Chapter 68 — Confrontation

_December 14, 1989, McKinley, Ohio_

{psc} "I hear you're being released today," I said to Nancy when I visited her on Thursday morning.

"Finally!" she exclaimed. "Four freaking weeks in the hospital!"

"Mind if I look at your chart?"

"Why not?" she said with a smirk. "You've seen everything else!"

I chuckled and picked up the chart. I'd looked at it each time I'd visited, but I wanted to see the final discharge notes from the physical therapist. Nancy was making excellent progress, though it would be a few months before she'd have the cast removed from her leg. She'd had her final surgery on her arm, removing some of the hardware that had been installed when they'd reconstructed it.

"Looks good," I said. "How does your arm feel?"

"It throbs, but Tylenol solves that. The cast is crazy uncomfortable and I itch."

"I'm glad the double-vision cleared," I said. "Concussions can be lifelong problems."

"Me, too! That was driving me completely nuts, even more than you did!"

"Ouch," I chuckled.

"I'm teasing, Mike! We had our ups and downs, and despite the problems, it was good. We just weren't meant for each other. Mom was disappointed, but she likes Matt, and she spoils Matty to death!"

"I believe that's the job of grandmothers and, apparently, little sisters!"

"Yours? Or your wife's?"

"My wife's, of course. I don't even want to think about what my little sister might teach my daughter! Being taught French is bad enough!"

"That's right, you told me your wife is a recent immigrant from France. And I would have figured you were teaching her Russian."

I shook my head, "No, we're American through and through. The French is only to annoy me, though, ultimately, her being able to speak French is probably far more useful than Russian. That said, with what's going on in Eastern Europe, you never know. Russia might become an ally once again, but this time without a communist government. It's really only since the end of World War II that Russia hasn't been a US ally."

"I take it you plan more children?" Nancy asked.

I nodded, "We do. Can you keep a secret? I mean, from everyone?"

"Your wife is pregnant?"

"Due in late June. We plan to announce it at Christmas dinner."

"If I recall correctly, you have to work holidays."

"I do. We'll have ours on the 24th after Vespers. I already received permission from the bishop for «ekonomia» for both families to have our celebration that night because I have a shift from 0500 to 2100 on Christmas day."

"Er, I don't do military time."

"Sorry. That's 9:00pm. The trick is that if it's before 1200, it's AM and if it's after 1200, it's PM, and you subtract twelve. We use it because it reduces confusion as to when your shift starts or ends, especially when it's a thirty-six-hour shift!"

"Ugh! How do you do that?!"

"Fortunately, I don't. The Emergency Department switched to eighty-hour weeks, with no more than twenty-four hours per shift and at least eight between shifts. There was a situation in New York attributable to overworked and overly tired Residents at the end of a thirty-six-hour shift with little sleep, and that's caused some hospitals to change their scheduling practices."

"What happened?"

I explained the basics of the Libby Zion case to Nancy, who just shook her head.

"Sorry to cut this short," I said at the end of the story, "but I need to get back to the ED. I just wanted to come say 'hi' before you're released."

"Thanks! Mom wants to have you and your wife to dinner. Is it OK for her to call you?"

"Absolutely. Let me write down the number."

I wrote my name and number on the scratch pad next to the bed, then said 'goodbye' to Nancy and headed back to the ED.

_December 17, 1989, McKinley, Ohio_

On Sunday, after Matins and the Divine Liturgy, Kris, Rachel, and I had lunch with the congregation, and then I met with Bishop JOHN.

"I'm sorry I didn't have time to speak last week when you asked about Nativity," he said after we sat down in his office.

"It's OK, Vladyka," I replied. "I totally understand, and I cannot monopolize your time!"

"I enjoy speaking with you, Michael! How are things at the hospital?"

"There's been a bit of drama surrounding a medical student and a doctor having an affair and an allegation that her grade was improved because of that affair."

"I find it hard to believe it's not against the rules for what amounts to a teacher being intimate with a student."

"It is _now_," I replied. "As a direct result of that situation. I've been pushing for that rule for two years, and things finally were serious enough that the medical school and hospital both instituted rules limiting that."

"Limiting?"

"There is a bit of leeway for students and doctors who are not on the same service, but it has to be disclosed."

