hours."

"Yes."

We headed upstairs and ten minutes later we were in bed, and two minutes after that, I was sound asleep. When the alarm rang early on Sunday morning, we got out of bed, quickly showered together, then fed and clothed Rachel, and the three of us headed to Dormition of the Mother of God Cathedral in Columbus for Matins and the Divine Liturgy.

Rachel wanted to be with Lyudmila during the services, which to me seemed to be one of her ways of showing independence. She still wasn't in a good mood, and I hoped going back to daycare would help, though I suspect it might take another few weeks until Abigail came home from Spain.

"You had your first day at the hospital yesterday, right?" Father Luke asked at lunch.

"Yes."

"I also heard from His Grace that you visited the man who murdered your friend in prison."

"I did. He was receptive to my visit, but he's locked into his Calvinist mindset and is convinced he's going to Hell."

"Just act in love, Michael."

I nodded, "I didn't take what might be considered his 'bait'. I'll see him again later this month to play chess. I did reach out to his daughter, who hasn't been to see him, but she hasn't returned my call. That could be because she elected not to, or because she's just starting her Residency in Kentucky."

"What's your goal?"

"To provide hope."

Father Luke nodded, and then moved on to speak to another parishioner, while I went to sit with Kris, Rachel, and the Korolyovs to have lunch. After lunch, Kris, Rachel, and I left the cathedral and walked out to the car for the drive home.

When we arrived, there was a message on the machine for Kris from Clarissa, and Kris returned it. I knew what it was about, and still wondered if what Clarissa intended was the right way forward, but I couldn't think of any real alternatives. I didn't know for sure how Kris would handle the revelation, but I hoped the 'privacy exception' would be sufficient to prevent serious problems between us.

Kris returned the call to Clarissa, and just over an hour later, Clarissa and Tessa arrived at the house. I wasn't surprised when Clarissa asked to speak to Kris privately, and they went into the study to talk.

"How do you think this will go?" Tessa asked quietly as we sat on the couch with Rachel playing with her dolls on the floor in front of us.

"Not as badly as if Kris somehow found out ten years from now, or whenever," I replied. "In the range of bad choices, this is the least bad. She's not going to mention you and me, is she?"

"No. I was adamant about that. It would serve no purpose except to create tension where none exists. Does Kris know about any of the other girls you were with?"

"Jocelyn and Tasha, because those two are, more or less, public. But she made it clear she didn't concern herself with what had happened before. And she doesn't see female friends as a risk the way Elizaveta did."

"Kris is very secure in who she is and views the world in a much broader way. Elizaveta was, and I mean no disrespect, very provincial where Kris is cosmopolitan."

"A very French way of putting it," I chuckled.

"But it's true, isn't it? Elizaveta was a very typical rural, religious person, whereas Kris is worldly, and mostly secular in her outlook, though also faithful. In other words, very much like you."

"I see the world through an Orthodox lens."

"Yes, you do, but how do you interact with the world? You're a scientist, not a monk. Think about your approach to miracles."

"I see your point," I replied, "but Elizaveta was growing in that regard, though she still had traditional conservative American values."

"And, as a deacon, that was what you needed. You need something different now."

"I don't disagree."

"Maybe Miss Cosmopolitan will allow you and Clarissa to conceive naturally!"

I laughed, "She's open-minded, but not that open-minded!"

"Just think," Tessa smirked, "It might take dozens of attempts!"

"Which actually wouldn't be as enjoyable for me as you might think, because I know how Clarissa feels about it."

"Weirdly, I believe you. Most guys would be happy to bang the hot lesbian!"

"Which is not how I feel about it. I banged you, but not Clarissa, if that makes sense."

"Of course it does. You and me was just casual sex, and purely physical. It was awesome, but it was just sex. That was not true between you and Clarissa."

"Exactly."

A few minutes later, Clarissa and Kris came out of the study.

"We're going to head home, Petrovich," Clarissa said calmly. "See you at the hospital for lunch tomorrow?"

"Sounds good."

I walked Clarissa and Tessa to the door, but couldn't discern anything from Clarissa, nor could I from Kris' demeanor when I returned to the living room.

"I never would have guessed," Kris said. "But it makes sense."

"Are you upset with me for not telling you?" I asked with a bit of trepidation.

"No. Clarissa pointed out that she swore you to absolute secrecy and it did fall under the exception I allowed for my 'nothing but the truth' rule. You look relieved."

"I am," I replied, after realizing I had been holding my breath. "I wasn't sure how you'd react. I thought you'd be OK, but I wasn't absolutely sure. You're OK with me spending time with Clarissa?"

"She made it clear that she could tolerate doing that with you to make a baby, but has no interest in doing it with anyone except Tessa. I trust both of you."

"Thank you."

"Was it your idea for her to tell me?" Kris asked. "Or hers?"

"Hers," I replied. "I wanted to tell you, but it was something I wasn't allowed to share."

"Which I understand. Given how she feels about you, I don't see how she could have done anything else."

"Is there anyone who would concern you?"

Kris smirked, "Besides the nurse that has had the hots for you for four years?"

I chuckled, "Ellie will just have to make do with her fantasies."

"Did you ever consider it?"

I shook my head, "No, for several reasons, the most important of which was she tried to entice me to cheat, and that, in and of itself, precluded even thinking about it. That was before I'd formulated my rule about relationships in the hospital, which really didn't matter except in terms of ethical behavior and patient care, because I was married to Elizaveta. Once she reposed, I made two firm rules -- I wouldn't date anyone who was on the same service and I would never even consider fooling around in the hospital."

"That happens a lot?"

"It does, unfortunately. And there are no rules against relationships, only against favorable or unfavorable treatment based on those relationships. The problem in my mind is that there is, in effect, no way to know unless someone makes a complaint. We all know about female students who use sex to gain advantage and male doctors who take advantage of female students, but it's difficult to prove. I would just ban any relationships where there was any supervisory or teaching relationship."

"It sounds as if you would prohibit relationships between students and doctors."

I nodded, "Completely. I don't see any way to allow that without opening the door to all sorts of potential ethical violations. Think about how easy it would be for a Resident to coerce sex from a student, given the doctor basically holds the student's medical career in their hands."

"Not quite as easy as playing a guitar," Kris smirked.

I laughed, "OK, but in that case, there is no ethical problem!"

"What will all those poor Code Blue groupies do now that José is married?"

"Cold showers," I chuckled. "Kim and Sticks get hit on, but not at the same level as José did."

"And you?"

"I was not lacking for attention," I replied.

Kris laughed softly, "Of that, I'm sure! Out of curiosity, was there anyone besides Ellie who wasn't a groupie who was persistent?"

"Erin Edwards," I replied. "She, too, was OK with cheating, which is, as I've said, an automatic lifetime ban, as it were. She did try to see me after Elizaveta reposed, but I was completely uninterested."

"Who is she?"

"The daughter of the President of the Hospital Board of Directors. I met her when she was a patient during my OB/GYN Clerkship. In those rotations, though, I couldn't touch patients, nor observe exams directly, if you get my meaning. She persistently hit on me despite me being married. The last time I saw her was about a year ago at Stirred Not Shaken."

"What is it with people willing to cheat?" Kris asked. "It makes no sense to me!"

"I agree. I mean, how could you ever trust someone who cheated with you? Well, I guess in Ellie's case, it's just sex, so that doesn't matter, but Erin strongly indicated she wanted a relationship, not just a roll in the hay. If I had to speculate, though, I'd say it's that the 'other woman' thinks she's so much better that she can hold on to the guy, but that's illogical."

"It makes sense you would see things through the eyes of logic, but attraction isn't based on reason, is it?"

"No. The heart wants what the heart wants," I replied.

"Or in their cases," Kris smirked, "the «minou» wants what the «minou» wants!"

"And you?"

"We could put Rachel down for her nap and you could find out!"

"Sounds great!"

July 3, 1989, McKinley, Ohio

"I hope you're happier after you see your friends in daycare," I said to Rachel as we walked into the hospital at 5:45am.

"Want Abby!" Rachel insisted.

"In about two weeks," I replied. "When she comes home from Spain."

"NOW!" Rachel demanded.

I suppressed a sigh because, as the quip went, the only difference between terrorists and toddlers was that you could actually negotiate with terrorists.

"Good morning, Rachel!" Marcie exclaimed when we walked into daycare. "We've missed you!"

Thankfully, Rachel gurgled happily as I handed her to Marcie.

"She's done with bottles," I said. "She's drinking exclusively from her sippy cup, and it has to be the purple one."

Marcie laughed, "OK. Is it in her bag?"

"Yes. Kris will pick her up around 5:30pm. I'm on until tomorrow evening."

"Ugh. Those shifts are terrible!"

"I do have a few hours off to play with my band at Milton Lake for the Fourth."

"But close to the end of the long shift, you're going to be beat!"

"I know. My goal is to catch a nap overnight, but there are no guarantees."

"We'll take good care of Miss Rachel!"

"Thanks."

I left my daycare and headed up to the surgical locker room to change, then reported to the ED for my shift.

"Morning, Mike!" Kylie said when she saw me in the corridor.

"Morning! How was overnight?"

"Sunday nights are usually quiet. Twelve hours down, twenty-four to go."

"Who's the Attending?"

"Doctor Taylor."

"Anything interesting on the board?"

"No. Sue Townsend, who's going off shift, just streeted her fender-bender. She's in the lounge."

"Thanks."

I went to the lounge and saw a short, stocky doctor with close-cropped brown hair.

"Sue Townsend?" I inquired. "Mike Loucks."

"Nice to meet you! Nothing to see here, so if you're set, I'm gone! I have a date with a bubble bath and a bed!"

"I'm set," I said. "Who are the students?"

"Bob Banks, Fourth, and Len Godwin, Third. They went to get breakfast."

"Thanks."

She left, and I went to the Attendings' office.

"Morning, Doc," I said to Doctor Taylor.

"Well, well, well, if it isn't Doctor Michael Loucks! How was your first shift?"

"Routine. I caught all fourteen walk-ins."

"You're on the regular rotation today, so you'll get a mix of cases. Check any procedures beyond the basics with me, please. I know you can do them, but we do need to follow protocol."

"Understood. OK to have Bob Banks do procedures he's had signed off in his book?"

"Yes. You can give Lawson a shot at the basics, too; he's competent."

"OK. I'll check in at the nurses' station and await my first case!"

"We're glad to have you here," Doctor Taylor said.

"Thanks."

I left the office, checked in with Ellie, and then went to the lounge. About five minutes later, two medical students walked in.

"Bob and Len?" I inquired. "I'm Doctor Mike Loucks."

"I'm Bob," a short, stocky guy with black hair said. "This is Len."

Len was tall and lanky and had blonde hair that was almost white.

"Nice to meet you both. Please call me Doctor Mike, I much prefer that. May I see your procedure books?"

They both handed them to me, and I flipped through them. Bob had done the usual procedures I'd expect a 'competent' Fourth Year to have done, while Len had far fewer, but that was no surprise, given this was his first clinical rotation.

"Have you decided on a specialty, Bob?" I asked as I handed back the books.

"Surgery," he said. "Doctor Roth said I should learn as much as possible from you."

"That should be true of every rotation with every doctor. And that means asking to do procedures, especially as a Fourth Year. I already cleared that with Doctor Taylor. You'll do as many as I can reasonably assign to you. Len, you'll have opportunities as well. Do either of you know how to read an EKG?"

"No," they both said.

"Len, during your Clerkship in cardiology, make sure you ask Doctor Strong to teach you. Bob, are you doing a Sub-I in cardiology?"

"Yes."

"Then do the same. I take it you know how to attach EKG leads?"

"Yes. I've done it."

"You should have written that into your procedure book," I said. "Next time, do so, and I'll sign off. Len?"

"I've seen several done, but haven't ever done it."

"Do you have a diagram in your notebook for the correct placement and lead colors?"

"No."

"Then the first time we do a twelve-lead, take notes, make a drawing, then study it. I'll expect you to know it by the end of the next shift."

"Got it."

"Doctor Loucks?" Nurse Jenny said. "EMS four minutes out with an MI."

"Doctor Mike, please. Which room?"

"Trauma 1 is open."

"Thanks. Meet us in the ambulance bay."

She left.

"Game time, gents. Bob, twelve lead EKG; Len, draw blood for CBC, Chem-20, and cardiac enzymes. Let's go!"

We left the lounge, put on gowns and gloves, and headed to the ambulance bay, where we waited with Jenny for the ambulance to arrive. I smiled when I saw the large white '2' emblazoned on the ambulance, and when it pulled up, Bobby hopped out.

"Hi, Doc! Jerome McArthur, sixty-eight; complained of severe chest pains while at breakfast; pulse tachy at 110, BP 90/60; diaphoretic; PO₂ 94 on five liters by mask; no history of heart trouble; no known medications."

"Trauma 1!"

Bobby and Jim unloaded the gurney, and the six of us began moving towards Trauma 1.

"Mr. McArthur, I'm Doctor Mike. Where is the pain?"

"Chest and left arm," he said, his words muffled by the oxygen mask.

"When did the pain start?"

"During breakfast, maybe thirty minutes ago."

We moved into the trauma room.

"On my count!" I said. "One, two, three!"

We all lifted the sheet and moved Mr. McArthur to the treatment table. Jenny switched the oxygen supply from the portable bottle to the hospital system, and Bobby and Jim left.

"We're going to get you on an EKG, draw some blood, and do an exam," I said to Mr. McArthur. "Do you smoke?"

"No," he replied as Bob cut open his shirt and undershirt to gain access.

"Drink?"

"Socially."

"Exercise?"

"No."

"Are you taking any medication?"

"No. Aspirin if I have a headache, but not today."

As Bob attached the EKG leads and Len drew blood, I performed an exam and on auscultation, I heard 'distant' heart sounds. I called out the vitals to Jenny, who scribed them on the chart. Bob turned on the EKG and I looked at the screen.

"No ST elevation," I said. "Len, call for a cardiology consult, then get that blood to the lab, stat, please."

"What does that mean?" Mr. McArthur asked.

"ST-Elevation is a sign of the most dangerous type of heart attack. You don't show any elevation in the S-T segment of your EKG, which measures electrical activity of your ventricles. What I do see is something called a low-amplitude QRS complex, which measures both electrical activity and contraction of your ventricles. To put it in layman's terms, your heart is struggling to beat."

"Why?"

"That's what a cardiologist will tell us. You aren't in any significant danger right now. How is the pain?"

"Stabbing."

"Jenny, 5 megs sublingual nitroglycerin, please."

"Right away, Doctor!" she exclaimed.

"Jenny is going to put a tablet of nitroglycerin under your tongue, which will help with the pain."

We continued to monitor Mr. McArthur until the cardiologist arrived.

"Well, well, well," Doctor Alana Pace chuckled as she came into the trauma room with a female Third Year. "Pace, Cardiology. What do we have, DOCTOR?"

"Jerome McArthur, sixty-eight; complained of severe chest pains while at breakfast; tachy at 110, BP 90/60; distant heart sounds on auscultation; weak distal pulse in both legs; diaphoretic; PO₂ 96 on five liters by canula; no previous history of heart trouble; no known medications. 5mg nitro sublingual. CBC, Chem-20, and cardiac enzymes ordered. EKG shows low-amplitude QRS complex, suggestive of pericardial effusion or infiltrative myocardial disease. Suggest transthoracic echocardiogram to confirm pericardial effusion."

"Good morning, Mr. McArthur," Doctor Pace said. "I'm Doctor Pace from cardiology. May I examine you?"

"Yes."

She repeated the exam I had done, then asked me to step out. I waved for Bob and Len to follow us into the corridor, as did Doctor Pace's student.

"How confident are you in your diagnosis?" she asked.

"Very," I replied. "He has the classic signs; the EKG and exams are consistent with pericardial effusion. We're waiting on blood tests, but I think the echo ought to be done right away."

"I agree. There's no need to wait for the blood test results. I'll take him, and we'll do the echo upstairs. Excellent diagnosis, Doctor!"

"Thanks."

"I see Cutter has you in red," she said.

"Does everyone know about that little battle?"

"I'd say so, given there was a heated debate at the Attendings' meeting that Doctor Getty told us about. He has no dog in the fight, so to speak, so he just sat back and ate popcorn."

"Of course!"

We went back into the trauma room.

"Mr. McArthur," Doctor Pace said, "Doctor Loucks and I agree you need to have an echocardiogram. That's an ultrasound of your heart and will help us confirm your diagnosis."

"Which is?"

"The most likely condition indicated by your symptoms is pericardial effusion, which is an accumulation of fluid around your heart. It's not technically a heart attack, but it could easily lead to one if not treated. Once we confirm, we'll most likely perform a pericardiocentesis, which means draining the fluid."

"What causes that?"

"Any number of things, and I can't really speculate until we do some tests. Once we confirm the fluid buildup, we'll look for the root cause."

"OK."

"Carol," Doctor Pace said to her student, "call for an orderly and bring Mr. Pace up. No need for an EKG during transport as he's not having an MI."

"Yes, Doctor," she replied.

Ten minutes later, Mr. McArthur was on his way up to Cardiology.

"You made a diagnosis straight from the EKG?" Len asked.

"A preliminary one," I replied. "But ultimately, what we found is secondary to the cause of the effusion. There are strong odds it's not a heart problem, so he might end up in Medicine once Doctor Pace performs the pericardiocentesis, assuming it's not some latent heart disease of which he was unaware."

"That happens?" Len asked.

I nodded, "Unless there are obvious symptoms, what happens today is the most common result -- a trip to the ED due to onset of chest pains. Most effusions aren't symptomatic, at least in a way that the person suffering from them would notice. And if they're due to viral infection, they usually clear themselves with no intervention. Did you make your drawing?"

"Yes."

"Good. Bob, I'll sign your procedure book."

He quickly wrote in the procedure and I signed off, then said, "Let's report to Doctor Taylor."

We went to the Attendings' office, and I let Doctor Taylor know that I'd sent the patient up to cardiology. He reviewed the chart, scribbled a note and his signature, and handed it back. I thanked him, returned the chart to the nurses' station, and Ellie directed me to the triage desk.

"Morning, Alex," I said to the Fourth Year manning the desk. "What do you have?"

"Take your pick! Nothing critical. Toddler with an apparent ear infection; FF with back pain; carpenter with an infected finger."

"I'll take toddlers with ear infections for $500, Alex," I grinned, hoping someone else would catch the Frequent Flier drug seeker.

"Good lord!" Nurse Lily groaned. "That joke!"

Alex handed me the chart, and I went to the door to the waiting room and opened it.

"Ms. Lopez and Arturo?" I called out.

"Us!" a very pretty Hispanic woman called out, standing up and walking over carrying a crying toddler of about three.

I escorted her and her son into the ED, checked the board, and took them to Exam 5, the larger of the two makeshift exam rooms.

"I'm Doctor Mike and these two men are medical students I'm training. What brought Arturo to us today?"

"He's been crying a lot and started pulling on his ear a couple of days ago. This morning, he complained about pain, so my husband suggested taking Arturo to his pediatrician. They couldn't see him until late this afternoon and he's miserable."

"Let's get Arturo on the table and we'll check him out."

I was reasonably certain what I'd find -- otitis media -- but obviously I had to do a complete exam.

"Has Arturo had an ear infection in the past?"

"No."

"Any recent injuries or illnesses?"

"No. He's pretty healthy, except for the usual scrapes a little boy gets playing."

"How is his appetite? Any changes in the past few days?"

"He eats a lot, but he burns it up playing fútbol at the park."

I was positive she meant what we usually called 'soccer'.

"OK to examine him?"

"Yes, of course!"

I turned to the fussy little boy sitting on the exam table, who eyed me warily.

"Hi, Arturo. I'm Doctor Mike and I'd like to listen to your heart and breathing, count your heartbeats, look in your eyes, ears, nose, and mouth, and take your temperature. Is that OK?"

"Mama?" he asked.

"He needs to check you, Arturo." Ms. Lopez said.

"OK," Arturo replied, sniffing with a tear running down his cheek.

I washed my hands, put on gloves, and began my exam by listening to Arturo's heart and lungs, explaining each thing I was doing. I used an otoscope to check his ears and nose, changing the speculum between each ear and each nasal cavity. I used my penlight to check his pupils, and combined with a tongue depressor his tonsils.

Arturo's left tympanic membrane was red and bulging, which was a strong indication of otitis media. I checked his tympanic temperature in his non-infected ear, and determined he had a fever of 38.1°C, or just over 100°F. His pulse was elevated, at 85 beats per minute, but he had no other symptoms.

"I believe Arturo does have an ear infection," I said to Ms. Lopez. "Generally, they resolve without treatment beyond Advil or Tylenol to help with the pain. You should give him over-the-counter children's pain killers and follow up with his pediatrician in two days if he's still complaining about pain."

"No medication?" she asked.

"Most ear infections resolve in less than a week without medical intervention. In addition, it could be from a virus, which would mean antibiotics won't help. Except for infants, the best option is Children's Tylenol or Advil, and allow the infection to run its course. Your pediatrician will decide if further treatment is necessary."

"I could have just waited, then, right?"

I nodded, "Yes, though we prefer you err on the side of caution. You should take his temperature every three hours, and if it reaches 102°F, bring him back right away. I can get you the medication now, but honestly, it'll cost ten times as much if I get it for you as if you stop at the drug store just down the road."

"OK."

"Let me fill out the paperwork, and we'll get you on your way."

Bob, Len, and I left the exam room and went to the nurses' station where I filled out the chart and the discharge form, then took everything to Doctor Taylor for his review and signature.

"Any pressure to prescribe antibiotics?" he asked.

"His mom asked, but seemed to accept my answer that they weren't necessary."

"She'll get them from his pediatrician," Doctor Taylor said, writing notes on the chart and signing it and the discharge form. "But not much we can do about that. OK to discharge."

"Thanks," I said as he handed me the clipboard.

We returned to the exam room, I reminded Ms. Lopez about taking Arturo to his pediatrician, then asked Arturo what kind of candy he liked.

"Skittles!" he said.

I pulled a pack from a fanny pack I had purchased to use in the ED when I wasn't wearing a medical coat, and handed them to him, making his eyes light up.

"Doctor Houdini?" Ms. Lopez asked.

"I have a dozen different things in my pack plus spares in my locker," I chuckled, then turned back to my patient and said, "Arturo, you only eat those when your mom says it's OK."

"Arturo, thank the doctor!" Ms. Lopez said.

"Thank you," he said.

"Ms. Lopez, you can see Patient Services on your way out. It's the office next to the door to the waiting room. They'll get your insurance information and make arrangements for billing them."

"Thank you, Doctor!"

We all left the exam room and Ms. Lopez and her son went to Patient Services.

"I thought antibiotics were routine for infections," Len said.

"They used to be," I replied. "But their efficacy with ear infections is iffy at best, and as I said, if it's viral, they won't do any good. Overuse of antibiotics is a major problem, which should have been covered in your pharma class."

"It was, but they didn't say anything about not prescribing for ear infections."

"OK. Just something to remember."

"Why did Doctor Taylor say her pediatrician would prescribe them?"

"Because it's easy for us here in the ED to say 'no', but pediatricians often give into parental pressure because it's the path of least resistance, not to mention the guidance on antibiotics for ear infections is relatively new."

We went to the lounge and less than a minute later, Nurse Ellie came to the door.

"Doctor Mike?" she called out. "Multi-victim MVA. Doctor Taylor wants you with him and Doctor Foulks."

"On it!" I said. "Bob, Len, let's go!"

We gowned and gloved and met Doctor Taylor in the ambulance bay where Doctor Foulks and his medical students, along with two nurses were waiting.

"Any idea how bad?" I asked Doctor Taylor.

"Two critical," Doctor Taylor said. "One in arrest."

Which meant that a firefighter would be assisting with CPR and the chances of survival were low.

"Nick," Doctor Taylor said to Doctor Foulks, "we'll take the arrest. You take the other one."

"OK," Doctor Foulks agreed.

A minute later the first EMS squad came to a stop in the ambulance bay and a paramedic jumped out.

"Male, fifty-ish; unrestrained driver; cardiac arrest as we prepped him for transport; continue CPR and bagging; obvious head, chest, and leg injuries. IV saline TKO."

"Trauma 3!" Doctor Taylor ordered. "How long was he down?"

"It's been at least twenty minutes," the paramedic replied.

The gurney was removed from the ambulance and a firefighter got on, straddling the patient, performing chest compressions while the paramedic bagged the patient. Doctor Taylor, Bob, Len, Nurse Kelly, and I all rushed the patient to Trauma 3.

"Mike, EKG and monitor! Bob, Foley! Kelly, hang a bag of plasma, draw for a blood gas, type, and crossmatch."

I grabbed the bandage scissors and quickly cut away the patient's shirt while Bob did the same with his jeans. I began attaching the leads which required a bit of contortion on my part so the fireman could continue with compressions.

"Hold compressions," Doctor Taylor commanded.

He quickly listened.

"No heart sounds," he said. "Continue compressions."

I turned on the EKG and quickly scanned it.

"PEA!" I declared. "Atropine and sodium bicarb, IV push."

"Do it, Kelly!" Doctor Taylor ordered. "Mike, he needs a chest tube. You're wearing red and have the 'S' on your badge, and we can't wait for a surgical consult."

That wasn't protocol, but it was technically within the rules, as I was a surgical intern and I was being supervised directly by an Attending.

"Len, chest tube tray!" I ordered.

He brought it to me, ripped it open, and I squirted Betadine onto the correct area.

"Atropine and bicarb are in!" Kelly called out.

"Cease compressions," I ordered.

Once the fireman stopped, I proceeded with the steps Doctor Rafiq had reluctantly taught me.

"Blood in the chest cavity!" I announced as blood came out of the tube.

"Heartbeat!" Bob called out. "Irregular, I think."

The firefighter climbed off the table and I looked over at the EKG and there was, indeed, indications that the patient's heart was beating. While I connected the ThoraSeal, Doctor Taylor auscultated and nodded.

"Faint heart sounds," he said. "Len find the on-call surgical Resident!"

The firefighter and the paramedics left, as CPR was no longer necessary.

"Thoracotomy?" I asked.

"If we can stabilize him," Doctor Taylor replied. "OK, heartbeat is weak but regular, let's intubate and do a full exam. Mike, tube him."

"OK to have Bob try it?" I asked.

"Once. First time or you do it."

"Kelly, intubation tray, please," I requested. "Bob, come stand by me."

"Are you sure, Doc?" he asked.

"I am, but if you aren't, stand aside, watch, and I'll do it and give you step-by-step instructions."

"Uhm, that's probably better."

"OK."

I intubated the patient and hooked the tube to the ventilator.

"Lindsay, surgery," Doctor Lindsay said, coming in with Jack Talbert, a Fourth Year.

It was odd for a Senior Resident to catch an early morning consult, but it happened from time to time. Most likely that meant her scheduled procedure had been canceled.

"Fifty-ish male; unrestrained MVA; arrested on site; CPR; PEA detected; revived with atropine and bicarb; pulse weak at 60; BP 80 palp; vent at eighteen with PO₂ 98%. Blood in the chest cavity; broken right tibia; severe contusion left temple; chest tube is in."

"Who did that?!" Doctor Lindsay asked, surprised.

"The surgical Resident!" Doctor Taylor said. "On my orders."

"Let me check that first, please. Hi, Mike."

"Hi, Doctor Lindsay. I followed Doctor Rafiq's technique."

She examined the tube, the ThoraSeal, and the sutures and nodded. "Looks good."

She did a quick exam and nodded, "We need to find the source of the blood, but he's unstable. Let's give him some pressers and blood and see if we can get his BP up. If not, he'll never survive me opening him up, and might not even make it upstairs."

"Kelly," Doctor Taylor said, "hang a unit; a meg of epi IV push, half a meg every five minutes."

"Yes, Doctor!" Nurse Kelly replied.

"Emergency thoracotomy?" I asked Doctor Lindsay.

"We don't have what we need here in the ED," she said. "You know the protocol."

I did, and when the new ED wing opened and I'd completed enough of my Residency, we would have emergency thoracotomy kits in the ED, but for now, we didn't, and couldn't, per hospital protocol.

The monitor blared, and I looked up.

"V-fib!" I said.

"Mike, charge to 150!" Doctor Taylor ordered.

I flipped the switches on the defibrillator, twisted the dial, then handed Doctor Taylor the paddles and squired gel on them.

"Charged!" I declared when the machine beeped.

"CLEAR!" he commanded.

I removed the vent connection and everyone stood back while he shocked the patient.

"No conversion!" I said once the EKG settled from the massive rush of electrical energy.

"Charge to 200!"

I did and Doctor Taylor shocked the patient again."

"No conversion," I said.

"250!"

I twisted the dial but before the machine beeped and the monitor tone went steady.

"Asystole!" I said.

"A meg of epi down the tube!" he ordered.

I grabbed the vial, as I was closest, drew the liquid into the syringe, then squirted it into the vent tube and reconnected the vent.

"Nothing," I said fifteen seconds later.

"There's no point in flogging him," Doctor Taylor said. "He's had three doses of epi, and another dose isn't going to make a difference. He was down for at least twenty minutes before he got here. Time of death, 08:13."

"I'll get the death kit," Kelly said.

I turned off the EKG and monitor, waved for Bob and Len, and we left the room.

"Why give up?" Len asked.

"At some point, you decide it's hopeless," I replied. "With a potentially severe head injury, internal bleeding, and having been down for thirty minutes, it was a near miracle we got any kind of heartbeat at all. You know the survival rate for CPR, right?"

"Under 20%," he replied.

"And that's for heart attacks. While it won't appear on Doctor McKnight's report this way, his cause of death was not wearing a seat belt."

"What a stupid way to die," Len said.

"I agree."

IX. Three In One Day

July 3, 1989, McKinley, Ohio

"Everything OK at home?" Clarissa asked as we sat down with our lunches in the cafeteria at a table away from most other people.

"Why wouldn't it be?"

"Nobody is that mellow!" Clarissa protested.

"Not only is she that mellow, we have permission to conceive naturally, if you want."

"NO WAY!" Clarissa gasped. "SERIOUSLY?!"

"No," I chuckled. "Of course not!"

"That was mean, Petrovich! Even for you!" Clarissa exclaimed, but I could see in her eyes she wasn't upset.

"How often do I have a 'gotcha' with you?"

"Not very! So she's all good?"

"She is. And as open-minded as my cosmopolitan French wife is, she's not open-minded enough to allow what I teased about. But she's fine with our agreement, and she's not reluctant or concerned."

"She has no idea how badly you want to sleep with me, does she?" Clarissa asked.

"Except I don't, for obvious reasons."

"OK, before you married! Both marriages, too!"

"And yet, it wasn't about sex, which, by the way, is what would concern her, not the act, in and of itself."

"So casual sex is OK?"

"No, of course not, but it wouldn't be casual with you, which both you and I know."

She nodded and then asked, "How was your morning?"

"Fairly typical for the ER, though I did get to put in a chest tube."

"You wheedled it out of the on call?"

"No. Doctor Taylor saw the red scrubs and the surgical 'S' on my badge and instructed me to do it because I was a surgical intern and was being supervised by an Attending, which is the letter of the law. There's a low-intensity war between Cutter and Northrup, and I believe Doctor Northrup lost the battle but might win the war."

"How so?"

"Cutter was so insistent that I'm a surgical intern that Northrup is taking him at his word. Obviously I can't do anything I haven't been trained to do, but I can do chest tubes and emergency pericardiocenteses, because I have been trained to do those. I'm sure that will lead to further internecine combat, but so long as I can stay out of the line of fire, they can fight all they want."

"Does he know about the tube?"

"I'm not sure if Doctor Pace will report it, or if he'll see it on a chart review a week from now, but one way or the other, it will get back to him. Heck, Northrup might tell him just to tweak him."

"You're enjoying the politics?! What's next? Human sacrifice, dogs and cats living together...mass hysteria?!"

"It's working to my advantage at the moment, and to Ellie's disadvantage!"

"How so?"

"My locker is in the surgical locker room!"

Clarissa laughed, "Poor Ellie, she'll have to get her thrills some other way than seeing 'Big Mike'!"

"She's never seen Big Mike!" I countered.

"Tell me she hasn't seen you in your briefs."

"Fine, but she's never seen Big Mike ready for action and she never will!"

"She'd redouble her efforts if she knew!"

"Twice nothing is still nothing," I replied. "How is your shift going?"

"A pair of interesting cases that have everyone stumped. I'm researching, but it would be so much easier if everything was computerized. Some stuff is, but not everything."

"I'll be happy with remote telemetry beds," I replied. "But your challenges are somewhat different from mine."

"I prefer the mental acuity tests to 'can I make the right decision in a split second to save a life'. I could do it if I had to, but you get off on it."

"I don't think I'd go quite that far," I chuckled. "But I certainly prefer the adrenaline rush of the ED to the mostly intellectual exercise of Internal Medicine."

"Including the walk-ins?"

"I have to come down off the adrenaline high at least occasionally!"

"Everything is pretty much exactly as we had hoped."

"Minus Kitten not being here to see it," I said.

"You suffered quite a bit to make it here, Mike, and sacrificed so much. I'm positive she's proud of you, and probably rolling her eyes at times."

"Of that you can be sure!"

We finished our lunches without interruption, which was something I wouldn't be able to count on for years to come. I walked Clarissa to the elevators, then headed back to the ED where Ellie asked me to catch some walk-ins. I found Len and Bob, then went to see Doctor Birch.

"Where are my toddlers?" I asked.

He laughed, "It does seem that way, doesn't it? They're in the lounge. Four students, all Second Years. No First years until August."

"That's something, I guess," I said with a wan smile.

Len, Bob and I went to the lounge and I introduced myself to the four students. I was tempted to call them by numbers -- one, two, three, and four -- but decided that was a bit too much hazing.

"Your task today is simply to observe," I said. "Take notes, ask questions between patents, and stand out of the way. Next week, there will be a quiz."

Three of the four groaned and I wanted to laugh, because as Second Years, they should have been ready for something like that.

I led my small entourage to the admit desk and asked Alex what he had.

"Puking five-year-old; sixteen-year-old with a rash that appears to be poison ivy; twenty-three-year-old construction worker with nail gun injury."

"Nail gun injury?"

"Right through his foot."

"That's going to be surgical, so I'll take him."

"Mr. Logan," Alex said, handing me the chart. "He's in the wheelchair. Vitals normal, only complaint is the nail in his foot."

"Thanks. Len, you push the wheelchair."

"Low man on the totem pole," he chuckled. "Got it."

"Bob, history and physical. I'll confirm, then we'll discuss the plan of action outside the room."

I looked up at the board and saw that Trauma 3 was open. Bob, Len, and I called for Mr. Logan, I introduced myself and my students, then Len and Bob took him to Trauma 3 while I went to the desk and asked for a nurse to join us. The four Second Years followed us and stood clustered in the corner of the room, and Alice, who Ellie assigned, followed me into the treatment room. Bob did a good job on the H & P, and I confirmed his exam.

"Could I get something for the pain?" he asked.

Because there was potential for surgery, the most I could offer was ibuprofen or acetaminophen, as any opiates would create potential interactions with a general anesthetic, should one be necessary.

"Alice, 600mg ibuprofen PO, please," I requested. "Then irrigate and paint with Betadyne."

"Right away, Doctor!" she said, making a note on the chart.

"Mr. Logan, I'll be right back," I said.

"Thanks, Doc."

We stepped out, and I asked Bob for his plan.

"Can you remove the nail?" He asked.

"Technically, I could, but I've never done it before, so I need either a senior surgical Resident or surgical Attending to supervise. What's your plan?"

"X-ray, then remove the nail, clean and irrigate, update tetanus, and a course of antibiotics. Ibuprofen or acetaminophen for pain."

"Any idea about the procedure to remove the nail?"

"No. I've never seen that done."

"OK. Len, call for a surgical consult, please."

Len went to the wall phone and made the call, and five minutes later, Doctor Rafiq arrived.

"Charles Logan, twenty-three, penetrating trauma to the left foot from a nail gun; irrigated and Betadyne applied; recommend x-ray, extraction, tetanus, and a course of antibiotics. If the x-ray shows significant bone involvement, then an ortho consult. I'd like to do the extraction."

"Have you done one?" Doctor Rafiq asked, sounding annoyed.

"No, but I know the technique -- lidocaine times four, clip the exposed portion of the nail distal from the point of extraction, remove with constant pressure, address any bleeding, apply topical antibiotics. No sutures unless surgical repair is necessary due to arterial or veinous damage."

