Chapter 21 — A Hot Appy

_July 15, 1989, McKinley, Ohio_

On Saturday morning, I'd actually gone to band practice, and afterwards, Kris, Rachel, and I had done our weekly grocery shopping, and then I'd headed to the hospital for my Saturday shift.

"Mastriano is gunning for you," Doctor Billings said when we met for the turnover. "Watch your back or you might end up with a scalpel in it."

"Wonderful. What do you have?"

"Rule-out MI, which turned out to be gastrointestinal going up to Medicine as we speak. OD from last night waiting on a psych consult for rehab referral."

"Drug of choice?"

"Speedball."

"Because mixing a stimulant and a depressant is a _wonderful_ idea," I replied, shaking my head. "Not that using IV drugs is a great idea to start with. Condition?"

"Coming down. Tachy, diaphoretic, and irritable."

"Male or female?"

"Male in Trauma 1. Callie and Gabby are up to speed."

"Perfect, thanks."

Doctor Billings left, and I went to find my medical students, who I discovered were in the lounge.

"The M & M was interesting," Callie observed. "Can I ask you about it?"

"Yes, though I probably don't have much more to add than I said."

"I was more interested in what 'internal matter' means."

"It's when the facts don't show a violation of the standard of care but do indicate bad judgment, poor reasoning, improper behavior, or policy violations."

"So what will happen?"

"That's up to the Chief," I replied. "And not something about which we should concern ourselves."

"I'm actually curious about what _could_ happen."

"Anything from counseling to a disciplinary letter to suspension to dismissal. That's up to the Chief and depends on the totality of the circumstances."

"Is following the standard of care a 'Get Out of Jail Free' card?" Callie asked.

"There is no such thing. Following the standard of care will protect your rotation evaluation and medical license, assuming there aren't extenuating factors. It won't prevent malpractice claims, nor prevent the malpractice claims being paid, because it's up to the insurance carrier and they almost always pay because it's more cost effective."

"But then you'd have a claim against you!" Gabby protested.

"In most of the settlements, the hospital doesn't admit liability. The other thing to remember is that medical students and Residents are working on the license of their Attending, who is ultimately responsible. For you as students, and me as a Resident, so long as we follow the instructions of our Attending, and those instructions conform to the standard of care, we're mostly safe. It's the Attending who is left holding the bag, so to speak. Anyway, let's go see the OD in Trauma 1."

We made our way to Trauma 1, and I handed the chart to Gabby.

"Present, please."

"William Bisch, twenty-six. Transported by EMS after being found unconscious by his girlfriend. Naloxone administered prophylactically upon arrival. Tox screen showed high levels of cocaine and heroin. This morning, patient admitted injecting himself with a 'speedball' last night. Tachy at 110, with no arrhythmia. All other vitals normal. Waiting on rehab consult."

I nodded to acknowledge her.

"Mr. Bisch, I'm Doctor Mike. How are you feeling?"

"OK," he replied.

"Hi, Mike," Doctor Silver said, coming into the room with a Third Year medical student.

"Hi, Leah. Gabby, please present to Doctor Silver.

Gabby repeated the details, and once Doctor Silver had introduced herself, Callie, Gabby, and I left the room.

"Good job on the presentation," I said to Gabby. "I know most doctors accept 'normal' for vitals, but I prefer the actual numbers."

"Yes, Doctor. Sorry."

"No need to apologize, I do some things differently. Remember, you can't spell 'details' without dotting the i's and crossing the t's."

"Got it!"

"Mike?" Doctor Varma said, coming up to us. "Can I get a surgical consult? The on-call Resident just took up a traumatic amputation."

"What do you have, Naveen?"

"Suspected hot appy; bounceback abdominal pain discharged last night. Exam 3."

"I'll take a look. Gabby, get the ultrasound, please. Callie, what are we looking for?"

"Male or female patient?" she asked.

"Female, twenty-five," Doctor Varma replied. "Negative pregnancy test last night."

"Then we're looking for pain in the lower right quadrant on palpation. Lack of appetite is indicative, as is nausea. Doctor Varma, did the CBC show elevated white count?"

"No."

"Temperature?"

"38.8°C."

"Also indicative, but not definitive," Callie observed.

Gabby brought the ultrasound and the four of us went into the exam room where Doctor Varma's medical students were waiting.

"Ms. Brundle, this is Doctor Mike Loucks, a surgical Intern."

"Good afternoon, Ms. Brundle," I said. "May I examine you?"