"Knowing you, I have to ask — how involved were you?"

"Up to my eyeballs, of course! The student was a troubled one who was assigned to me when everything went down. She was dismissed for making false sworn statements and the doctor in question is suspended pending a completion of the investigation."

"What was your part?"

"The false accusation was leveled against me, but I'd taken steps beforehand to ensure a claim like that wouldn't stick."

"Now I have to ask — did you do anything at all questionable?"

"Not in the way you mean," I replied. "I did speak to Father Herman about my response to some of the tension that was created because of the internal battle over the rules change and the responses to the situation."

"May I ask what steps you took?"

"On the advice of one of my mentors, I began carrying a pocket tape recorder and recorded a meeting with the student. Her characterization of the meeting was directly at odds with the tape recording, which led to her dismissal."

"That could have gone very badly," Bishop JOHN observed.

"It was actually that meeting that caused her to make the false accusation because I confronted her with other lies she'd told. I was also careful to have a trusted nurse stand in a strategic spot so she could see the student and me."

"Perhaps you should start at the beginning and explain, as best you can, without violating any hospital rules."

I nodded and gave a complete rundown of the situation, beginning with Felicity Howard and running through the hearing the previous Monday. Bishop JOHN listened intently, but didn't ask any questions until I finished the story.

"You discussed this with Father Roman?"

"Most of it, yes. I'm seeing him face-to-face the first Sunday in January."

"Good. How are things otherwise?"

"Very good. I'll tell you now, as I won't have a chance to do so before the usual gossip brings it to your attention — Kris is pregnant and we're due towards the end of June."

"Wonderful news, Michael! When will you make it public?"

"We'll tell our families on the Eve of Nativity at the dinner for which you granted «ekonomia»."

"Of course, Michael! Your schedule is such that accommodation is totally warranted. I assume you've modified your fasting rule?"

"Yes. Father Luke, Kris, and I worked out a rule for any time she might be pregnant, and I believe she informed him in confession that she was pregnant. The one place, besides your office, completely immune to gossip!"

"If there was one thing I could end with the wave of my staff, that would be it! How is Rachel taking it? Or does she know?"

"We'll tell her right before we tell our families; toddlers are not known for discretion or keeping secrets!"

"Nor many adults, sadly! I'm very happy for you, Michael."

"Thank you, Vladyka."

_December 18, 1989, McKinley, Ohio_

On Monday afternoon, just after 3:00pm, Shelly Lindsay appeared in the ED and asked to speak to me. The consultation room was free, so we went there.

"Mark King reached an agreement with the hospital," she said. "Exactly along the lines you and Strong predicted. He'll be permitted to finish his Residency on probation, but agreed to not even apply for an Attending role here."

"Plus a payoff?"

"Yes. He'll pay Krista some amount, but it's a private agreement between them in exchange for her dismissing her case with prejudice. Also, as you two predicted, she was allowed to withdraw from the medical school on condition she not apply to or attend a medical school for two years."

"I think, all-in-all that works out best," I observed. "I know you and the other female staff aren't happy, but it's also the case that as scummy as Mark King might be, he didn't break the rules in force at the time. Thankfully, those rules have changed. I can't imagine Krista would be able to get into medical school again."

"You never know," Shelly said. "Stranger things have happened."

"If she gets in touch, which I expect her to do, I'll encourage her to use the money from her settlements to enroll in a PhD program and become a researcher. She's intelligent enough; her problem was always clinical skills."

"You really do try to find the good in everyone," Shelly observed.

"I believe the world would be a better place by finding the good in each and every person, insofar as that's possible. Orthodox Christianity doesn't believe in unforgivable sin in the sense that some individual act or series of acts puts you on what AC/DC called a _Highway to Hell_ with no exits. But I'll spare you the rest of the theology lesson."

Shelly laughed, "I do appreciate you doing that, though I am always curious about what makes you tick. I need to get back upstairs for afternoon rounds; dinner?"

"You're welcome to join Clarissa and me."

"See you for dinner, then. Just call when you get your break."

"Will do."

We left the consultation room, Shelly headed back to the surgical ward, and I went to the lounge to get water from the cooler.

"Doctor Mike?" John said, coming to the door. "Labs are back on the abdominal pain in Exam 2."