Doctor Rafiq glared at me but nodded his assent.

"Len, call for a portable x-ray, please," I said, and the four of us went back into the room.

"Mr. Logan, this is Doctor Rafiq, a surgeon. We're going to x-ray your foot to confirm it's safe to extract the nail without surgery. Just relax as best you can and we'll get the nail out as soon as possible."

The x-ray tech arrived about five minutes later with the portable fluoroscope, which had a monitor that would give us a real-time image of Mr. Logan's foot. Doctor Rafiq and I examined the image.

"Soft tissue only," I observed. "The nail is in the dorsal interossei between the first and second left metatarsal with no bone involvement."

"I concur," Doctor Rafiq said.

"Lidocaine times four, clip the three centimeters that extend through the plantar, then extract dorsally."

"Proceed."

"Alice, lidocaine times four, please, and a procedure tray."

"Right away, Doctor!"

"Mr. Logan, I'm going to numb your foot with lidocaine. Have you had any problems with local anesthetics, including at the dentist?"

"No. I've had cavities filled and didn't have any trouble."

The procedure was straight forward -- I numbed his foot with lidocaine injected near the nail on both sides, then used 5¼ inch podiatric nail nippers to cut through the part of nail that was protruding from Mr. Logan's foot. Once that was completed, I grasped the upper end of the nail with 5½ Kellys, and slowly and carefully extracted it.

"Minimal bleeding," I observed. "How are you feeling, Mr. Logan?"

"OK. My foot is throbbing, but otherwise, not bad."

"Great. Alice is going to irrigate and dress your wound and give you a tetanus shot. Do you have any allergies to antibiotics or have you had a bad reaction?"

"No," he said, confirming what he'd told Bob during the H & P.

"OK. I'll be back in a few minutes with your discharge instructions."

"Thanks, Doc."

Doctor Rafiq left, and the Bob, Len, the Second Years and I went to the Attendings' office to see Doctor Taylor. I reviewed the injury and procedure, and recommendation for 500mg amoxicillin three times a day for seven days.

"Approved," Doctor Birch said, making a note on the chart and signing it. "Good job, Mike."

"Thanks," I replied.

"You'll need to stay off your foot for at least a week," I said. "Then follow-up with your regular physician. I'll fill out the necessary form for you to provide to your employer, and Patient Services will assist you with the Workman's Comp forms. Len, would you please call for an orderly with a wheelchair; Bob, get a set of crutches, please."

"Right away, Doctor!" Bob acknowledged.

"Will do," Len said.

"Mr. Logan, have you used crutches before?" I asked.

"Yeah, when I was sixteen, I broke my ankle."

I filled out a prescription form, the first one I'd personally written, and handed it to Mr. Logan.

"You can fill this at the hospital pharmacy or any other pharmacy of your choice. Make sure you take the antibiotics as prescribed and take them all, even if there are no signs of infection. For pain, you can use over-the-counter analgesics -- Tylenol and Advil are good choices, and whichever one works better is fine."

"What about Anacin? That's my usual go-to for pain."

"If that works for you, and it doesn't cause you stomach problems, that's fine. We tend to recommend ibuprofen or acetaminophen, which are the ingredients in Advil and Tylenol, respectively, as they have fewer side effects."

"Never had trouble with aspirin, and it's all I've ever used."

"OK. Len will stay with you until the orderly arrives, then escort you to patient services. Do you need to call someone to pick you up?"

"My foreman brought me in. He'll take me home."

"OK. Keep your foot dry until you see your personal physician, but come back if you run a fever over 101°F, or you see any discharge beyond a small amount of blood or clear fluid, or a rash or redness that is spreading, come back right away."

"Thanks, Doc."

"You're welcome, have a nice day."

"You, too."

I left the room, and a minute later, Bob returned with a set of crutches, which he took into the trauma room for Mr. Logan. He came back into the corridor a few seconds later.

"What was up with that surgeon?" he asked quietly. "He was giving you dirty looks the entire time."

"Doctor Rafiq is unhappy that I was allowed to do procedures as a Fourth Year that he wasn't allowed to do as a PGY1, and doesn't agree with Doctor Roth's training program for me. Fortunately, he's not my supervising Resident."

"Who would normally do the procedure you just did?"

"Historically, only a surgeon, but in the past year the policy changed such that after a surgical consult, the trauma specialist can do it. If there had been any bone involvement, we'd have needed an orthopedic surgeon, and they'd have taken Mr. Logan up to the OR. Long term, a trauma surgeon would make the call, and then take the patient up, and consult with an orthopedic surgeon on the extraction and repair."

"What if an artery of vein had been compromised?"

"It depends on the volume of blood, but many times it would require a surgical repair. That's not something I could even contemplate doing for four or five years, at least."

"How do you get your surgical training?"

"After two years in the ED, I'll handle all surgical consults during my shifts and assist with any emergency surgery. I'll have some scheduled procedures as well, as I have to be sufficiently versed in them to pass my surgical Boards. It works out to about eight or nine years, including a Fellowship. Let's catch another walk-in. Len can join us when he's finished with Mr. Logan."

We went to the triage desk and someone had taken the puking five-year-old, and two others had arrived, but neither was sufficiently urgent to jump the queue ahead of the sixteen-year-old girl with suspected exposure to poison ivy.

"Miss Munroe?" I called out.

A tall, athletic blonde who was standing, raised her hand.

"I'm Doctor Mike," I said. "I understand you believe you've come in contact with poison ivy?"

"Yeah, uhm, could I see a lady doctor? It's kind of in an embarrassing place."

"Let me see if someone is available," I said. "If not, do you want to wait?"

"Er, I guess it depends on how long."

"OK. Hang tight and I'll see."

Bob and I went back into the ED and I checked the board. Only Doctor Billings and Doctor Townsend were on shift, and they were in a trauma, so I walked over to Ellie to inquire.

"It's a bad one," she said. "Stabbing victim."

I contemplated offering to switch and take over for Doctor Townsend, a fellow PGY1, but Jill Munroe's situation wasn't serious enough to warrant interrupting a severe trauma. I began walking back to the waiting room.

"Patients are allowed to do that?" Joe, one of the Second Years asked.

I nodded, "Yes. For any reason, too. We, as physicians, cannot choose our patients, but patients can determine who provides their medical care, and yes, that includes for racist or sexist reasons, though in this case, I'd say modesty."

"I didn't see the chart, obviously, so where is the rash?"

"Her buttocks and upper thighs. I suspect you can work out how that might have happened."

"I'd hate to be the guy and have it where I suspect he'd have come in contact with poison ivy!" Len declared.

"I might need to ask you to swap with Leslie to limit the number of guys in the room. It's not about you, but about the patient. It's happened to me a few times."

"Understood."

"Let's see if our young woman will accept me as her doctor, or wants to wait. We'll need a female nurse if Miss Munroe does agree, and we'll probably end up calling for an OB/GYN consult."

"Jill Munroe? Like Charlie's Angels?"

"Never watched it. Which actress was that?"

"Farrah!" Ken, another of the Second Years declared. "Seriously? You don't know that?"

I chuckled, "I know about Farrah, but I never watched the show. My best guy friend had the poster of her in his room."

"Who didn't?"

"Me," I chuckled. "It didn't fit with the icons."

"Icons?"

"I'm Russian Orthodox. Anyway, let's see what she has to say."

I went back into the waiting room with Bob and over to where Miss Munroe was standing in obvious discomfort.

"Doctors Townsend and Billings, the two females on shift, are both in a trauma, and it might be some time before they can see you. You're free to wait if you like. If you'd be more comfortable, I can also have a female medical student assist me, instead of Bob."

"How long do you think?"

"I can't say, but the nurse said the trauma was bad."

"There are only two women doctors in the hospital?"

"Only two in trauma. I could call someone from OB/GYN, but you'd be in line behind any women in labor or needing pre-natal care, and that might take even longer. You could see your own OB/GYN or GP, if either of those is an option."

She contemplated for a moment, "I'll wait."

"OK."

Bob and I returned to the triage desk and I let Alex know.

"Want me to call OB and see if they have someone?"

"Probably a good idea, as we have no idea how long Doctor Billings and Doctor Townsend will be. I'll take the rule-out broken ankle."

He handed me the chart, and Bob and I went back to the waiting room. I first stopped to let Miss Munroe know that we'd called for an OB/GYN, but couldn't give her an ETA, then went over to Miss Lucy Knight, age nineteen, and sitting in a wheelchair.

"Hi," I said. "I'm Doctor Mike and this is Bob, a medical student I'm training, and some other students who are observing. What happened?"

"I missed a step and landed badly. I twisted my ankle. My mom thinks it's broken, but I think it's just a bad sprain."

"We'll do an exam and an x-ray and see what's up. Is this your mom?"

"Yes."

"Mrs. Knight, we'll take good care of her and someone will come let you know when we've finished our exam."

"Can I come back with her?" she asked.

"That's up to Lucy," I said.

"Sure," Miss Knight agreed.

"Bob, if you'll do the honors," I said. "Exam 3 is open."

Bob pushed the wheelchair, and we went to Exam 3 where I conducted the H & P.

"I need to get an x-ray of your ankle," I said. "Is there any chance you're pregnant?"

"What kind of question is that?" Mrs. Knight asked, sounding offended.

"A required one," I replied. "We want to limit exposure of a fetus to x-rays, and we ask that question to help us determine the correct diagnostic procedures and decide on which medications are OK. I meant no disrespect at all. Lucy?"

"No," she said. "No chance."

"OK."

I had Bob call for the portable x-ray, and twenty-five minutes later, after reviewing the fluoroscopy, I had Bob call for an orthopedic consult, as there was a hairline, non-displaced fracture of the ankle. I didn't think it needed to be set, nor did I think it needed surgical intervention, but all fractures required orthopedic review.

"Your mom was right," I said to Miss Knight. "But it's a hairline fracture, so I don't think you'll need anything more than a cast, but I'm going to have a specialist from Orthopedics verify my diagnosis."

"How long will I have to wear a cast?" she asked.

"Let's wait for the orthopedist before we say anything definitive."

"Are you a new doctor?" Miss Knight asked.

"I finished my formal training about a month ago," I replied. "But I've been performing exams and doing procedures for over two years."

"Is that why you're wearing red and everyone else is wearing blue?"

"No, the red scrubs are because I'm a surgical Intern, but I'm assigned to the Emergency Department as a trauma specialist."

"That seems strange."

"My specialty is trauma surgery, which is a combination of emergency medicine and surgery, so I've trained in both areas, and my training will continue for another eight or nine years."

"I thought you said you finished your training!"

"I graduated from medical school a month ago, so now I'm a Resident instead of a Trainee Doctor," I said, using the lay term. "That means I'm properly trained, but need experience before I'm Board certified and could practice completely on my own, rather than be supervised by a senior doctor called an Attending."

"But he's not here," she replied.

"Supervision means I report to him or her, confirm my diagnoses, and then receive approval to perform any procedures that haven't been signed-off, which means I know how to do them and have demonstrated that to their satisfaction. To set your mind at ease, I've been doing basic exams for over two years, and I'm fully trained in everything I might need to do to help you."

"So why call the other doctor?"

"Because broken bones aren't my specialty," I replied. "If you were having a heart attack, I'd treat you but still call for a cardiologist -- a heart doctor -- to confirm my diagnosis and to continue your treatment after you left the Emergency Department. If you were having a baby, I'd call for an OB for the same reason. I'm sure you see an OB/GYN in addition to your regular physician, right?"

"Yes."

"For the same reason," I replied. "Your GP could do the exams, but he or she doesn't have the extensive training in gynecological concerns that an OB/GYN has. Trauma specialists, and trauma surgeons, which is what I am, focus on treating emergency cases, which means diagnosing and stabilizing a patient before we hand them off to another specialist. In your case, you won't need to be admitted, so I'll complete your treatment with help from a nurse once the orthopedist confirms my diagnosis."

"Are you married?" she asked.

"Yes, and I have a daughter who's almost two."

"Jackson, Orthopedics," Doctor Valerie Jackson announced as she came in with a medical student in tow.

"Doctor Mike Loucks," I said. "Lucy Knight, nineteen; vitals normal; complained of ankle pain after a missed step on a staircase. Exam shows swelling and tenderness, but no ecchymosis. Negative exam for Maisonneuve fracture. Fluoroscope shows a non-displaced hairline fracture right posterior malleolus."

"Let me take a look," Doctor Jackson said.

She reviewed the image, then examined Miss Knight's ankle.

"Confirmed," she announced. "I recommend an orthopedic boot and normal ankle protocol."

"Thank you, Doctor," I said.

"Val, please. We're both PGY1s!"

I nodded and she and her student left.

"You're in luck," I said. "No cast, just an orthopedic boot. It fits snuggly and has Velcro closures. You'll be able to take it off to bathe, but you shouldn't put any weight on your ankle. You'll need to follow up with Doctor Jackson in two weeks to ensure the break is healing properly, and she'll decide exactly how long you'll need to stay off your ankle."

"How long could it be?" Miss Knight asked.

"That depends on a number of factors, but the norm for this type of fracture is six to ten weeks. Have you used crutches before?"

"No."

"I'll have the nurse who fits your boot show you how to use them. Let me get everything in motion and I'll come back and see you in a few minutes. What size shoe do you wear?"

"Six."

"OK. Bob, I'll write the order and you'll need to go up to Orthopedics and get a size-six boot, please. Just ask the duty nurse. Then get a set of crutches."

"Will do."

I wrote out the order on a prescription pad and handed it to Bob, then made notes on the chart.

"Be right back," I said to Miss Knight.

"Thanks, Doctor."

"You're welcome."

I stepped out and went to see Doctor Taylor, who reviewed the chart, made his notes, and signed it.

"No pain meds?" he asked, handing me the chart.

"I'd prefer to avoid any opiates if at all possible. I'll recommend ice and ibuprofen or acetaminophen, and have her come back if the pain is severe."

"You're concerned about addiction?"

"Very. I'm not about to deny pain meds to someone who needs them, but I'd prefer to take a staged approach. That's my personal preference, but if you tell me to prescribe something stronger, I won't fight you."

"No, I don't disagree with you. We see too many drug seekers as it is. No need to create more, especially a teenager."

I left his office and went to the nurses' station and asked Ellie for a nurse, and she assigned Jamie, the male nurse. He accompanied me back to the treatment room, and I introduced him to Miss Knight and her mom.

"Jamie will show you how to put on the boot and use the crutches," I said. "You should elevate your ankle as much as possible, and ice it for twenty-minutes at a time, with twenty minutes between applications. I'm writing you a prescription for 600mg ibuprofen, which you should take every eight hours for the next week, then as needed. That will help with the pain and swelling. No weight on that ankle before you see Doctor Jackson in two weeks, and then follow her instructions. Any questions for me?"

"No."

I wrote out the prescription and gave it to her along with the discharge instructions, and then left Jamie to complete her care.

"Mike?" Ellie called out. "Are you free?"

"Yes," I replied. "Jamie will finish up."

"Paramedics are three minutes out with a construction injury. Doctor Taylor needs you in the ambulance bay."

"Let Bob and Len know where to find me," I said.

"OK," she acknowledged.

I put on a gown and gloves, called the Second Years follow me, and hurried to the ambulance bay where I found Doctor Taylor, Nurse Kelly, and Naveen Varma, a fellow PGY1.

"Any idea what's coming in?" I asked.

"Multiple penetrating trauma," he said. "That's all I know."

"Surgical consult?" I asked. "That's way beyond my training and current skill set."

"Already called. You intubate, please. Naveen, EKG and monitor. Kelly, hang two units, then a complete trauma panel; type and cross match."

We both acknowledged his orders and two minutes later, Bobby jumped out of the cab of his rig.

"Bad one, Docs!" he called out. "Jack Nelson, thirty-three; fell from scaffolding on to rebar. Thirty minute rescue requiring saws; significant penetrating trauma to chest and abdomen; BP 90 palp; pulse 120 and thready; resps labored; PO₂ 94 on ten liters; IV saline TKO; morphine x2; GCS 8."

My eyes went wide when they pulled the gurney from the back of the right as I saw three rods of green rebar sticking out of the patient's torso. From their position, I was positive he had at least one compromised lung, and probably severe internal abdominal injuries.

"Trauma 1" Doctor Taylor ordered.

We moved quickly to Trauma 1 and carefully moved Mr. Nelson to the treatment table just as Doctor Roth arrived.

"As soon as he's stable, we'll take him up," Doctor Roth said, then went to the phone.

As Mr. Nelson was unconscious, I dispensed with the intubation drugs and quickly inserted the endotracheal tube and connected the vent, setting it on low pressure.

"Right lung sounds only," I said.

"Left one is penetrated," Doctor Taylor said.

"V-Tach!" Naveen announced, to nobody's surprise.

"What do you want to do, Owen?" Doctor Taylor asked Doctor Roth.

"I can't do anything here, and a chest tube is like a fart in a hurricane at this point. Let's get him upstairs. OK to take Mike with me?"

"He's your Intern!" Doctor Taylor replied. "As was made clear."

"Forget the BS politics and leave that to the Chiefs. Mike, bring Mr. Nelson up."

I acknowledged him, then quickly hooked up the portable EKG and portable vent. Fortunately, Len came in just at that minute.

"Help me with the gurney," I said to him. "We're going to OR..."

"Three," Doctor Roth confirmed. "See you upstairs."

He took off at a trot, because he'd need to scrub in while Len and I fetched a gurney, and then everyone in the trauma room helped move Mr. Nelson to it. I instructed my Second Years to shadow Doctor Taylor, then moved out of the room.

"Ellie," I called out as we rolled by, "I'll be in OR 3 with Doctor Roth," I said. "Have Bob work with Doctor Varma, please."

"I'll tell them," Nurse Ellie confirmed.

"You're doing surgery?" Len asked as we quickly moved towards the elevators.

"Doctor Roth is, but he asked for me to bring up Mr. Nelson up, so I suspect he'll have us scrub in because this is exactly the kind of case I'm training for."

"Is he going to make it?"

"HOLD THAT ELEVATOR!" I called out.

The staff who were about to get into the elevator cleared out of the way, and Len and I pushed the gurney into the waiting elevator. He hit the button for the surgical floor and the doors closed.

"Whether he makes it will be up to God and Doctor Roth," I said. "He has at least one compromised lung, and multiple internal abdominal injuries. I'm not sure what will be first -- fixing the lung or an ex-lap to see just how bad things are."

"No x-ray?"

"They'll use the surgical fluoroscope to get an idea, but only an ex-lap will reveal the extent. And they'll need to open him up to repair what they can. This one bar is in a position that might have compromised his liver, and if that's the case..."

"He won't make it."

"Let's just say it'll take more than extreme surgical skills. If you're a praying man, now would be a good time."

"Do you pray for your patients?"

"Silently for every one of them."

The elevator doors opened, and we rushed Mr. Nelson to OR 3, where Nurse Penny and Doctor Lindsay were waiting.

"Doctor Roth wants you to scrub in," Doctor Lindsay said as we carefully transferred Mr. Nelson to the surgical table.

"What about my student?" I asked. "He's Third Year."

"First rotation and never scrubbed in?"

"Correct."

"Send him back to the ED; we don't have time to sort out sizes and teach him to scrub."

"Sorry, Len," I said. "Go back and see Doctor Varma."

"OK," he replied.

He left, and I went to the scrub room where Doctor Roth was finishing up. I realized I needed a surgical cap, so I stepped through into the locker room and retrieved one of mine from my locker, then Nurse Jackie helped me scrub and gown. Once I was finished with the scrub procedure, I went into the OR where Doctor Roth was discussing anesthesia with Doctor Vandermeer.

"Mike," Doctor Roth asked when they finished the discussion, "how are your arm muscles?"

"I lift free weights as part of my exercise routine."

"OK, you're going to extract each piece of rebar once I view the scope. Smooth, straight motions, and then hand it to Jim, the Third Year who's standing by the door. Once that's done, I'll have you put in a chest tube while I begin the ex-lap with Shelly."

"With a through-and-through penetration, that's not going to re-inflate the lung," I said.

"No, but we'll need it and it's something you can do while we see if we can get the abdominal bleeding under control. I'll talk you through what to do after that."

"OK."

"What do we have?" Doctor Cutter asked, coming in.

Doctor Roth looked at me and I gave the report.

"Thanks, Mike," he said when I finished. "OK, Owen, what's your plan?"

"Shelly and I are going to see if we can stop the abdominal bleeding after we remove the rebar. For the lung, I asked Mike to put in a chest tube, and we'll decide from there what approach."

"Let me take the chest while you take the gut," he said.

"Still want the chest tube?" I asked.

"Yes," Doctor Cutter said. "He'll also need drains, which are similar, and we can teach you that, too. Interesting style choice on the cap."

I'd chosen solid black surgical caps, which had a pocket for my pony tail.

"The good guys wear black in my church," I replied.

"You wore colored cassocks here."

"That's permitted, but black is traditional."

"He's ready," Doctor Vandermeer said. "But I don't like his BP or his tachycardia."

"Let's see what we can do about that," Doctor Roth said.

A masked medical student I didn't recognize wheeled the fluoroscope over and positioned it. Doctor Roth looked intently at the screen.

"OK. Lung is compromised, but ribs are all intact, and the rod is a full six centimeters from his heart. Mike, extract the rod, please."

I stepped over, grasped the rebar with both hands and pulled slowly, trying to keep the metal rod at exactly the same angle as it had penetrated Mr. Nelson's chest and once it was clear, handed it to Jim.

"Some blood," Doctor Cutter observed. "But we'll manage it."

The student repositioned the scope to Mr. Nelson's abdomen as Doctor Roth directed.

"I do not like the looks of this," Doctor Roth said. "What do you think, Shelly?"

"His liver is compromised," she said. "And there is free fluid, suggesting injury to the hepatic portal vein. Let's check the other rod, because he might well bleed out if we pull this one."

"Agreed."

The scope was repositioned to view the third rod and Doctor Roth shook his head.

"His stomach is compromised and at least a partial resection will likely be necessary. We're going to be tied up for at least six hours, if not more. Penny, push our afternoon surgeries, please."

"I'd suggest we can remove this bar," Doctor Lindsay said. "And then do the laparotomy so we have access to the portal vein when we pull the rod."

"I'd say that's the best option," Doctor Roth said. "John?"

"I don't have any better options for you," Doctor Cutter said.

"OK," Doctor Roth said. "Mike, remove the second bar, same as the first."

I nodded and moved into position and once again slowly and carefully extracted the rebar, handing it to Jim.

"Moderate amount blood," Doctor Lindsay observed. "The liver injury is still primary."

"OK," Doctor Roth agreed. "Mike, we're going to do this fast. We'll get him open, I'll signal you, and you get that bar out and get out of the way. Once that's done, you put in the tube then assist Doctor Cutter."

"Yes, Doctor," I said.

"Ten blade," Doctor Roth said to Nurse Penny. "Shelly, stand by with suction. And Kelly, I'll need the needle driver as soon as the rod is out."

Nurse Kelly handed him the instrument and Doctor Lindsay picked up the suction.

"Everyone ready?"

"Move fast, Owen," Doctor Vandermeer said. "He's in bad shape."

"Tell me something I don't know!" Doctor Roth snapped, then said, "Sorry. OK. Here we go!"

He quickly made the necessary incisions and there was a LOT of blood.

"Penny, hang two units on the rapid infuser!" Doctor Roth barked. "Mike, go!"

I stepped up and grasped the rebar and pulled it out, quickly stepping back.

"Suction!" Doctor Roth ordered.

"Mike, chest tube, please," Doctor Cutter ordered as he used the fluoroscope to evaluate his next move.

"Chest tube tray to me, please!" I requested.

Nurse Amy brought it to me and I set to work.

"BP is bottoming out," Doctor Vandermeer announced.

"I'm working as fast as I can," Doctor Roth said. "Penny, hang a third unit."

"V-Fib!" Doctor Vandermeer announced.

"Paddles to Mike at 200!" Doctor Roth commanded. "Jim, pads!"

Jim put the pads on as Amy handed me the paddles, then squirted gel onto them.

"Charged!" Amy declared.

"CLEAR!" I commanded.

Doctor Vandermeer disconnected the vent, and I put the paddles on the pads and triggered the shock.

"No conversion!" Doctor Vandermeer declared.

"250!" I requested.

"Charged!" Amy declared a moment later.

"CLEAR!"

I shocked him again.

"No conversion," Doctor Vandermeer called out. "BP is unmeasurable. No pulse."

"He's lost too much blood," Doctor Cutter said. "We're not getting him back."

"Asystole," Doctor Vandermeer announced.

"Call it, Owen," Doctor Cutter said.

"God damn it!" Doctor Roth swore. "Time of death 14:49."

What had been a frantic, noisy OR was suddenly quiet as machines were turned off and people filed out of the room to the locker room.

"May I ask why you're so upset?" I asked Doctor Roth as everyone stripped off their scrubs.

"Third one of the day," he growled. "The first one had an embolism; the second had a fatal MI."

"It's just one of those days, Owen," Doctor Cutter said. "You have nothing scheduled for the rest of the day, so go home, relax, and tomorrow is a new day."

"OK to return to the ED?" I asked Doctor Cutter.

"Yes. We'll try to bring you up on traumas such as this, but it won't be every time because we can't leave the ED short-staffed."

"Thanks, Doctor Cutter."

I put on clean red scrubs, elected to begin wearing my surgical cap regularly, then headed back to the ED.

X. Call On Line 3

July 3, 1989, McKinley, Ohio

"Hi!" I said to Kris when she and Rachel came to the Emergency Department just before 5:30pm. "How are my girls?"

"She seems a lot happier than she was this morning," Kris said. "Marcie said she had fun playing with her friends."

"Want to come to Daddy?" I asked Rachel.

"NO!"

"What have you done now, Doctor Mike?" Nurse Wendy asked, laughing.

"I am sure the list of my failures as a dad is long and growing," I chuckled. "And once Rachel is able to articulate them, I'm positive I'll be given detailed instructions for improvement!"

Wendy laughed, "That sounds just like my fourteen-year-old son who never misses a chance to explain just how clueless and out of touch I am!"

"Mike, do you have time for dinner?" Kris asked.

"Let me check with Doctor Taylor," I said.

I quickly checked with him and was cleared for my thirty-minute dinner break, that, as with always the case in the ED, I could be paged if I was needed. I signed out, let Kristy know I'd be on break, let Len and Bob know, then accompanied my wife and daughter to the cafeteria.

"How has your day been so far?" she asked as we got into line to get our food.

"Busy and mostly good. We did lose one patient, but in all honesty, he was lucky to be alive when the paramedics got him to us. He fell off scaffolding onto reinforcing bars. Those are the green metal rods they use to make poured cement stronger. The fire department had to cut him from them, and he had three of them lodged in his body when they got him here. His internal injuries were too severe to survive."

"Wow! Does that happen often?"

"Usually construction injuries are things like stepping on a nail, cuts, or broken limbs. This was a first for me."

"What else?"

"A broken ankle, an injury from a nail gun, a broken wrist, and two rule-out MIs, that is, heart attacks. I did miss treating the sixteen-year-old female with poison ivy on her buttocks, upper thighs, and inner thighs."

"Not careful enough making love in the woods?"

"That's my guess," I said. "She requested a female doctor, which I totally understand. Doctor Carmichael came down from OB to treat her. I just wonder about her paramour!"

Kris laughed softly, "I bet that's even MORE uncomfortable!"

"Imagine explaining that to your parents as a teenager!"

Kris laughed again, "Even more uncomfortable!"

"My mom would have laughed," I said. "And would have had no sympathy for the discomfort caused by sinful behavior!"

"God works in mysterious ways?" Kris asked lightly.

"Could be," I chuckled.

I paid for our meals, though mine was subsidized, and we found an empty table. I put down the trays and retrieved a wooden high chair for Rachel, and Kris put her in it. I said the blessing, and we began to eat with Rachel, happily munching on a dinner roll.

"Do you think you'll be able to get any sleep tonight?"

"I'll try, but there are only three of us on overnight, so if it's at all busy, Naveen and I will be up all night and only Doctor Mastriano will get any sleep."

"Is that doctor Italian?"

"Yes, though she went to medical school and served her Residency in the US. How was your day today?"

"Good. My one and only math class, but it should be easy. When I arrived home, there was a message on the machine from the attorney who's helping Angie, Tom Kirkland. He'd like you to call him when you have a chance. He left both his work and home numbers."

"I'll see if I can find time tomorrow morning, otherwise it will have to be Wednesday."

"What time do you want me to have your music and instruments at the lake tomorrow?"

"I'll leave here around noon," I said. "So around then would be good. Just bring them to the band shell."

"My parents and Lyudmila will come with me."

"Great!"

"«Tante»!" Rachel exclaimed.

"My daughter is being corrupted by French women!" I groused good-naturedly.

"It could be worse," Kris replied.

"I'm not sure how," I chuckled. "She's three quarters Russian and a quarter Dutch! That's a dangerous mix!"

"You're half and half!"

"As I said!" I chuckled.

We finished our meal, and I had time to walk Rachel and Kris to the car. I got Rachel settled in her car seat, then kissed her forehead.

"Dada home?" she asked.

"No, Daddy can't come home," I replied. "Daddy has to help sick people. I'll see you tomorrow."

Rachel pouted, but there wasn't much I could do about it. I hugged Kris, we exchanged a quick kiss, and she got into the car. Once she'd driven off, I headed back to the ED. Bob and Len had gone off their shift, and Mary Anderson and Tom Lawson had replaced them.

"Doctor Loucks?" a short blonde with long, braided hair asked as I walked into the lounge.

Next to her was a lanky guy about my height with short brown hair.

"Doctor Mike, please. You must be Mary and Tom. May I see your procedure books, please?"

They handed them over, and I quickly flipped through them. Tom, being a Third Year on his first rotation, didn't have many procedures in his book, but Mary had the usual number for a Fourth Year. Both had EKG diagrams at the end of their notebooks, and I wondered if word had been passed somehow.

"We're catching walk-ins overnight," I said. "So, Mary, you'll be at the triage desk with a nurse. Tom, you'll stay with me and help with histories and physicals."

"Should I go now?" Mary asked.

"Yes. You relieve Alex, who goes off shift in about five minutes. Make sure you go over everyone who's waiting. We'll take a patient in a few minutes."

She left the lounge, and I used the restroom, then Tom and I went to the triage desk.

"What have you got for me?" I asked Mary, who was sitting with Nurse Margie, a brand new nurse who had graduated from nursing school at the end of May.

"Dad versus carving knife, carving knife wins; toddler with croup; and the ever popular 'back pain and I lost my pills'."

"FF?" I asked.

"Three visits in six months; prescribed drugs each time."

"Assessment?"

"I don't have one; Alex did the exam. There is no red dot on the most recent chart."

"I'll take the kitchen injury," I said. "Tom needs suturing practice. I'll come back for the toddler. The drug seeker gets to wait."

"OK," she said, handing me a chart.

"Al Crowe; forty-two; vitals normal; bleeding from injury to left index finger; missing about 2mm of the distal tip."

"Oops," I said.

"Yeah. His kids are a bit freaked out by the blood."

"The family of four over there?" I asked.

"Yes."

I accepted the chart, went to the door and called out, "Mr. Crowe?"

"That's me," he said, standing up.

"I'm Doctor Mike. If you'll come with me, we'll get you fixed up."

He kissed his wife and left her with two boys I guessed were around ten and twelve, and Tom and I escorted him to Exam 1.

"Tom is a medical student doing his clinical rotations," I said. "He's going to perform the exam under my direct supervision, if that's OK with you."

"A student?" Mr. Crowe asked.

"We're a teaching hospital and that's how we train doctors. He's had six years of classroom work, and now is being trained by doctors. I'll be right here the whole time."

"OK."

"H & P, Tom, please."

"What brings you to the hospital today?" Tom asked Mr. Crowe.

"I thought that was pretty obvious!" Mr. Crowe said, holding up his left hand.

"Yes, Sir, but we always ask," Tom said. "What happened?"

"I was slicing a roast and not being careful. I sliced off the tip of my index finger."

"Did you save the fingertip?" Tom asked.

"Didn't even think of that," Mr. Crowe said. "Is that a problem?"

"Most likely not," I interjected. "We generally can't reattach a small piece of tissue. Go ahead, Tom."

He did a competent job of taking the patient's history, including asking about a tetanus shot, which the patient hadn't had in five years. After washing his hands and putting on gloves, Tom performed the auscultation, reporting what he heard, with everything being normal.

"How do you want to proceed?" I asked Tom.

"Irrigate the wound, sterile dressing, elevate, ibuprofen for pain, update his tetanus."

"Proceed," I said to Tom.

"Mr. Crowe," Tom said, "I'm going to examine your finger, rinse it with sterile saline, then apply a gauze dressing. We'll have you keep your hand elevated and wait for the bleeding to stop. Once it does, we'll give you a tetanus booster, and get you on your way. You can take Advil or Tylenol for any pain. Is it OK to examine your finger?"

"That's why I'm here!" he said.

"We always ask permission before touching a patient if they're conscious," I said.

Tom irrigated the wound with saline, then examined it. I looked over his shoulder, and as I had suspected, there would have been no way to reattach the missing tissue, and the wound would heal with only minimal scarring. Tom applied a sterile dressing, then had Mr. Crowe put his hand on the opposite shoulder to elevate it above his heart.

"Mr. Crowe, I need to get the tetanus booster," I said. "I'll be right back."

"Don't nurses do that kind of thing?" he asked.

I nodded, "They do, but it seems silly to bother a nurse who is busy when I have keys to the drug room."

I left the room, went to the drug room, used my key to get in, then went to the refrigerator to get the tetanus booster. I recorded that I'd taken it on the clipboard on the fridge, then returned to Exam 1. I handed Tom the pre-filled syringe, he shook it, opened the package, and after cleaning Mr. Crowe's arm with the included alcohol wipe, administered the injection.

"We're done," I said to Mr. Crowe. "I would like you to stay for twenty minutes so we can ensure the bleeding has stopped. Just keep your hand on your shoulder and we'll come back in about fifteen to twenty minutes to check on you."

"Thanks, Doc! Your student seems to know his stuff."

"Thank you," I said.

Tom and I left the room and walked towards the Attendings' office.

"Not to be impertinent, but aren't you supposed to clear all procedures with the Attending?"

"Every Resident has a set of guidelines as to what they can do without expressly asking, and what we just did falls completely within my list of authorized procedures."

"So the rumors are true that you receive special treatment?"

"I receive treatment commensurate with my demonstrated abilities and skills. That will happen with you, too. Once I'm satisfied you are able to suture, you'll do minor repairs without me standing over your shoulder. Yes, I'll check your work when you finish, but you'll do it without direct supervision. Have you decided on a specialty?"

"No. I want to wait to complete my Clerkships before I decide."

"You'll need to do that a bit sooner than that," I replied. "You'll need to set your Sub-Internship schedule in the Spring. But you still have time to think about it."

"Any advice?"

"Figure out what motivates you and do that," I replied. "It's what will get you through the thirty-six-hour shifts, among other things."

"You're on one of those now, right?"

"Yes. Just over a third of the way through, and there's little chance I'll get to sleep much before 7:00pm tomorrow. I will be ducking out for about four hours to play a gig at Milton Lake, and Kylie Baxter will cover for me."

"She's on until midnight, though, right?"

"Yes. But we have an arrangement that started when we were medical students."

We reached the Attendings' office, and I had Tom report to Doctor Mastriano and have her sign the chart.

"Come see me when you have a chance," Doctor Mastriano said.

"Tom, I'll catch up with you in a few minutes at the triage desk."

"OK," he said and left.

"What's up?" I asked.

"Overnight, do not wake me unless a patient is dying. You can handle anything that comes in either yourself or with a consult."

"I'm not signed off on every procedure," I said.

"Use your best judgment," she said. "I need to get some sleep. I'll sign your charts in the morning before I go off shift at 0700."

"OK," I agreed, deciding I wouldn't win an argument and knowing that I could never get in serious trouble for waking her up, no matter what she might have said.

I left her office and went to the triage desk.

"Anything new?" I asked Mary.

"Eighteen-year-old female reporting that 'it burns when I pee'. Vitals normal but with a slight fever at 38.1°C. Twenty-two-year-old with a forehead lac from, you'll love this, trying to crush a beer can on his forehead. Vitals normal, but has a headache, as you can imagine."