"Yes."

"Cough please," I requested as I palpated her abdomen.

She did and winced in pain, exhibiting Dunphy's sign.

"Have you eaten anything since last night?" I inquired.

"No. I haven't been hungry."

"Have you felt nauseated?"

"Yes."

"I'd like to do an ultrasound," I said. "Gabby?"

She wheeled the cart over, turned it on, and handed me the transducer. She squirted gel on Ms. Brundle's abdomen and I placed the transducer at the approximate location of the appendix. I moved it around to locate her appendix and quickly found it.

"No obvious enlargement," I said. "But there is free fluid in the right iliac fossa. Callie?"

"Not determinative, but the combined signs suggest it's an appy."

"I agree. Call upstairs and let them know we have a hot appy. Ms. Brundle, it appears you have acute appendicitis and you'll need to have your appendix removed immediately."

"I knew that last night, but they sent me home!"

"Appendicitis is difficult to diagnose," I said.

"Mike," Callie called out three minutes later. "The nurse wants to speak to you."

I excused myself and went to the phone.

"Mike Loucks."

"Doctor Mike, Doctor Aniston is taking the other case that just arrived with Doctor Rafiq and Doctor Burke, and we're shorthanded today. He said to bring up the patient and scrub in. You'll assist Doctor Blake on the appendectomy. Bring your students. He said you should ask Doctor Mastriano to call in someone from Medicine to cover for an hour."

That meant all the Attendings were either tied up or unavailable, because it was rare that a Resident, even a PGY6 such as Doctor Blake, took the lead on a surgery without an Attending in the OR to supervise.

"We'll bring her up right away," I said.

I hung up, asked Gabby to call for an orderly, excused myself, and went to speak to Doctor Mastriano.

"What?" she asked.

"Doctor Anniston instructed me to bring up a hot appy and scrub in."

"You can't leave us short-handed!" Doctor Mastriano protested.

"Doctor Anniston suggested following the protocol to call someone down from Medicine."

"This experiment gets worse every day," she groused. "Just go."

I left the office and went back to the exam room.

"You two get to scrub in," I said. "Naveen, the OD in Trauma 1 is having a rehab consult with Psych. You'll need to take him."

"Got it," he replied.

The orderly arrived, and we helped Ms. Brundle move to the gurney, then we accompanied her up to the surgical ward.

"OR 2," Nurse Penny said.

"Follow me," I said to Callie and Gabby.

"Callie, you had your surgical rotation, so start scrubbing in. Gabby, do you recall the scrub procedure from your Preceptorships?"

"No," she replied.

"OK. Step up to the sink and I'll talk you through it."

I began scrubbing and explained each step along the way. The scrub nurse, Jean, came in about halfway through and assisted us with masks, hats, gowns, and gloves. Once we were scrubbed, we went into the OR where Doctor Blake, two nurses, and an anesthesiologist were preparing Ms. Brundle for surgery.

"First solo, Bill?" I asked.

"Second. First was an appy as well."

"Open procedure?"

"Yes. I'm not certified on laparoscopy yet."

"Under and stable," Doctor Peter Larson, the anesthesiologist, announced. "You may cut when ready."

"Mike, take the assisting surgeon's position, please. Who are your students standing in the corner?"

"Callie Newsom and Gabriella Martin."

"Step up, ladies, but ensure you leave room for Mike to move his arms."

They moved to stand just behind me on my right and left.

"OK, here we go!" Bill said. "Mike, I'll cut, you retract, Annie will suction."

He began with a transverse incision parallel to McBurney's point, incising the epidermis and dermis. I retracted, and he used a Bovie to dissect down to the external oblique aponeurosis. Following that, he opened the aponeurosis, exposing the internal oblique muscle, and I added a second retractor. After dividing the muscle, he divided the transverse abdominal muscle, and I shifted the retractors. He then grasped the peritoneum with forceps and made an incision, then located the appendix.

"There's that little bugger," He said. "Babcocks, please."

Nurse Felicity handed him the forceps, and he grasped the taeniae coli and advanced until the appendix was externalized.

"Good call, Mike," he said. "Inflamed and enlarged."

He dissected the mesoappendix, then applied two clamps to the appendiceal vessels, divided them, and ligated with silk sutures. Finally, the appendiceal stump was inverted into the cecum.

"And that's it," he said. "No rupture, no involvement of any surrounding tissue. Nice and clear. Mike, Doctor Aniston said you could close if I felt comfortable. What would you do?"