"Interpretation?"

"Everything is within nominal ranges."

"So, tell me what's wrong with him."

"I don't know."

"What do we know?"

"Sharp, localized abdominal pain that increases, peaks, and subsides; vomiting; no fever; no signs of appendicitis."

"So, where do you go from there?"

"EKG, and if it shows no signs, then the most common differentials are gallstones, kidney stones, or small bowel obstruction."

"We have plenty of time, so set up a twelve lead and come get me."

"Right away!"

He was back about five minutes later and let me know the EKG was established. I followed him to Exam 2, where Kelly was waiting with the patient, Mr. Wolff. The EKG appeared normal, and auscultation and palpation had not provided any evidence. I asked John and Kelly to step out of the room.

"Clear EKG," I said. "What next, John?"

"Ultrasound."

"OK. Let's do it. You can handle the transducer, and we'll review the screen together."

"I haven't done that before."

"There's a first time for everything," I said. "Do you know the theory?"

"Yes."

"And you've observed ultrasounds?"

"Yes."

"Watch one. Do one. Teach one. Learn it. Know it. Live it."

"Wait!" Kelly exclaimed. "Did you just quote _Fast Times at Ridgemont High_?"

"I did indeed!"

"Phoebe Cates or Jennifer Jason Leigh?" Kelly asked.

"A girlfriend asked me that right after we saw the movie, and I replied it was Jennifer Jason Leigh, hands down, no question, not even close!"

"Most guys prefer Phoebe Cates!" Kelly declared.

"One thing of which you can be sure is that I'm not 'most guys', nor am I 'normal'! Get the ultrasound cart, please."

We performed the ultrasound, and I appreciated small masses both in the gall bladder and in a bile duct. I directed John's attention to them, then asked for a diagnosis.

"Choledocholithiasis," he replied.

"What's that mean?" Mr. Wolff asked.

"Gallstones," I replied. "Two of them have migrated into the bile duct."

"What's the treatment?" Mr. Wolff asked.

"A laparoscopic cholecystectomy," I replied. "It's a routine procedure where we make small incisions, insert special surgical tools, and remove your gall bladder. You don't need it, and most people have no lasting side effects from its removal. Let me call upstairs and see when they can take you."

I went to the phone and dialed the number for the scheduling nurse.

"Jackie, this is Mike Loucks in the ED," I said. "I have a patient who presented with symptomatic cholelithiasis. Ultrasound revealed stones in the gall bladder and bile duct for a diagnosis of choledocholithiasis. We need a team for a laparoscopic cholecystectomy, and I'd like to scrub in, if the Attending will permit it."

"OR 2, with Doctor Burke and Doctor Lindsay; we'll be ready in twenty minutes."

"Thank you."

I hung up and let Mr. Wolff know we'd be taking him upstairs. I had Kelly call for transport, then updated the chart. I excused myself to present to Doctor Gibbs, and let her know I was taking Mr. Wolff up, and had asked to scrub in.

"Who'll do consults if you're upstairs?"

"Whatever poor PGY1 is on the ward," I replied. " I think it's Penny Nichols."

"OK," Loretta replied. "We're not busy, so, go, learn how to be a sawbones."

"Did you hear about Mark King?"

"No."

"Shelly let me know they cut a deal with him. He'll finish his Residency on probation with an agreement that he won't interview or apply for an Attending position here."

"The Board agreed to that?"

"I don't know the exact details, but I'd speculate that Doctor Rhodes simply lifted the suspension that put King on probation. That would bypass the Board."

"I take it Shelly isn't happy."

"She's not, but in the end, there was insufficient proof to sustain dismissing King from the program. He has to pay Krista some undisclosed sum to go along with whatever the hospital and medical school paid her, and she will be shown as having withdrawn from the program."

"So she can try again?"

"Not for at least two years. I hope she goes to graduate school and becomes a researcher. She'll be very good at that."

"You're an odd duck, Doctor Loucks. Go play with your surgeon friends!"

She signed the chart, and I returned to the exam room and began going over the consent paperwork with Mr. Wolff. We finished just before the orderlies arrived to transport him to surgery.

"Come along," I said to John and Kelly. "We'll see if we can get you into the OR to watch."