"An interesting variation on 'hold my beer and watch this'," I chuckled. "Let me take the bawling toddler and give the others a break."

Mary handed me the chart, and Tom and I went to the door of the waiting room.

"I'll do this one," I said.

"Your reputation as 'Kid Whisperer' precedes you," Tom said.

"Yes, but also Mom looks harried, so I don't want to do anything to make her stress worse. No reflection on you, just on the circumstances."

"Got it."

I opened the door and called out, "Ms. Travis and Benny?"

The woman who appeared to be about twenty stood up and carried her crying two-year-old over to us.

"Hi," I said. "I'm Doctor Mike and this is my student Tom, who'll observe as part of his training."

"OK," she said.

We went to Exam 2, and I went to the sink to wash my hands.

"What seems to be Benny's problem?" I asked, as I rinsed the soap from my hands.

"He won't stop crying and I'm basically at my wit's end," she said.

That was an indication we'd need a social worker, as a mom in that condition was considered a risk. It was a judgment call, and one I'd make once I'd completed the exam and learned more about the situation.

"Has anything changed with his health recently? Or at home?"

"Not that I can think of," Ms. Travis said.

I dried my hands and put on gloves and went over to the exam table where Benny was lying down, still crying.

"Hi, Benny," I said. "I'm Mike. Does anything hurt?"

He didn't answer or stop crying, which meant I'd have to detect any potential pain via exam, which was an inexact science.

"OK to examine Benny?" I asked.

"Yes, of course," Ms. Travis said.

I did my best to listen to his heart and lungs, though the crying made that difficult. I didn't hear any crackles in his lungs, but I couldn't tell much about his heart. I draped my stethoscope around my neck and removed the otoscope from the holder, put on a fresh speculum and looked into Benny's right ear, seeing a red, bulging tympanic membrane. I changed the speculum, then checked his left year, finding the same thing.

Next, I examined his nose and throat, noting inflamed tonsils. I set the otoscope aside and palpated Benny's neck, finding swollen cervical lymph nodes, with Benny crying harder when I touched them. My final check was his temperature, which was 39°C. I decided to re-examine his tonsils, noting significant exudates, and concluded the most likely diagnosis was streptococcal pharyngitis.

I reviewed the Centor criteria, and Benny scored 5 out of 5 -- no cough; swollen and tender cervical lymph nodes; a fever over 38°C; tonsillar exudates; under age fifteen.

"I believe Benny has strep throat," I said, using the layman's term for my diagnosis. "Has he had diarrhea, been coughing, or had a runny nose?"

"No to the first two, but he's had a runny nose."

"Before or after he began crying?"

"After," she replied.

That meant, most likely, the red eyes and runny nose were related to crying, and didn't provide contraindication for strep.

"I'm going to take a throat culture, but that will take twenty-four hours. Given the symptoms and signs, I'd say the odds are strong that it will be positive. I'm going to prescribe antibiotics. Is he allergic to anything?"

"No. He's normally really healthy and active."

"And he's had all his regular vaccinations?"

"Yes. He saw his pediatrician about a month ago and everything was fine."

"OK. Right now I'll give him some liquid ibuprofen with an eye dropper for the pain, and we'll get you on your way. The lab will call you tomorrow with the results. Benny needs to take the antibiotics as prescribed for ten days, even if he feels better. If you stop, the infection could come back, and possibly be worse. It's vital you don't stop before ten days."

"Pills or liquid?" Ms. Travis asked.

"At his age, we'll go with liquid," I said. "I'm going to prescribe penicillin V, and you'll give him 125mg every six to eight hours, depending on his sleep schedule. I'll give you a discharge sheet that will have all the details. You can fill the prescription at the Walgreens down the street that has a twenty-hour-hour pharmacy. You should also pick up some liquid ibuprofen for his discomfort."

"OK."

"You should also follow up with Benny's pediatrician in seventy-two-hours, but if Benny spikes a fever higher than 102.5°F, bring him back, or if he develops a rash, has trouble breathing, or becomes listless. A nurse will call you with the test results."

"OK," Ms. Travis agreed.

"Let me get the ibuprofen now, and then I'll finish the paperwork so you can be on your way."

"Thanks, Doctor."

Tom and I left, and we went to the drug room where I prepared a dropper of liquid ibuprofen, then returned to the Exam room to administer it to Benny. I was happy he accepted it without fighting, then Tom and I went to see Doctor Mastriano. I presented, and she signed off on the chart with no comments.

On our way back to see Benny, we stopped in to check on Mr. Crowe. The gauze had soaked through, so I had Tom add an additional layer, and we promised to come back and check in ten minutes. We left his room, I went to the nurses' station and got the appropriate antibiotic discharge instructions, filled in the blanks, then wrote out the prescription. We returned to Exam 2, I went over everything with Ms. Travis, then directed her to Patient Services.

"Doctor Mastriano didn't say a word," Tom observed when we left the room.

"You'll find that every Attending is different, as is every Resident. Some want detailed reports, some just want the salient points. Doctor Mastriano appears to trust her Residents."

Or, she was lazy, which was a bigger concern, but I didn't have enough experience with her to know one way or the other. At some point, Naveen and I would compare notes, but he was working with Doctor Williams and handling incoming trauma, though it had been relatively quiet for the past few hours, which meant he was mostly monitoring patients waiting on admission or discharge.

"Tom, I need to speak to Mary, so sit at the desk and take your cues from Margie."

"She's brand new, too!"

"And has two full years of clinical experience compared to your five weeks!"

We went to the triage desk, and I asked Mary to join me in the consultation room, as we Residents did not have an office to use, and wouldn't until construction of the new ED was completed.

"What exam did you do on Benny Travis?" I asked.

"Why?" she asked apprehensively.

"Just answer my question, please."

"He was crying, so auscultation was pretty much useless. I checked his temp and wrote down what his mom said, and it sounded like croup. It wasn't, was it?"

"No, it wasn't. Did you do an otoscope exam of his ears, nose, and throat?"

"No. Was I supposed to?"

I nodded, "Yes. You do an abbreviated physical, but for a crying toddler, the number one thing to check is for otitis media."

"He has an ear infection?"

"No, he has streptococcal pharyngitis, or at least he has all the indications. Do you know the Centor criteria?"

"I know it was taught, but I don't remember."

"Here's a tip -- create flash cards with things like that and review them constantly. CENTOR is a mnemonic which will make it easier. C -- Cough absent; E -- Exudate; N -- Nodes; T -- temperature; OR -- young OR old modifier. Benny scored 5 out of 5. You should have detected all of those on your intake exam."

"Sorry," Mary said, sounding dejected.

"There's no need to apologize," I said. "And actually, I'm the one who should apologize to you for assuming something about which I had no specific knowledge. I should have given you better instructions. Also, I understand the difficulty of treating toddlers, especially very unhappy ones with frustrated moms. Just make sure you do an otoscope exam for any patient under five who doesn't have an obvious physical injury."

"You're not going to write me up, are you?"

"For what? It's only a problem if I have to tell you something more than once. Well, with regard to something like this. For procedures and diagnoses, I expect you to ask questions, even if you've asked them before. That said, my comment about the flash cards is something you should take to heart. Studying isn't just for exams. You need to be able to recall almost everything you've learned the past three years at any time.

"As for your evaluation, it's done on the totality of your rotation, and there are two main factors -- subject matter knowledge and improvement. If nobody has said so before, YOU are responsible for your training, not anyone else. Yes, of course, I have a duty to train you, but I'm sure you've noticed Residents have different styles, and with some of us, you'll need to demand we teach you. Be smart about it, and don't demand something well beyond your experience and skills, but challenge yourself, and your Resident."

"You?"

"I do my best, but there are competing motivators -- I'm graded both on my own work, and on my ability to teach. And, to be honest, I like being a doctor and doing doctor things, including things other doctors believe are scut. I was always happy to do it as a student, though, like every other student, I was champing at the bit to do 'interesting' things. But you know what? Every single thing we do, from running blood to the lab to surgery, is in the interest of the patient, and that has to be our primary concern. What speciality are you considering?"

"I was considering pediatrics, but I don't do well with crying babies or toddlers, so it's either internal medicine or endocrinology."

"Get to know Clarissa Saunders," I said. "She's a fellow PGY1 in Internal Medicine and is my best friend and confidante."

"There were all sorts of rumors about you two, but then she showed up with a girlfriend, which kind of explained things."

"People have WAY too much time on their hands and worry WAY too much about what other people are doing. Focus on medicine and ignore all the hospital scuttlebutt. My advice is to not date anyone at the hospital, and certainly not anyone on the same service. Too much drama and too many opportunities for problems."

"It's not against the rules, right?"

"No, but it should be, at least with regard to students and doctors."

"I agree with you on that one. As my little sister said when we discussed some of the stuff that goes on, it's 'creepy'."

I chuckled, "Not the word I would use, but I understand what she's saying. Let me be clear, it's none of my business unless it affects patient care. Then I'll make it my business."

"Again, I agree," Mary said. "Thanks for not getting on my case."

"That serves no useful purpose unless the student is WAY out of line."

"Tim Burg? I heard you helped flunk him."

"Tim flunked himself," I replied. "I simply gave an honest appraisal of his performance, the same as I'll do for you when I'm asked by Doctor Casper. The Chief Resident collects the input from the other Residents and does the appraisals together with Doctor Gibbs, the Chief Attending."

"She's on leave, right?"

"For another week or so, yes. Let's get back."

We went back to the triage desk and nobody new had come in, so we checked on Mr. Crowe, and I decided he was ready to be discharged so I provided the discharge form, and advised him to see his physician in two days for a wound check, or he could return to the hospital and we'd do it. Once we'd sent him to Patient Services, Tom and I returned to the triage desk.

"I'll take the rule-out UTI/STD," I said. "Tom, get a nurse please, but not Jamie, as we need a female in the room with us. We'll use Exam 2."

"Right away!" Tom replied.

I accepted the chart from Mary and went to the door to the waiting room.

"Miss Frost?"

A thin young woman with long brown hair go up and came over to me.

"Hi," I said. "I'm Doctor Mike. If you'll come with me, please."

She followed me to Exam 2, where Tom and Nurse Julie were waiting. I introduced them, then began my H & P with the usual question -- "What brings you here today?"

"It burns when I pee," she said. "I think I have an infection."

"Have you had a UTI before?" I asked.

"Yes, about two years ago."

"Are you sexually active?"

"Uh, yeah," she said, blushing slightly.

"Were you when you had your first UTI?"

She nodded.

"Is anything else bothering you?"

"No."

"No cough, fever, rash, swollen glands, earache, or nausea?"

"No."

"Is there a chance you could be pregnant?"

"Er, I guess, I mean, I've had sex since my last period, but we use rubbers."

"Have you been tested for sexually transmitted diseases?"

"No! You think I might have one?"

I smiled, "I think I have to ask the question. I'll perform an exam, take some samples, and have them tested both for STDs and for a UTI. The exam will be similar to your gynecological exams, so if you'd be more comfortable with a woman doctor, I can get one."

"Uhm, no, it's OK. My OB/GYN is a guy."

"I'll need you to change into a gown. The three of us will step out while you do that. You can keep your bra on, but you'll need to remove your panties. Once you've changed, just lie down on the exam bed, please."

"OK."

Julie handed her a gown, then she, Tom, and I stepped into the corridor.

"It's not policy," I said to Tom, "but in addition to having a female in the room with you, you should always offer a female patient the option of a female doctor if she needs a pelvic exam. Most don't mind, but some do, and patient comfort is important."

"Poison ivy girl earlier today?" Julie asked. "I heard she waited at least an extra hour for a female from OB."

I nodded, "Her choice, and I did explain she'd have to wait, and she elected to do that."

"'Poison ivy girl'?" Tom asked.

"On her buttocks, upper thighs and inner thighs. Even a Third Year can work out how that happened!"

Tom laughed, "I think a third grader could work that out!"

"Not much difference," Julie teased. "Especially with men!"

"Hey now!" Tom protested.

"She's not wrong," I chuckled. "As every woman in my life takes every opportunity to remind me!"

"We all wondered about her partner," Julie smirked.

"Oh, man," Tom groaned. "That would SUCK!"

"I hope she didn't, after," Julie said, "or she'll have it there, too!"

"What do you do?" Tom asked. "I mean, if it gets in your mouth?"

"Most guys want you to swallow," Jamie observed.

"NOT THAT!" Tom exclaimed. "I meant medically."

"Not much," I said. "Antihistamines for itching, but calamine lotion isn't meant to be taken internally."

"Neither is..." Julie began.

"STOP!" I commanded.

"Spoil sport!" she said with a silly smile.

"I can be as crude and funny as the next guy," I said, "but one slipup in front of Miss Frost, and we'll all be written up. Game faces, please. Tom, have you seen a pelvic exam before?"

"No."

"I'll ask Miss Frost if it's OK for you to observe. If she says 'no', you stand in a place where you cannot see. Got it?"

"Yes, Doctor," he said.

I knocked on the door and the three of us went back in. I washed my hands, put on gloves, then went over to the table.

"I'll do the pelvic exam and swabs first," I announced. "Miranda, Julie will help you get your feet in the stirrups just as would be done at your OB. Tom, as I said before, is a medical student, and I'm training him. Are you OK with him watching me do the exam?"

"Does he have to?"

I shook my head, "No, he doesn't. As I said, you decide, and that includes asking for a female doctor."

"No, it's fine for you to do the exam."

"OK. Julie?"

She helped Miss Frost get her feet into the stirrups, then brought me a gynecological exam tray.

"This might be a bit uncomfortable," I said to Miss Frost. "I need to swab your urethra, in addition to your labia and vagina."

"Go ahead," she said.

I did the exam using three swabs, one of which I pressed slightly into Miss Frost's urethra, causing her to grimace.

"All set," I said. "Let me do the rest of the exam and then we'll discuss options. Julie, draw blood for an STD panel, then Tom, take everything to the lab, please."

I stripped off my gloves, quickly filled out the lab order, then re-washed my hands and put on fresh gloves. I had Miss Frost sit up, and I took her vitals, auscultated her heart and breathing, then had her lie down so I could palpate her abdomen, check her distal pulses, and finally, sit up so I could check her lymph nodes.

"You don't have any other symptoms I can detect," I said. "That doesn't rule out either a UTI or an STD. Do you have more than one partner?"

"No. I've had the same boyfriend for three years and he's the only one."

"And his history?"

"He'd never done it with anyone before me."

"The odds are that you do have a UTI," I said. "I'm going to prescribe oral antibiotics, and if by some chance the STD test comes back positive, we'll call you to have you come here or visit the McKinley Free Clinic for injected antibiotics."

"I live at home," she said.

"Then we'll give you a number to call and we'll make sure nobody calls your house. It's imperative that you call, though, because if we don't hear from you, we're legally required to report a positive test to the County Health Department and they will track you down."

"But how if neither of us has been with anyone else?"

"As I said, it's unlikely, but it's possible to contract certain diseases via blood transfusion, sharing needles, and other risky behavior. Don't fret about it, because I'm fairly certain it's a UTI. In addition to the oral antibiotics, you want to drink lots of fluid, and cranberry juice is a very good choice as it's effective against UTIs."

"I've heard that, but thought it was BS!"

"It has been shown to help," I said. "And it might be preventative, so drinking it every day is a good idea. The other thing is you want to refrain from sexual contact until you finish the course of antibiotics, or about ten days. Not just intercourse, but oral or manual stimulation as well. The other thing is to remember to be careful when you clean yourself after a bowel movement, always wiping back, away from your vagina."

"My mom taught me that when I was little."

"Good. Do you use rubbers every time?"

"Yes. There is no freakin' way I'm getting pregnant while I'm in High School!"

"Good. Do you have any questions?"

"What causes the UTI?"

"Sex, improper hygiene, wearing pads too long during your period, and any number of things. When you have your period, you should change your pad every few hours, even if your flow is light. And make sure you put on clean underwear if there is any leakage. I'd also recommend showering after sexual contact, and fresh underwear as well. But, as I said, no contact, intercourse or otherwise, until you finish the antibiotics."

"Jim is not going to be happy," she groused.

"Jim will live," I replied. "And if he truly cares for you, he'll want you to be healthy. If he complains, send him to me and I'll straighten him out."

She smiled, "Thanks."

"We'll step out so you can dress, I'll complete the paperwork, and we'll get you on your way. You should pick up the prescription at the Walgreen's down the street and take the first dose immediately."

"OK."

Tom, Julie, and I left, and I stepped over to the nurses' station to complete the chart and write out the prescription, then filled out a discharge form for UTIs/STDs, and grabbed a 'Safe Sex' pamphlet published by the Free Clinic. Everything in order, I took the chart to Doctor Mastriano to sign, which she did after a cursory review. That completed, Julie, Tom, and I returned to the exam room, reviewed the discharge information with Miss Frost, and answered a few questions. Tom walked her to Patient Services, and I went back to triage.

"I'll take the back pain," I said. "Unless there's something pressing."

"He's the only patient in the waiting room."

I accepted the chart and went to the door, opened it, and called out, "Mr. Brown?"

He stood up gingerly and slowly walked over to me. I evaluated his movements and either he was a good faker, which was possible, or he was actually in pain. People who were not in pain, but were seeking drugs, often exaggerated their symptoms, believing that was the path to success, when in reality it was the first sign they were faking.

I escorted him to Exam 5, and Tom joined us.

"Mr. Brown, are you able to get onto the exam table?" I asked.

"Yeah, I can," he replied.

"Just sit up at first so I can listen to your heart and lungs, then you can lie down if you're more comfortable."

I washed my hands, put on gloves, and then auscultated his heart and lungs detecting no problems, and at the same time judging his demeanor. I made a small bet with myself that he was actually in pain, and might actually have lost his meds, because his behavior was not that of a typical drug seeker. That said, there were some VERY good con men, and he might be one.

"The triage team said you lost your pills," I said.

"Somebody stole them from my locker at work," he said. "I reported it to my boss, and we filed a police report with the County Sheriff."

"How many pills?" I asked.

"Twenty-four. I had just had it refilled on Friday."

"When did the pain begin?" I asked. "I mean the first time."

"I was playing intramural football when I was at OSU and got hit hard in what was supposed to be flag football."

"When was that?"

"About three years ago, when I was a Junior."

"What do you do for work?"

"Electrical inspector for Hayes County."

"My dad is a building inspector and supervisor in the Property Division in Harding County. Why not go to your regular doctor?"

"He doesn't have hours on Monday, and when I called his service, they couldn't get hold of him. I'll see him tomorrow, so I just need a couple of pills to get me through until tomorrow afternoon."

"Who's your doctor?" I asked.

"Mark Goetz at Medical Practice Associates."

Which was where my friend and personal physician, John Smith, was medical director.

"Do you know the medical director there?"

"You mean Doctor Goetz's boss? Doctor Smith? Yeah, I've met him."

"He's my physician. In order to prescribe pain pills, I need to have my supervisor sign off. Give me about ten minutes to get things sorted and I'll come back with them."

"Thanks, Doc."

We left the room, and I walked over to the nurses' station and picked up the phone. I looked up Doctor Smith's number in my pocket address book and dialed the number. Doctor Forsberg answered, and after asking how I was doing, put Doctor Smith on the phone.

"Hi, Mike! What's up?"

"Hi, Doctor Smith..."

He cut me off, "John. We're colleagues now!"

"John, I have a patient who is seeing Matt Goetz and claims his prescription for pain meds was stolen."

"You know that's a sign of drug seeking, right?"

"Obviously, but the typical drug seeker doesn't file a police report! Anyway, the service said they couldn't reach Doctor Goetz, and I wanted to check."

"Who's the patient?"

"Steve Brown," I said. "He says he's met you."

"Matt consulted with me on him. Matt was going to be unavailable tonight, but they're supposed to call me in that case. I'll deal with the service, but your patient is telling the truth, at least about that. What's your plan?"

"Three pills which will get him through tonight and tomorrow until his afternoon appointment."

"I'd say that's a good plan. I'll let Matt know when I see him in the morning, and he'll follow up."

"Thanks," I said.

"How does it feel to be a doctor?"

"I'd be happier without patients dying," I said. "But otherwise, good."

"A function of your chosen specialty. I take it you had a bad one?"

"Construction worker who fell onto rebar with predictable results."

"Damn."

"Yeah. Are you and Candace free for dinner next week?"

"Sure, what day?"

"Wednesday. And bring the tyke with you."

"Of course!"

We said goodbye, and I hung up, then wrote out the drug order, but didn't sign it, as I wasn't authorized. I took the chart to Doctor Mastriano and gave her the synopsis.

"We don't give drugs to drug seekers," she said firmly.

"And he's not," I replied. "I confirmed with the medical director at Medical Practice Associates, where Mr. Brown's doctor works, and as I said to Doctor Smith, drug seekers don't file police reports. If you want, call the Sheriff and ask, but I believe Mr. Brown. He shows no signs at all of drug seeking."

"Fine," she said.

She signed the chart and the drug order.

"I'll need you to get three tablets from the Schedule Drug locker," I said.

She glared at me, but got up and we went to the drug room. She used her special key to open the Schedule Drug locker and I found the correct bottle, then counted out three tablets and put them in a small envelope. I wrote out the detailed information on the clipboard and Doctor Mastriano signed and I initialed the note that they'd been dispensed to me to give to the patient. I returned to the exam room, gave Mr. Brown the tablets, watched him take one, then quickly went over the discharge instructions before having Tom escort him to Patient Services.

"Mike?" Nurse Bonita called out from the nurses' station. "There's a Doctor Bush on the phone for you, calling from Kentucky. Line 3."

I walked over, picked up the handset, and pushed the button for Line 3.

XI. Get Out Of Here!

July 3, 1989, McKinley, Ohio

"Mike Loucks," I said.

"Mike, it's Melissa Bush. I'm sorry I haven't returned your call. What can I do for you?"

"First, tell me, how are you doing?"

"I'm a doctor, so that's a major plus. I split my time between the Internal Medicine ward and trauma. Eastern Kentucky coal country is not my idea of a great place to live, but it beats the alternative. I take it you're loving every minute of the Moore ER."

"This is my first full shift," I said. "I had a short shift on Saturday, but took a delayed start so I could spend time with my wife and daughter before the full-scale insanity began."

"Why did you call?" she asked. "I'm positive you don't expect us to be friends."

"And there you'd be mistaken," I replied. "Again. Nobody is irredeemable, Melissa, and that includes your dad. I saw him about a week ago."

"He was in the hospital again?"

"No, I went to Southern Ohio Correctional Facility to visit him."

"What the heck?! Why would you do that?"

"There's this book that reminds us of how we're supposed to behave. I believe you've read it once or twice."

"It's all bullshit!"

"Not to get into a theological debate, but 'bullshit' accurately describes the Calvinist interpretation of the Scriptures. It's a good thing I don't buy it, and never have. Sadly, though, your dad thinks he's on a Highway to Hell with no offramp available."

"Well, if such a place actually existed, I'd say that's where he belongs."

"You're no longer a believer?" I asked.

"I was fed a steady diet of that bullshit for twenty-five years and it nearly wrecked my life. It certainly wrecked my mom's and did a serious number on my brother as well."

"And on your dad, too. Fundamentally, that's why he is where he is. I was going to suggest you get in touch with him, but now I'm not sure it's a good idea. He needs love and hope."

"And you thought I was brainwashed? He murdered your friend!"

"Yes, he did, but that does not make him any less a child of God. Misguided and sinful, but still a child of God, and in the end, not all that different from me."

"That's crazy talk."

"If I be a fool for Christ, that is a credit to me," I replied, quoting a monk. "Anyway, I did want to congratulate you on Matching, and I hope you're successful. The people of that area need good medical care."

"They need way more than that!" Melissa protested.

"I don't doubt it, but as has been said to me, we have our roles to play and our jobs to do, and have to do them to the best of our ability, and leave other things to others. It's not that we don't care, but neither of us is a social worker. What kinds of cases do you see?"

"Respiratory problems related to mining, poor nutrition, pregnant teenagers, and drug addiction."

"I suspect that's par for the course for a poor rural county."

"It is. How is your daughter?"

"Healthy and almost two," I replied. "I'm sure you heard I re-married."

"I did."

"Anyone special in your life?"

"Nah, just the usual Friday night hookups with unemployed rednecks at the local bar."

"Now, why don't I believe that?"

"What's not to believe? I'm not the same person I was a year ago."

Nurse Bonita tapped my arm and said, "Doctor Williams needs you in the ambulance bay."

"Sorry, Melissa, but there's an ambulance run. OK to call you again?"

"Suit yourself, but I'm not going to contact my dad."

"OK. Could I get your phone number?"

She gave it to me and I wrote it in my address book. We said 'goodbye' and I hung up.

"Let's go," I said to Tom.

We gowned and gloved and went to the ambulance bay where Doctor Williams, Naveen, his two medical students, and two nurses were waiting.

"Two gunshot victims on their way in," Doctor Williams said. "One's a deputy with an arm wound, which you'll take. Naveen and I will take the guy he shot twice in the chest."

"Any idea what happened?"

"No. But you can expect half the Sheriff's Department will swarm the place and they'll know. Kelly is with you."

An arm would could be anything from grazing to a through-and-through with only soft tissue damage to a shattered bone. None of which were directly life-threatening, and certainly not serious compared to a pair of .357 slugs in the chest. That might well be futile, but, as always, we had to try.

"OK," I said. "Kelly, I'll want a full trauma panel, no matter what. Tom, EKG and pulse oximeter, please. Beyond that, we'll see what we have."

The two EMS squads arrived in quick succession, and the victim with the two gunshot wounds to the chest was extremely critical, as expected, and Doctor Williams and Naveen rushed him inside as the Sheriff's deputy was unloaded.

"Sam Kenseth, thirty-one;" the paramedic called out. "Through-and-through small caliber gunshot wound to the upper right arm; tachy at 110; BP 110/60; PO₂ 99% on nasal canula; IV saline TKO; morphine x1; awake, alert, and oriented times three."

"Take good care of him, Doc!" another Deputy who hopped out of the squad after the gurney.

"Best care anywhere!" I declared, quoting the sign for the 4077 MASH from the TV show. "Trauma 2!"

We quickly brought Deputy Kenseth into the trauma room and moved him to the bed and Kelly connected the nasal canula to the hospital oxygen system.

"Deputy Kenseth," I said. "We need to get your Kevlar off and it's not going to be comfortable if we don't cut the straps.

"Don't cut it," he grunted.

"Tom, bandage scissors," I instructed. "Cut up the sleeve to the shoulder, then across the chest and down the other sleeve. Be cognizant of the wound."

He did as I asked, then hooked up the monitor while I undid the straps on the Kevlar vest. I had the deputy sit up so I could remove it without cutting the straps, and he grunted and grimaced, but his vest was intact.

"Tom, cut away the t-shirt for an EKG," I said as Kelly moved to draw blood from the deputy's good arm.

I did a quick exam, and other than the gunshot wound and slightly depressed blood pressure, likely from the morphine, I found nothing amiss.

"What caliber bullet?" I asked Deputy McCallum, the one who had come in with the patient.

"A snub-nose .32," he said.

"Please tell me it wasn't a Walther PP," I said.

"James Bond, the scumbag ain't!" Deputy McCallum said. "But that pistol fits in a pants pocket."

"Deputy Kenseth, we'll get an x-ray, irrigate the wound, and possibly throw in a couple of stitches on either side. You'll need a tetanus shot and we'll give you antibiotics, but you should be able to walk out of here in a few hours."

"How's the dirtbag?" he grunted.

"He's next door with Doctor Williams and Doctor Varma. I'm sure they'll fill you in when they know something. Mind if I ask what happened?"

"Kid had a trunk full of weed and pills," Deputy McCallum said. "Sam pulled him over for speeding and he came out blasting."

"That doesn't appear to have ended well for him. Tom, call for the portable x-ray, please, then get the blood to the lab."

"Yes, Doctor."

"Kelly, trauma kit with sutures times four."

"Right away!" she said brightly.

"How much time will I miss?" Deputy Kenseth asked.

"That's up to your boss," I said. "From a medical perspective, I'm not going to prescribe anything other than antibiotics. For pain, use over-the-counter Advil or Tylenol. You'll need to have the wound checked in a few days, but the duty nurse from the lockup can do that. On the other hand, if you want some time off, I can write that up for you."

Both Deputies laughed.

"I love all you docs," Deputy McCallum said. "You take good care of us. You're the doc who disarmed the asshole in your waiting room, right?"

"Yes."

"And you turned down the recognition award."

"Let's just say I don't want to draw attention to doing something bordering on foolish."

"Nah, you did the right thing in a room full of people. I heard you had a good wrist lock on the idiot."

"Karate training," I replied.

"Radiology tech is on his way," Tom announced, then left with the blood.

Five minutes later, I had the image on the screen.

"It's your lucky day, Deputy," I said. "No ligament or bone involvement, and no major blood vessels impacted. Four sutures, antibiotics, and you'll be outta here. Have you had any negative reactions to anesthesia, including when you've had dental work?"

"No."

"Forget the drugs, Doc!" Deputy McCallum declared. "Just give him a bullet to bite on."

"There's bravery and then there's stupidity," I replied. "The difference is minor!"

"I'll take the drugs, Doc!" Deputy Kenseth declared. "Pete can bite me!"

"Pass," Deputy McCallum retorted.

"Lidocaine times four, Kelly," I said.

Twenty-five minutes later, after the lidocaine, irrigation with saline, application of Betadine, and four sutures, I was finished.

"Your blood work will be back in about fifteen minutes," I said. "Once we see that's clear, we'll get you out of here. Kelly, would you administer the tetanus booster, please?"

"Right away!" she exclaimed.

I sat down at the table wrote out the prescription for antibiotics, updated the chart, then went to the nurses' station to get the proper discharge form which I filled out, then took everything to Doctor Mastriano, who, if I judged correctly, had not treated a single patient since her shift began. She once again reviewed the chart perfunctorily and signed off.

"What's wrong with her?" Tom asked as we walked back to the trauma room.

"No clue, but that's something for Doctor Gibbs or Doctor Northrup to handle."

Tom went to the lab to get the blood work results while I returned to the trauma room. I went over the discharge information with Deputy Kenseth and gave him the prescription. When Tom returned with the results, which were normal, I informed Deputy Kenseth he could go.

"What about the perp?" he asked.

"Emergency surgery, according to the board," I replied. "Someone upstairs can keep you posted."

"Powers and Green are with the perp, Sam," Deputy McCallum said. "I'm going to get you home to Nancy and the kids."

"She's going to kick my butt for not calling her."

"You're alive and not badly hurt," Deputy McCallum said.

"Not for long! You might see me again soon, Doc!"

I chuckled, "My advice is the next time you get shot at, don't get shot!"

"No shit, Doc! Fortunately, the little bastard was a lousy shot."

"That .32 wouldn't have penetrated the vest," I said. "But in the head, it would have ruined your entire day. Try to avoid showing up here with extra holes in your body, please."

"You know it, Doc!"

We shook hands, and Kelly helped him put on a scrub shirt so he didn't have to leave bare-chested.

"Be sure to have that checked and make sure you take the full course of antibiotics."

"Will do. Thanks for patching me up."

"You're welcome."

I left and went to find Doctor Williams, who was in the lounge.

"How bad?" I asked.

"Two to one, he doesn't make it," Doctor Williams said. "Missed his heart, but he lost a lot of blood and he'll likely lose a lung if he does make it. Your deputy is an excellent shot -- both center mass. How is he?"

"I just sent him home to a wife who might send him back because he didn't call her."

"The man has a death wish!" Doctor Williams said. "Treatment?"

"Irrigation, four sutures, tetanus shot, antibiotics, and over-the-counter NSAIDs for pain. I cleared him for work as soon as he wants to go back, though obviously that's up to his boss."

"You're really averse to pain meds, aren't you?"

I nodded, "Some docs are handing out opiates as if they were Skittles. I think that's a really bad idea. Obviously, I'll suggest them when absolutely necessary, but why exacerbate what's already a growing problem?"

"Good point, but expect some pushback."

"Story of my life so far in medicine," I chuckled.

"You are something of a maverick."

"While there is value in 'this is how we always do it', that's what led to rejection of handwashing, though I'd like to think I'm not as much of an ass as Ignaz Semmelweis was reputed to have been."

"You'd like to think!" Doctor Williams said.

"OK, so I come across as an arrogant, egotistical prick at times, but am I wrong?"

"No. Just remember what my grandma always said -- you catch more flies with honey than with vinegar."

"I prefer to keep the flies away, not attract them!"

"Get out of here"! Doctor Williams ordered.

I chuckled and Tom and I left the lounge.

"That was weird," he observed. "Why say that about yourself?"

"Why not? It's not like I hide it! And in the few hours we've worked together, I bet you've noticed."

"I just figured it was a surgeon thing."

I laughed, "You figured right! That said, I do not have the bedside manner of a surgeon."

"Nobody does," Tom said. "They don't have one!"

I laughed, "Often, too true. Let's go see what Mary has for us."

"Naveen just took the beer can to the forehead," Mary said. "Nothing else at the moment."

"He waited a long time," I said. "Did you call Doctor Mastriano?"

"Yes, but she said she was busy and he could wait for you or Doctor Varma."

Busy my ass, but I couldn't say that to my medical students.

"OK. I'm going to get some fresh air. Send a nurse to get me if anything comes in, please."

Mary acknowledged me and Tom and I went to the ambulance bay. I was surprised when he pulled out a cigarette.

"Seriously?" I asked.

He shrugged, "It helps with the stress and nicotine isn't on the prohibited list like alcohol or pot."

"Just remember, you're going to have to look patients directly in the eye and tell them to quit smoking. If you smell like smoke, you'll come off as a hypocrite."

"I hear you. And what's with Mastriano? Busy? She's sitting in the Attendings' office reading a book!"

I shrugged, "As I said, not my place to say anything to her, but I will mention it to Doctor Gibbs as soon as I see her."

Which would be Wednesday night when she, Bobby, Ghost, and Oksana would join us for dinner.

"Can I ask you something?"

"Always."

"You seemed to be sucking up to the deputies. Why?"

"I have great respect for firefighters and law enforcement," I replied. "While I have serious problems with the excesses of the criminal justice system, the patrol officers are not the problem. I wasn't sucking up, only treating them with the respect I think we owe to the men and women who put their lives on the line to keep us safe. I have several good friends who are firefighters or deputies."

"You've never dealt with a big-city police department, have you?"

"No. Where are you from?"

"New York City, where the cops are all on the take, totally corrupt, and only look out for themselves."

"I hope you've noticed our deputies and city cops aren't like that."

"It is a whole different world from Queens."

"I believe it. Doctor Nielson did his Residency at Cook County in Chicago and says it's night and day different from here. Doctor Taylor said the same thing, but Matched here which made him very happy. Are you going to try to Match back home?"

"Upstate New York or Eastern PA," Tom said. "Basically close to home, but not in the City."

"Mike?" Bonita said, coming out into the ambulance bay. "Mary needs you for a walk-in with facial contusions and lacerations."

"Stub out the cig, Tom," I ordered. "Duty calls."

We went to see Mary at the triage desk.

"Approximately twenty-two-year-old who appears to have been in a bar fight," she said. "He's clearly drunk and his buddies dropped him off and left. He was at least somewhat awake, but appears to have fallen asleep. No ID."

"Those are usually closer to closing time," I observed, accepting the proffered chart. "Tom, get a wheelchair, as I don't think our patient is in any condition to walk."

He left and returned a few seconds later with a wheelchair. We went out into the waiting room and I tried to rouse the patient, whose name we didn't know. He was basically incoherent, from the booze, the beating, or, more likely, a combination of the two, so Tom and I moved him to the wheelchair.

"Exam 2," I said.

Tom began pushing, and I went over to Mary.

"When the Law shows up, send them back."

"What makes you think the cops will show up?"

"Nobody gets this drunk and this beat up in a bar without someone calling the cops."

"I'll send 'em back if they show up."

"Thanks."

I stopped at the nurse's station and asked Bonita to send in a nurse with a banana bag, then went into Exam 2. Tom and I were strong enough to get our patient onto the exam table. Nurse Becky came in with the banana bag and I had her set it up.

"What do we do?" Tom asked.

"Trauma panel with EtOH, and wait for him to sober up. None of his lacerations are bleeding badly, so we wait. Go ahead and draw the blood and take it down to the lab. I'm going to do a quick physical to make sure he's not bleeding internally."