"Begin with an antiseptic lavage, then each of the three muscle layers are closed separately with running absorbable sutures. With no rupture, no drain is necessary, so close the dermis with 3-0 subcuticular absorbable sutures, then close the epidermis with basic mattress sutures.

"Correct. Felicity, surgical closure tray to Doctor Mike."

"Bill, could you see your way clear to allow Callie to close the epidermis? She's signed off for unsupervised laceration sutures, and this is an extremely simple procedure."

"Are you sure?"

"Positive," I said firmly.

"If you complete everything else with no complications, then, yes."

I could tell from her body language that Callie was about to burst, but she didn't say anything, which was the appropriate response. I worked slowly and methodically, ensuring I made no mistakes, and when I had closed the dermis, Doctor Blake gave Callie permission to close the epidermis, which she did flawlessly.

"Good work, Ms. Newsom. Mike, you may now resume your regularly scheduled duties!" he said. "Peter, You can bring her out from under."

"What happened that you're shorthanded?" I asked.

Doctor Blake laughed, "Department golf outing. Didn't you get the memo?"

"No. When was it sent out?"

"End of June. Ah, before you started. But it's on the bulletin board, which you should check on a daily basis."

"Will do."

"Scrub out and we'll get her to recovery. Stop by on break and I'll sign your procedure book. I'm here until midnight."

"Thanks, Bill," I said.

We left the room and scrubbed out, and the three of us went to the locker room to change scrubs.

"Holy shit!" Callie gasped when the three of us were alone in the locker room.

"You may be the first Fourth Year to ever suture in surgery," I said. "May I suggest you put it in your book, but keep it to yourself?"

"Mastriano?" she asked.

"Let's just say you don't want to put a target on your back. With two weeks to go on this rotation, there's no point in riling her up. Let me take all the flak from her."

Five minutes later, dressed in fresh scrubs — red for me and blue for my students — we returned to the ED where, unsurprisingly, I found Clarissa covering for me.

"One patient," she said. "Finger fracture. Splinted and discharged. Meet for dinner?"

"I'll call you when I take my meal break."

She left, and I went to Doctor Mastriano's office to let her know I was back.

"Let me guess, you performed the appendectomy," she said, disgustedly.

"Of course not," I replied. "I've only seen a few and I've never used a scalpel on a live patient except for chest tubes. Doctor Cutter may be changing the norms a bit, but nobody is going to let a PGY1 perform even something as simple as an appendectomy."

"Walk-ins."

"Yes, Doctor," I replied.

I left her office and after the 'high' of surgery, we now had the 'low' of walk-ins with complaints that mostly should have been handled in a physician's office or at the free clinic. The afternoon was entirely routine, and I managed to meet Clarissa for dinner at 6:15pm.

"I take it from the lack of details earlier you stood and watched?"

"I closed," I replied with a grin. "Well, everything but the epidermis. I asked, and Callie was allowed to put in the final sutures."

"Holy shit, Petrovich! You're an Intern! She's a Fourth Year!"

"Surgery was short-handed," I replied. "Yesterday was the departmental golf tournament."

"You're joking!"

"You know how serious they are about golf! The problem really was a traumatic amputation, which required three surgeons, leaving Doctor Blake to take a bounceback hot appy. Protocol is they call in a surgeon, but neither case could wait, and Bill Blake had done a solo appy before. I held retractors, then closed."

"What did Mastriano say? She must have totally lost her shit!"

"She asked if they let me do the appy, and I said that Doctor Cutter would never allow an Intern to perform surgery, even something as simple as an appendectomy. That's only the third or fourth one I've seen, and despite knowing the procedure, I've never used the Bovie electrocautery before, nor made any incisions in living tissue except for chest tubes."

"You didn't tell her you closed?"

"Why create more animosity?"

"She's going to find out."

"Probably. I did tell Callie to simply write it in her procedure book and not talk about it."

"Riiiigggghhht! Because a Fourth Year who sutured in the OR isn't going to tell every single person she knows? I don't know a single female med student who wouldn't offer to have your baby for the chance to do that!"

"You know my take on that, Lissa."

"And you know I was exaggerating for effect! Besides, you'd prefer the seventeen-year-old who offered!"

"I prefer my wife," I replied. "Period."

Clarissa smiled, "With one exception."

"Yes, but you know that will never happen, no matter how much we might prefer to conceive that way."

"Speaking of that, how are things at home?"