We walked along with the orderlies and Mr. Wolff and made our way to the surgical ward on the second floor.

"Done slumming in the ED?" Shelly asked.

"You know that's my natural habitat! Permission for my students to scrub in?"

"Granted. Are you expecting to assist?"

"No. I haven't seen enough of these to be ready for contingencies. Put in someone with more experience."

Shelly smiled, "For all your attitude, you do know when to pull back."

"And you know that I've never allowed my personality to negatively affect patient care. I save it for all the _other_ BS. I think the best thing for me to do is observe closely and take notes."

"I agree. I just wish we had our surgical theatre and video system. It's coming, but not soon enough. Scrub in, please."

I asked John and Kelly to wait, and went to the locker room to remove my baptismal cross, as I couldn't wear it during surgery. I stashed it, along with my wedding ring, which I normally carried in my pocket because I couldn't wear it under my gloves, in my locker. I rejoined John and Kelly and we went to the scrub room. I guided them through the process, assisted by Maddie, the scrub nurse, and we went into the operating room. I stood in the place for a student observer, and directed my students to a spot further from the operating table, but with a decent view of the video screen.

The procedure went well, and I took notes on paper that had been sterilized before being brought into the OR, and made drawings of the proper placement of the trocars, and the steps for inserting and removing them. By the time the procedure was completed, I had two pages of notes, in addition to the drawing. My students and I scrubbed out, I retrieved my baptismal cross and ring from my locker, and we headed back downstairs.

"Why did you say you shouldn't assist?" Kelly asked.

"Because I'm not ready," I replied. "I'm allowed to do procedures PGY1s are not normally permitted to do because I'm responsible enough to say when I'm out of my depth and ask for help. That includes admitting to Doctor Lindsay that I wasn't ready to assist because if something went wrong, I wouldn't know what to do, and that is a recipe for adverse outcomes. Doctor Lindsay will tell Doctor Roth what happened, and that will improve my standing with him. The lesson to learn here is that you are credited with acknowledging your limitations, so long as it isn't because you're tentative or skittish."

"That seems counterintuitive to your normal advice to students," John said. "You tell students to demand to be taught."

"Yes, I do. And what exactly did I do in that OR?"

"Took notes and drew diagrams," John replied, then smiled. "You were learning."

"Yes. That's how surgeons learn. There's a difference between me talking you through inserting a Foley, or even intubation, and a surgeon trying to talk me through a procedure I've never done and haven't seen more than once."

"That makes sense," John agreed.

"I try," I chuckled.

_December 22, 1989, McKinley, Ohio_

"Is there anything you want to cover before we present at the M & M?" Ghost asked.

"Not that I can think of," I said. "I know you don't mean 'get our story straight' because we both agreed on all the relevant facts and we both agree the expected outcome without intervention was death due to hypovolemic shock caused by multiple penetrating trauma."

"Carl mentioned he warned you about the likelihood of someone challenging you given the adverse outcome and your initial objection."

"Yes. My money is on Rosenbaum from Pedes."

"No bet," Ghost said. "He's the one, though I'd give decent odds on Tim Baker."

"He'd be my second choice," I agreed.

"While it shouldn't come up today, you did exactly the right thing reporting yourself to Doctor Cutter, too. That deflects any claims of trying to hide it or cover it up."

"The goal is creating and maintaining trust," I replied. "This being a completely new program cuts both ways — what engenders trust from the surgeons and the emergency medicine specialists creates mistrust from other services."

"They always think we're a bunch of cowboys who don't believe there are any limits, and often refuse to acknowledge that seconds count here, sometimes even more than in surgery. You're straddling both services, so you have a somewhat unique perspective. Shall we go?

I nodded and the two of us walked to the auditorium where the M & M conferences were held, choosing to sit about a third of the way back, rather than right in front. Clarissa sat down next to me, and Shelly, Carl, and Loretta joined us a few minutes later. Promptly at 3:00pm, Doctor Rhodes called the M & M conference to order.

"Our first case concerns a twenty-three-year-old female who presented with multiple stab wounds. Doctor Casper and Doctor Loucks, please present the case."

We got up and made our way to the lectern.