Once Tom drew the blood, I did a basic exam, checking for blood in his eyes, ears, nose, and mouth, and palpated his abdomen. His pulse and breathing were reasonable given his inebriation, though I was concerned about aspiration if he vomited.

"Vitals are acceptable," I said. "No obvious internal injuries. Becky, please stay with the patient, please, and let me know when he comes to."

"Soft restraints, Doctor?" Becky asked.

"I see no need," I replied. "Let's see his EtOH level, then decide what to do next."

July 4, 1989, McKinley, Ohio

I left the exam room and went to check with Mary, but there were no additional patients, so I went to the lounge. I was just over halfway through my thirty-six-hour shift and still had plenty of energy. I'd done twenty-four-hour shifts and been OK, but those additional twelve hours looked to be tough, not to mention I had a concert gig to play on Tuesday afternoon -- actually, later this afternoon, as it was after midnight.

Tom returned with the EtOH results about ten minutes later.

"0.19," Tom said.

"Take another in twenty minutes, please, and add a blood gas. Once those are back, along with the trauma panel, we'll decide what else to do."

"I'll take care of it," Tom said.

He left and about five minutes later, Nurse Peggy came into the lounge to let me know a Sheriff's Deputy was looking for my patient. I went to the nurses' station and saw Deputy Schmidt, who I'd spoken with on several previous occasions.

"Overnight shift before a holiday?" I asked. "Who did you piss off?"

"Hi, Mike! Well, I guess it's Doctor Loucks, now. And I traded similar to how you docs trade, and it was a good deal."

"Doctor Mike, please. What can I do for you?"

"I hear you have Peter Firth in Exam 2."

"I have an African-American twenty-something John Doe who was in a bar fight, but we didn't find an ID. He's basically incoherent at the moment, and we have him on a banana bag, waiting for him to sober up before we treat him further."

"What injuries?"

"Contusions and lacerations consistent with a fist-fight, but no internal injuries were detected. I can't imagine he fought back, given how drunk he was."

"He was beaten up by four guys for talking to one of their girlfriends."

"White guys, I take it?"

"We got two of them, and we're looking for the other two. Can I see him?"

"Yes, though he's not in any state to question at the moment."

"I just want to get a record of his injuries, including a Polaroid."

He held up the camera.

"You assume he's going to press charges?"

"I hope so. Those guys have done this before and managed to walk. This time, though, the bartender swore out a complaint for disorderly conduct and property damage, so we can keep them cooling their heels at least until they see a judge on Wednesday."

We heard a crash from Exam 2 and both Deputy Schmidt and I rushed to the room and saw a turned over stool and the patient on the floor, with Becky standing in the corner. The IV had been pulled out, and I saw a small amount of blood.

"He came to, pulled out the IV, and tried to leave," Becky said.

"Did he strike you in any way?" Deputy Schmidt asked.

"No. He could barely stand."

"Becky," I said, "get some help and we'll move him to a trauma bed."

"Soft restraints, Doctor?" she asked.

"Yes."

She nodded and left, while I checked on Mr. Firth, who had face-planted, and now had a bloody nose, which might well be broken. Two minutes later she was back with two orderlies and a gurney, and between the five of us, we got Mr. Firth onto it, then moved him to Trauma 3. We moved him to the trauma treatment bed and Becky attached the soft restraints to the patient's wrists and ankles, then set up a fresh banana bag, and the orderlies left the exam room.

I performed an exam and instructed Becky to pack Mr. Firth's right nostril with gauze.

"I owe you an apology," I said to Becky. "I should have listened to you when you suggested the soft restraints. I won't make that same mistake in the future."

She smiled, "After twenty years, I have learned a few things."

"Why not insist, then?"

"How well do you think that works with new doctors?"

"Badly, I suspect."

"You suspect correctly," Becky answered with a smile.

"Next time, be more forceful if you think I'm making an error in judgment. I promise it will be received positively. How did you know?"

"I didn't know for sure, but drunks tend not to be coherent when they come around, and it happens often enough that soft restraints are advisable."

"I'll remember that."

"What do you want to do next?"

"He'll need a skull series to see if there are any fractures from the beating he took, as well as the fall. We'll also need to rule out a concussion for the same reason, but we can't be certain about that until his EtOH is undetectable."

"How long do you figure before I can speak with him?" Deputy Schmidt asked.

"Call it three hours or so," I replied.

"I'm going to go back on patrol, then. If you plan to discharge him before I come back, have dispatch call me."

"Will do."

"OK to take the Polaroids?"

"Yes, though after the fall, I suspect you'll have trouble distinguishing his injuries."

"Then let me take your statement now, along with one from the nurse."

"OK."

Both Becky and I described Mr. Firth's injuries when he presented, and I made sure to update the chart to match both our descriptions of the contusions and lacerations. Deputy Schmidt left after taking our statements, and a few minutes later, Mr. Firth struggled against the restraints, groaning.

"You're in the hospital, Peter," I said. "I'm Doctor Mike. Just relax and we'll take care of you."

He continued to struggle and groaned, and I wondered if the beating he'd taken had actually caused brain trauma. I'd likely need a neuro consult, but until his EtOH was below 0.1, they wouldn't send anyone to consult, and they might even insist on waiting until the level of alcohol in his system was undetectable. But I was concerned about doing nothing, and Becky picked up on it.

"You might want to talk to the Attending," she suggested.

I was positive Doctor Mastriano was asleep, and my patient wasn't dying, though if he had a brain bleed or other injury I hadn't appreciated, he could be in real trouble. One thing was certain -- no matter how upset Doctor Mastriano might be, a PGY1 would never be reprimanded for calling their Attending in a case such as this one.

"You're right," I said. "Doctor Mastriano is probably sleeping."

"Well, we aren't!" Becky said.

I got her point, asked her to stay with Mr. Firth, and went to the Attendings' office and knocked on the closed door, waited fifteen seconds, then opened it, to find Doctor Mastriano stretched out on the couch with a sleeping mask over her face.

"Loucks," I said. "I need to discuss a patient."

"He better be dying," she growled, not moving.

"Peter Firth, early twenties; involved in a bar fight; significant facial contusions and minor lacerations; potentially broken nose from a fall; incoherent. I'm concerned about trauma to his brain, and a potential bleed. He might have internal injuries, but no guarding or rebound on palpation."

"EtOH?" she asked, still not moving.

"0.19."

"YOU WOKE ME FOR A DRUNK? GET OUT OF HERE UNTIL HE'S BELOW 0.05!"

"Doctor, I'm concerned that if we wait, he'll suffer neural deficits and possibly herniate. I'd like to get a neuro consult and a CAT scan."

"What part of 0.05 don't you understand?"

I took a deep breath and let it out while I thought about how to proceed. While it was true, I had been cleared to work semi-independently, I still technically needed signed orders, even if I had permission in advance. Nobody would say anything so long as I stuck to things I knew how to do and asked for help when I was concerned or potentially out of my depth. That was the case here, so I decided to press the point in a way to which Doctor Mastriano could not reasonably object.

"I need you to write that order on the chart," I said.

"Gibbs and Ghost both cleared you. Go do your job."

"Doctor," I said. "I insist. I was instructed to ask for help when I needed it, and I need it. If you won't examine the patient, I need you to write your order on the chart."

She removed her mask and sat up. I handed her the chart and pen, she wrote on it, signed it, handed it back without a word, put her mask on, and reclined on the couch. I shut the door and reviewed what she had written -- 'monitor until EtOH is below 0.05'. That meant I could perform blood tests, use life-saving measures, but otherwise not take any actions such as calling for a neuro consult, asking for a CAT scan, or even bothering Doctor Mastriano unless the patient was dying. I felt she was mistaken, but I had written orders, so I returned to the trauma room.

"Monitor until under 0.05," I said. "She expressly stated that order twice and wrote it on the chart."

Becky frowned, but didn't say anything, which indicated her thinking at least paralleled mine. If it were during the day, I'd call neuro and simply talk to an experienced neurologist, but that wasn't possible at the moment, as only a PGY1 was on overnight, and their Attending was at home, on call. While I might convince the PGY1 to wake his or her attending who was at the hospital, I seriously doubted he or she would be willing to make a call about a patient Doctor Mastriano had called 'a drunk' with significant EtOH in his system.

"Neuro checks?"

I shook my head, "Most of the signs would be similar to the effects of his EtOH level. Absent a blown pupil or blood in the auditory canals or nostrils, I don't have anything on which to hang my hat. Let's do a blood glucose stick test and give him D5W if it's low, and get him on a nasal canula."

"You know about the stick test limitations, right?"

"Yes, but I'd prefer not to order the labs because they'll take at least an hour. I'll write it on the chart."

"OK," Becky replied. "Canula first, then glucose."

She attached the canula, then performed a glucose stick test which showed 96, which wasn't too low, and might or might not be diagnostic, given the inexact nature of the stick test and the fact we didn't know when Mr. Firth had last eaten.

"Let's repeat that in thirty minutes," I said as Tom came into the room.

"Mary has a patient for you," he said. "Doctor Varma has three already. Still want the EtOH and ABG?"

"Yes, please. Becky, please stay with Mr. Firth. Tom, come find me once you've taken the blood to the lab."

They both acknowledged, and I went to the triage desk.

"Sixty-nine-year-old male with a syncopal event about forty minutes ago, but vitals are normal. His wife insisted he come in."

"How long has he been here?"

"About ten minutes -- long enough for me to take vitals and send Tom to get you."

"In a case like this," I said. "Consider it similar to a trauma and get them right in, get them on oxygen, and wake someone if you have to."

"Sorry, but that's not listed as an 'immediate care' case."

"It is now," I said. "At least when my students are at the triage desk. I'll raise it with Doctor Casper in the morning."

"OK," Mary replied.

I accepted the chart from her and went out to the waiting room.

"Mr. Temple? I'm Doctor Mike. If you'll come with me, please."

"Can I come, too, Doctor?" a woman of about the same age, who I assumed was his wife, asked.

"If your husband is amenable, yes."

"It's OK," Mr. Temple said.

I escorted them to Exam 4, had Mr. Temple lie on the table, and hooked up a nasal canula to the hospital oxygen supply.

"This is simply precautionary," I said as I fitted it around his head. "What brings you here today?"

"He fainted when he got up to use the commode," his wife interjected. "He didn't want to come in, but I made him."

"A wise precaution. How long was he out?"

"Maybe a minute or so. I was about to call 9–1–1 when he came to and told me not to."

"OK. Any previous lightheadedness, dizziness, or unsteadiness?" I asked Mr. Temple.

"No."

"Do you drink or smoke?"

"I'll have a Scotch on occasion, but I quit smoking about twenty years ago."

"Good for you. How much did you smoke?"

"A pack a day from age fifteen to age fifty. When the Surgeon General came out with the warnings in '66, Nellie insisted I quit. Took a few years, but I did."

"Stopping smoking will immediately improve both your short- and long-term health. Do you exercise?"

"We take an early morning walk every day when it's nice enough. During the winter or if it's raining or too hot, we go to the mall to walk."

"What about your diet?"

"My doctor has me on a high-fiber, low-fat diet. Seems to work OK, though I miss the 12oz steaks!"

"Between 4oz and 6oz would be a better portion," I replied. "Just go for the lean cuts."

"Did you hear that, Nellie?" Mr. Temple asked.

"Confirm that with your personal physician," I said, hoping to stay out of Dutch with his wife. "He knows your entire medical history, so he's better suited to giving you advice."

"He's a smart young man, Jon!" Mrs. Temple said.

"I have a grandma," I chuckled. "And a mom, a wife, and a daughter, so I have good survival skills!"

She laughed, "You learned that at a young age!"

"Well, I'm not sure the women in my life would agree I've learned. When was your last meal, Mr. Temple?"

"Dinner, which was salad, chicken, potatoes, and bread."

"Anything to drink this evening?"

"No."

"Any prostate trouble?"

"Who doesn't at my age? But it's not too bad."

"How many times a night do you get up to urinate?"

"Twice, usually. If I'm careful about how much I drink after dinner, once, but then I get dehydrated by morning."

Which was all typical for a man his age.

"Any recent illnesses, fevers, or coughs?"

"No."

"Any history of heart trouble?"

"None."

"OK. Would it be OK for me to examine you?"

"It would be stupid to come here and say 'no', wouldn't it, young man?!" Mr. Temple asked.

"Indeed it would, but I always ask before I touch someone beyond an oxygen mask or canula, unless it's an emergency. Let me wash my hands and we'll check you out."

I washed my hands, put on gloves, then began an exam, finding nothing except slight crackles in his lungs, and a slightly elevated blood pressure, neither of which were specifically diagnostic in a nearly seventy-year-old man. The crackles in his lungs could well be related to his smoking history, though without an earlier auscultation to compare it to, I couldn't be sure.

"Your heart and lungs sound fine, though you do probably have a small amount of fluid in your lungs, which isn't a problem, though it bears watching. I'd like to put you on an EKG monitor. Would you remove your shirt and t-shirt, please?"

"I'll help," Mrs. Temple said, reminding me very much of my grandmother.

I left the room to get one of the spare EKG monitors and wheeled it into the room as Tom returned from the lab. After checking with Mr. Temple, I had Tom hook up the EKG and pulse oximeter, and then reviewed the EKG, which looked normal.

"Tom, let's get a trauma panel, blood gas, metabolic panel, and cardiac enzymes, please."

"Will do. Anything specific you're looking for?"

"The cause of a syncopal incident. It could be anything at this point."

Tom drew the blood and was about to take it to the lab when Nurse Jackie opened the door.

"Doctor, Mr. Firth is seizing!"

"Tom, go wake up Doctor Mastriano, and I don't care if you have to drag her from the couch!" I ordered. "Mr. and Mrs. Temple, excuse me, please."

Tom and I left the room, and I asked Jackie to send a nurse in to monitor Mr. Temple while I hurried into Mr. Firth's room.

"Bite guard is in," Becky said. "Lorazepam?"

"4 megs, IV push!" I ordered.

She had the drug ready, which didn't surprise me, and injected it into the IV port. The seizure subsided after about a minute, and I immediately checked Mr. Firth's pupils.

"Left pupil is blown," I said. "Right is sluggish. Call neuro for a consult, please."

"Right away, Doctor."

She went to the phone and Tom came in with an angry-looking Doctor Mastriano.

"What happened?" she demanded.

"He seized," I said flatly. "Becky called me and put in the bite guard, then injected 4mg lorazepam on my order. His left pupil is blown and his right is sluggish. I just ordered a neuro consult. Tom, lets get him on an EKG and monitor, please."

"No way to know that would happen," Doctor Mastriano said.

She moved over to the table and examined the patient, then moved so Tom could finished connecting the monitor.

"Come get me after the neuro consult," she said.

"Doctor, I prefer you stay," I said. "This is beyond my experience and training at this point."

"You're fine," she said. "Come talk to me after the consult."

"Tom, get a nurse to take Mr. Temple's blood to the lab, then swap places with Mary. Tell her I need her here, please. No knock on you, but she has a full year of clinical experience."

"Understood."

"Rely on your nurse at the triage desk, please."

He nodded and left, and a minute later, Mary came in. I advised her what had happened, asked her to monitor closely and come get me if there were any changes or when the neurology Resident arrived, and then returned to Mr. Firth's room.

"Sorry about that," I said.

"Is your other patient OK?"

"I stopped the seizure and I have two people with him now, waiting on a neurologist. I'm going to put your EKG in continuous print mode to see if it picks up anything. Other than that, I need to see the lab results because from every sign I have, you're in excellent health for any age, let alone nearly seventy. I should have asked before -- are you taking any medications?"

"A daily baby aspirin which my doctor recommended and prednisone for arthritis."

"Any side effects from that?"

"None that I'm aware of. My doctor ran a bunch of blood tests about a month after I started them ten years ago, then every year since. He said there were no effects on my blood sugar, and none on my bone density."

"Good. No mental confusion?"

"Depends on who you ask!" he chuckled. "I have trouble remembering things on occasion, like where I left my car keys, but otherwise, no."

"I have trouble remembering where I left my car keys at times," I chuckled. "So that might be related to our Y chromosomes!"

"It's testosterone," Mrs. Temple said.

I chuckled, "A friend of mine said all men are suffering from testosterone poisoning."

"She's not wrong!" Mrs. Temple agreed.

"I'm going to check on my other patient, but I'll be back in a few minutes."

I left the room and went to Mr. Firth's room, where nothing had changed. The Resident from neurology arrived while I was reviewing the EKG which showed no abnormalities.

"Cohen, Neurology," a female PGY1 said, coming into the room.

I glanced at her name badged, "Hi, Rebekah, I'm Mike Loucks. This is Mr. Firth, early twenties, brought in after a bar fight. His vitals were normal, but he had significant trauma to the face, with contusions and minor lacerations. He fell and injured his nose. EtOH was 0.19 on admission, down to 0.15 on a repeat test. On a banana bag. 4 megs of lorazepam IV push resolved the seizure. Left pupil is blown, right is sluggish."

"Let me do an exam," she said. "Did you do a Babinski?"

"No," I replied, silently cursing myself for not thinking of that.

She did the exam, including the Babinski, which thankfully was normal.

"I'd say subdural hematoma," she said. "We need to get a CAT scan and I'll take him. Let me call and get authorization for the test and to take someone with high levels of EtOH on our service."

She went to the phone and dialed an outside line, which didn't surprise me, as her Attending wasn't required to be in the hospital overnight. She explained the situation, answered a few questions, then hung up.

"Doctor Baker says I can run the CAT scan and take him on our service," she said. "He'll come in once the CAT scan results are available."

"Let me call for an orderly. Do you have a med student?"

"Fourth Year, who is on the ward."

"OK. I'll have one from the ED go with you to assist."

"Thanks."

We made the arrangements, and I borrowed Naveen's Third Year to go with Mr. Firth, then sent Mary back to the triage desk and Tom rejoined me while I went to report to Doctor Mastriano who listened to what I said, then dismissed me.

"Jesus," Tom said. "What the fuck?"

I shrugged, "I have no clue."

I had some ideas, but I couldn't express them to a medical student. I had to take it to either Doctor Taylor or Ghost. We returned to Mr. Temple's room. I reviewed the EKG and saw my first hint of what might be wrong.

"Mr. Temple," I asked, "did you feel your heart flutter or feel faint about six minutes ago?"

"No. Why?"

"The EKG shows a brief period of atrial fibrillation, which could cause a near-syncopal or syncopal event, that is, cause you to become light-headed or even faint. Have you ever seen a cardiologist?"

"No, never had trouble with my ticker at all. How bad is it?"

"One brief period, especially in someone over sixty-five, is pretty ordinary. It's a fairly common thing, and is only treated medically if it's constant or severe. It's not something to worry about at this point, but you should see a cardiologist to confirm, no matter what we find tonight."

"Why see a heart doctor if it's not serious enough to treat or worry about?" he asked.

"Because he's a smart doctor, Jon!" Mrs. Temple said. "Why take a risk when all it'll cost you is a $20 co-pay?"

"To expand on your wife's comments, it's something a cardiologist will monitor because it can get worse. The cardiologist might well simply have you see your primary care physician to manage this, if anything needs to be done, which, at the moment I don't believe is necessary."

"So that caused me to faint?"

"It could be," I replied. "But I can't know for sure because it could have been a drop in blood pressure, low blood glucose, or a number of other things. Once I see the results of the blood work from the lab, I'll have a much better idea. Do you eat many sweets?"

"Hard candy, but not a lot, why?"

"A spike or dip in blood sugar levels can cause light-headedness. Do you happen to know your blood glucose or Hemoglobin A1C levels?"

"No. I know my doc ran those tests, but all I know is he said they were normal."

"Just try to relax and I'll be back in about twenty minutes with the test results."

"Thanks, Doc."

XII. The Patient Is Our Focus

July 4, 1989, McKinley, Ohio

Mr. Temple's lab results came back and, as I'd suspected, showed absolutely nothing outside the normal ranges for a man of his age. I updated the chart and added some diagnostic notes.

"Now what?" Mr. Temple asked.

"We'll keep you until 6:00am to monitor you, but if there are no signs of problems on the EKG or with your vitals, we'll send you home and you should follow-up with your personal physician. He or she can get your records from the hospital and take it from there. I'll also write a referral to a cardiologist so Medicare doesn't give you grief. If you like, I can turn down the lights and you can try to get some rest, though someone will come check on you regularly."

"Could I get something to drink?" he asked.

"We're fresh out of Scotch," I replied. "But I'll have the nurse get you some ice water or orange juice."

"Orange juice, please."

"Someone will bring that to you right away."

Tom and I left the room and went to the nurses' station where I asked Jackie to see that Mr. Temple received a bottle of orange juice and to take vitals every thirty minutes.

"Is that on the chart, Doctor?" she asked.

"It is," I replied. "Well, not the juice, but the vitals."

She laughed, "Which is, of course, what I meant. I'll note the juice when he drinks it."

"Thanks. Is Doctor Varma still busy?"

"Three patients," she said. "One admission and two monitoring."

The dispatch phone rang, and she picked it up, wrote notes on her notepad, then hung up.

"EMS four minutes out with an MI."

I looked up at the board, "Trauma 2 is free, have a nurse meet us in the ambulance bay, please. Tom, let's go."

We gowned and gloved and headed to the ambulance bay.

"I've never had ten hours like this," he said. "All last month, it was mostly calm overnight."

"I had a few nights like his during my clinical rotations, but they weren't all that common. We are seeing more visits overall since EMTALA passed, but that's not really responsible for overnight. The hospital expansion will barely keep up with the demand at the rate we're going."

"Then what?"

"Waiting times increase, as they are in New York City, Chicago, and LA, and to a lesser extent, Cleveland."

Nurse Kelly came out to the ambulance bay to join us.

"Kelly, I'll want a trauma panel, cardiac enzymes, and blood gas," I said. "Tom, 12-lead EKG and monitor, then Foley if the patient is unconscious."

Both of them acknowledged my orders and a minute later, the ambulance pulled up.

"Leroy Gibson; fifty-nine; working third shift at the water treatment plant; complained of severe chest pain, then collapsed; tachy at 120; BP 80 palp; PO₂ 93% on ten liters; diaphoretic and non-responsive. Saline IV TKO."

"Trauma 2! Tom, cardiology consult first."

"Got it!"

We rushed Mr. Gibson into Trauma 2 and the five of us moved him to the treatment table. Tom called for the cardiology consult while Kelly switched the oxygen feed and I listened to Mr. Gibson's heart and breathing. Tom finished the call and came over and began cutting away Mr. Gibson's shirt, then attached the EKG and pulse oximeter.

"What do you see?" I asked when he turned on the machine.

"It's not a sinus rhythm," he said. "But I don't know more."

"ST elevations," I said, pointing to the phosphor line on the monitor. "STEMI. Kelly, given his estimated weight, 350 megs ASA IV push."

"ASA 350 megs IV push," she repeated.

"Tom, put in the Foley, please."

"I've done exactly one," he said.

"Then you know how. I'll watch and correct anything you've done wrong."

"What size?" he asked.

"Try 18 French," I said. "But cut away his pants and underwear before you get the catheter, as he might not be average in size."

Tom cut away the clothing, I estimated my judgment had been correct, and told Tom. He retrieved the correct Foley and did a competent job of inserting it without need for correction.

"Urine in the bag," he said. "Light yellow, no pink tinge."

"OK. What would you do next?"

He shook his head, "I don't know. You gave him an ASA bolus, he's breathing on his own even if his PO₂ is a bit low and short of an angiogram, I don't know what to do."

"That's it, actually. Cardio will take him and do exactly that, though they might do a cardiac echo instead or in addition. We've done what we can -- he has a heartbeat, is breathing, and has the monitor."

"Shore, Cardiology," a PGY1 with a female Third Year medical student I didn't recognize in tow.

"Hi, Patrick," I said, looking at his name tag. "Mike Loucks. We have Leroy Gibson, fifty-nine; working third shift; complained of severe chest pain, then collapsed; tachy at 120; BP 80 palp; PO₂ 93% on ten liters by mask; diaphoretic and non-responsive. EKG shows classic STEMI. ASA 350 megs IV push; Foley is in with urine in the bag."

"He needs to lose about forty kilos," Doctor Shore said, as he examined Mr. Gibson.

"At least," I agreed.

"Nicki," he said, "call upstairs and tell them we need the cath lab and an Attending."

"Yes, Doctor Shore!" she said, going to the phone.

"I'll take him," he said. "Did your Attending sign off on the chart?"

"No," I replied. "I'm authorized to handle MIs. You can verify that with Doctor Strong or any of the other senior Residents or Attendings. Who's your Attending?"

"Doctor Blackburn."

"He's new, so he might not know, but if he has questions, he can call Doctor Bielski or Doctor Getty to confirm."

"I need the signature."

"OK," I replied. "Let me go wake up Doctor Mastriano. Tom, switch to a portable monitor and stay with Mr. Gibson until he's in the cath lab. I'll be right back with the chart."

I left the trauma room and knocked on the door to the Attendings' office, waited fifteen seconds, then opened the door.

"What?!" Doctor Mastriano asked without getting up.

"Cardiology won't take my STEMI without your signature."

"You're authorized."

"You explain it to the PGY1 cardiologist and his new Attending who wasn't trained at Moore Memorial, because they insist on you signing off."

"Give me the short version."

"Morbidly obese fifty-nine-year-old male complained of severe chest pain, then collapsed at work. EKG shows classic STEMI. ASA IV push."

"Give me the chart," she demanded.

I did, she sat up, took off her sleeping mask, scribbled her approval below my admission note and handed it back. She put her sleeping mask back on and reclined again, so I left without a word and returned to Trauma 2.

"Signed off," I said, handing the chart to Doctor Shore.

"Then let's go!"

We transferred Mr. Gibson to a gurney and Doctor Shore, Nicki, and Tom left to take him to Cardiology. I updated the board, then went to the lounge to get a bottle of water. I considered coffee and decided to pour myself a mug. I drank the bottle of water down, then took my mug of coffee with me to triage.

"Nothing, I see," I said, seeing an empty waiting room.

"Doctor Varma took the last patient about five minutes ago."

"OK. At 0600 you'll switch with Nanette, Doctor Varma's Fourth Year."

"What happened to the man with the syncopal episode?"

"He had one short run of A-fib, but everything else is normal. Smoker's lung, though he quit twenty years ago."

"Wait, if he quit..."

"A pack a day from age fifteen to age fifty," I said. "The damage is often permanent. If he hadn't quit, he'd be in far worse shape, assuming he was still alive. We'll monitor until 0600 then street him if nothing changes. I'll refer him to his personal physician and a cardiologist, but this could be something as simple as a brief bout of vertigo because he had a slight, undetectable viral infection."

"Common cold?"

"Yes. But that's just speculation, as I didn't find any symptoms or signs except the crackles in his lower lungs. He may have had a bout of A-fib when he got out of bed, might have stood up too quickly and had his BP drop, or any number of things, none of which we can justify looking for in the ED. His personal physician is best qualified to manage any testing and investigation in consultation with specialists as necessary."

"And right there is why I don't want to be a trauma specialist. It would drive me nuts."

"Me, too! And it's a VERY short drive! But this is what I've wanted to do since fourth grade. And I've had several doctors remind me of that 'feature' of my chosen speciality because it bugs the heck out of me."

"So why do it?"

"I like the adrenaline rush," I replied. "It's my drug of choice!"

Both Mary and Nurse Bonita, who was taking a few hours at the triage desk, laughed.

"Fourth grade?" Mary asked.

I explained the playground incident and how that had set my course for the rest of my life.

"I didn't decide on medical school until halfway through college when my biology prof at Bowling Green suggested it," Mary said.

We were interrupted as Deputy Schmidt came into the waiting room. Mary buzzed him through, and he came over to the triage desk from the inside, rather than the waiting room side.

"I had to admit your victim," I said. "He had a seizure and neuro took him."

"Well, shit. We did grab the other two dirtbags, and I do have the bartender's statement."

"No security cameras?"

"Outside only, nothing inside. But one of the guys we grabbed has hand injuries consistent with being in a fight. Any idea what happened with Mr. Firth?"

"I could only speculate. If you go up to neuro, they can give you more details, but I doubt he'll be able to give a statement any time soon, or perhaps ever."

"He could die?"

"Yes."

"Then we'll hold the scumbags on attempted murder charges, which means we keep them locked up unless they can raise bail."

"Four white guys?" I asked.

"Yep. According to the bartender, Dirtbag #1's girlfriend talked to the vic and Dirtbag #1 and his friends took exception."

"Someday this racist BS is going to stop," I said. "And that day can't come too soon."

"Don't hold your breath, Doc. This bar has Confederate flags on the walls."

I shook my head, "That's not the symbol of freedom from an oppressive government certain moronic elements think it is. I could see the Gadsden Flag, but the Confederate battle flag makes no sense. Anyway, at least the bartender is cooperating."

"Their liquor license is under supervision for serving underage on at least four occasions in the past two years."

"I'll keep my opinions of stupid laws to myself," I chuckled.

Deputy Schmidt laughed, "And you just gave your opinion! Anyhoo, I'll go up to neurology and see what they have to say. Thanks for taking care of Sam earlier."

"You're welcome. I take it you heard the shooter survived, but is in critical condition."

"Yeah, he'll spend a long time breaking rocks for shooting at a deputy. The County Prosecutor will throw the book at him. The sick part is that he'd probably have been able to plead out the drug rap and get off with a short stint in the county jail. Now he'll do hard time."

"What pills?"

"A whole pharmacy! Uppers, downers, you name it. And a kilo of pot."

"Mule?"

"Good guess. He was coming up from Eastern Kentucky on his way to Columbus."

"Harlan County?" I asked.

"OK, how did you know that?"

"A fellow med student is from Harlan County and told me about it, and another of my fellow students Matched at a regional medical center there."

"Who the heck volunteers to go there?"

"Well, the one who was from there wanted to go back to serve her community; the other one didn't Match last year and took anything she could find."

"Washed out?"

"No, she graduated, but had some personal problems that blocked her from Matching to any of the hospitals of her choice. This time she cast her net as wide as possible to Match."

"Makes sense. I'd have taken a job with any department who would have hired me for my first job, even with one of those Southern cracker J. W. Pepper sheriffs!"

I laughed, "Live and Let Die and The Man With the Golden Gun! Maybe a bit of Buford T. Justice."

"Smokey and the Bandit? He was just incompetent, not an asshole!" Deputy Schmidt retorted. "I need to get upstairs."

"See you later, Deputy," I said.

He left and as there were no patients, I went to the lounge and sat down for the first time since dinner, which had been about ten hours earlier. Tom returned from Cardiology and plopped down on the sofa next to me.

"He's in the cath lab. I returned the portable monitor to the alcove."

"Good. How are you holding up?"

"Fine. I've only been on ten hours or so. You've been on twenty-two, right?"

"Yes. And fourteen to go, though as I said, I'll duck out for four hours and Kylie Baxter, who went off shift at midnight, will cover for me."

"How long have you had your band?"

"Roughly four years," I replied.

"I need to get to a gig of yours. Got any lined up except later today?"

"We'll play at Taft in August and Stirred Not Shaken in September. We only took the one summer gig because of my schedule. We play school dances and clubs, and end up with about ten gigs a year, total. We'd play more, but we all have full-time jobs."

"Doctor Mike?" Nurse Becky said from the door to the lounge. "EMS ten minutes out with DUI MVA."

"How many?"

"Just the driver, per the dispatcher."

"OK. What's free?"

"Trauma 1 and 3."

"I'll take 3," I said. "I'll need a nurse, please."

"OK. Margie will meet you in the ambulance bay in a few minutes."

"Thanks."

She left, and I finished my cup of coffee.

"Wake Doctor Mastriano?" Tom asked.

"Let's see how bad it is first," I replied.

"How do you stay so calm? I feel like I'm about to have a panic attack every time I cover an EMS run."

"You're only five weeks into your first rotation," I said. "It's normal. By this time next year, you'll feel a lot more comfortable. The problem is that what you learn in the classroom is theory, and here the rubber meets the road. It's easy to do diagnosis in the classroom with no real pressure, but here, well, either you thrive on the pressure and get off on the adrenaline high, or you pick a different speciality. Don't sweat the feeling, just take it into account next Spring when you chose your electives. That said, you absolutely want a Sub-I in trauma, as it applies to every single specialty and you'll see a wide range of cases."

"You're like ice, though. I mean, totally unflappable."

"It's a personality trait," I replied. "Look at the other doctors in the ED who you admire. Are any of them emotional or wimpy?"

"No. You're all like automatons. Well, except for, never mind."

"You're entitled to your opinion, and I won't repeat it."

"Doctor Lewis seems awfully high strung," he said.

"And he'll either get past it or burn out and quit or switch to another speciality for his PGY2."

"People actually quit? After they Match?"

"They do. I heard about a PGY3 quitting at Cook County from Doctor Taylor. They literally just walked out of the ED one day, saying they quit, and ever came back."

"But that's seven years! Twelve if you count college! How do you not know?"

"Everyone has a breaking point," I replied. "I'd hit mine in pediatric oncology, which is why I want to stay away from there, period. Doctors who can do that for their whole careers are pretty amazing. I sure couldn't."

"Why?"

"I couldn't deal with kids dying on a regular basis, or worse, some ways, telling them they're going to die and you can't do a damned thing about it. Let's go meet the ambulance."

We left the lounge, gowned and gloved, and went to the ambulance bay.

"But people die in the ED," he said.

"Yes, they do, but nearly all of our patients leave here alive, or with a chance. In oncology in general, and pediatric oncology specifically, most of their patients are dying and are likely to die. At least here in the ED I have a fighting chance to do something other than administer IV poison in doses just low enough to not kill the patient in the hopes it'll kill the cancer cells. It's barbaric, but we don't have any better options. Radiation therapy isn't much better -- microwave the tumor or whatever in the hopes you can kill it before the patient dies from radiation sickness or other organs fail. The only thing worse is psychiatry."

"How so?"

"Whereas oncology is barbaric, it's modern, while psychiatry is medieval and cares more about docile patients than anything. A close friend of mine, well, more, because she was a girl I intended to marry, was diagnosed with schizophrenia while we were undergrads and the treatment she received is right out of the Soviet psychiatric hospitals -- drug them into docility and lock them away. The only reason she's not institutionalized is because I've fought tooth and nail to prevent it. And that has taken serious resources and good lawyers."

"Becky said you needed me," Nurse Margie said, coming out into the ambulance bay.

"Yes. DUI MVA, so trauma panel plus EtOH. Tom, EKG plus monitor, then Foley if the patient is unconscious. I'll intubate if necessary and conduct a primary exam."

The ambulance pulled into the driveway and came to a stop in front of us.

"Kimberly Bond, nineteen, unbelted driver; alcohol on her breath and open container in the car. Hit a telephone pole at low speed. Incoherent, but conscious; tachy at 115; BP 100/70; PO₂ 98% on nasal canula; resps labored at 20; multiple contusions; head hit the windshield; fractured left wrist; possible internal injuries; IV saline TKO; no meds as she's feeling no pain."

"Trauma 3," I said as the five of us moved off. "Tom, do the Foley once you have the monitors hooked up."

"Do you need help, Mike?" Nurse Becky asked.

I considered, "A second nurse would help, but I don't need another doctor right now."

"Julie will be right in."

Five minutes later, Ms. Bond was connected to the various monitors, but I forewent the intubation as she was breathing on her own. I did have Tom put in a Foley, and when nurse Julie came in, she assisted by covering the patient with a sheet and then scribing as I continued my exam.

"I think we need a neuro consult," I said. "And orthopedics, but I suspect she's bleeding internally. Margie, would you get the portable ultrasound, please?"

"You aren't going to call the surgical Resident?" she asked.

I smiled, "See these red scrubs? I am the surgical Resident!"

And I was going to make use of that by simply calling up to get Ms. Bond an ex-lap if I felt she needed one, rather than bothering the on-call surgical PGY1 for a consult who would have no more experience or skills than I did.

"Right away, Doctor."

"What do you see on the EKG, Tom?" I asked.

"I think this is V-tach."

I nodded, "Yes. But it's not high enough to warrant intervention just yet. Why is her BP low?"

"Alcohol impairment or blood loss, possibly both. That's why you want the ultrasound."

"Yes. Julie, get me a unit of plasma, please, and type and cross match. Surgery will need to know that."

"Hang the plasma?"