"Good afternoon," Ghost began. "We received the patient via EMS transport with multiple penetrating trauma to the chest and stomach, as well as lacerations on her arms and hands. EMS had applied pressure bandages and administered a unit of plasma and saline for volume. She had a pressure of 70/30, her pulse was 120 and thready, and her PO₂ was 90% on ten liters by mask.

"Before we even began moving, Doctor Loucks determined that a central line would be necessary to combat obvious hypovolemic shock and gave orders to Nurse Martin to get a central line kit. Nurse Martin sprinted ahead while the remainder of the team and two firemen transported the patient to Trauma 1. We quickly moved her to the table, and I performed rapid sequence intubation to establish an airway. At this point, I'll allow Doctor Loucks to take over."

He moved aside, and I stepped up to the lectern.

"While Doctor Casper was performing RSI, I completed a blind central line without sonography or lidocaine, as time was of the essence. As soon as the line was in, a unit of plasma was run in via the rapid infuser, and blood was typed and cross-matched. As the blood was running in, Julie Baker, a Fourth Year on the team, announced that there was serious resistance showing on the ventilator display, and Doctor Casper ordered a chest tube.

"At that point, I was concerned that the pressure dressings were causing a tamponade compressing at least one, if not both lungs. A quick evaluation showed at least eleven stab wounds made with some kind of knife; the autopsy report showed fourteen, as three of them were almost perfectly congruent with three others. I stated my concern aloud to Doctor Casper, and almost immediately John Abercrombie, a Fourth Year on the team, announced that the patient's PO₂ had dropped to 86% and was continuing to fall.

"Doctor Casper instructed me to insert the tube and having observed her PO₂ had dropped to 83%, I felt I had no choice and asked for a chest tube tray which was retrieved by Nurse Martin. I had sign-off to perform the procedure autonomously and followed the steps as I'd been trained. As I made the final incision, a rush of fluid, mostly blood, in significant volume, poured out of the patient. I estimated about a litre of blood on the floor.

"Again, almost immediately, John reported the monitor showed no blood pressure and announced 'asystole'. I continued to work, inserted the tube and connected the ThoraSeal. Doctor Casper ordered two units pumped in and announced he was beginning compressions. John announced, 'no pressure; no pulse' and I stated that the situation appeared hopeless due to hypovolemia.

"I noticed significant blood in the ThoraSeal, running out almost as fast as we could pump it in. Doctor Casper ordered one more unit plus epinephrine down the tube, both of which had no effect. There was no change on the monitor, and based on the extent of the patient's injuries, I concluded further attempts at resuscitation would be futile and suggested to Doctor Casper that he call the time of death. He agreed and pronounced the patient at 18:18."

"Questions?" Doctor Rhodes prompted.

Unsurprisingly, Doctor Seth Rosenbaum stood up immediately.

"If you knew the chest tube would result in exsanguination, why perform it?"

"Left untreated, the patient would most certainly die due to a combination of trauma, hypovolemia, pulmonary tamponade, cardiac tamponade, and lack of oxygen circulating to the brain and other organs. Inaction would result in death."

"'Cut first, ask questions later' seems to be your style, Doctor. You performed an unauthorized procedure on another patient. You need to explain yourself."

Doctor Cutter immediately stood up.

"Not to you, he doesn't!" he said firmly. "Contrary to the implication of your question, Doctor Loucks immediately reported his emergency percutaneous cricothyrotomy to me, and filed the appropriate form, co-signed by Doctor Gibbs, who had commanded the procedure. By performing a crike, he saved the patient, a decorated lieutenant in the Hayes County Fire Department. With no adverse outcome, I have thirty days to complete my investigation, and until such time, your question is out of line."

"I disagree," Doctor Rosenbaum countered. "You're covering up!"

"Doctors!" Doctor Rhodes said sternly. "This is not the time nor place to discuss an incident which is being investigated, and for which no report is due until thirty days after the incident."

"Conveniently when Doctor Cutter will be Medical Director, allowing him to sweep a violation of hospital policy under the rug!"

"DOCTOR!" Doctor Rhodes said firmly. "Enough! Take your seat and report to my office immediately following this session. Doctor Sumner, please attend as well."

Doctor Rosenbaum stood petulantly staring at Doctor Rhodes, then stalked out of the auditorium.

"Any other questions?" Doctor Rhodes inquired.