"No, just get it on the stand. If I see fluid in her belly, we'll give her the blood. Everything else, except her wrist and forehead, are superficial."

"Hi again, Doc," Deputy Schmidt said, coming into the trauma room.

"Are you the only guy working the entire county?" I asked.

He laughed, "No, but they knew I was here and asked me to arrest the driver."

"Consider her under arrest, but I hope you'll forego the cuffs. She's likely going to need surgery."

"She doesn't look like she's going anywhere, so no problem."

"Soft restraints if we need them," I said to Tom and Julie.

Margie returned with the ultrasound and after we set it up, she squirted gel onto Ms. Bond's stomach and I put the transducer against Ms. Bond's skin and moved it around.

"Fluid in Morison's pouch," I said. "Surgical case for sure. Run that unit in, please, Julie."

I handed Margie the transducer and went to the phone and called the surgical scheduling nurse while Julie connected the plasma bag to the IV.

"This is Mike Loucks in the ED. I have a surgical case I'm sending up for an ex-lap after an ultrasound exam showed fluid in Morison's."

"On whose authority?" she asked.

"Mine," I said. "I'm a surgical Intern. We'll bring her up in about five minutes. She's stable, with minor V-tach, but also inebriated. She can't wait, though."

"I'll have to check with Doctor Blake."

"Do that, but we'll be there in five minutes."

I hung up and turned to the team, "Portable monitor and portable oxygen, please."

"Orderly?" Margie asked.

"Tom and I will take her up," I said. "I don't think we should wait."

I quickly wrote my own consultation notes on the chart, signed it, and then we moved Ms. Bond to a gurney. Tom and I moved her from the trauma room to the elevators, and two minutes later were outside OR 1.

"Causing trouble already, Mike?" Doctor Blake asked.

"Hey, if Doctor Cutter insists I'm a surgical Intern, and I have the red scrubs and the S on my badge, I'm going to act like a surgical Intern!"

"What do we have?"

I ran through the report, including vitals and my findings with the ultrasound.

"EtOH levels?"

"They'll be ready in about five minutes. I'll have them call the OR so the gas passer knows what he's dealing with."

Doctor Blake laughed, "Painless?"

"I liked the movie and the TV show!"

"Give the chart to Ben. Can you scrub in?"

"No. We're a bit short in the ED, with just Doctor Varma and me working."

"Who's the Attending?"

"Mastriano."

"Say no more," he said, shaking his head. "We have this. Good catch, Mike. I'll let you know how it went."

"Thanks, Doctor Blake."

"Bill, please."

I nodded, handed the chart to Ben, a Fourth Year, then Tom, and I left to return to the ED. When we arrived, I called the lab and instructed them to call OR 1 with the EtOH levels and send the rest of the labs up when they had them.

"We have the level," he said. "It just came up. 0.22."

"OK. Call that up to OR 1, please. She's about to have an ex-lap."

"Will do."

I hung up and made notes in my notebook as I didn't have the chart to update.

"You cut at least fifteen minutes off the normal time in the ED," Margie observed, coming over to us.

"That's one point of the new trauma surgeon specialty," I replied. "Another is being able to do chest tubes, pericardiocentesis, central lines, and other things that usually require a surgeon. I can't do them all yet, and it'll be a few years, but long-term, we should dramatically improve patient care. I suspect, ultimately, that at least half of all trauma specialists will follow this new path.

"The other change that I'm sure you've heard about is that EMS paramedics are being trained to perform intubations and read EKGs, as well as eventually do chest tubes. And all of us will do ride-alongs that coincide with the training of the EMS paramedics in the ED. We should seriously improve patient outcomes will all of these changes."

"Mike?" Nurse Becky called out. "A deputy is bringing in an arrestee with a dog bite to the arm. They'll be here in about ten minutes. Doesn't sound serious."

"OK. Call me when they arrive, please, and put them in an exam room."

"I'll put them in Exam 5."

"Thanks."

She left, as did Margie.

"What do you think Doctor Blake meant by what he said about Doctor Mastriano?"

"I think she has a reputation and given she's an Attending, I think we should let the Attendings deal with it. I've stuck my nose a few places and had it figuratively whacked with a rolled-up newspaper."

"It doesn't seem to have hurt you."

"No, but it could have," I replied. "It's simply a matter of following protocol. I'll let either Doctor Gibbs or Doctor Gabriel know what happened, and if anything needs to be said, they'll say it."

"So you say less as a doctor than you did as a medical student?"

"Let's just say that my advice is to follow my medical example, not my philosophical or political example. I had a penchant for tilting at windmills, and it took a dozen or so rolled-up newspapers to bring me to a point of being pragmatic and practical. It's more about the approach I take, rather than what I say or don't say, and that's what I'm trying to convey, albeit poorly, apparently."

"No, I understand it, I was just surprised by the fact that you say less from a position of relative power than in one where you totally depended on the approval of the people who you were speaking with."

"I learned. Everyone has different things to learn or change about themselves to become a good physician, beyond medical knowledge. Figure out what it is you need to learn or change, then do it."

"Good advice; now I just have to figure out what it is."

"That's the challenge."

We sat quietly for several more minutes, then Becky came to the door and let us know the deputy was here with his prisoner. Tom and I went to Exam 5.

"Hi, Deputy Foster," I said, looking at his name tag. "Doctor Mike Loucks."

"Hi, Doc. K-9 bite on his right arm during a raid on his farm a few hours ago."

"Let me take a look," I said. "Are the dog's shots up to date?"

"Completely."

"I'll need you to take the cuffs off," I said. "At least from the arm I need to examine."

"Stand up, Weisz," the Deputy said to his prisoner.

Mr. Weisz stood up and turned so the Deputy could remove the handcuffs, though he only removed the right cuff, then attached it to the railing on the treatment bed. It wasn't ideal, but I could work with it.

"Tom, bandage scissors, please."

He got them from a drawer and handed them to me.

"I need to cut away your sleeve, Mr. Weisz."

"Just do it."

I did and saw what was clearly a superficial bite.

"Could I get your full name and age, please?"

"Jim Weisz, thirty-six," he said.

"Tom, start the chart, please," I said.

"Mr. Weisz, have you had a recent tetanus shot?"

"Last year."

"Are you taking any medications?"

"No."

"Using illegal drugs of any kind?"

"I'm not saying shit in front of the deputy."

"I'm not asking specifics, just 'yes' or 'no', and if you've used anything in the past twenty-four hours."

"Never get high on your own supply," Mr. Weisz said.

He was quoting Scarface, a movie I'd never seen, but I knew the line.

"I'll take that as a 'no'," I said. "The wound is superficial, so we'll clean it, apply a topical antibiotic, and then a sterile dressing. You'll need to have the wound checked in seventy-two hours."

"He'll be in our lockup," Deputy Foster said. "Or the Feds might have him. There might be federal firearms charges."

"I'll give you instructions, which I expect the Sheriff to follow," I said firmly. "If the Feds have him, then it's on them."

"I'll make sure the duty nurse at the jail gets the paperwork," Deputy Foster said.

"Tom, saline, an irrigation basin, a tube of triple antibiotic, gauze, and an Ace bandage, please."

Tom got the things from the cabinets and drawers while I washed my hands. I irrigated the wound, applied the triple antibiotic, which consisted of neomycin, polymyxin B, and bacitracin, then wrapped the wound in gauze and secured it with an Ace bandage. I updated the chart, filled out a blank discharge form, and gave it to the deputy.

"He needs to keep it clean and dry," I said. "The Ace bandage should keep it in place and clean, but it'll need to be wrapped if he's going to shower."

"What am I? A sack of potatoes?" Mr. Weisz asked.

"If you're in the lockup, you're not going to be able to care for yourself, and that means this deputy will convey the information to the nurse at the jail. She can't take your word for it. If you need a doctor, she'll call one, but your wound isn't serious. You're all set."

"OK to cuff him?" Deputy Foster asked.

"It'll need to be in front," I said. "And don't tighten the cuff too tight on his right wrist."

"Stand up, Mr. Weisz," Deputy Foster said.

Mr. Weisz complied, Deputy Foster re-cuffed him, with hands in front, instead of behind, picked up the discharge papers, and then marched Mr. Weisz out.

"I don't get it," Tom said once they were out of the room.

"What?" I asked.

"You have a reputation as a soft touch and are always on the patient's side, but in this case, you weren't."

"We insist they remove handcuffs if they interfere with patient care," I said. "In this case, it didn't. Given there was no way I could admit Mr. Weisz, and nothing I could do to improve his situation except have the cuffs in the front, I did what I could. Had he been more seriously injured, I'd have insisted the cuffs be removed completely and would have handled things differently."

"Innocent until proven guilty?"

"Yes, of course, and if I were on a jury, they'd have to prove it to my satisfaction. But this isn't that. I have very little sympathy for people who sell drugs, and, to be honest, I'm tired."

"And you still have over twelve hours to go, right?"

"Yes. And with no sleep overnight, it's unlikely I'll get any before the end of my shift."

"Do you think it will change because of what happened in New York?"

"I think either the medical profession will change things or we'll be forced to change, and I'm not sure which will win out -- preservation of relative autonomy or resistance to change. Even scientific ideas are often resisted. I'm sure you remember the primary example."

"The doctor who discovered that washing our hands and changing clothes cut infant and maternal mortality?"

"Doctor Ignaz Semmelweis," I replied. "Part of the problem was that he wasn't tactful in how he presented the information and thus met resistance. Several doctors have reminded me of that over the course of the past four years. Fast forward and there's resistance to my Residency, and a significant turf war is underway, but look at what happened with the MVA who needed an ex-lap. We cut somewhere between ten and twenty minutes from the time she presented until she was in the OR. That can be the difference between life and death."

"I heard you came up with this idea."

I chuckled, "I wish, but also I don't. Had I actually come up with it, I doubt I'd have made any headway. I cribbed it from a doctor who implemented it at Indiana University Hospital, and later at the University of Chicago Hospital, where he's Chief of Emergency Medicine. He tried to recruit me to the medical school at Indiana University, then encouraged me strongly to apply to Match in Chicago with him."

"That's a prestigious hospital; why not go?"

"Because I want to serve my community," I replied. "I was born and raised one county over, and I'd actually have preferred Matching at the hospital there, but they aren't a teaching hospital. It's also the case that my family and closest friends are all in Southern Ohio, and I needed the support system after my wife reposed."

"What's that word?"

"Reposed? It's the word Orthodox Christians use when someone's mortal life ends because death has no actual power over us, and because the believer is alive in Christ, in eternal union with God."

"Mike?" Nurse Peggy said, coming into the lounge, "EMS four minutes out. Car versus bicycle. They say it's bad."

"Wake Doctor Mastriano," I said.

"She gave express instructions..." Peggy protested.

"And I'm overriding them," I said, interrupting her, "If she has a beef, it's with me. Wake her. What room is available?"

"Take your pick, the trauma board is clear."

"Trauma 1, then," I replied. "Tom, let's go. Peggy, two nurses, please."

"Bonita and me," she replied.

The three of us left the lounge. Tom and I gowned and gloved and Peggy went to wake Doctor Mastriano. It was 5:40am, so only twenty minutes from her 'do not wake me up until' time, and frankly, I didn't give a damn if she was upset or not. I'd heard about lazy and indifferent Attendings, but I'd never run into one. Residents tended to be all over the map, but an Attending had passed their Boards, was licensed, and had survived Residency. There were doctors who were, in effect, eternal Residents, who were not 'good enough' to become Attendings, but Doctor Mastriano had demonstrated to somebody that she was qualified.

"Tom, a lot will depend on how bad this is, but I'm likely going to need to intubate. Your job is to get the EKG and monitor going, then take the blood draw to the lab. Don't wait for anyone to tell you. If I change my mind, I'll tell you."

Peggy and Bonita joined us, both gowned and gloved.

"Doctor Mastriano is awake," Peggy said.

"OK. Bonita, stat trauma panel, and type and cross match. Tom will take the blood to the lab. Peggy, Foley, and then blood if we need it."

They both acknowledged my orders, and a minute later the EMS squad turned into the driveway and pulled up in front of us. Bobby jumped out and called out the vitals.

"Female, approximately twenty, hit-and-run while biking; pulse 120 and thready; BP 80 palp; lungs are compromised, PO₂ 91%, hard to bag; serious head injury; left arm and left leg fractured; GCS 3; IV saline TKO; cervical collar and backboard."

"Trauma 1!" I ordered.

We rushed the patient into the hospital and into the Trauma room, where Doctor Mastriano was waiting. I repeated the vitals as we moved the young woman to the trauma table.

"Doctor Mastriano, primary assessment, please," I said. "I'm going to intubate. Let's go, people!"

Everyone sprang into action, in what to an outside observer would appear chaotic, but which was actually a carefully choreographed ballet. Two minutes later, the patient was intubated, the EKG and pulse oximeter were attached, the Foley was in, two units of plasma had been hung, and Tom was on his way to the lab with the blood.

I was most concerned about the head injury, but it had to wait until we completed the assessment of the patient's internal injuries. There was blood in the urine bag, and her chest injury was impacting her breathing, and unless we controlled the internal bleeding and resolved the respiratory problems, she wouldn't live long enough for neuro to do anything.

"Bonita, ultrasound, please!" I ordered.

"No," Doctor Mastriano said. "Call for a surgical consult."

"I'm a surgical intern," I countered. "Bonita, get the ultrasound."

"And I'm an Attending. Do NOT touch the ultrasound. We need a surgeon."

"Bonita, get the unit," I said. "I'll make the call."

We'd waste precious minutes while someone came down from surgery, so I chose to interpret Doctor Mastriano's orders in the way most favorable to the patient.

"Hi, this is Doctor Mike in the ED. I need Doctor Roth or Doctor Cutter to authorize me to perform a surgical assessment."

"One minute," Nurse Penny said.

"Doctor, that is NOT what I told you to do!" Doctor Mastriano growled.

I put the phone on speaker and a few seconds later Doctor Roth came on the line.

"What's up, Mike?"

"You're on speaker. Car versus bicycle, significant internal injuries. I want to do the surgical assessment but Doctor Mastriano insisted I all for a consult."

"Doctor Mastriano," Doctor Roth said. "Mike is qualified and it'll save at least five minutes. He's authorized. Mike, call and let us know if you're bringing her up."

"Will do," I replied.

I pressed the button to disconnect the call and moved back to the trauma table as Bonita came in with the ultrasound.

"Doctor..." Doctor Mastriano said.

"Not now," I replied. "The patient is our focus. You can chew me out later if you feel it necessary."

Bonita squirted gel onto the patient's abdomen and chest, and I did not like what I saw at all. She had several broken ribs in a classic flail chest, and her heart and lungs were both compromised by those injuries.

"Fluid in the pericardium," I announced. "And in Morison's. Peggy, Bonita, splint the arm and leg, and let's get her up to surgery."

While they did that, I went back to the phone and dialed the surgical scheduling nurse. I gave her the details, and let her know we'd be up immediately. Tom had returned and assisted preparing the patient for transport. A minute later, Tom, Bonita, and I rushed the patient out of the trauma room and headed for the elevators.

"HOLD THAT ELEVATOR!" Tom called out, seeing people about to get on.

As per protocol, one person pressed the hold button while the other three moved out of the way. Two minutes later, we were outside OR 3 where Doctor Blake was waiting.

"What do you have for us, Mike?" he asked.

"Car versus bicycle," I said, then gave the vitals and the actions we'd performed.

"You and your student scrub in," he said. "I'll have you do the pericardiocentesis while Robert and I handle the ex-lap."

"OK. Tom, let's go. Just follow my lead, please."

We went into the scrub room where Doctor Robert Aniston, one of the new Attendings, was scrubbing.

"The famous, or is it infamous, Mike Loucks, right?" he asked.

"And my student, Tom Lawson. Nice to meet you."

"I'd shake your hand, but..."

"Yeah," I replied. "Tom, tear open a scrub pack. You did this for your Preceptorship, right?"

"Yes, but that was over a year ago."

I quickly ran through the steps to scrub, and he followed them. Five minutes later we were in the OR waiting for Doctor Kelsey from Anesthesiology to give the OK to proceed, which she did a minute later.

"I'll talk you through this, Mike," Doctor Blake said. "There's no time for fluoroscopy, so you'll need a cardiac needle with the electrical lead attached via alligator clip. Alice, syringe with a cardiac needle and lead to Mike."

"Bill," Doctor Aniston said, "I'm ready to open."

"Multitasking is my specialty!" Doctor Blake declared. "Go ahead, Robert. Mike, insert the needle between the xiphisternum and left costal margin, and direct it towards the left shoulder at a 40° angle to the skin. Go slowly, and as this is unguided, stop when you hear the warning tone, back off about 2mm, then aspirate. If you don't get fluid, advance the needle slightly and try again."

"Bill, tie off that bleeder," Doctor Aniston ordered.

I began the procedure, moving carefully with Doctor Blake splitting his attention between tying off bleeders and me advancing the needle. I got the tone and the cardiac monitor showed the heart reacting, so I backed off the needle and began aspirating.

"Blood in the pericardium," I said as the fluid began filling the large syringe.

"Pulse and rhythm improving," Doctor Kelsey announced.

"Keep going until the syringe is full," Doctor Blake said. "Then attach a valve in case we need to draw more fluid."

I did as instructed, handing the filled syringe to Alice , who put it in a tray and gave it to a circulating nurse to send down to the lab for analysis.

"Spleen is compromised," Doctor Aniston announced. "Complete resection. Liver lac, but it can be repaired. How's she doing, Jennifer?"

"Better," Doctor Kelsey confirmed. "But don't dawdle."

"Mike, we have this," Doctor Blake said. "Two more of these and we'll sign off on you doing the procedure in the ED."

"Somebody needs to let Doctor Mastriano know."

"Doctor Cutter will take care of that," Doctor Blake said. "You can scrub out."

"Yes, Doctor."

"Bill," he prompted.

"I'll get the hang of it eventually," I said.

Tom and I left the OR, changed into clean scrubs, then headed back to the ED, where an angry-looking Doctor Mastriano was waiting.

XIII. A Long Night during a Long Shift

July 4, 1989, McKinley, Ohio

"I need to discharge Mr. Temple," I said to Doctor Mastriano.

"Do that, then come to my office."

"Yes, Doctor," I agreed.

Mr. Temple had not had a repeat of his syncopal event, nor had he experienced additional bouts of A-fib, so I wrote out the cardiology referral to keep Medicare happy, completed the discharge papers, directed him and his wife to Patient Services, then went to the Attendings' office where Doctor Gabriel was with Doctor Mastriano.

"Give us the room, please," Doctor Mastriano said to Doctor Gabriel.

"Morning, Mike," Doctor Gabriel said.

"Morning, Pete," I replied.

"Rough night?"

"Long, but I'm doing OK."

He left, closing the door behind him.

"If you EVER contradict me or undermine my authority again, I'll bounce you from this program so fast you won't know what happened."

I was tired, and I knew it, and that meant I had to be extra careful in what I said and how I said it, lest I allow fatigue to cause me to say or do something foolish.

"May I please suggest you take this up with Doctor Cutter and Doctor Northrup?" I requested. "My situation is different from all other trauma Residents because of my special program."

"You aren't special. You're a PGY1 and you have neither the experience nor the skills to make the judgments you're making."

"Which is why you slept all night and insisted that I not bother you?" I asked snidely, instantly regretting it.

"This is not about me, Loucks. You directly disobeyed my instructions."

"I'm sorry I mentioned you sleeping all night," I said, intending to twist the knife despite my earlier resolve to be careful. "But, Doctor, I didn't disobey your instructions. You instructed me to call for a consult, which is performed by a surgical Resident. I'm a surgical Resident, and Doctor Roth confirmed that I was authorized to make the assessment."

"You know very well that I meant to have the on-call surgical Resident come down, not to play word games. And then you disappeared for forty minutes!"

"Doctor Blake directed me to scrub in to help with the surgery."

"You're a fucking Intern! You don't touch patients in an OR!"

"I performed a blind pericardiocentesis under Doctor Blake's instruction, with the goal that I'll be able to do those in the ED."

"Not in MY trauma rooms."

"I don't know what to say beyond that you should take it up with Doctor Cutter and Doctor Northrup, or Doctor Gibbs, once she comes back on Friday."

"This is going in your file, Loucks. And I won't stand for a repeat."

"Yes, Doctor," I said, knowing an argument would do me no good.

"You are to confirm every single procedure with me."

"If you insist, I'll be happy to wake you to ask about giving a patient a Tylenol."

"You know what I meant!"

"I heard you say 'every single procedure', Doctor. I'm going to err on the side of caution to ensure there are no misunderstandings or misinterpretations."

"Don't be a smart ass."

"It's not being a smart ass. It's a proper response to being reprimanded for interpreting your instructions in a way you consider incorrect or insubordinate, but which benefitted the patient. May I be dismissed so I may speak with my mentor about this?"

"Doctor Casper is not here."

"No, but Doctor Taylor, is."

"What does he have to do with anything? Casper is your mentor."

"Not Josh Taylor," I replied. "Vince Taylor."

"He's a surgeon, not a trauma specialist!" Doctor Mastriano protested.

"Indeed, and the red scrubs and the 'S' on my badge indicate I'm on the surgical service. May I go?"

"Get out of here!" she growled.

I left and went to the nurses' station and called to see if Doctor Taylor was available. The nurse said he was just about to go into surgery, so I decided to go up and talk with him while he scrubbed.

"Hi, Mike! What's up?"

"Hi, Vince," I replied. "Doctor Mastriano basically put me on double secret probation because I followed the program set by Doctor Cutter."

"She's...no, I can't say that to you. Let me handle it with Doctor Cutter. Can you give me the nutshell in two minutes?"

"Yes."

I explained the events of the previous twenty-four hours, including the contradictory things Doctor Mastriano had said.

"Her shift ends right about now, doesn't it?"

"Yes."

"When are you on with her again?"

"I'm not sure of her schedule, but certainly next week, Monday."

"OK. Who's the senior Attending today with Gibbs out?"

"Brent Williams."

"Explain briefly what happened, and have him clear you to perform the procedures everyone has signed off on. Keep your comments about Mastriano neutral, please."

I nodded, "I will."

"OK. I'll get in touch this afternoon after I speak with Doctor Cutter."

I thanked him, left, and returned to the ED.

"You OK?" Tom asked.

I nodded, "Just part of the turf war, I think. I need to go see Doctor Williams."

I saw him in the Attendings' office, and decided to wait until Doctor Mastriano left before talking to him, so I went to the lounge where Mary was on the couch.

"How do I get off triage and get to work with you more?" she asked.

"There isn't much I can do about the policy," I replied. "Given EMTALA requires us to provide an exam and treat all emergent cases and active labors, we have to have someone trained in H & P handle walk-ins, where before it was done by the clerk, who now has other duties. There's a staffing problem with exclusively using nurses, and that's why more medical students are assigned to trauma now than in the past. Next week, for this shift, Doctor Varma's student will handle overnight, and you'll just have a two-hour shift during the day. Did that happen last month?"

Mary nodded, "Yes, but I also wasn't working with you. You're more willing to allow your students to do procedures than anyone else, and I want to learn."

"I'll do my best when you aren't on the triage desk, but I can't change that."

"It just sucks that Tom got to scrub in on the emergency surgery; no offense Tom."

"None taken," he replied. "But I also won't apologize!"

"Nor should you," I interjected. "Mary, I'll do my best to make sure you get procedures, and we should have plenty of opportunities today, if history means anything. If you'll excuse me, I need to see Doctor Williams. You two should get your breakfast now."

They left, and I found Doctor Williams in the corridor and asked to speak to him.

"I got an earful from Mastriano," he said.

"Vince Taylor in surgery suggested I speak to you about the restrictions Doctor Mastriano placed on me."

"Well, she's not here and if you come ask me about giving a patient Tylenol, you'll regret it!"

"Understood."

"Is it true she blew off a patient with a head injury?"

"She insisted, and wrote on the chart, that I was to wait for his EtOH level to drop before she'd consider any further actions beyond life support."

"He seized and herniated?"

"I didn't get a report from neuro, but that would be my impression based on what I know."

"That's going to be an ugly M & M if he's gorked."

"Yes, it will," I confirmed. "May I raise one other topic?"

"You never stop, do you?" he asked with a sly smile.

"No, which I suspect is part of Doctor Mastriano's problem with me. In any event, this isn't a request or even recommendation, but my Fourth Year asked about less time on the triage desk and more time doing procedures."

"Stop the presses! Breaking news! Medical Student wants more procedures! Film at 11!"

I chuckled, "You kind of mixed your metaphors there with print and broadcast media."

"You are a pain in the ass, Mike!" Doctor Williams declared with a grin. "A great young physician, but a major pain in the ass!"

"All part of my master plan for world domination!" I chuckled.

"I'd actually be OK you with you being Emperor of the World! You care too much about people to be an evil dictator!"

"I suggested you ask Rachel that question in about twelve years!"

Doctor Williams laughed, "I have an eleven-year-old daughter, and I'm positive she thinks I'm a cross between Genghis Khan, Attila the Hun, and Pat Robertson!"

"Two of those aren't so bad," I replied.

Doctor Williams laughed, "Let me guess, you think Robertson is the truly evil one in that trio?!"

"Let's just say that I have significant differences of opinion from the so-called Moral Majority."

"You and me both! And yet, I believe that's the main area of conflict with my daughter!"

"May I ask how old you are?"

"Thirty-three. We had Michelle as my graduation present from UofI. Not the best timing, but I'm very happy we have her. How is your daughter?"

"Asserting her newfound independence," I replied. "Her favorite word is 'no', followed closely by demanding to see her Aunt or her best friend."

"It doesn't get much better! Wait until she discovers boys!"

"Oh, she has, and has ZERO use for them!" I chuckled. "But that will change in about twelve years."

"Or sooner. My daughter decided they were interesting just before her eleventh birthday."

"Lord have mercy!"

"You can say that again!" he replied, then immediately said, "STOP!"

"What? " I asked with a 'What, me worry?' look.

"You were going to actually say it again! I could tell by the look on your face!"

"My reputation precedes me. OK to get my breakfast?"

"Yes. Make sure your students eat."

"I sent them to have their meal when I came to speak with you."

"When are you with Mastriano again?"

"I honestly don't know. I only looked at my schedule.

He pulled open a drawer and pulled out a calendar.

"Saturday," he said. "I'll speak to Doctor Gibbs and Doctor Northrup and let them decide what to do."

"Thanks, Brent."

"You're welcome. Naveen has walk-ins, so you're on trauma and monitoring as soon as you come back."

"OK."

I left the Attendings' office and hurried to the cafeteria where I got eggs, bacon, yogurt, toast, and coffee, then sat down with Mary and Tom, who were already eating.

"How much trouble are you in?" Mary asked.

"The usual amount," I replied. "It won't affect anything for the rest of this shift."

"Tom wasn't sure exactly what happened."

"Neither am I, in the sense that everything seemed more or less OK with Doctor Mastriano during my shift on Saturday."

"She slept all night?" Mary asked.

"I'd prefer we didn't discuss what Doctor Mastriano did last night," I said. "As I mentioned, there's something of a turf war between the ED and Surgery, and it's best if we all keep our heads down as best we can. I'm kind of stuck in the middle with a balancing act, and I need to let the Attendings and Chiefs fight this out and try not to be hit by friendly fire, so to speak."

"But the new specialty makes so much sense!" Mary protested.

"So did hand washing and the germ theory of disease," Tom interjected. "And I'm sure you remember that from Practice of Medicine."

"I just don't get it," Mary said, shaking her head. "Just because something is new doesn't mean it's bad."

"No, but what's the number one rule of thumb in medicine?" I asked. "Not what they taught you in Practice of Medicine, but in reality?"

"Go with what works," Mary replied.

"Exactly. So if something works, the system is designed to stick with it until it's proved that there is a better way. Sometimes that's easy, usually around pharmaceuticals. Sometimes it's difficult, such as with new surgical techniques. Can you tell me why?"

She thought about it for a moment, then nodded.

"Because the system is designed to protect physicians who follow a specific standard of care, and looks askance on variations from that standard, even if they're successful."

"Why?"

"To prevent a 'Wild West' environment where anything goes and there are no standards."

"Yes, and think about what that means for emergency medicine. What's different there?"

"You don't have time to think in many cases."

"Right. What do you know about succinylcholine and etomidate?"

"They're used for intubation," Mary said.

"Why?"

"Adverse effects are exceedingly rare, they're short-lived, and have standard dosage for adults."

"And the value of that?" I prompted.

"You save precious seconds and don't have to worry about contraindications."

"Correct. So if someone came up with a new drug, how would that be received?"

"Skeptically because what we have works and is very, very low risk."

"So even something that is somehow better would be difficult to adopt. Why?"

"Because the new benefits are unlikely to be sufficient to take the risk."

"Yes. And what mentality does that engender?"

"Semmelweis," she replied.

"Here endeth the lesson," I said with a smile. "We need to finish eating and get back."

"Sean Connery in The Untouchables?" Tom asked.

"Yes," I replied.

We finished our breakfast and headed back to the ED where Doctor Fitzgerald and Doctor Lews had come on shift alongside Naveen Varma and me, which was the normal daytime contingent of PGY1s, with Doctor Williams as the Attending and Doctor Gabriel as the senior Resident. The Attendings would work between twelve and eighteen hours, while senior Residents worked between eighteen and twenty-four, and the PGY1s, as much as thirty-six hours. The only doctor with regular hours was Doctor Gibbs, who, as the Chief Attending, worked between ten and twelve hours Monday through Friday.

"Mike," Doctor Williams called out, seeing us walk into the ED.

"Yes?" I inquired.

"Hand lac in Exam 6 if your student wants a procedure."

"Nah," I replied. "What med student ever wants more procedures?"

He laughed, "OK, because, not if."

"Mary, do you feel comfortable doing the procedure with Tom, explaining what you're doing and completing the discharge?"

"Yes!" she exclaimed.

"Then we'll all go in and I'll stand in the corner and observe. Introduce yourself as a Sub-Intern, but don't explain what that is unless asked. If they ask, you say it's a 'trainee doctor'. Introduce me as your supervisor, and Tom as a new student."

"Yes, Doctor!"

"Then let's go."

The three of us went to Exam 6, stopping at the door so Mary could review the chart which was in the holder on the wall.

"Forty-two-year-old male," she said. "Bagel-slicing accident; five centimeter lac on his palm with no tendon involvement and clean margins."

"Before we step in, what are you going to do?"

"Appreciate the wound; irrigate; inject lidocaine, probably times five; paint with Betadine; suture with 4–0 nylon; apply a clean dressing."

"Good," I confirmed. "Tom, what else?"

"Verify his tetanus. Mary should also ask about negative reactions to local anesthesia and allergies."

"Very good. I'll stand aside and only step in if I see something that concerns me."

We went into the room and Mary introduced herself, Tom, and me as I'd instructed. She proceeded exactly along the lines she'd suggested and did an excellent job suturing. Tom administered a tetanus shot, and then Mary discharged the patient.

"How does it feel to be a doctor?" I asked Mary after we returned to the lounge.

"That's the first time I was ever allowed to do everything from start to finish."

"And you did an excellent job. Write it into your procedure book and I'll sign it. Do one more like that, and I'll sign off for you to do them without observation. Tom, you'll get your chance before the end of the month as well."

"Thanks," he replied.

"Doctor Mike?" Nurse Ellie said from the door to the lounge. "EMS five minutes out with failure to fly."

"Thanks, Ellie. Which room?"

"Trauma 4. I'll send you Nancy."

"Thanks."

"Failure to fly?" Tom asked.

"Kid, usually between four and eight, almost always a boy, who fell out of a bunk bed or something similar," I replied. "Let's go."

Five minutes later, the EMS squad arrived.

"Danny Baldwin, six; fell from his bunk bed; BP 110/70; pulse 90; PO₂ 98% on room air; contusion on forehead; no other obvious injuries; unconscious for about two minutes; GCS 11 on arrival, 14 now; cervical collar. His parents are right behind us."

"Trauma 4!" I ordered, and we began moving. "Hi, Danny. I'm Doctor Mike and we're going to take good care of you."

"My head hurts!" he said.

"We'll do our best to fix that!" I said. "Mary, primary survey, please. Tom, pulse oximeter only."

"Trauma panel?" Nurse Nancy asked.

"I think we can dispense with that for the moment," I replied.

The four of us, plus the two paramedics, gently moved Danny to the trauma table.

"Danny, this is my friend Mary," I said. "She's going to check your eyes, ears, nose, and mouth, and listen to your heart and lungs. My other friend Tom is going to put a clip on your finger to measure how fast your heart is beating."

"Will it hurt?" he asked.

"No."

Mary, who already had on gloves, picked up the otoscope and put on a fresh speculum, and began her exam.

"No CSF in either ear; pupils reactive; nasal passage clear and free of fluids; throat clear."

"OK. Tom, Babinski, please. Danny, my friend Tom, is going to rub the bottom of your feet."

Tom did the test and reported his findings.

"Normal flexor, both feet."

"Indicating?" I asked.

"No spinal damage, but it's not definitive."

"Correct. Danny, I need to check your neck," I said. "I'm going to ask my friend Mary to hold your head and you need to keep very still."

"OK," he said.

Mary stabilized Danny's head, and I carefully loosened the cervical collar and appreciated his spine and neck muscles.

"No indication of trauma," I said.

"Everything OK in here?" Doctor Williams asked from the door of the trauma room.

"Just completing the primary exam, and about to remove the cervical collar."

"Proceed," he said. "Call me if you need me."

I removed the collar and asked Bobby to slowly turn his head from side to side.

"Does that hurt at all?" I asked.

"No, but it feels like somebody is pounding on the inside of my head."

"We'll give you some medicine to help. Mary, which analgesic?"

"Liquid ibuprofen or acetaminophen; I know your preference is for ibuprofen, so I'd go with that."

"Dosage?"

"OK to look in my book?" she asked.

"Yes. With kids, we always look it up because drug dosage and contraindications are different from adults."

She quickly paged through her notes, then said, "Estimate about 22 kilos, so 10 milliliters PO."

"Nancy, would you retrieve the ibuprofen for Mary, please?"

"Right away, Doctor."

"Mary, complete the exam, please."

She palpated Danny's abdomen, checked for signs of other injuries, then asked Danny about being in the hospital or going to the doctor, to which he said just for his shots.

"What's your diagnosis, Mary?" I asked when she finished.

"Mild concussion."

"And what would you do?"

"Monitor for two hours then release with instructions to see his family physician, and return if has dizziness, nausea, double-vision, or any other signs of neural compromise."

"And that contusion on his forehead?"

"Ice, as needed, if he'll tolerate it."

"What are you missing?" I prompted.

Mary thought for a moment, "I think that's it."

"Possible skull fracture?" I asked.

Mary frowned, "I should have thought about that. Skull series?"

"Maybe," I replied. "What would be my concern?"

"X-ray exposure. But don't we need to know?"

"It would be preferable, yes, but we need to discuss it with his parents, as well as find out if he's had other x-rays recently."

"What about the new CAT scan?" Tom asked.

"It uses ionizing radiation just like an x-ray," I said. "In fact, more. What we really need is one of the new Nuclear Magnetic Resonance Imaging systems that don't use ionizing radiation; they use magnetism, instead. Unfortunately, they're only in research centers and very large hospitals."

"How do we get one?" he asked.

"It's about money and space, the same as every other thing we need. Would you go see if his parents are in the waiting room and escort them back?"

"Right away!" he replied.

Nancy returned with the liquid ibuprofen and Mary administered it via a small plastic cup, just as Tom brought in Danny's parents.

"Mr. and Mrs. Baldwin," I said. "I'm Doctor Mike."

"How is he?"

"Other than a headache for which we've given him ibuprofen, which is the active ingredient in Advil, everything seems fine. We would like to take a series of x-rays of his head to check for a skull fracture, but I need to ask about other x-rays he's had recently."

"None," Mr. Baldwin said. "No broken bones and his dentist said no x-rays until Bobby has his adult teeth, unless there's a problem."

I nodded, "That's a good policy. There's nothing dangerous about the x-rays, so long as he doesn't have too many. Is it OK to send him to Radiology for x-rays of his head?"

"Yes," Mr. Baldwin said.

"Tom, call Radiology and then take Danny for his x-rays. Wait with him and let me know when the radiologist has the wet read."

"Right away, Doctor," Tom said.