Leila Javadi stood up.

"Doctor Casper, were there any alternatives?"

He stepped up to the mic, shook his head, and said, "No. Doctor McKnight?"

Doctor McKnight stood up.

"As Doctor Loucks noted, I appreciated and recorded fourteen penetrating stab wounds made with a chef's knife, as well as obvious defensive wounds to the arms and hands. Of those fourteen penetrating wounds, there were three which, each in and of itself, would have been fatal. This was the most brutal assault I've seen on an adult in my entire career here at Moore. A fully equipped trauma surgery team arriving with the paramedics could not have saved her. It's a minor miracle she arrived at the hospital with any vital signs. Kudos to the paramedics who responded and brought her in. Just for completeness, both lungs were penetrated, the pericardial sac was nicked, the liver, spleen, stomach, descending colon were all penetrated."

"Doctor Loucks, you were authorised to perform the two procedures, correct?" Leila asked.

"Yes, I have full sign-off for chest tubes and central lines, including without sonography."

She sat down and Carl Strong stood up.

"Mike, how did you feel after performing the procedure?"

"Relevance?" Doctor Rhodes asked.

"A lesson for all the Residents here, and probably some doctors."

"I'll answer, Doctor Rhodes," I said. "Intellectually, I knew I didn't cause the young woman to die, but in my heart I felt I had, given a procedure I had performed led directly to her death. Without question, she would have died had I done nothing, but that did not relieve the heaviness of heart I felt when Doctor Casper pronounced her.

"I sought advice and counsel from Doctor Lindsay, and others, as well as my spiritual advisor. Most importantly, my spiritual advisor cautioned against becoming so inured to death that it has no impact at all. That would be dehumanizing both for the physician and the patient, and medical care is already dehumanizing in many aspects, especially in the ED."

"Would you expand on that thought?" Doctor Deborah Atkins from Internal Medicine asked.

I nodded, "We already refer to patients in the ED by their presenting condition — the MI in 3 or the hot appi in 1. Anyone brought in by ambulance has numerous things done to them with no explanation and no consideration for the psychological effects on the patient and practitioner. I know, of course, that is dictated by the 'Golden Hour', among other things, and by the need for speed, but we need to stop to remember that every patient who enters the ED is a human being, not a collection of symptoms.

"The key is balancing lifesaving actions and holistic care. I know full well that there are times when nothing matters except the emergency procedure and moving the patient to surgery, the cath lab, or ICU, but again, we can't forget our patients are human beings. I pray, silently, for every patient by name, and in the more severe traumas, for the team caring for them."

"You pray for every patient?" Doctor Silver from Psych asked.

"Yes — the most simple of all prayers — Lord have mercy."

"And you think that's appropriate?"

"I do. I pray silently, and nobody knows about it except God and me. Well, and now about sixty of my colleagues."

"I find that offensive," she declared.

I shrugged, "So don't do it. That's what's great about the US — nobody can force you to pray, nor can they force you to _stop_ praying, except in very, very limited circumstances, and even then, they cannot stop you from praying silently. We have no Thought Police here, and a Constitution which protects all of us."

"We're veering off topic," Doctor Rhodes said.

"Are we?" Carl Strong asked. "Isn't the mental health of everyone in this room critical to providing the best possible medical care? And honestly, in the scheme of things, a prayer addiction is FAR less problematic than alcohol, drugs, or philandering!"

There was quite a bit of laughter at that quip.

"Carl and Mike make good points," Ghost said. "Our mental health is vitally important, and if someone has something that helps and doesn't put patients at risk, more power to them. It's far better than going home and drinking half a bottle of scotch, kicking the dog, beating your kids, or cheating on your wife. We've had ALL those in spades. We burn out, and it's cases like the one we're discussing that we have to come to terms with, or we'll be of no use to anyone."

"All very good points," Doctor Rhodes acknowledged. "If nobody has any questions, we'll turn to Doctor Bielski about a case of malignant hyperthermia from administration of succinylcholine for the purposes of intubation."

The case was interesting, and they'd successfully treated the patient with 180 megs of dantrolene, and were able to complete the surgery. There were no further cases, so once Doctor Bielski had completed his presentation and fielded questions, the M & M conference ended. Several of us, including Clarissa, went to the cafeteria to get drinks and snacks for the seminar on advances in diagnostic imaging, specifically Nuclear Magnetic Resonance Imaging.