"Mr. and Mrs. Baldwin, one of you can go to Radiology with Danny, and as soon as we get the results, I'll come speak to you."

"Thanks, Doctor."

"You're welcome."

I wrote my orders on the chart, signed it, then said, "Mary, with me, please; Nancy, Tom will handle things for now."

The three of us left the room and Mary and I went to present to Doctor Williams.

"OK to present the case?" I asked.

"Go ahead."

"Mary?"

"Danny Baldwin, age six; fell from a bunk bed; contusion on the right temple; upon exam, no indications of spinal injury; ibuprofen administered for headache; skull series ordered. If no cranial compromise, monitor for two hours, then release with concussion protocols."

"Very good," Doctor Williams said. "Social Services?"

"In my judgment, not necessary," I said. "No signs of abuse or other injuries. He's well-nourished, communicative, and minus the contusion on his temple, completely healthy. No previous hospital visits and he reports only going to the doctor for his shots and checkups. He's seen a dentist recently as well."

"OK. Continue. If the skull series shows anything, what's your plan?"

"Mary?" I prompted.

"Neuro consult," she replied.

"Just so. Let me have the chart, please."

He scanned it, wrote some notes, signed it, then handed it back.

"Good job, Miss Anderson," Doctor Williams said.

"Thank you."

"Mike, how are you holding up?"

"Tired, but I'm OK. You remember I have four hours off for my gig at Milton Lake, right?"

"Yes. Kylie Baxter is covering for you, right?"

"Yes. She'll be here at noon, and I'll be back by 4:00pm to finish out my shift."

"Off at 1800, so you'll miss all the fun of July 4th!"

"Where 'fun' means dealing with people who would win awards for proving Darwin was right!"

Doctor Williams laughed, "That's one way to look at it! Dismissed!"

Mary and I left the Attendings' office and were immediately stopped by Ellie.

"Can you take an ankle injury?" she asked.

"Yes. We're waiting on x-rays for the failure to fly."

"What is it with boys and bunk beds?" Ellie asked.

"What is it with boys and anything?" Mary asked.

"On that note..." I chuckled.

"Exam 2 is open," Ellie said.

Mary and I went to the triage desk and asked for the chart for the ankle injury.

"Seventeen-year-old female," Nanette said. "Track star out for her morning run, encountered a dog, stumbled, and landed badly. Vitals normal. Ecchymosis and swelling appreciated on exam."

"Thanks," I said, accepting the chart. "Mary, get a wheelchair, please."

She retrieved one and then we went out to the waiting room and walked over to the only teenage girl who was with a woman I suspected was her mother.

"Alicia Sanderson?"

"Yes," she said.

"I'm Doctor Mike and this is Mary, a Sub-Intern. We'll help you into the wheelchair and get you to an exam room and take a look at your ankle."

"I can walk with my arm over a shoulder," she said.

"I'm sure you could, but hospital policy dictates a wheelchair."

"Just do that, honey," her mom said.

She glared at her mom, but didn't object to Mary helping her into the wheelchair.

"Can I come with her?" her mom asked.

"That's up to Alicia," I said.

"She's a minor!" her mom protested.

"Yes, and according to the State of Ohio, at age sixteen, she's entitled to make the decision for herself so long as she's not mentally impaired. You can object to treatment, but if she wants it, generally, we're required to provide it by law."

"How is that possible?" her mom asked.

"Because she's in the ER, by law, we're required to provide an exam and treatment. Alicia?"

"Mom, chill," Alicia said. "I'm fine. Just stay here."

Her mom was clearly unhappy, but absent finding Alicia incompetent to consent to an exam, Alicia had the choice.

"We'll update you as soon as we know more," I said. "Mary, let's go."

We went to Exam 2 and Mary helped Alicia onto the exam table while I washed my hands and put on gloves.

"What happened?" I asked.

"I'm on the track team and run cross-country. I'm training over the Summer, which means running 10K every morning. I was close to the end when a neighbor's stupid little dog ran right under my feet and caused me to stumble. I landed badly and my ankle turned. I thought I was OK at first, but then couldn't put weight on it. My neighbor helped me home and Mom brought me here. How long before I can run again?"

"Let me examine you first," I said. "Once we have a diagnosis, then we'll discuss the next steps and rehabilitation. Are you taking any medications?"

"No."

"Any illegal drugs? Including performance enhancers?"

"Not a chance. They drug test at competitions and I'd be banned."

"Any recent illnesses or hospitalizations?

"No. I don't get sick and this is my first injury beyond a muscle pull about four years ago while playing soccer."

"Same leg?"

"No, the other one. Hamstring."

"Are you allergic to anything?"

"My little brother!" she declared.

I chuckled, "I think my little sister had the same opinion of me growing up. OK to do an exam? I need to listen to your heart and lungs, get your BP, then examine your ankle."

"Sure."

She was wearing a thin, cotton t-shirt, so there was no need to have her remove it or even lift it. I auscultated her heart and lungs, finding everything to be normal, then took her pulse and BP, both of which were low, but which was normal for an athlete who ran long distances.

"Lie back, if you would," I said.

She did as I requested and I checked both ankles, appreciating significant swelling, tenderness, and ecchymosis.

"How bad is your pain?" I asked.

"Scale of one to ten, about a six," she replied.

"We'll need to get an x-ray of your ankle. Is there any chance that you're pregnant?"

"Is that an offer?" she asked with a smirk.

Mary laughed, but I managed to maintain my composure.

"It's a standard question we ask before we order x-rays or medication."

"No. I had my period late last week."

"Then Mary will take you for an x-ray. Would you like some Advil?"

"I took Tylenol at home and it helped some."

"Mary, ice pack for Alicia's ankle, then call Radiology for an ankle series. I'll update her mom."

"Right away, Doctor."

I left the room and went to the waiting room to speak to Mrs. Sanderson.

"Her ankle is likely only sprained," I said. "We're sending her for x-rays to confirm that diagnosis."

"How long will that take to heal?"

"For a mild to moderate sprain, she should be able to walk on it in about two weeks, but it will be around twelve weeks before she can return to running."

"Three months?! School starts before then!"

"I understand. I'll refer you to a sports physiologist who can give you a better idea and provide rehabilitative therapy which can improve the recovery time."

"And if it's broken?"

"Potentially much longer," I replied. "But let's not get ahead of ourselves. My exam and what Alicia said makes me believe it's a Grade 1 or Grade 2 sprain, and those are in line with the recovery period I mentioned before. It will probably be an hour before we know for sure."

"I'd like to sit with her."

"Let me ask, and if she agrees, I'll have a nurse bring you back."

"Thanks, Doctor. Can I ask how old you are?"

"Twenty-six," I replied. "I'm a first-year Resident."

"Is that why you're wearing red, instead of blue like everyone else?"

"No. I'm a surgical Intern assigned to the ER," I replied, using the common public reference to the Emergency Department. "Our surgeons wear red."

"Why are you in the ER not surgery?"

"I'm training to be a trauma surgeon, that is, someone who can perform emergency surgical procedures in the ER. It's a relatively new specialty."

"Too bad you aren't ten years older!" she said.

"I'll take that as a complement, but my wife and daughter might have a problem with that comment!"

"You aren't wearing a ring!"

"We generally avoid jewelry on our hands due to wearing exam gloves. I have my ring on a chain around my neck when I'm working in the ER. Let me go see if Alicia is willing to have you sit with her."

I left the waiting room amused by the fact that I'd basically been hit on by both a mother and daughter. I went into the exam room and asked Alicia about her mom and she relented, so I left and asked Ellie to send a nurse to bring Mrs. Sanderson to Exam 2.

"Doctor Mike?" Tom called out.

"Yes?"

"X-rays for our failure to fly are negative for skull fracture."

"Good. How is your patient?"

"No signs of impairment and no complaints other than his headache, though the ibuprofen has made it hurt less, according to him."

"OK. Let's update his parents and we'll monitor him for two hours, I'll have a nurse take vitals every twenty minutes, and then we'll discharge him."

We went into the trauma room and I explained the x-ray results to Danny's parents, and that we'd keep him under observation for two hours. Once they were satisfied, I asked Ellie to have a nurse take Danny's vitals, then went to the lounge to get a cup of coffee. I filled a mug, sat down, and had just taken my first sip when Ellie came to the door.

"EMS four minutes out with a twelve-year-old with a hand injury," Ellie said.

"Fireworks?"

"Firecracker exploded in his hand."

"Wonderful. Did they say how bad?"

"All his digits are still attached, but I don't know more."

"OK. Mary, get Tom and meet me in the ambulance bay. Ellie, who's my nurse?"

"Me, if you'll have me!" she said with a twinkle in her eye. "I need to see two patients a day to keep up with my license requirements."

Of course, she'd put just enough emphasis on 'have' to make it a double entendre, but I let it go as occasional teasing was OK, so long as she wasn't actively trying to seduce me. I took a sip of coffee, put the mug down, knowing it would be cold before I returned, then headed to the ambulance bay, putting on a gown and gloves on the way.

"You totally didn't react to the girl with the sprained ankle hitting on you," Mary said.

"Not the first time I've been flirted with by a patient, or a mom."

Mary laughed, "No way!"

"She asked how old I was and said it was too bad I wasn't ten years older."

"Mother-daughter fantasy?" Mary teased.

"Not anywhere on my list," I replied. "There's a lesson, though, and that is that you need to be stoic in those instances."

"Sorry. I guess I shouldn't have laughed."

"What did I miss?" Tom asked.

"An object lesson," I said. "When I asked a seventeen-year-old female patient if she might be pregnant before I ordered x-rays, she asked if it was an offer. Mary laughed, which she shouldn't have. I simply ignored the obvious flirtation and replied that it was a standard question before x-rays.

"You both will be hit on or flirted with by patients at some point, and you need to be very careful how you respond in those circumstances. What you don't want to do is encourage them, or turn the exam into something that borders on sexuality, or worse, is blatantly sexual."

"I heard you dated a patient," Mary countered.

"After she was no longer a patient," I replied. "I kept the exam completely formal, and she approached me later, after discharge. It's a fine line, I admit, but the key is to keep the exams professional and to not get involved with a patient while they're a patient. And, it's better if they're the one who approaches you after the fact. It's not a violation of policy to become involved after, but if you were, for example, to get their phone number from their records, that's an ethics violation."

"Can I ask a question about that?" Tom inquired.

"Sure."

"How did you handle your OB rotation? I know what they said in Practice of Medicine, but I'm not sure I can simply convince myself that it's 'just anatomy'."

"I had similar concerns," I replied. "And I was very uncomfortable the first time I observed a Foley catheterization of a teenage female. I know this might sound bad, but in the end, it literally is just anatomy and you don't really notice. And, to be honest, I was actually more uncomfortable the first time I handled a penis other than my own. That was WAY stranger and FAR more uncomfortable than seeing female anatomy."

"Uh, yeah," Tom said. "I can see that."

"What is it with guys being so freaked out about that?" Mary asked.

"Honestly?" I replied. "It's probably the social taboo and the fact that teens equate ANY contact like that to be 'gay' and are merciless in their harassment of gay males."

"Men are wimps," Ellie declared mirthfully. "But Mike does have a point, and I think he's probably right. As for being uncomfortable, I think everyone is, at least at first. You either get past it, or you find another profession. Sure, you can find a specialty where it's rare that you would do those things, but you can't graduate from med school without learning those procedures."

The ambulance pulled into the driveway and came to a stop in front of us. The paramedic jumped out and gave the vitals, and described a wound which included burns and minor evulsion.

"Hi, Timmy," I said as we wheeled the patient to Trauma 4. "I'm Doctor Mike. How is your hand?"

"It hurts!"

"What happened?"

"I lit a firecracker, and it exploded before I threw it."

I performed the exam, and after irrigating the hand, I decided to call for a plastic surgeon to examine Timmy's hand. He arrived about ten minutes later, and after conferring, we agreed he'd take Timmy on his service. I went back to the lounge, emptied the cold coffee from my mug, refilled it, then went to use the phone in one of the consultation rooms to call Tom Kirkland, the attorney who was handling Angie's complaint to the State Medical Licensing Board.

"What specifically, do you think he did wrong?" Mr. Kirkland asked after some basic preliminary questions about my relationship with Angie.

"When Angie decided she was going to do whatever was necessary to get to a point where we could marry, she was thinking about the future, outside the moment, had made a plan, and was successfully executing it. That is absolutely not a sign of someone who is suffering from full-blown schizophrenia and is a strong indication that something has changed. In my opinion, Doctor Greenberg ignored that, and that is where the malpractice claim arises."

"You're asserting that she showed signs of recovery and he purposefully and intentionally ignored them?"

"I am, and I'm willing to testify to that."

"You understand what that might mean, right?"

"I do. And I'm willing to take that risk."

"Good. I'll be in touch soon."

"What do you think the chances are?"

"Of a reprimand? Very high. If what you said is accurate, and I have no reason to believe it's not, there's actually a chance of a suspension or revocation of his license. Not a good one, but a chance."

"That's all I'm asking."

XIV. A Long Shift Finally Ends

July 4, 1989, McKinley, Ohio

I had just enough time to finish my phone call and coffee before the x-ray results were back for Alicia Sanderson's ankle.

"I'd call this a Grade 2 sprain," I said, looking at the x-rays with Doctor Williams on the light panel in the Attendings' office. "That was the radiologist's assessment as well."

"Then it's unanimous," Doctor Williams said. "Treatment plan?"

"Wrap in an Ace bandage, crutches, rest with the ankle elevated, ice as necessary, Tylenol or Advil for pain, and a referral to a sports physiologist in the medical building next door for follow-up."

"Make it happen."

I took the x-rays from the viewer, then Tom, Mary, and I left the Attendings' office and went back to the exam room to discuss the results with Alicia and her mom. In the exam room, I put the x-rays on the light panel and turned it on, then explained what we'd found.

"Long-term, it should heal completely with no permanent impairment," I said. "I'm going to refer you to Doctor Jeong Kim, a sports physiologist. You should call his office today and make an appointment for Friday. Until then, rest, keep your ankle elevated, use ice to bring down the swelling, and take Tylenol or Advil for the pain. We'll give you crutches, and you can put no weight on your ankle at all until you're cleared by Doctor Kim to do so."

"When can I run?" she asked.

"Typically, about twelve weeks, but Doctor Kim will discuss that with you after he examines you, and he'll recommend a proper course of rehabilitation. It's very important you follow my instructions, and his, so you don't do any permanent damage to your ankle."

"That stupid dog!" Alicia growled.

"Tom, would you get me an Ace bandage, please?" I asked. "Then get a set of crutches. Alicia is tall, so she'll need the larger size."

He went to the supply cabinet and took out a package with an Ace bandage, opened it, and handed me the bandage, then left to get the crutches.

"OK to wrap your ankle?" I asked.

"Yes," she replied.

I wrapped the Ace bandage tightly around her ankle, using a clip to attach the loose end to the layer below it.

"Leave this on until you see Doctor Kim," I said. "I take it you haven't used crutches before?"

"No."

"Then let me explain. Mrs. Sanderson, you could go to Patient Services while we do this."

"OK," she agreed.

I gave her the discharge papers, and she left. I went through the proper usage of crutches, and when Tom returned, Mary and I helped Alicia practice until she had the hang of moving with them.

"You'll need to sit in the wheelchair," I said. "Policy again."

Alicia rolled her eyes and Mary helped her from the table into the chair, and set the crutches next to her.

"Tom will wheel you out," I said. "Good luck with your rehab."

"Thanks! You have a really soft touch!"

"Thank you," I said. "Tom?"

He wheeled her out and as soon as they were in Patient Services and out of earshot, Mary laughed.

"And just what exactly did she want you to touch?"

"Whatever it was, if I did that, it would result in me dying somewhere between climbing out of my Mustang in my driveway and the front porch of my house!"

"Mike?" Ellie called out. "Doctor Gabriel needs you in Trauma 1."

Tom, Mary, and I went to Trauma 1.

"You asked for me?"

"Probable surgical case. Rafiq is in Trauma 2. Can you do the consult?"

"Yes."

The ultrasound was set up, as he had used it for his assessment. I immediately saw fluid in Morison's, and said so.

"Let me call upstairs," I said.

I called the scheduling nurse and let her know, then Mary and I took the patient up to the OR, but given how busy we were in the ED, there was no way we could scrub in.

"Bummer," Mary said as we returned to the elevator.

"You'll get your chance," I replied. "I felt the same way, by the way. Always ready for more."

"It's your fault! You let me manage two cases and that made me want more!"

"It is addictive," I replied. "Or like Lay's chips -- nobody can eat just one! Remember how concerned you were with missing the toddler with croup?"

"Yes, and obviously you didn't hold it against me."

"You accepted correction and committed not to making the same mistake a second time. That's all we can ask. You weren't given a chance to do any procedures in June?"

"Sutures only," she replied. "I was mostly with Doctor Townsend and Doctor Lewis, and they did everything."

"When you do your evaluation, make sure you note that. There won't be any negatives, and it will help Doctor Gibbs know how to help them."

"I was warned to not say anything seriously negative on evaluations."

"I was never given that advice, and I certainly wouldn't have followed it! Simply be truthful and honest. I want feedback, and if I'm doing something that interferes with your training, I want to know about it, and Doctor Gibbs should absolutely know about it."

"At the risk of you making my life hell because I sound ungrateful, I'd say more procedures!"

"As Doctor Williams said to me earlier, it's not news that med students want more procedures! I'm totally with you on that, and I'll do my best, though the rules are pretty strict about when I can let you handle things. Other times, it's a judgment call."

"Cute teenage girls?"

I laughed, "I did notice, but that wasn't a consideration. It was that I hadn't seen any sprains or fractures in your procedure book, so I felt you should watch one before I ask you to do one or teach one."

"I had seen them, but never had a chance to do anything."

"Next one, then," I said. "How are you on x-rays?"

"Other than the Preceptorship in Radiology and the plates we saw in class, I haven't had a chance."

"Then next set of x-rays, I'll have you look at them before I say anything to see how much you can discern. You notice I took them to Doctor Gabriel before I spoke to the patient, right?"

"Yes. Is that required?"

"In the sense that we're supposed to go to our Attending with anything beyond our comfort level, yes. I haven't seen enough films to be confident in my diagnosis, though I could rely on the radiologist if I elected to do so. I'd rather confirm the finding with my Attending, because every doctor makes mistakes or misses something, and that's as true of radiology as any other service."

We reached the ED and Ellie directed me to triage again.

"Fifteen-year-old male; line drive to the chest during a Little League game; large contusion just over the right nipple; vitals normal."

I accepted the chart and asked Mary to find Tom and meet me in Exam 2, which I saw was open on the board. She walked back into the ED and I went to the door of the waiting room.

"Nick Smith?" I called out.

"Me," a boy in a baseball uniform called out.

I went over to him and introduced myself.

"Is this your dad?"

"My coach," he said.

"Coach Nichols," he said. "I was concerned about the line drive, so I brought him in. I heard about an incident in Cincinnati last year where a kid died after a similar incident."

"You were wise to bring him in. There's a rare condition called comotio cordis that can occur with a blow to the chest at a specific point in the heart rhythm. Let's go back and I'll do an exam. Have you notified his parents?"

"They both work," Nick said.

"Then we'll call them once we check you out. Your coach can come back with you if you want."

"Yeah," he agreed.

The three of us went to the exam room where Tom and Mary were waiting. I introduced them, then went to the sink to wash my hands.

"Tom, history, please."

He completed the history, and then I did the physical exam.

"Everything appears to be OK," I said. "The bruise is pretty nasty, but I don't believe there are any other injuries. I do want to get an EKG just to be sure. If you'd take your jersey off, Mary will attach the leads."

Five minutes later, with a perfectly clean EKG, I was confident Nick was fine.

"You're good to go," I said. "Ice and either Tylenol or Advil for pain."

"Can I play?"

"As long as you're comfortable," I said. "Let me speak to my supervisor and we'll discharge you. Coach, you can use the phone there to call his parents."

Tom, Mary, and I went to find Doctor Williams, and I had Tom present the case.

"No x-rays?" Doctor Williams asked Tom.

"Uhm, Doctor Mike didn't think we needed them."

"And what do you think?"

"Well, he did a physical exam and ran an EKG and didn't find any signs of injury beyond the bruise."

"And what would we do for a broken rib?" Doctor Williams asked.

"Unless a lung or other organ was compromised, monitor and refer to his physician."

"And there were no signs of breathing trouble?"

"I didn't listen, but Doctor Mike said his lungs were clear."

"So, about the x-ray?"

"I don't think it's necessary because it basically wouldn't matter."

"Correct. Good report, Mr. Lawson. May I have the chart, please?"

Tom handed Doctor Williams the chart, and Doctor Williams returned it after making notes and signing it. We returned to the exam room and let Nick and his coach know they were OK to leave, and to return if Nick had any breathing problems or an irregular heartbeat.

"I wasn't sure what to say to Doctor Williams," Tom said after Nick and his coach had left.

"Never be afraid to say that you don't know," I counseled. "I get asked those same questions, only I'm expected to have the complete answer, not need to have it drawn out by questions. But you're a Third Year in your first clinical rotation, so you did fine. Eighteen months from now, you'd be expected to give the same answer, just complete in response to the initial question."

"You had questions like that?"

"All the time. And there were times when I had to say that I didn't know. What I figured out early on is that you have to ask to be taught and you need to be both curious and proactive. Every Resident is different, and you'll find good teachers and ones that aren't good teachers. Your job is to figure out how to learn in both cases."

"How? I mean, if the teacher is bad, how can the student learn?"

"By observing and generally making a nuisance of themselves with questions. If the Resident refuses to answer, you go to your Attending or your advisor at the medical school and let them handle it. But mostly, you should find a way. That's what I did when I had suboptimal teachers. They were good doctors, mind you, just poor teachers. Sometimes you have to go to someone else, and generally nobody will complain about you doing that."

"Is there any way to choose our Residents?" Tom asked.

"Not really," I replied. "And if you truly don't get along with your Resident, it's incumbent on you to find a way to get through the rotation. After all, you can't expect to like every doctor and no doctor is liked by everyone."

"Even you?" Mary asked, with a twinkle in her eye.

"Especially me! I am, as a number of Attendings and Residents will attest, a pain in the ass."

"But you graduated first in your class!" Tom protested.

"Which has nothing to do with not being a pain in the ass! Part of it is what I said before - make a nuisance of yourself, if necessary, to learn. I sure did. Most of the time, it showed the Resident or Attending how serious I was; other times, it simply pissed them off. I've had Residents do thing which might be considered retaliatory or punitive and my response was to grin and bear it."

"Like what, if you can say?" Mary asked.

"A Resident who decided he didn't like me and assigned me shifts that knowingly conflicted with church attendance and only assigned me every single bit of scut available."

"That's not right."

"No, it's not, but I won the battle by not letting it faze me or affect my attitude. In fact, it actually ensured I was the cheeriest I'd been on any Third Year rotation!"

"An interesting way to get revenge," Tom said.

"Indeed. That Resident was more perturbed that I wasn't upset than I was perturbed by the hazing. That is how you deal with the BS."

"Mike?" Ellie called out. "Doctor Williams would like to see you."

The three of us went to his office.

"Your neuro consult gorked," Doctor Williams said. "Expect to be called in front of the M & M a week from Friday."

"Thanks for letting me know," I said.

We left his office and went to the lounge, got a bottle of water, then I basically collapsed onto the couch. I'd been on for twenty-nine hours and had no sleep, and I could feel it. I wondered how I'd get through the concert, let alone the two or three hours afterwards.

"What happens now?" Tom asked.

"You mean the M & M? Have you been to one?"

"No."

"You should attend as many as possible, even coming in if you aren't on shift. If you are, ask for permission to go. It'll usually be granted. You, too, Mary."

"I've been to a couple," she replied.

"Good. The answer to your question, Tom, is that it's a question-and-answer period about interesting or difficult, or, in this case, cases with bad outcomes. What will happen is I'll present the case, then answer questions from other doctors about the management of the case. They'll critique my handling of it, give advice, and try to find the root cause of the problem."

"Why don't you seem nervous?" he asked.

"First, it's not adversarial, but second, think about what I did."

He was quiet and shook his head.

"I insisted Doctor Mastriano write her order on the chart," I said.

"Whoa! That was self-defense?"

"Very much so. In my opinion, she was wrong, so I made her put it in writing. She'll be roasted at the M & M, even though it's not adversarial."

"Roasted how?" Tom asked.

"For sleeping," Mary interjected. "She was more interested in not being disturbed than spending five minutes examining the patient."

"That about sums it up," I said.

"Mike?" Ellie said from the door to the lounge, "Doctor Williams needs you. EMS is three minutes out with a young drowning victim."

"Lord have mercy," I said aloud. "Be right there, Ellie."

"Survival rate?" Tom asked as I got up.

"During the Summer? Near zero if not revived at the scene. During Winter, one in four due to the effects of hypothermia."

We hurried to the ambulance bay, grabbing gowns and gloves on the way.

"EMS is performing CPR en route," Doctor Williams said, conveying that anything we did was likely going to be futile.

"Intubation and EKG?" I asked.

"Yes. Is your student ready for that?"

That question reinforced what I'd surmised.

"Mary is capable," I replied. "I'll guide her."

"Good," Doctor Williams said. "Tom, EKG and monitor."

"Yes, Doctor."

"Mary, tell me the steps for intubation, please," I said.

She took a deep breath, let it out, then said, "Select the correct endotracheal tube based on the patient's physiology, then gently open the patient's mouth, insert the laryngoscope blade, and slide down right side of mouth until the tonsils are visible. Move the blade to push the tongue centrally until the uvula is visible. Next, advance over the base of the tongue until the epiglottis is seen.

"At that point, advance steadily until the tip of the blade is at the vallecula and the epiglottis is visible below it. Lift gently forward and upward to raise the epiglottis and reveal the arytenoid cartilages and vocal cords. Once the cords are visible, insert the tube in the groove of the laryngoscope so that the cuff passes the vocal cords. Once the tip of the tube is at the glottis, remove the stylet and gently advance until the cuff is past the vocal cords. Inflate the cuff to protect the airway from secretions and form a seal around the tube. Then confirm placement."

"Textbook answer, almost word for word," I said. "How do you confirm placement?"

"With a ventilator or bag at one breath every five or six seconds, checking for chest movement and bilateral breath sounds."

"Correct. And if you don't hear them?"

"Reposition the tube, usually withdrawing slightly, unless no sounds are heard, in which case you remove the tube and begin again.

"Good. Do exactly that. Remember, slow and smooth is the fastest way, even though is sounds contradictory."

"Because it's more important to get it right than to be fast and get it wrong."

"Exactly. Thirty seconds sounds like a short amount of time, but it's really a long time in the scheme of things. Again, I know that sounds contradictory, but it's true. If the patient is conscious, what drugs?"

"How old?" she asked.

"Around ten," Doctor Williams said as the Fire Department EMS squad pulled into the driveway.

"For adults, it's weight based," she said. "For a ten-year-old, there's a set dose in my book."

"Look it up now," I said.

She did as the squad came to a stop.

"Ten-year-old male found floating in a pool; unresponsive and not breathing; no vitals; CPR performed after recovery."

I was positive the boy was dead, but that didn't mean we wouldn't try.

"Trauma 1!" Doctor Williams ordered. "How long down?"

"At least twenty minutes," the paramedic said as we rushed the gurney with a firefighter performing CPR while the other paramedic bagged him.

In the room, the six of us quickly moved him to the treatment table and Nurse Amelia took over bagging while I relieved the fireman who was performing chest compressions.

"Intubation kit to Mary!" Doctor Williams ordered. "Mike, stop compressions."

I did as Nurse Jenny brought the kit to Mary, who picked up the laryngoscope and the pediatric endotracheal tube.

"No heart sounds," Doctor Williams announced. "Mike, resume compressions. Jenny, stat pH!"

Tom worked around me to get the EKG leads attached, Amelia got an IV into the boy's arm, and Jenny drew blood for the pH test. As they did that, I watched as Mary used the correct technique to get the tube inserted.

"I'm in!" she said.

"Connect the vent and set it to ten per minute," I said. "Once it's on, I'll stop compressions so Doctor Williams can listen."

"Asystole," Doctor Williams declared. "An amp of epi down the tube, please."

Nurse Amelia squirted the contents of a pre-prepared syringe into the tube, then Mary connected the vent to the tube. I stopped compressions, and Doctor Williams listened.

"Good breath sounds, resume compressions."

We tried for another ten minutes, and couldn't get even a blip on the EKG, nor any heart sounds, and the pH test showed a level incompatible with life.

"Stop compressions, Mike," Doctor Williams said, then listened one last time. "Time of death 11:44."

"Lord have mercy," I said.

"Is there nothing else we can do?" Mary asked.

"No," Doctor Williams said. "After two doses of epi, continual CPR, and a dose of bicarb, his pH level is so low that even if we could get his heart started, he'd be in multiple organ failure. If he was in the water for more than five minutes, he'd have severe brain damage. He was likely dead when the paramedics got to him."

"I'll get the death kit," Amelia said.

"Tom, Mary, have you seen a death kit routine?" I asked.

"No," they both said.

"Then stay and watch. I'm going to go shower and change and Kylie Baxter will be your Resident for the next four hours."

They acknowledged me and went out into the corridor. Kylie came up about two minutes later.

"You look like shit," she said.

"We just lost a ten-year-old drowning victim. Mary Anderson and Tom Lawson are with Amelia in Trauma 1 to witness their first death kit."

"What a shitty way to end the morning."

"Yeah. I'm going to shower, change, and head to the lake. We don't have any patients on the board at the moment, so go see Doctor Williams."

"See you in about four hours," she said.

"Thanks."

I let Ellie know I was leaving, went up to the surgical locker room, showered, dressed, and then headed out to my car for the drive to the lake. I met Kris and Rachel near the band shell, as we'd planned.

"Dada!" Rachel exclaimed happily when she saw me.

I took her from Kris, hugged Kris with one arm and we exchanged a quick kiss.

"How are you doing, Mike?" Kris asked.

"I'm beat," I replied. "And down."

"Bad?"

"Ten-year-old drowning victim didn't make it. That was right before I left."

"Lord have mercy!"

"Yeah," I replied.

"Do you have time to eat with us?"

"Yes."

The three of us sat on a blanket not far from the band shell and quickly ate a picnic lunch before I and the other band members met in the small room set aside for us.

"You look beat, Mike," José said.

"I think I feel worse than I look," I replied. "No sleep since about 5:00am yesterday."

"That's just crazy!"

"Yeah, and I'm also on an adrenaline low because we had a bad trauma right before I left. Ten-year-old boy drowned."

"Damn," he said.

"Yeah."

"How many patients have you seen since your shift started?" Sticks asked.

"I have no clue," I replied. "If I stop and think about it, I could probably count, but I don't keep track. I was constantly busy from 0600 yesterday until I left about forty minutes ago."

"Are you up for playing your signature song?" Kim asked.

"I don't know," I replied. "All I can do is hope my autopilot works."

Fortunately, it did, and I got through the concert with only a few mistakes, but nothing too terrible. When we finished, Kris and Rachel came to see me, I kissed and hugged them, then headed back to the hospital, feeling more tired than I'd ever felt in my life.

"You OK, Mike?" Kylie asked when she saw me. "I can stay."

"No. Go get your nap before your next shift starts. I'll gut out the last two hours. Anything on the board?"

"Badly torn ACL waiting on Ortho. The films are pretty clear, but you know the rules."

"I do. See you in two hours."

She headed for the Internal Medicine on-call room, which would otherwise be empty during the day so she could nap undisturbed, and I went to find Tom and Mary.

"How did it go?" Tom asked.

"I fumbled through a couple of songs, but otherwise, OK. How long did Ortho say they'd be on the consult?"

"At least another thirty minutes," Mary said. "They only have one Resident in the hospital and she's busy."

"Did Doctor Baxter provide any pain medication?"

"Oxycodone PO, after consulting with Doctor Williams."

I nodded, "Necessary for any Schedule II or III drugs. Patient details?"

"Male, forty-nine, playing touch football with his buddies at the lake."

"He's going to regret that," I replied.

"Not as much as he's regretting his wife's reaction. She's all over his case about 'behaving like a kid' when he's 'old enough to know better'."

"Maybe give her a sedative?" I suggested.

Mary laughed, "She's the classic shrew, and I'm saying that as a woman. She annoys me, and I usually agree that guys exercise poor judgment."

"I'm a guy and I agree with that! Hang around the ED enough and you'll see all the evidence you need!"

"Sorry to change the subject," Tom said, "but what electives did you take?"

"I doubled emergency medicine, plus surgery, cardiology, ICU, and pathology."

"Pathology? Why?"

"As Doctor Roth put it, where else can a medical student or intern handle a scalpel every single shift? It was good practice, both in terms of using surgical tools as well as honing my diagnostic skills. I would recommend against the ICU because I was bored to tears. There are basically no procedures, just monitoring, admissions, and transfers. I had thought it would be interesting, but it wasn't."

"What would you have done instead?"

"Probably internal medicine," I replied. "My other option would have been pediatrics. I didn't feel OB was necessary because I was allowed to do normal Fourth Year stuff during my Clerkship."

"How?"

"By being totally prepared, knowing my stuff, and asking. Remember that last one. Show you know your stuff and ask. You'll get plenty of negative responses, but all it takes is one positive one. Another good option would be the Free Clinic, especially if you're going into private practice, as you'll see the same kinds of urgent, but not emergent, cases."

"Why doesn't the hospital set up something like that and direct patients who don't need emergency treatment there?" Tom asked.

"Mary?" I prompted.

"It's illegal to direct someone away from the ED without first giving them an exam and providing stabilizing treatment. The hospital attorney who spoke to us made it clear that even a sign encouraging people to use a clinic could be a violation."

"Seriously?" Tom asked.

"Seriously," she said. "It might be OK to put up a sign that had comparable wait times, but you can't actively encourage them to leave without risking an EMTALA violation."

"Which is why we're seeing an increase in patient presentations in the ED," I said. "We can't ask about the ability to pay because EMTALA says that doesn't matter. There's a debate about whether we can ask for insurance information, which we might be able to, so long as no weight is assigned to insurance or lack of insurance during triage and initial treatment. And it's all speculative at the moment because we're still waiting on the final rule from HHS. But the attorneys insisted we create a policy first, so it's in place when the rule is promulgated."

"Mike?" Ellie said from the door to the lounge. "Do you have time to take a severe sunburn?"

"With this pasty skin, that's about two minutes without sunscreen for me!"

Ellie laughed, "We northern European types burn to a crisp!"

"In the waiting room?"

"Yes. Exam 6 is free."

"We'll handle it, thanks. Mary, go fetch our patient, please. I'm going to use the facilities and I'll meet you in the treatment room. Tom, go with her. Mary, start a chart with history, please."

They left, and I went into the bathroom, emptied my bladder, washed my hands, then washed my face. Once I finished, I went to Exam 6 where Mary was speaking with a teenage girl who on first glance had second-degree sunburn.

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

"Cindy Sundstrom, sixteen," Mary said. "Fell asleep in the sun at Lake Milton."

"Continue your H & P, please," I instructed.

There was nothing remarkable about the young woman's history, and her vitals were slightly out of range, with her pulse at 90 and her BP at 90/60.

"What do you want to do?" I asked Mary.

"IV Ringer's for dehydration, aloe gel, and NSAID for discomfort."

I nodded, "Good plan. Advise your patient."

"Cindy, you're dehydrated, and drinking water won't resolve that as quickly as we would like, so we're going to give you an IV with something called Ringer's Lactate, which will ensure your electrolytes are in balance. We'll also apply aloe gel to your sunburn, and we can give you some ibuprofen to help with the pain."

"Do I really need an IV?" she asked.

Mary looked to me and I nodded, then I said, "Yes, you do. We could try giving you oral electrolytes, but they aren't as effective. Your sunburn is severe, with some blistering, and it covers most of your front, except where your bikini covers you. That can be dangerous, though not life-threatening. Are your parents here?"

"No. They're in Toledo until late tonight. I was with friends."

"Do you have someone to stay with you at home until your parents arrive?"

She smirked, "My boyfriend, but I don't think my dad would approve."

"Being a dad, I suspect you're right, though my daughter is only two. What about another friend?"

"Yes, my best friend. She's in the waiting room with my boyfriend."

"Mary, complete your physical carefully, then treat as you proposed."