I didn't see the county being able to allocate the kind of money necessary to obtain an MRI system, but that didn't mean I was any less interested. We might have to send a patient to another hospital for the scan for the near future, but, as with almost every medical advancement, the costs would come down and what was now rare would become commonplace. After the seminar, Clarissa pulled me aside.

"How much trouble can Rosenbaum cause you?" she asked quietly.

"None. The entire point of turning myself in, as I've called it, was to head off anything like what Rosenbaum is doing. He'll get nowhere. Rhodes is already in 'short-timer' mode, and everyone already goes to Cutter about things for next year. Rosenbaum went out on a limb and sawed it off between himself and the trunk of the tree. And imagine how it would look if he did make a stink and I decide to accept the medal Bobby and Sam proposed."

"Medal?"

"The Fire Department has an award they give out in extraordinary circumstances to someone who isn't a firefighter. They propose awarding it to me, and invited Kris and me to dinner at the station."

"I hear Lieutenant Greer is a very popular guy," Clarissa observed.

"I saw that during my ride-along stint. I checked on him this morning, and he's recovering nicely. He'll barely have a scar, according to Plastics."

"Back to the M & M, I figured it would be Lawson."

"I knew it would be Rosenbaum. Lawson can't really say much, given his friend admitted clinical error to the State Medical Board."

"But he blames you."

"Sure, and I'm happy to take that blame, though I prefer the term 'responsibility'. Baker was my second bet, but once Rosenbaum was slapped down, Baker kept quiet."

"He's not a bad guy," Clarissa said, "he's just a bit quick to throw stones at surgeons."

"The age-old battle between pill-pushers and real docs," I said with a sly smile.

"«Иди в жопу»!»" Clarissa declared. ("Kiss my ass!")

"Been there, done that, had the orgasm," I chuckled.

Clarissa laughed, "You're such a goofball, Petrovich!"

"I yam what I yam!" I declared.

"Well, Popeye, Olive Oyl has to get back to work! Later!

"Later!"

We hugged and went our separate ways.

"Sorry, Mike," Doctor Mastriano said when I walked into the ED.

"News travels fast!" I observed. "There's no need to apologize! You kicked him to the curb months ago!"

"Perhaps someone should let Mrs. Rosenbaum know," Becky suggested, coming up behind Isabella.

"Please don't," Isabella replied. "That'll just make things worse. Just allow Kelly Sumner to address it."

"Ready for the turnover, Mike?" Jody Billings asked, coming up to where I was standing with Isabella and Becky.

"I was at the M & M and then the seminar. Paul has the board, and he has a few hours to go."

"Great! See you tomorrow morning!"

A few minutes later, I left the ED and went to the surgical locker room.

"Rosenbaum is such a huge prick, he should have Matched for urology!" Shelly observed when I walked in.

"Let's just say I'd take any PGY1 in Pedes to care for Rachel before I'd allow him anywhere near her."

"Did you hear anything more?"

"No. Word of the confrontation spread like wildfire," I replied, "but I haven't heard anything. You?"

"No," she said, grabbing her towel and heading for the shower.

I finished undressing, except for my briefs, which was the norm, and went to the shower. I removed my briefs, showered quickly, and dried off. With my towel wrapped around my waist, I returned to my locked, pulled on a fresh pair of briefs, then dressed. Shelly and I left the locker room together, headed for our cars, then each headed home.

_December 23, 1989, McKinley, Ohio_

"Doctor Mike, I'm ready to present," Andy said just after I'd arrived in the ED on Saturday morning.

I followed him to Exam 3, where Karl, my other Saturday student, was waiting with a man of about sixty.

"Ted Fahey, sixty-one; complains of extremely blurry vision in his left eye with overnight onset; BP 120/74; pulse 65; PO₂ 98% on room air; no trauma, no recent illnesses, and no other symptoms."

"Good Morning, Mr. Fahey, I'm Doctor Mike. Can you tell me more about what happened?"