Cindy winced when Mary listened to her heart, which Mary reported sounded fine. I needed to confirm, so I did a repeat auscultation and confirmed no problems. Fifteen minutes later, Nurse Jackie came in to apply the aloe, and once that was complete and the entire liter of IV fluid had run in, we discharged Cindy to her friend and boyfriend, with instructions to come back if she felt sick, her skin turned purple, or she was in intense pain, and to see her doctor on Thursday for follow-up.

"She's going to be a hurting puppy," Mary said when we returned to the lounge. "At what point would you admit a patient?"

"She was close," I said. "But her vitals weren't totally out of whack and she had no signs of edema, no nausea, and no coronary or pulmonary compromise. Also, her face wasn't burned because of her hat. She also urinated, which was a positive sign as well. Absent that, I might have kept her longer."

"So it's a judgment call?" Tom asked.

I nodded, "As is just about everything we do except things which can be absolutely confirmed by specific tests. We use differential diagnosis to narrow down the possibilities, then make a judgment call as to the likely cause of the collection of symptoms we've observed. But the most obvious answer may not be correct."

"So what do you do?"

"As much as you can to narrow down the diagnosis, then decide your best options. You've heard the saying 'medicine is an art, not a science', I'm sure."

"Yes."

"It's partly true," I replied. "There is a lot of science, but there is also an art to successful diagnostic skills. That's especially true when clusters of symptoms point in very different directions. Sometimes you go with the most likely answer simply because you don't know and can't prove it's NOT the most likely thing. The key is to avoid taking any actions that might be adverse if you're wrong.

"You can't always do that, but that is the best approach. Something like 95% of the cases you see will have fairly obvious, correct diagnoses. The other 5% will be a mix of difficult diagnoses or cases where the obvious answer is wrong because the correct answer is statistically rare. It's those 5% that are candidates for Morbidity and Mortality conferences.

"A good example is the UTI versus STD diagnosis. We acted as if it was a UTI because that was our best evidence. But, and this is super important -- patients lie. While not suggesting this is the case, the young woman could have cheated on her boyfriend, or been more promiscuous than she reported. If she'd reported a dozen partners, what would I have done differently?"

"Assumed it was probably an STD, right?"

"I'd have leaned more that way, yes. Mary, why would I not have assumed?"

"Because multiple partners means an increased risk for UTIs, along with HPV."

"Exactly. My counsel for her for no intimate relations had a double purpose. Mary?"

"Both to wait for the UTI to clear, but also to limit the chance she'd spread an STD."

"And remember, this isn't judgment about her behavior, simply about the risks associated with having multiple sex partners."

The phone on the wall rang and Tom answered it and said it was Doctor Taylor calling for me.

"Hi, Vince," I said. "What's up?"

"I spoke to Cutter. He'll speak to Northrup. Anything Mastriano adds to your file will be removed once Northrup speaks to her."

"Thanks."

"You're cleared completely."

"Thanks again."

I hung up, then went to sit down.

"Everything OK?" Mary asked.

"It appears so..."

"Mike," Ellie interrupted from the door of the lounge. "No rest for the weary! Four-year-old with a bee sting being brought in by EMS. Anaphylactic reaction, treated by epinephrine autoinjector. Trauma 2 is open. Three minutes.

"Thanks, Ellie."

Tom, Mary, and I got up, left the lounge, put on gowns and gloves, and headed to the ambulance by.

"Treatment plan?" I asked Tom.

"Uhm, mainly supportive for anaphylaxis," he said. "ABC, then monitor, with IV antihistamine if warranted, and albuterol via inhaler if needed."

"Very good. EKG?"

"I'm not sure."

"Only if indicated by tachycardia or signs of tamponade, or severe pulmonary distress. Just the pulse oximeter unless I say otherwise. Mary, be prepared to intubate, but I don't expect you to need to, given someone had an EpiPen handy."

"Those things are lifesavers," she said. "A friend of mine college had one, and it saved her life after she accidentally ate strawberry jam."

"EMS has started carrying them as a regular part of their drug box, and it's made surviving severe allergic reactions much more common," I said. "I think every school nurse should have them, along with every cop. I think the same is true for naloxone, which the paramedics carry, but currently there is no approval for untrained people to administer it."

"That's the OD drug, right?" Tom asked.

"Yes. It's also called Narcan, which is the name you've probably heard. It's fast acting and can reverse the effects of opioids within minutes."

The EMS squad turned into the driveway and pulled up.

"John Tyler, four, stung by a bee; parents administered EpiPen almost immediately; pulse 110; BP 130/80; resps good at eighteen; PO₂ 99% on nasal canula; GCS 15. Mom is in the squad with him."

"Trauma 2!" I said.

They unloaded John, I introduced myself, and we took him to Trauma 2 where five of us moved him to the trauma table as his mom came into the room.

"How are you feeling, Josh?" I asked.

"My arm hurts where the bee stung me," he said. "But mom shot me, so I didn't die!"

"Where did you inject the EpiPen?" I asked his mom.

"Right thigh."

"Josh, I need to listen to your heart and lungs, then my friend Tom here will remove the stinger and wash your arm. OK?"

"Yes."

Other than his fast pulse and slightly high blood pressure, both of which were likely related to the epinephrine injection, he was in very good shape. Once I finished the exam, Tom used topical anesthetic, then removed the stinger with a pair of tweezers, irrigated the small puncture with saline, then put a dab of triple antibiotic on it before covering it with a small bandage.

"You can take Josh home," I said to his mom. "He's in no danger, but I'm going to give you an emergency inhaler with albuterol in case he has any breathing trouble. Two pumps is sufficient, and then call 9–1–1. I doubt you'll need it, but I just want to be safe."

"Can I still see the fireworks?" he asked.

"That's up to your mom," I said.

"Is it OK, Doctor?" she asked.

"There's no medical reason he can't go, though please don't let him run around, and absolutely avoid bees. Do you have a second EpiPen?"

"No."

"OK. We'll get you one of those as well. You should follow up with Josh's doctor just to let him know what happened. He can call here for the treatment records, and he may or may not want to see Josh."

"Thanks, Doctor."

"You're welcome. Give me about ten minutes to fill out the paperwork and we'll have you on your way with the inhaler and a new EpiPen."

"Thanks again."

Tom, Mary, and I left and went to the nurses' station where I filled out the appropriate forms, updated the chart, and then went to Doctor Williams to sign off, which he did. That completed, I retrieved the albuterol inhaler and EpiPen from the drug room and took them to Mrs. Tyler.

"Any other questions?" I asked.

"No. Thank you very much, Doctor."

"You're welcome!" I replied, then turned to Josh and asked, "What's your favorite candy?"

"M&Ms!" he declared.

I pulled a small packet from my fanny pack and handed them to him.

"Only when your mom says it's OK to eat them."

Mrs. Tyler laughed, "Go ahead, Josh. And what do you say?"

"THANK YOU!" he exclaimed, the ripped open the pack and began munching M&Ms.

"You can stop by Patient Services on your way out," I said.

"Thanks again," she said.

Tom escorted them to Patient Services, and I went back to the lounge where Kylie was waiting.

"I am out of here," I said. "So are Tom and Mary. Nothing on the board. We just discharged a bee sting."

I left the lounge, let Ellie, who was also going off shift, know I was leaving, and she walked with me towards the locker room.

"I'm upstairs," I said.

"Bummer!" Ellie exclaimed. "See you later in the week."

"See you then."

I walked upstairs, showered, dressed, then left the hospital, got in my car, and headed home.

XV. A Wise Man Listens to Those With Knowledge and Experience

July 4, 1989, Circleville, Ohio

"DADA!" Rachel exclaimed when I walked into the house, dead tired after having been awake for over thirty-seven hours.

I scooped her up, hugged her, kissed her cheek, then carried her over to Kris.

"How are you feeling, Mike?" Kris asked after we exchanged a quick kiss.

"Beat," I said. "Dinner, then bed."

"It'll be ready in five minutes," Kris said. "Come to the kitchen with me, please."

I followed her to the kitchen with Rachel in my arms.

"Was your afternoon better than your morning?" Kris asked.

"Nobody I was caring for died, so I think the answer is yes. Middle-age man with a torn ACL, teenage girl with a severe sunburn, four-year-old with a bee sting, and an offer to shower with a nurse."

"You'll need a trauma surgeon if you did that!" Kris declared.

"Something I understand quite well! It was Ellie."

"Does she ever quit?"

"Apparently not! But I used the surgical locker room, not the one in the Emergency Department."

"Did you get to see Clarissa at all?"

"No. Our breakfast, lunch, and dinner breaks didn't line up at all. We'll try for Thursday or Friday. Saturday is a bit easier because she can match her break to mine."

"How are your students?"

"Pretty good, but this is the first rotation for the Third Years and the first Sub-Internship for the Fourth Years, so I have to do the normal teaching plus the orientation stuff."

"But didn't they start in June?"

"Yes, but they were with Doctor Mastriano and she's not a very good teacher. I had a run-in with her about a patient; actually, a few patients. She wrote me up, but it'll be removed from my file and she's likely to be called on the carpet at a Morbidity & Mortality Conference because a patient gorked when she refused to allow me to call a neuro consult."

"Gorked?"

"Sorry. Suffered brain damage which is very likely irreversible. If you're OK with it, I can explain more tomorrow after I sleep."

"Yes, of course! Let me get dinner on the table. Put Rachel in her High Chair, please."

"NO!" Rachel declared forcefully. "DADA HOLD RACHEL!"

"Her Majesty, the Tsarina of All Russians, has spoken!" I chuckled. "I think I can manage the stew and bread one-handed. If she eats after we do, that's fine with me if it's OK with you."

"It is."

We ate, and I gave Rachel a piece of French bread to munch, and also fed her some of the stew, though not nearly enough for a normal meal for her. As soon as we finished eating, I handed a protesting Rachel to Kris, and with Kris' blessing, I went upstairs. I made sure the blackout curtains were closed, undressed, and put on my sleeping eye mask for extra protection against light, got into bed and instantly fell asleep.

July 5, 1989, Circleville and McKinley, Ohio

"How are you feeling?" Kris asked when I came downstairs just before 8:00am on Wednesday morning.

"Better," I replied. "Twelve hours of sleep seems to have helped. Where's Rachel?"

"She's on a playdate with Abigail. I set that up because I had no idea how long you would sleep. I'm leaving in a few minutes for class, and I'll pick Rachel up on the way home from OSU. Do you need anything before I leave?"

"Just a hug and a kiss," I replied. "What time will you be home?"

"About 4:00pm."

I walked Kris to her car, we hugged and kissed, and once she had driven away, I went back into the house. I made myself breakfast, and after I had eaten and cleaned up, I checked the menu for the evening, noted we needed a few things, and after I showered and dressed, went to Kroger to pick up a few things, then headed back home.

I really had nothing to do but relax, so around 11:00am I called Clarissa to see if she wanted to have lunch. She agreed, and just before noon, we met at Frisch's.

"I expected you to show up with toddler attached to hip!" Clarissa said when we met in front of the restaurant.

We exchanged a quick hug, then walked inside.

"Kris arranged a playdate for Rachel with Abigail because she had no idea how long I'd sleep. I woke up around 8:00am and Rachel was already at Abigail's house and Kris was ready to leave for her class at OSU."

The hostess seated us in a booth and when the waitress came over, we ordered right away.

"How does fasting work when you have your crazy schedule?"

"With «ekonomia». Health is always the primary concern. When I discussed it with Father Roman, we agreed I'd refrain from red meat on fasting days, but no other restrictions on what I need to eat to stay healthy. For marital harmony, Kris will follow the same rule."

"How are you handling church?"

"Just Sundays for now," I replied. "We could go Wednesdays, but we decided to entertain, and I have Father Roman's blessing on what amounts to minimal attendance, at least for the first few months. Obviously, I can't go on Saturdays, and tonight and next Wednesday, we're having guests. Anyway, how much sleep did you get?"

"About four hours, in a pair of two-hour stints, which I guess is far more than you had."

"You guess correctly."

"Did you have the drowning victim?"

"Yes. He was basically DOA, but you know the drill. That was right before I headed to the lake for our gig."

"Anything else interesting?"

"I asked a seventeen-year-old girl who needed an ankle x-ray if there was a chance she could be pregnant and she wanted to know if it was an offer."

Clarissa laughed, "And you can't be a pig in the ED!"

"Kris might have an objection as well! But you know me. I simply ignored the obvious flirting."

"Flirting? She was asking the cute young doctor to fuck!"

"Whatever," I chuckled. "Not the first and won't be the last. Did you have anything interesting?"

"Just the usual, and with the Fourth, no scheduled admissions or transfers, just the admissions from the ED. We have one interesting case where we're having trouble diagnosing. Doctor Subramani has a conference call with a specialist at Mayo and one at Emory tomorrow. I heard you had a run-in with the new Attending."

"Several, actually. Between you and me, and not to be repeated, she's lazy and I have strong suspicions about her ability to do the Attending job. She's going to get lit up at the M & M a week from Friday."

"Why?"

I explained what had happened with the guy who was beat up in the bar.

"You're covered because you made her write it on the chart," Clarissa observed. "No way she can throw you under the bus on that one."

"Probably not," I replied. "And I will acknowledge during my presentation of the case that I should have listened to my nurse."

"Ellie?" Clarissa smirked.

"She's obviously still interested, but she's also dialed it way back. It wasn't her, though, it was Becky, who's been a nurse nearly as long as I've been alive!"

"And your med students?"

"Mary and Tom are great; the other four are about what you'd expect. The one downside for Mary and Tom is that they were assigned to Doctor Mastriano during the interim period before the new PGY1s started, and she's not a very good teacher."

"Sleeps, can't teach, and lazy?"

"That's my assessment. Hopefully, the M & M will be a wake-up call. If not, the next year is going to suck. I'm on with her again on Saturday. On the plus side, the end result of one of our spats was that I was allowed to do a blind pericardiocentesis in the OR."

"You're not even a week into your Intern year!" Clarissa exclaimed.

"That was Doctor Mastriano's objection, though she called me a 'fucking intern'."

"Think about how rare it is for an Intern to do anything like that."

"And think about how DUMB that historical practice is! The advantage of the new program is that nobody has to 'do what has always been done' because it's never been done before."

Clarissa laughed, "Says the man for whom 'I have never seen it done that way before' is the ultimate reprimand for a clergyman!"

"If you think about it, we're priests and priestesses, and expected to follow tradition -- what has been done always, everywhere, and by all."

"You're saying medicine is Orthodox?"

"I'm saying our rituals and traditions are handled exactly the same way -- anything new is viewed skeptically until accepted by the medical community at large. We have our deanery meetings every Friday, our medical conferences are like synods, and AMA meetings are, in a way, Ecumenical Councils."

"Oh, for the love of God!" Clarissa said, laughing hard. "Seriously?"

"The parallels are there," I said as the waitress brought our food.

I said the blessing, and we began eating.

"Have you heard anything about Kris' citizenship application?"

"Just that it was filed on the 3rd. I believe we provided everything they need, so the next step will be interviews, potentially as soon as next month, but it could be as much as six months."

Clarissa smirked, "That should be interesting. 'Does she swallow?'"

I chuckled, "While the attorney suggested those types of questions might be asked, he felt that Kris formally adopting Rachel would obviate such questions, given no sane person would risk losing custody of their kid for a sham marriage."

"We are talking about you, Petrovich, and sanity was never an option!"

"No kidding!" I chuckled. "But the government doesn't know that! Someone from INS will come to the house, see all the obvious signs of marriage and a family, and that should be it."

"And your «minou»'s politics?"

"Starting that again, are we?" I asked.

"Of course!"

"Being a socialist isn't a cause for denial of naturalization, only advocating the violent overthrow of the government. And despite flying the red and black flag on May Day, she hasn't advocated a violent overthrow of the government."

"Sorry to bring this up, but how are you handling the memorial this year?"

"Viktor arranged with Father Nicholas to have the memorial that morning, which is a Saturday. Kris, Rachel, and I will be there. I'll still be on my current schedule, so I have to be at the hospital from noon to midnight, so we'll have to figure out our family birthday celebration for Rachel, and I'm sure the Kozlovs will want to do something. Kris and Lyudmila are planning a party with Rachel's friends from daycare and church, and that will be on Saturday afternoon while I'm on shift."

"Thereby avoiding a house full of toddlers and their moms!"

"One toddler is a challenge for the two of us! I can't even imagine a dozen little girls!"

"But when they grow up..." Clarissa smirked. "I recall you enjoying graduation parties!"

"That's even MORE reason to be out of the house! But seriously, at forty-two, I'd be ancient in their minds!"

"Mostly, but I think you'll be hit on by cute teenage girls for decades!"

"That does seem to happen to doctors right up into their forties."

"Speaking of one toddler being a challenge, are you still planning on having a baby next July?"

"If I have a baby in July, it'll be in every medical journal on the planet and I'll be famous!"

"You know what I meant, you nut!"

"That's the plan," I replied. "The timing coincides nicely with the end of the thirty-six-hour shifts and weeks longer than eighty hours, though I have a strong suspicion that's about to change."

Clarissa nodded, "Doctor Subramani said she spoke to a friend in New York who said the end result is going to be a limit of eighty hours a week and shifts no longer than twenty-four hours with at least twelve between them. Which means more Residents."

"Which requires more money, and that is a complex mess with federal, state, and local funding sources, plus patient fees and insurance receipts."

"I think we'll be bitching about lack of resources when we retire in forty years or so."

"I was thinking about that, and surgeons typically retire by sixty, or at least significantly reduce their actual surgeries and teach instead. I could work longer in the ED, as I could take regular shifts instead of trauma surgeon shifts, but I think at that point I'll hang out a shingle or work in a clinic. I just don't see retiring from medicine. Doctor Evgeni is nearly eighty and still sees some patients."

"You'd make a great teacher."

"I suspect so, but not seeing patients would frustrate me to no end. It's why I'll never take a job in administration. I'd rather be a locum tenens on contract than Medical Director."

"There's no chance you'll be an eternal Resident! You'll get the Attending slot the second you pass your boards and can put FACS behind your MD! There's no way they'll risk losing you."

I smiled, "And yet, there is one thing that could take me away."

"Rutherford, right? If they become a teaching hospital and upgrade to a Level I trauma center."

"That would be it, and they're on that path, but who knows what will happen over the next decade."

"Want to make a wager?"

"On?"

"That Doctor Michael Peter Loucks, MD, FACS, will be the Chief of Emergency Medicine of Rutherford Hospital before the end of the next decade."

"And what would the bet be?" I asked with an arched eyebrow.

Clarissa laughed, "I can't make it too interesting for you because your «minou» would object."

"Yeah, but if that was what I would get for winning a bet that I wasn't going to have that role, do you think I'd take the job?"

Clarissa laughed, "There is no way you would trade one night with me for your ultimate dream job!"

"Are you sure about that?" I asked with a smirk.

"Positive!" Clarissa declared. "Mainly because you could never collect."

"Truth. Despite the tragic events around Rachel's birth, I fully expect to grow old together with Kris."

"How are things going? And I don't want a flippant answer."

"They're good. We have our areas of disagreement, but they're peripheral, not core. Kris is very different from any girl with whom I've ever been involved and is more mature than most girls her age. We're going through what is likely to be the toughest time we'll ever have to, and she's handling it well. Rachel, on the other hand, is annoyed that she can't see me and alternates between clinging and giving me looks that remind me of Elizaveta when she was unhappy with me."

"Complete with hands on the hips?"

"A couple of times," I chuckled. "It was uncanny how much she reminded me of her...Elizaveta."

"You can say that to me, Petrovich. It won't cause any trouble."

"No, I can't," I countered. "I do not want to send mixed messages to Rachel or Kris. Yes, Elizaveta is Rachel's biological mom, but Kris is the only mom Rachel will ever know, even when she finds out about Elizaveta."

"She's almost two, and at some point, probably not too far in the future, she's going to ask about the icon and prayers. You don't display any pictures, right? I haven't been in your bedroom."

"Much to your chagrin!" I teased. "But no, no pictures. I have albums, of course, but the framed pictures were put away because I didn't want Kris to feel slighted in any way. And being Orthodox, it's the icon that truly matters."

"Theologically, sure, but you don't feel that way. Well, at least not a hundred percent."

"Yes and no," I replied. "The struggle for me is honoring Elizaveta and remembering her, without making Kris feel like my, and I'll use this term with you only, second wife."

"I think you've done a good job balancing things, and Kris has a good head on her shoulders. She accepts your relationship with Angie and your relationship with me, and didn't freak out over our desire to have a baby together. Any woman who can do that is a keeper!"

"And you keep your hands off, Lissa!" I said with a grin.

"I told you I think she's hot, but Tessa and I are as committed as you and Kris are."

"With one exception."

"You had your chance, Petrovich!"

"And you know that wasn't for me, and why."

"Well, if a threesome with Deb and Milena left you nonplussed, I'm not sure what would work besides a monogamous relationship."

"You, Tessa, and me did NOT leave me nonplussed!"

"Except that was all about you and me. Your pleasure with Tessa was directly related to me being there, participating and watching, not having a threesome."

"You might have a point. OK to change subjects?"

"Sure."

"I spoke with the attorney handling Angie's case and he thinks an official reprimand is likely, and that it's even possible we'll get Greenberg's license suspended."

"I hope that's the case! What happens now?"

"The complaint has to be submitted to the Medical Licensing Board. The attorney will interview me to get the details, from my perspective, and I'll testify in my official capacity as a doctor to his errors."

"Risky."

"I know, and I'm going to take the risk. Angie deserved better and while I can't fix what Greenberg did, I can certainly make sure he never does it again."

"Just be smart, Mike."

"Nobody in Surgery or Emergency Medicine is going to cause me trouble for doing the right thing, and I don't care what Psych says, or any other department, for that matter. My guess is that Doctor Greenberg files a nolo contendere with the board in exchange for a reprimand. I won't like it, but it's better than nothing."

"Basically a plea bargain?"

"Basically. The other thing that happened is that Melissa Bush returned my call. She seems to be doing OK, but she's completely rejected Christianity, well, her version of it."

"Do you blame her? You reject it, too!"

"Yes, of course, be she claims to no longer believe in God and to be engaging in promiscuous sex with random guys on Friday nights."

"I don't believe THAT!" Clarissa declared.

"Neither did I, but she made the point that she's not the same person she was a year ago. I let her know I'd seen her dad, and her response was such that I don't believe she has any interest in getting in touch with him."

"Again, do you blame her?"

"No. Her comment was that he'd messed up her life, as well as her mom's and her brother's, and she basically expressed no sympathy for the Gospel message that everyone is redeemable."

"You are the lone voice in the wilderness on that one with regard to Lee."

"I know, but I have to be true to myself, even when it forces conclusions and actions I don't like."

"You're going to see Frank Bush again, right?"

"Yes. On a monthly basis. Maybe at some point I'll do some evangelism at the prison, but I need a sane schedule before I can consider that."

"So a year, at least?"

"Probably. At least at first, I'm just going to visit Frank and play chess with him. I did pre-order a book for him, which I think I told you about. Baby steps."

"I don't think I could do it, but I completely understand why you're doing it. It's you."

"Changing topics, have you and Tessa considered a commitment ceremony of some kind?"

"Marriage?"

"Use that term if you want," I replied. "You know my take on it."

"That so long as nobody tries to force your church to perform weddings for homosexual couples, you won't object, even if the government, at some point, permitted it."

"Exactly. I mean, why should you and Tessa have fewer rights and privileges simply because of something you can't control any more than I can control? It's not a 'lifestyle' despite the claims of some on the right."

"We haven't really discussed it. Hey, you could do the ceremony at this point!"

"I could but that might get me the wrong kind of attention from Father Luke, Father Roman, and Vladyka JOHN. How is your dad taking everything?"

"I think he'll lose it when I announce I'm pregnant, but chill by the time I present him with a grandson or granddaughter. Speaking of that, how are things with the Kozlovs?"

"They're fine. Rachel will spend time with them on Saturday afternoons. She still doesn't like her cousin Viktor, mainly because he's so rambunctious."

"She does prefer girls..." Clarissa smirked.

"I don't think it's about sex at age two!"

"It's always about sex!" Clarissa teased. "Wasn't that the primary goal of your life from Freshman year?"

"No. Being a doctor was more important. It did come a close second, though. But fourteen is different from two!"

"Except the interactions with the opposite sex start very young, and they're all practice for the future."

"Given my relationship with Jocelyn in kindergarten, I can't really disagree."

"Any progress with them on adoption?"

"They're very close, and once Jocelyn passes the bar next month, I expect them to receive a baby or toddler in a reasonable timeframe."

"I've heard there aren't that many babies or toddlers available."

"A lawyer and a nuclear physicist with a Master's and working on his PhD are basically the perfect couple."

"What is she doing?"

"Mostly studying for the Bar, but she also is writing briefs and handling motions and filings in simple cases."

"Have you heard from Maryam, Peter, or Nadine?"

"No, but I figure they're in the same boat we are, so I'm not surprised. I'm sure I'll hear from Maryam in the next few weeks with a wedding date."

"That fast?"

"They've known each other for close to ten years," I replied. "So it's not too surprising."

We finished our lunch and when we left the restaurant, we exchanged a quick hug and then got into our Mustangs. I decided to swing by Doctor Blahnik's house and see if she was home, but there was no answer at the door, so I headed back to Circleville. Once I arrived home, I put on some music, then went to the kitchen to prep the vegetables and peel the shrimp for the stir fry we were serving our guests, and put the rice in the rice cooker we'd been given as a wedding gift.

Kris arrived home with Rachel, and the three of us relaxed together on the couch while I explained what had happened with Doctor Mastriano as I'd promised Kris I would do.

"You're sure you aren't in any trouble?" she asked when I finished explaining.

"Positive. Well, not about that. The reason I insisted on her writing her orders on the chart was that she refused to even examine the patient, and I was concerned. As a PGY1, having written orders on a chart is a perfect defense. Someone might say I should have disobeyed Doctor Mastriano's instructions, but I can't get in any real trouble for not doing that."

"What would you do the next time?"

"Make a nuisance of myself until she checked the patient herself or I'd call for a consult and make my argument to the Resident from the consulting service. But in the end, the Attendings decide and they have the final say."

"But didn't you say you did things you were told not to do?"

"By Doctor Mastriano, but she's not my Attending -- that's whoever is the surgical Attending. Yes, she supervises me and assigns my work, but in the end, I answer to Doctor Cutter, the Chief of Surgery. And that's what's caused the turf war, of which this is likely part."

"It all seems so silly."

"It is, but anything new in medicine causes tumult. On the plus side, I did get to do a surgical procedure -- a pericardiocentesis, which is draining fluid from the sac around the heart."

"What causes that?"

"In this case, severe injuries from an MVA, a motor vehicle accident. The young woman hit her chest on the steering wheel."

"Did you save her?"

"I honestly have no idea. I performed the procedure and left her with the other surgeons, which is going to be a fairly common occurrence. And I don't have time to check on every admission."

"Dada?" Rachel, who was on my lap, said.

"Yes?"

"Git-arr?"

I handed Rachel to Kris and went to get my guitar. I played six songs for Rachel, ones I knew she liked, which included one I'd never play with Code Blue -- Baby Beluga, a Raffi song. When I finished, Kris and I went to the kitchen to work on Dinner, and a few minutes later, the doorbell rang, signifying that at least some of our guests had arrived. Ghost and Oksana were at the door, and I saw Loretta and Bobby pull into the driveway.

Once everyone was inside, I offered a glass of wine to anyone who wanted one, and everyone except Loretta accepted. I poured the wine, gave everyone a glass, then began preparing the stir fry, cooking the shrimp first, then adding the vegetables and the sauce I'd made. When it was ready, Bobby helped me bring everything to the table, and we all sat down to eat.

"Ready to come back to work?" I asked Doctor Gibbs.

"I'm going slightly stir crazy at home, so yes, I am! Fortunately, Bobby's mom is available to watch Bobby Junior until he's old enough for the hospital daycare."

"Mike, did you see the scheduled for paramedic training?" Bobby asked.

"No."

"Starting September 1st, we'll work weekly six-hour shifts at the hospital until we reach fifty hours and you docs sign off that we can intubate and read EKGs. They also published the drug list, and we'll have lidocaine, succinylcholine, etomidate, and midazolam."

"Good. Chest tubes?"

"Not this round, because Doctor Cutter isn't ready to sign off on that."

I nodded, "That procedure is more complicated than intubation. It's rare for Fourth Year medical students to do it, and even Interns."

"Says the PGY who did one while he was a med student!" Ghost said.

"And who'll teach his Fourth Years who double on trauma to do them."

"Just don't feed his ego!" Doctor Gibbs ordered. "It's big enough already!"

"Mike isn't conceited!" Oksana protested. "He's the most humble person I know."

"Cousin, you don't see 'Doctor Mike'!" Kris declared. "He's a very different person from the one you saw at church or I usually see at home."

Ghost and Loretta looked at each other and broke up laughing.

"For sure!" Doctor Gibbs said.

"He's a surgeon," Ghost said. "Having a big ego is a prerequisite!"

"I have Clarissa for this kind of abuse," I chuckled. "I don't need it from all of you! Not to mention she's had eight years of practice! And if she's not sufficient, the Tsarina will absolutely point out every minor failing!"

"How are the wedding plans coming along?" Loretta asked.

"Who knows?" Ghost said with a smile. "I took Mike's advice and I'm just along for the ride! Oksana's mom is handling everything!"

"A wise man listens to those with knowledge and experience," I observed.

"Physician, heal thyself!" Loretta said, causing everyone to laugh hard.

July 6, 1989, McKinley, Ohio

"Morning, Mike!" Doctor Lindsay said when I walked into the surgical locker room on Thursday morning.

"Morning, Doctor Lindsay!"

"Shelly, please. I heard you did a blind pericardiocentesis on Tuesday."

"Drunk driver MVA," I said. "Any idea how she did?"

"Coded from an aortic transection. It blew about ten minutes after you left the OR."

"I missed it," I said ruefully as we began undressing.

"No, you didn't!" Shelly said firmly. "If the aorta had been completely torn, she'd have been dead before EMS arrived at the scene. There were no signs, and she bled out in seconds. McKnight said it was a pseudoaneurysm, which means short of a CAT scan, you couldn't have seen it, and maybe not even then. Had you ordered a CAT scan, the aorta would have blown while she was in the machine. There was nothing you could have done, Mike, unless you have a direct line to God and He was in the mood to grant a miracle of the type YOU don't believe occurs!"

She was right, but that didn't make me feel any better.

"It still sucks."

"Yes, it does," Doctor Lindsay said, taking off her skirt. "But you know what really sucks? Drunk driving. In this case, it was the driver. You know what usually happens.

"Some innocent person dies and the driver survives," I said, having stripped down to my underwear.

We each put on red scrubs and left the locker room. She stayed on the surgical ward while I headed down to the ED.

"Morning, Mike!" Nate said when I walked up to the clerk's desk to check in.

"Morning Nate. I see the board is almost empty. Quiet night?"

"Mostly. You know the new EMS protocol started yesterday, right?"

"Yes."

In order to free up nursing resources, the ED clerks were going to answer EMS calls, and soon, we'd have an EMS radio, similar to the setup they had on Emergency, so that the paramedics could talk directly to us. That would allow them to get advice from doctors directly, rather than work through dispatch, and eventually, the EMS squads would radio directly when they were on their way, which would give us a few extra minutes' warning on their arrival.

"Morning, Mike!" Doctor Casper said.

"Hi, Ghost! Haunting the ED today?"

"Keep your day, night, and day job!"

"Morning, Doctor Mike!" Len Godwin said. "We have a seventy-two-year-old bowel obstruction waiting to go up. Otherwise, our board is clear. Surgery will take him at 8:00am."

"Last vitals?"

"EKG is clear; BP 130/80; pulse 80; PO₂ 99% on nasal canula. Surgery saw him at 0500."

"Orders on the chart?"

"Monitor vitals; IV Ringers; NPO."

"Did you and Bob have your breakfast?"

"Yes. Doctor Baxter sent us right after the surgical consult."

"OK. Where is she?"

"Sacked out in the on-call room. She said you should wake her when you arrived."

I went to the on-call room and saw only Kylie, so I simply called her name. She sat up almost immediately.

"What do we have?" she asked, pulling off her sleeping mask.

"A tired doctor in need of sleep! My prescription is to go home, sleep, and have a nice warm bath."

Kylie laughed softly, "Now, if only you could keep me warm and take that bath..."

"Time to go home, Doctor," I said. "Len gave me the scoop on the bowel obstruction."

"Sorry," Kylie said.

"It's OK," I replied. "I appreciate the sentiment."

"These shifts are WAY too long."

"I was basically dead on my feet on Tuesday evening."

"I believe it!"

We left the on-call room, and I went to Exam 3 to check on the bowel obstruction, then went to the lounge to get some coffee, where Len and Bob joined me.

"We're catching walk-ins," Bob said. "I'll be at the triage desk."

"OK," I said.

Bob left, and once I finished my coffee, Len and I went to the triage desk.

"LOL, weak and dizzy all over," Bob said, handing me a chart.

"Huh?" Len asked.

I kept my voice low to ensure I wasn't overheard, "Little Old Lady, near-syncope, with trouble standing."

I scanned the chart and had Len get a wheelchair before we went out to the waiting room to where the woman was sitting with an elderly man.

"Mrs. Valerio?" I said. "I'm Doctor Mike and this is Len, my student. Let us help you into the wheelchair, please. Mr. Valerio, you're welcome to come with us."

Len and I helped Mrs. Valerio into the wheelchair, and Len pushed her into the ED, where I directed him to Exam 3, then asked Ellie for a nurse. She sent Wendy, who had a nursing student with her, to help. Between the four of us, we helped Mrs. Valerio onto the exam table.

"What brought you to us today?" I asked, handing Len the chart to scribe for me.

"I got up early, as we always do, went downstairs to make breakfast, and I had just started the Mr. Coffee when I felt dizzy and could barely stand. Julius insisted I come here."

"Are you still feeling dizzy?" I asked.

"A little, yes."

"Anything else bothering you? Or anything else that's not normal for you?"

"My chest feels a bit heavy."

"Wendy, portable EKG, please," I said. "Mrs. Valerio, I'm going to examine you and put you on a heart monitor to see if we can figure out why you're feeling dizzy."

I got up to wash my hands and put on gloves, then returned to the exam table. I had a suspicion that Mrs. Valerio might have had a mild heart attack. The signs and symptoms for women were different, and often less pronounced than in men. For women, in many cases, only cardiac enzymes were definitive to rule out an MI as EKGs were not as reliable for women as they were for men. That meant I'd do the primary exam first, get blood drawn, and then do a history.

"Karen," I said to Wendy's student, "Chem-20, ABG, and cardiac enzymes, please."

"Right away, Doctor."

"Mrs. Valerio, I'm going to listen to your heart and lungs," I said. "Then Karen will draw some blood."

"What do you think is wrong?" Mr. Valerio asked.

"Right now, I don't know," I said.

I listened to Mrs. Valerio's heart and lungs, but didn't detect anything except minor crackles in her lower lungs, which might, or might not, be a sign of cardiac trouble. I had Len take her blood pressure, which was slightly elevated, then Karen drew the blood. For the EKG, Mrs. Valerio would need to take off her dress, so all of us except Wendy and Karen left the room. Normally, they would have left as well, but given Mrs. Valerio needed help, they stayed.

"All set, Doctor," Wendy said coming out the door about five minutes later. "Leads are attached, along with the monitor."

"OK. Please have your student take the blood to the lab. I want those cardiac enzymes stat."

"Right away, Doctor."

Len and I returned to the room, and I looked at the EKG, which was showing what appeared to be a normal sinus rhythm, though she was a bit tachy at 110, and her PO₂ was a bit lower than I preferred to see it at 95%.

"What's it show?" she asked.

"Your blood pressure is slightly elevated and your heart is beating a little fast," I said. "Your blood oxygen levels are a bit low, so out of caution, we're going to put you on oxygen via a nasal canula, which is a tube that sits right under your nose. Wendy?"

She hooked up the oxygen and a minute later, the monitor showed 98%.

"Are you taking any medication?" I asked.

"Naproxen for my arthritis," she said. "Plus a multivitamin with iron."

"Are you anemic?" I asked.

"Not since I started taking the vitamins about a year ago."

That could account for the low oxygen saturation I'd seen on room air, and might account for her other symptoms, if her anemia had worsened.