"I think it might have started last night," he said. "I walk every day for exercise, even when it's cold out. About halfway through my walk last night I saw floaters, you know, specks in my eye that move around. I've had 'em before, but these were worse…"

"You mean more? Or larger?" I asked, interrupting him.

"Both," he replied. "But since I've had 'em before and I could see just fine, I didn't think anything of it. Then this morning, when I woke up around 4:00am to use the can, I felt something was wrong. We have nightlights, so I didn't turn on any other light, but things seemed blurry. I chalked it up to not being fully awake, but then I went downstairs to start the coffee and I realized I couldn't see anything except light, color, and some fuzzy shapes with my left eye. I told my wife, and she insisted I come get checked because she's convinced I have a brain tumor."

"There are many reasons for blurry vision, and that would not be the most common, especially given your age. Do you wear glasses or contacts?"

"Readers only. The BMV thinks I can see well enough to drive without 'em."

"Did you feel at all unsteady or dizzy?"

"No. It's a bit weird only seeing with one eye, but I didn't run into cabinets or fall down the steps or anything."

"When was you last eye exam?"

"March. The doc said everything looked good."

"Optometrist or ophthalmologist?"

"What's the difference?" he asked.

"Optometry is a trade; ophthalmology is a medical profession. Optometrists don't go to medical school while ophthalmologists do. Both are called 'Doctor' by convention. Basically, an optometrist cannot prescribe medication or perform procedures. Most people only ever need an optometrist until they get older and have to deal with glaucoma, cataracts, or other eye diseases. Where does your doctor work?"

"Advanced Family Eyecare."

"He's an optometrist," I replied. "Any history of diabetes in your family?"

"No."

"Stroke? Heart attack?"

"No."

"I'd like to take a look."

"Go right ahead, Doc!"

I washed my hands, put on gloves, then got the ophthalmoscope from the holder and used it to look into both of Mr. Fahey's eyes. His right eye was clear and I could see his retina, but his left eye was clouded and I couldn't see it at all.

"Is your blurry vision tinted at all?" I inquired.

"A bit reddish brown, I'd say," Mr. Fahey replied.

"You have what appears on initial exam to be a vitreous hemorrhage, that is, blood in the fluid inside your eye. There are any number of potential causes, with the most common being a retinal tear or a retinal detachment. Both of those can be repaired. I don't have the equipment or expertise to determine the exact cause, so you're going to need to see an ophthalmologist who is a retinal specialist. We don't have one here at the hospital, but there is one on-call. I'm going to call him and arrange for him to see you this morning, most likely in his office in the medical building across the parking lot."

"How bad is this?" he asked.

"It's not my specialty, but the procedure to repair either of the things I mentioned is fairly routine and has a very high success rate. Before I make the call, I'd like both my students to look at your eyes, as we don't see this condition very often in the ED. Would that be OK?"

"Sure, Doc," Mr. Fahey agreed.

I guided Andy and Karl through looking in Mr. Fahey's eyes and noting the difference, then excused myself to go to the Clerk's desk.

"Nicki, I need the number for the on-call ophthalmologist, please."

She looked it up, dialed the number, and handed me the phone.

"Dave Hulen," he said when he answered the phone.

"Mike Loucks at Moore," I said. "I have a sixty-one-year-old male patient with an obvious vitreous hemorrhage who needs to be seen today."

"He's there now?"

"Yes."

"Have him meet me at my office, which is Suite 209, in an hour. I'll be there with a nurse."

"Great! Thanks."

"You're welcome."

We said 'goodbye' and I hung up, then returned to Exam 3.

"Doctor Dave Hulen will see you in an hour in his office. Let me fill out the discharge papers, which will have his name, phone number, and the suite number. Doctor Hulen will take good care of you. Is your wife here?"

"In the waiting room."

"Andy, please bring Mrs. Fahey in," I said.

I filled out the paperwork, explained my diagnosis to Mrs. Fahey, and once I'd reviewed the discharge papers with them, they left.

"Why did you ask about diabetes when he doesn't have it?" Andy asked.

"Diabetic retinopathy is a common cause of retinal detachment. And all he did was deny he had it when you asked. Asking about history does two things. Karl?"

"He can change his answer, or tell you that someone else in his family has it, giving you a clue he might have undetected diabetes. Or, he might have lied."

"Exactly right! Grab the next chart!"