"Did you have another diagnosis?"

"What do you mean?"

"Sorry, did your doctor tell you what was causing your anemia?"

"No. He said it was mild, and I wasn't showing having any problems besides my arthritis."

"Have you had any health problems at all, besides your arthritis, in the past six months?"

"I have trouble falling asleep some nights, but otherwise, no."

Insomnia was a common problem that came with advanced age, and given Mrs. Valerio was seventy-eight, occasional insomnia wasn't a problem.

"Do you get any exercise?" I asked.

"Not since my arthritis started acting up about two years ago. The Naproxen lets me do my daily stuff around the house, but we don't take our walks at the mall the way we used to."

"What do you think is wrong?" Mr. Valerio asked.

"Everything your wife has said is consistent with her anemia worsening, but I want to wait for the blood test results before I say for sure that's it."

And I didn't want to worry them needlessly with my suspicion she might have had a heart attack, or even a mild stroke. Nothing I had seen so far called for a cardiac or neuro consult, though I could call for a gerontology consult without a specific reason for any patient over seventy-five, just as I could call for a pediatric consult without a specific reason for any patient under age fourteen.

"Mrs. Valerio, when was the last time you saw your physician?"

"February, just after my birthday. He said my anemia was under control and my arthritis was being controlled by the pills."

"How's your diet?" I asked.

"I don't eat as much as I used to, but I make sure I get plenty of fiber to keep things moving."

"Balanced?"

"Yes. I try to eat a good mix of meat, vegetables, and fruit. I take Metamucil for fiber every morning."

"I'd like to do a complete exam, if that's OK."

"Of course," she said with a sly smile. "I was a dancer in a cabaret when I met Julius almost sixty years ago, and I'm wearing more now than I was in front of an audience!"

"I was in the Navy," her husband said. "I went to a show, took one look at her, and said to myself I was going to marry her! Two months later, I did!"

I had a vague idea of what 'burlesque' had been like in the late 1920s, and her comment about her clothing strongly indicated she had been a striptease artist. And with her husband being in the Navy in the 1920s, I was sure they both had some very interesting stories to tell.

I performed the exam, noting nothing out of the ordinary, with her distal pulse and muscle tone being typical for someone who was nearly eighty and suffering from arthritis. I had just finished when the phone rang. Karen answered, then hung up.

"Lab results are ready," she said. "I'll go get them."

She left the room and returned about two minutes later and handed me the printout with the results. The results were basically what I'd expected, showing slight anemia, but also showing elevated cardiac enzymes.

"Mrs. Valerio," I said. "I believe you've had a mild heart attack."

XVI. Defeated

July 6, 1989, McKinley, Ohio

"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!"

XVII. Air Ambulance

July 6, 1989, McKinley, Ohio

"What do you need, Doctor Casper?" I asked as Mary, Tom, and I entered Trauma 2.

"Doctor Wilson is in Trauma 3 for a chest tube and central line, so I need you to put those red scrubs to use and confirm my MVA needs an ex-lap for splenic rupture."

"Indications?"

"Abdominal pain, epigastric tenderness, Kehr's sign, tachy, hypotensive, strained respiration requiring intubation. The patient consented before intubation."

"Tom, ultrasound, please," I said.

"Be right back!"

"Mary, Kehr's sign?"

"Acute pain in the shoulder, usually resulting from blood in the peritoneal cavity in a supine patient with their legs elevated. Left shoulder referred pain is a sign of splenic injury."

"Differential?"

"Diaphragmatic injury, kidney stones, and, in a female patient, ruptured ectopic pregnancy."

"Very good. You perform the ultrasound."

"Uh..."

"You can do it," I said. "We'll all see the image."

Tom returned with the ultrasound unit and I walked Mary through the procedure.

"What do you see?" I asked.

"I have no idea what I'm looking at," she said.

"This," I said, pointing, "is his spleen, right below his left lung and to the left of his liver. And this," I pointed again, "is free fluid around the spleen, indicating bleeding. We could do a peritoneal lavage to prove it's blood, but I think that's wasting time. Mary, call up and say we have a surgical case -- ex-lap for probable splenic fracture. Tom, we need an orderly."

"Thanks, Mike," Ghost said, handing me the chart.

I made my notes, signed it, and handed it back.

"Somebody call for a surgeon?" Doctor Mary Wilson asked, coming into the room.

"Mike did the consult," Ghost said. "You were busy with the driver."

"Then I'm going up because they'll need two teams."

And if she was going up, that meant my students and I couldn't scrub in, as I'd be the only surgical Resident available.

Twenty minutes later, Mary, Tom, and I were back in the ED.

"I thought we might get to scrub in," Mary said.

"Once Doctor Wilson said there were two surgeries, and she was going to scrub in, I knew that couldn't happen."

"Doctor Mike?" Nurse Tiffany, who was at the triage desk, called out. "Walk in chest pain."

Which meant they had to be seen immediately, with only someone transported by EMS having priority. I looked at the board and saw Trauma 4 was free.

"Tom and Mary, wheelchair, and bring the patient to Trauma 4. GO!"

I went to the nurses' station and asked for a nurse, and Billie followed me to Trauma 4.

"What's your name, sir?" I asked, as my students brought him in.

"Mike Meyer," he grunted.

"Let's help him onto the table," I said. "Mary -- EKG, monitor; Tom -- IV saline and start a chart; Billie -- nasal canula, CBC, Chem-20, ABG, and stat cardiac enzymes."

We got Mr. Meyer onto the bed and I performed the primary exam while the others executed their tasks.

"How old are you, Mr. Meyer?" I asked after auscultating his heart and lungs.

"Forty-nine," he grunted.

"Do you smoke?"

"No."

"IV is in!" Tom announced.

"Do you consume alcohol?"

"A couple beers after work with the guys most days."

"When did the pain start?" I asked.

"About an hour ago, I guess."

"BP 190/120," Mary reported. "Tachy at 125; PO₂ 92%; EKG shows arrhythmia."

"What do you see?"

"The T-wave doesn't look right."

I looked up and saw she was correct.

"Inverted T-wave. Call for a cardiologist, please. Tom, get the blood to the lab."

"Right away!" Mary replied.

"On it!" Tom declared.

"What's that mean?" Mr. Meyer asked.

"That your heart has been damaged in some way. Just try to relax, please. We're calling for a cardiologist and we'll give you some medicine to help. Billie, 250mg ASA IV push and sub-lingual nitroglycerin tab."

"250mg AGA IV push; sub-lingual nitro," Billie repeated.

The nitroglycerin brought down his blood pressure slightly and helped with the pain. About four minutes later, Doctor Shore from Cardiology arrived with a Third Year I didn't know.

"Shore, Cardiology. What do we have?"

"Hi, Pat," I said. "Mike Meyer; forty-nine; presented with chest pains; hypertensive; tachy; inverted T-waves on the monitor; murmur on auscultation. Administered ASA and nitro. Recommend cardiac echo."

"Thanks, Mike. Mr. Meyer, I'm Doctor Shore from Cardiology."

He proceeded to listen to Mr. Meyer's heart and reviewed the EKG.

"I'll take him on my service," Doctor Shore said. "Mr. Meyer, we're going to take you upstairs and perform an echocardiogram -- an ultrasound of your heart -- to get a better idea of what's going on. Mike, enzymes?"

"Ordered stat. We should have them momentarily."

"Kyle," he said to his student, "call for an orderly. Mike, I'll need him on a portable monitor."

"Tom," I said. "Switch to a portable monitor and escort Mr. Meyer upstairs."

"Will do."

I updated and signed the chart, then said, "Mr. Meyer, you're in very good hands. Mary, with me, please."

We left Doctor Shore, Tom, Kyle, and Billie with the patient.

"Mike," Angela called out. "Arm lac in Exam 6. Doctor Varma asked if your student could suture."

"Absolutely," I said. "Mary, this is all yours. I'll watch. Remember, identify yourself as a Sub-Intern and me as your supervisor."

"Got it!"

The arm lac was clearly a simple repair, so once Mary had explained what she was going to do, I left the exam room and saw Tom walking down the corridor from the elevators.

"Trouble?" I asked.

"V-fib in the elevator, but he cardioverted immediately. How did you know?"

"You were gone too long for a simple transport," I said.

"Mike?" Nicki, the clerk called out, "EMS two minutes out with a burn victim. It's a bad one. Doctor Casper needs your help."

"OK. Tom, let's go. Mary is suturing."

We gowned and gloved and hurried to the ambulance bay. I looked across the driveway and saw the slowly rising building that would be our new trauma center, but the paramedics arrived just a few seconds later, and I cleared my mind to focus on the patient who was about to be unloaded.

"Mike, if this is as bad as it sounds," Ghost said, "we'll stabilize, then you'll take him to the burn center in Columbus."

"I haven't made all my flights," I said. "I'm one short."

"The number of flights is advisory only," he said. "Josh will sign off, I'm sure. The problem is that if one of the senior Residents or Attendings go, we'll have to call someone in and we're short-staffed because Loretta is on leave until tomorrow and Boyd and Fitzgerald are out sick."

"OK. I'll leave you Mary even though she'll have a fit. She can do suturing and other basic procedures for which Tom hasn't yet been trained."

"Helicopter?" Tom asked nervously.

"Yes."

"They come off the assembly line with the single mission of killing all their occupants!"

"I can take Doctor Varma's third year," I said.

"No, I'll go."

The EMS squad pulled up, and the paramedic jumped out.

"Bad one, Doc!" he said as he moved to the back of the squad and opened the door. "John Doe, mid-to-late twenties, with third-degree burns on his arms and most of his torso; smoke inhalation; BP 90 palp; tachy at 130; PO₂ 90% on ten liters by mask with no cyanosis; morphine administered; IV saline."

That amount of burn coverage meant, based on the rough calculations, about 50% and his chances of survival were around 60%, though with smoke inhalation, that number was likely generous.

"Mike, have them warm up the chopper. Tell Mary I need her, and the sutures will have to wait. Get ready to go, because as soon as I evaluate him and get another IV into him, he's going to Columbus."

"Right away, Doc! Tom, come with me."

My first stop was at the clerk's station, where I asked Nicki to call for the helicopter, which she did. Next, I went to Exam 6 and asked Mary to step out.

"Doctor Casper needs you in Trauma 3 to help with a burn victim. Tom and I are going to take him to Columbus by chopper as soon as he's stabilized. I'll let your patient know you'll be back in a few minutes.

"Not to be a bitch..."

"I know, but we're short-handed and no disrespect to Tom, but you can be much more useful here, rather than babysitting the patient on the helicopter. Go!"

"Yes, Doctor."

She left, and I went into the exam room and informed the patient that we had a serious emergency case and that Mary would be back shortly. We left the room and Nicki signaled me.

"Fifteen minutes," she said. "The crew is on their way to the pad."

"Thanks!"

I took Tom to the locker where I gave him the same basic instructions I'd once been given, and I put on a red flight surgeon jacket while Tom donned a blue trainee jacket. We grabbed our helmets, but didn't put them on, then headed to Trauma 3.

The patient had been intubated and now had two large-bore IVs for fluid replacement. The burns made an EKG impossible, and the pulse oximeter was on his ring finger, rather than index finger, due to burns. And the room smelled of charred flesh, which caused my stomach to turn.

"Chopper will be ready in about ten minutes," I said, fighting the nausea.

"Full-thickness burns over his arms and torso," Doctor Casper said. "Tom, get Doctor Taylor please. Drag him in here if you have to."

"Yes, Doctor," Tom replied.

He left and returned with Doctor Taylor about a minute later.

"What do we have, Ghost?"

"Male; late-twenties; 50% full-thickness burns; hypotensive and tachy; IV Ringers with dobutamine; intubated; minimal urine in the bag; he needs to go to the burn unit in Columbus as soon as surgery does an escharotomy. The chopper is warming up and I plan to send Mike and Tom. You'll need to formally sign off for Mike to fly solo. He's done three and has the signoffs for those in his book."

"Mike, let me have your procedure book, please," Doctor Taylor said.

I pulled it from my back pocket and handed it to him. He wrote on a blank page, signed it, and handed it back.

"You're cleared. I'll update the hospital records. Ghost, I think he should take a nurse as well. Kellie can go with them; she's a certified flight nurse from her Navy service. I'll let her know. She'll bring the drug box."

"What do we have?" Doctor Lindsay asked, coming into the room.

"Hi, Shelly," Ghost said. "50% full-thickness burns with pulmonary compromise. He needs an escharotomy."

"OK. Mike, put a gown over that flight jacket and assist, please."

Nurse Billie helped me into a gown, and put a mask on me, and I stepped up to the table with Doctor Lindsay, who had been helped into her gown and mask by Nurse Jenny.

"Have you seen one of these?" she asked.

"No."

"We incise the burn skin down to the subcutaneous fat and into healthy skin lengthwise, if possible. The goal is to relieve the constriction of his chest and allow for better respiration. When you cut, you need to take care to avoid nerves and veins. Watch and one of us will supervise you performing this in the future."

She made the necessary incisions, which only increased my nauseated feeling. I'd always heard severe burns were the worst, and now I was sure of it, and not just for the patient, but for the surgeon and other medical staff. The smell, combined with the sights and sounds of crackling flesh as she cut, was enough to induce nausea into anyone.

"Billie," Doctor Lindsay said, once she'd completed the procedure, "antimicrobial dressing, please. Vancomycin, 100mg IV push then drip at 10mg/min."

"Vancomycin, 100mg IV push, drip at 10mg/min; antimicrobial dressing," Nurse Billie repeated.

She and Jenny quickly and efficiently set up the IV and dressed the escharotomy.

"50%?" Mary asked quietly.

"It's a rough calculation -- 9% for each arm, 36% for the torso, 9% for head and neck, 18% for each legs, and 1% for genitalia."

"Thanks."

"PO₂ now 93%," Ghost said. "A slight improvement. Mike, your key number is his BP. Keep the fluids flowing, and keep the dobutamine drip going. The fluids and dobutamine should keep his pressure up. Increase the dobutamine if you see the pressure drop. If you need help, they'll patch you through the radio to us or the burn center."

"OK," I said. "Let's go."

Ten minutes later, Tom, Kellie, and I were buckled in and the patient was loaded on the helicopter.

"Hayes County Air Ambulance departing Moore Memorial Hospital for Ohio State University," I heard in my helmet as the helicopter lifted off.

"Relax, Tom," I said, seeing his knuckles whiten as he gripped the armrest to his left.

"First time on a helicopter?" Kellie asked him.

"Yeah," he said. "You were in the Navy?"

"I was a nurse aboard the carrier Nimitz for six years. I flew on dozens of SAR missions."

"Ever jump into the water?" I asked.

"No, we had divers who were trained as corpsmen for that. My job was to assist the flight surgeon, as I'm doing now."

"Fishing pilots out of the water?"

"Mostly, yes. Occasionally over land, but mostly at sea. Rescue choppers take off before air operations, and I flew those, too, but mostly that was simply sitting waiting for something that rarely happened -- a catapult problem or engine problem that dropped a Tomcat into the water."

"Get a BP for me, please," I said. "You'll need to use the ankle given the burns on his arms and the dressing."

She took the measurements and reported them as 110/80, which I adjusted, as ankle systolic pressure was anywhere from ten to twenty percent higher than brachial pressure. That meant his brachial pressure would be somewhere around 100/70, which was much better than when he'd first come in.

"No changes to the IV," I said. "Sats look as good as we could hope for."

It was 94%, and given his smoke inhalation combined with the circumferential burns, I doubted we could get it higher until his lungs recovered.

"Mike, can I ask why they didn't send an Attending?" Tom inquired.

"It's only required for cardiac cases," I replied. "And despite hypotension and tachycardia, the patient doesn't appear to have any compromise of heart function. In effect, we're acting as paramedics, and both Kellie and I have more training than they receive. Both pilots are paramedics as well, and you've had two years of med school. Given the limited ability to do procedures in the chopper, it doesn't make much difference. And I can radio in if something happens that concerns me."

"I wonder what happened?"

"One thing you'll learn in the Emergency Department is that you will likely never know much about what happened before or after you see a patient. Our job is assessment and then stabilization or treatment. After that, we admit or discharge them. Either way, what happens after they leave the ED is opaque in most cases. That was the most difficult thing for me to adapt to."

"Five minutes out," came over the headset.

I listened as the co-pilot spoke to the controllers and, as predicted, just under five minutes later, the helicopter touched down on the helipad. As usual, the rotors continued to turn as the local staff rushed out, ducking, and the co-pilot opened the door.

I carefully jumped out, took off my helmet, and moved directly to the doctor, who had arrived with two nurses, an orderly, and a medical student. I put my ear near his mouth and my mouth near his ear so we could converse over the noise of the helicopter engines and blades.

"Jones, burn specialist," he said loudly.

"Loucks, trauma surgeon; John Doe; late twenties; 50% full-thickness burns to arms and torso; escharotomy; IV Ringers; dobutamine and vancomycin; ankle BP 110/80; pulse 100; PO₂ 94% on vent; minimal urine production."

I handed him a copy of the chart, he signed my form for our chart, and they moved the patient from the helicopter. As soon as the patient was clear, I got back into the helicopter and the co-pilot shut the door. He climbed in, checked with the controller by radio, then announced our departure. As was my usual practice, as soon as the helicopter left the ground, I leaned back and closed my eyes.

I wasn't sure how long I slept, but I was jolted awake when a klaxon sounded and the helicopter shuddered. The nose of the helicopter dipped, and I felt my stomach move as it did on rollercoasters.

"Engine failure!" I heard over the headset. "Emergency landing! Hang on!"

"Oh, God!" Tom moaned in distress. "No!"

"We have two engines," Kellie said calmly. "They'll put us down on a road or other flat surface."

She was WAY too calm in my mind. Sure, I slept on the return flights, but this was different. I did the only thing I could -- prayed the Jesus Prayer. About thirty seconds later, we made a rough landing, and the co-pilot ordered us out of the chopper. Tom needed no encouragement, throwing open the door and bolting out. I quickly followed him, but Kellie simply calmly exited the passenger compartment.

I immediately surveyed where we were, and saw we'd landed on a baseball field, in the shallow outfield, just past second base. I turned and saw a bit of smoke coming from one of the two engine compartments, VERY happy the helicopter had two engines. The pilot and co-pilot both had extinguishers in hand, but weren't using them.

Tom, still moving, stumbled, and collapsed onto the ground. Kellie quickly moved to him. She checked his pulse, then had him lie down.

"180!" she announced.

My heart was racing, too, but probably around 130. Kellie, on the other hand, was cool as ice.

"Let's see if it resolves," I said. "Tom, just try to breathe normally."

"How are you, Doctor?" Kellie asked.

"Well, I managed to avoid soiling my underwear, so there's that."

After about a minute, Tom sat up and seemed to be doing better, with his pulse down to about 130. The pilot came over to us.

"I called it in. We're about six miles from the hospital. They'll send someone for you; we'll stay with the bird until the maintenance crew arrives."

"Will you fly it out?"

"No way. They'll put her on a flatbed and take her back to the barn."

About fifteen minutes later, a van arrived to take Tom, Kellie, and me back to the hospital. Kellie and I helped Tom into the van, we all buckled in, and the co-pilot closed the door of the van.

"Tom," I said when the van pulled away, "when we get back, take a thirty-minute break in the on-call room."

"Thanks," he said.

"Come see me after your rest period, and we'll evaluate."

"I will."

"How many mechanical failures did you experience, Kellie?"

"Four, but as with this, the pilot simply managed it and set the helicopter down on the deck. We had one really hard landing, worse than the one we just had, and that helicopter was salvaged for parts because it wasn't worth fixing. The others were back in the air within a day or two."

When we arrived back at the hospital, the news had spread, and Ghost came to talk to me while we took off our gear.

"Tom is going to take a break," I said. "His pulse skyrocketed."

"How are you?"

"Fine. My pulse went up from the adrenaline hit, but it resolved quickly. Kellie, on the other hand, has ice water in her veins!"

"Eight years in the Navy, six on a carrier will do that," Ghost observed.

"Kellie, when did you get out?" I asked.

"In May. I flew home, had my interview here the next day, and started a week later."

"Your work wife wants you to call her," Ghost said to me. "Then go see Josh."

I chuckled, "Thanks."

"Work wife?" Tom asked.

"Doctor Clarissa Saunders," I replied. "We did undergrad and medical school together, and now are doing our Residencies together. Eventually, we'll be Attendings in the same hospital."

"THIS hospital!" Ghost corrected.

"Who knows what will happen in seven or eight years?" I replied. "I have a long way to go."

I made sure Tom went to rest, then went to the lounge to get some juice and call Clarissa.

"I can't leave you alone for two seconds, Petrovich!" she said.

"It's been hours since I've seen you, Lissa! And, as Nurse Kellie said, the helicopter has two engines."

"What happened?"

"Flying machine break; alarm sound; land hard; Ogg not know more!"

Clarissa laughed, "The crew didn't say?"

"No. Just 'engine failure' and I saw some black smoke from one engine compartment after we'd landed."

"You might want to call Kris, because it'll probably hit the news."

"No reporters showed up, and I doubt my name will be attached to it. Not to mention no blood or gore and nobody died, and the chopper isn't obviously damaged, so the Press won't care too much. Tom had a bit of an anxiety attack, and I had the expected adrenaline rush, but our nurse, who is ex-Navy, was cool as a cucumber. I don't think her heart rate went up a point! She served on the Nimitz as a flight nurse."

"Let me guess -- you were sleeping."

"That is what I do on the flights back. The engine alarm woke me up."

"Call Kris. If she finds out some other way, it won't go well."

"You're right."

"I usually am!"

"Uh-huh," I replied flatly. "Snacks at 11:00pm if I'm free?"

"Call me when you are."

We ended the call, and I dialed the house, surprised when Lyudmila answered.

"You're not my wife!" I declared.

"Is that a good thing or a bad thing?" she teased.

"Oh, no you don't! You French girls are troublemakers!"

"Yes, we are! Kris is putting Rachel to bed. Is there a message, or do you need to speak to her?"

"I should probably speak to her," I said.

"Let me take over for her. Rachel won't mind her «tante préférée» stepping in!"

She set the phone down, and about a minute later, Kris was on the line.

"Mike? Is something wrong?"

"No, but I didn't want you to worry. I was on an air ambulance flight that made an emergency landing on a baseball field on the way back from Columbus. Everyone is safe, but I know TV can blow things out of proportion, so I wanted to call."

"What happened?"

"All I know is what the co-pilot said -- one of the two engines failed. My mechanical abilities are near zero, and I don't know anything more than the basics about engines."

"How did you get back?"

"They sent a van to pick us up."

"Why were you on the flight?"

"A patient with third-degree burns over more than fifty percent of his body. We're not equipped to treat a patient with those kinds of injuries, so we stabilized him, performed emergency life-saving procedures, and then loaded him onto the air ambulance to take him to the burn center in Columbus."

"What happened to him?"

"I have no idea. The paramedics didn't say, and he obviously couldn't talk because he was unconscious and intubated. I'm sure it'll be on the 11:00pm news."

"And I'll be in bed. Lyudmila is staying, so I don't have to take her home, and that's why Rachel was up late. I'll read about it in the Columbus Dispatch or McKinley Times in the morning."

"OK. I need to go."

"What's the answer?"

"To?"

"If it's a good thing or a bad thing that Lyudmila isn't your wife!"

"There is no way I am answering that question! In the immortal words of Admiral Ackbar -- It's a trap!"

Kris laughed, "A very wise man! See you tomorrow evening. Remember, Rachel won't be in daycare."

"I remember. See you!"

We said 'goodbye' and I hung up, then went to see Doctor Taylor.

"Are you OK?" he asked. "You can take some time if you need it."

"What? And get no end of grief from Kellie Martin?"

Doctor Taylor nodded, "I spoke to her. She's one cool customer."

"The alarm went off, the co-pilot called out 'Engine failure' and she just calmly said the helicopter had two engines."

"The Navy trains them right. She said Tom had an anxiety attack."

"Me, too! I nearly soiled my underwear, but Kellie was so calm that I didn't freak out. I sent Tom to rest for thirty minutes."

"Wise. Other than that, Doctor Loucks, how was the flight?"

I chuckled, "Nice play on Mrs. Lincoln and the play! No troubles at all. The patient's vitals were constant the whole way and an entire team was waiting for us on the pad when we arrived. I slept from the time we lifted off until I was rudely awakened by the klaxon. Where's my student?"

"Helping Naveen with walk-ins, but I don't know which room she's in. You OK with another trip when necessary?"

"If Kellie can do it, I can do it!" declared.

"Can't let a girl beat you?" Doctor Taylor asked with a grin.

"You don't know Russian women, do you?" I asked. "Or French women. Or Doctor Saunders."

He laughed, "No, but I have two daughters, eight and six, and I am not looking forward to the next ten years!"

"I think my dad would commiserate with you about my little sister."

"You'll get yours in about fifteen years!"

"I can wait, thanks!"

Nurse Angela came to the door of the Attending's office.

"No rest for the weary! Multiple MVA coming in. Trauma 2 and 4 are open. Four minutes out."

"Let's go, Mike!" Doctor Taylor said. "Angela, send us three nurses and see if Mary is free."

"Will do!" she said.

Fortunately, the accident wasn't serious, and both patients were transported as a precaution. After exams, both were discharged with what a news report would call 'bumps and bruises', with instructions to see their personal physicians. It was a testimony to the effectiveness of seatbelts that they had no serious injuries.

"Don't sit down," Nicki said as I left the trauma room. "EMS two minutes out with motorcycle accident. Doctor Casper is in the ambulance bay and wants your help."

"OK. Mary, let's go."

"Doctor Mike?" Tom called out, coming from the on-call room.

"How are you, Tom?"

"OK, I think. My hands a shaking a bit, but I feel better."

"Go home. I'll clear it with Doctor Taylor. Get a good night's sleep, and take tomorrow off. I promise this won't count against you in any way."

"Thank you."

He left and Mary and I hurried to the ambulance bay, arriving just as the EMS squad pulled in. As soon as the paramedic reported the vitals, I was sure it was a hopeless cause, but that didn't mean we wouldn't try.

"Traci, call for a neuro consult!" Ghost ordered as we rushed the patient to Trauma 1.

My assignment was intubation, and I considered allowing Mary to do it, but decided I needed to do at least some procedures. I did that, then did a neuro check while Ghost examined other injuries.

"CSF in the right ear," I announced. "Right pupil blown, left sluggish. He's going to need mannitol. Mary, check his pockets for his license, and see if he's an organ donor."

"Mind if I finish my exam?" Ghost asked.

"Sorry."

Given the patient wasn't breathing on his own, had cerebrospinal fluid in his ear, had a blown pupil, and had no response to the Babinski, and arrhythmia, the odds of him recovering were almost infinitesimal.

"Cohen, Neuro," Doctor Rebekah Cohen said, coming into the room, with her Fourth Year student Al Temple.

"Mike?" Ghost prompted.

I gave the report, and she nodded, then repeated the tests I'd done, and reached the same conclusion.

"Skull series, then an EEG," she said. "Mannitol, stabilize, then send him to Radiology."

"He's an organ donor," Mary announced.

"OK." Doctor Cohen said. "Is there a family member here?"

"We don't know," Ghost said. "Mike, see if someone is here. Mary, call Radiology for an emergency skull series."

I left the room and went to the admit desk and asked if Mr. Jackson had anyone waiting for him, and was directed to a young woman who was about my age.

"Ms. Jackson?" I asked.

"Yes! How is Mark?"

"We're evaluating him now," I said. "There are two doctors besides me with him and I came out to let you know we're going to take x-rays and run some tests, but his injuries are quite severe."

"Will he die?" she asked, a hitch in her breath.

"It's too early to say anything just yet. Someone will come speak with you, soon. I just wanted to make sure you knew we were taking care of him."

"Thank you, Doctor."

I returned to the Trauma room and let Doctor Cohen know.

"OK. Once the skull series is done and he's upstairs, have your student bring her up to Neuro and we'll take it from there."

"Will do."

"He's not stable enough to move yet," Ghost announced. "And I'm not sure we can do anything about that arrhythmia."

"ICP," Doctor Cohen said. "Mike, could you assist with an emergency craniectomy?"

"I could," I replied. "Here?"

"If we don't relieve that pressure, he's going to herniate and we'll lose him. We might anyway. Al, call Neuro for a nurse and a craniectomy tray, stat. Let's prep."

We washed our hands and put on fresh gloves while the nurses draped the patient. When the nurse arrived from neuro, the tray was opened and set up.

"I'll make the incision in the scalp," Doctor Cohen said. "I'll have you retract the scalp and clip it, and control any bleeders. I'll cut the skull with the saw, separate the dura, then make an incision to allow fluid to drain. We're going to remove a six centimeter section of skull."

"OK," I replied.

My part of the procedure was simple, as it basically involved pulling back the section of scalp she'd loosened, clipping it back with a surgical instrument, then using two hemostats to stop bleeding, while the neuro nurse carefully applied suction. Doctor Cohen, an experienced surgeon, but new to Neuro, cut out the section of bone, and put it in a basin.

"Herniation, Doctor!" the neuro nurse declared as the brain visibly swelled through the skull flap.

"Mannitol, IV push!" Doctor Cohen ordered and her nurse picked up a pre-loaded syringe and injected it into the IV.

"V-fib!" Ghost announced. "Paddles to me!"

Two rounds of shocks and a dose of epinephrine resolved the V-fib, but the patient still had arrhythmia.

"Al, call upstairs and ask for Doctor Baker to come down immediately, please."

He went to make the call and five minutes later, Doctor Baker came into the room. Doctor Cohen reviewed the case with him and he performed his exam, shaking his head.

"I don't think we're going to save this one," he said. "You can't move him and it wouldn't matter if you could. At this point, if the swelling resolves, he might make it. If not...is a next of kin here?"

"His wife is in the waiting room," I said.

"Rebekah, let's go talk to her," Doctor Baker said. "Ghost, with us. Mike stay here and monitor the patient."

"Yes, Doctor," I replied.

They left, along with Al, leaving Mary, me, and two nurses in the room.

"Is there anything more we can do?" Mary asked.

I shook my head, "I already said a prayer, and at this point, that's all that was left to do. The brain swelling isn't reducing after two doses of mannitol, and he's likely to suffer cardiac arrest at any moment. That V-fib before was the harbinger. Some time in the next ten minutes, most likely, he'll have another bout of V-fib which will lead to asystole, if not immediately, then shortly after. There is nothing we can do to stop that."

"You were sure when you did the neuro exam."

I nodded, "So was Doctor Casper, but he was correct to ask me to wait until he'd finished his full exam. A blown pupil, CSF in the ear, and no response to a Babinski all indicate serious neurological compromise. And then when the brain flap was created, the brain swelled significantly. A helmet might have saved his life."

"Why would anyone ride a motorcycle without a helmet?"

I shrugged, "It's a free country, which means we're free to do foolish things like smoke, drink to excess, ride motorcycles without helmets, and get on helicopters!"

"I was pissed right up until they called in that you'd made an emergency landing. After that, not so much."

"If we weren't short-handed, I'd have taken you, but they needed you here."

"I heard Tom was freaked out."

"He was. I sent him home to get a good night's sleep."

The monitor blared, and I reached over and pressed the silence button.

"V-tach," I said. "Run of eight."

"I thought you said V-fib," Mary observed.

"I did. V-tach in short runs isn't life-threatening, but it's an indication of trouble. Any drugs I could give him at this point would likely be counterproductive. Is there any urine in the bag?"

She checked and held it up, "Pink."

"Internal bleeding, too," I said. "Too many things wrong and not much we can do about it."

"I feel helpless," Mary said.

I nodded, "Me, too. But in the end, we're not gods, the red scrubs I'm wearing notwithstanding."

She laughed softly, "You aren't a..."

"Prick?" I prompted.

"I was going to say 'a-hole' like most surgeons."

"Because I'm not a surgeon and don't have the right mentality for it. I'll be a competent general surgeon, but my main role will be emergency procedures. I live for the adrenaline rush."

"Including helicopter accidents?"

"That one was over the top even for me."

The monitor blared again, and I hit the silence button.

"Run of ten," I said. "It won't be long now."

The three doctors came back into the room.

"Two runs of V-tach," I said. "Runs of eight and ten. I expect he'll go into V-fib soon, then arrest."

"I'd say that's right," Doctor Baker said. "We did get consent, so I had Al call for the transplant team to stand by."

"Do we try to shock him?" Mary asked.

"Yes," Doctor Casper said. "With no advance directive, we have to try."

Just under ten minutes later, the expected scenario played out, and after five shocks and two doses of epi, the monitor showed asystole.

"Call it, Mike," Ghost said.

"Time of death, 23:51," I said.

"Let's get him up to surgery," Doctor Baker said. "No time to wait for an orderly. Al, grab the gurney."

I filled out the chart while they moved the patient to a gurney, connecting a portable ventilator to keep his lungs perfused with oxygen. Doctor Beker, Doctor Cohen, and Al left with the gurney and Doctor Casper sent Mary to bring his wife to the consultation room.

"Ms. Jackson," I said when she came into the consultation room. "Please have a seat."

"He died, didn't he?" she asked, tears welling up in her eyes.

I nodded, "Yes. We used every skill and every procedure we could, but his injuries were too severe, and he died. With the consent you provided, he's being taken to surgery for organ donation, and you'll be able to see him afterwards. Would you like us to call someone for you? There's a chaplain on call, if you want."

"Our priest at Saint Augustine," she sniffed. "Father Clifton."

"I'll see that he's called," I said. "Mary will take you upstairs and sit with you until your priest comes."

"Thank you," she said.

Ghost and I left the room, and I went to the clerk's desk and asked Nicki to call Father Clifton and ask him to come to the hospital, then Ghost and I went to the lounge to get bottles of juice.

"You jumped the gun a bit," he said. "You were right, but it's important to always finish the exam, no matter how obvious the situation is. It's too easy to start taking shortcuts and making assumptions. And that is the way to kill your first patient."

"Message received loud and clear," I said.

"Just remember, Mike, ninety-five percent of the time the obvious answer is the answer. It's those other five percent that will burn you."

"Doctor Casper?" Nicki said from the door to the lounge, "There's a Sheriff's Deputy here who wants to speak to the pronouncing doctor."

"That's Mike," Ghost said.

"Send him in," I said. "I really do not feel like standing up at the moment."

She left and about fifteen seconds later, Deputy Schmidt came into the lounge.

"Hi, Doc," he said to me.

"Hi, Deputy. You're here about the donorcycle?"

"Yes. I just need a time of death and a summary of his injuries for my report."

"Mind if I ask what happened?"

"He was in the left lane and a car changed lanes without signaling or looking for him. The driver is at the sub-station being questioned. We have two witnesses in a car behind them."

"Reckless operation and negligent homicide?" Doctor Casper asked.

"Most likely, because they can make that stick based on what I've seen."

"Time of death was 23:51. Severe head injuries, which resulted in an irregular heartbeat that we couldn't resolve. He was paralyzed at least from the waist down, and wasn't breathing on his own. He also had internal injuries, but we won't know the extent until we see the surgical report from the transplant team."

"Can you give me a cause of death?"

"Not wearing a helmet," I said. "Beyond that, you'll need to wait for the surgical report or hear from Doctor McKnight."

"What do you think?"

"That I'm not a forensic pathologist or medical examiner," I replied. "All I can say is that we saw his heart stop, which is, in the end, the cause of every death. Which specific injury caused that, I'm not equipped nor prepared to say."

"OK. That's all I need. I heard his wife is here."

"Upstairs with my student, Mary, waiting for a priest. They're in the surgical waiting room."

"Thanks, Doc."

He left, and I leaned back again, the effects of multiple adrenaline rushes making me feel ready to collapse, despite being only halfway through my shift.

"Go take a nap," Doctor Casper said. "Barring the outbreak of World War III or giant grasshoppers attacking, we won't wake you for two hours."

"If World War III starts, let me sleep. I'd rather the nuke went off and I didn't know about it."

"I hear you on that one. Nice work deflecting Deputy Schmidt."

"It was drummed into my head by Doctor McKnight that he's the only one who can say definitively what happened except in cases of decapitation, which is routinely fatal and obvious."

"You think?" Doctor Casper said, shaking his head. "Go get some sleep."

"Thanks," I said.

I got up, made my way to the on-call room, put on the sleep mask I carried, got into bed, and fell asleep almost instantly.