"I sleep. Rachel is very unhappy. I'm gone for long stretches, then eat and sleep when I get home. Kris is handling it OK, and we're on track for trying for our first starting in September. You?"

"I feel as if I never see Tessa, but she seems to be handling it OK."

"The lot of Interns everywhere," I replied. "And even if changes are made, they couldn't be implemented before we're PGY2s, because the ED would need five more Residents to have the same coverage; more if hours are reduced across the board."

"Think it'll happen?"

"I suspect, eventually, the pressure will be so great that the Accreditation Council will make changes to fend off legislation in other states. For the entire medical industry, the nightmare scenario is states having different, incompatible standards. That plays havoc with licensing and the ability of doctors to move from one state to another. It's the same with medical school, though adding Preceptorships doesn't create the same problem, though it does disadvantage students who don't have them."

"I can't imagine you closing an appendectomy without having had that extra experience."

"Me, either. I think, importantly, it also allows students to form important relationships early on. That was certainly a major plus for me."

"Playing golf?"

"Yes, but the relationships were far more important than the golf. Another important thing to consider with regard to hours is whether there are actually enough qualified Residents and enough slots in medical schools to train them. I'm not sure there are, given that Residency slots go unfilled every year."

We finished eating and after a quick hug, returned to our services.

"I was just about to page you," Becky said. "Doctor Gabriel said you should handle the incoming EMS run."

"What do we have?"

"Sexual assault," she said. "They're two minutes out. Trauma 2 is open."

"I'll need an OB/GYN and a nurse trained on rape kits, please."

"I'm trained, so I'll assist. Let me call for the consult. Female, right?"

"Preferably, in case the victim refuses a male doctor. Get a kit once you've done that, please."

She acknowledged my orders, and I went to the lounge to get Callie and Gabby.

"Sorry, I can't let you have your dinner now. We have a sexual assault victim two minutes out."

"Oh, God," Gabby moaned. "I _hate_ these."

"I understand, and if you can't stay in the room without exhibiting emotion, you can swap with Kim, Doctor Varma's student. These can be tough."

"No, I can handle it," she said.

"Then let's go."

We hurried out of the lounge, put on gowns and gloves, and went to the ambulance bay, stepping outside just as the EMS squad turned into the driveway. It pulled up, stopped, and Mark Klein, a new paramedic, jumped out of the cab.

"Hi, Doc. We got a bad one. Julie Rafferty, nineteen, beaten and sexually assaulted. GCS 7; pulse thready at 120; BP 80 palp; PO₂ 96% on five liters; facial and abdominal contusions; blood around the vagina."

"Oh, God," Gabby gasped again.

"Keep it together, Miss Martin!" I said firmly. "Trauma 2!"

The three of us and the two paramedics rushed Ms. Rafferty to Trauma 2, where Becky and Kellie were waiting for us. The seven of us quickly moved Ms. Rafferty to the trauma table. She was so badly injured that the rape kit took a back seat to stabilizing her.

"Callie, EKG and monitor; Kellie, CBC, Chem-20, pregnancy test, ABG. Becky, IV Ringer's. Gabby, ultrasound."

"What about the kit?" Callie asked.

"Cut away her t-shirt and bra, and put them in the bags. The protocol is different for a badly injured victim. She'll need a Foley, but that can wait. Becky, modesty cloth, please."

"Mike?" Nurse Angie said, coming into the room. "Detective Kleist is here."

"She can come in," I said.

I began a careful primary exam as the others sprang into action, following my orders.

"Are you preserving evidence?" Detective Kleist asked.

"As best we can with an unstable, unconscious patient. I'll forego the Foley until OB performs an exam."

"What do we have, Mike?" Doctor Alice Carmichael asked, coming into the trauma room with her student.

"Apparent sexual assault. Primary exam not yet complete, but patient is unstable. Would you perform the pelvic exam and kit, please?"

"Right away. Jacqui, assist me, please."

She and her medical student began the pelvic exam while I completed my exam, calling out my findings.

"Belly is rigid," I announced. "Possible surgical case. Gabby, I need the ultrasound. Becky, type and crossmatch; Kellie, hang a unit of plasma."

"Blood around the vagina and anus," Doctor Carmichael announced. "Suspect internal injuries; collecting swab samples before the internal exam."

"Free fluid in Morrison's," I announced. "With the contusions to her stomach, she may have multiple internal injuries. Gabby, call upstairs. Let them know the patient has multiple injuries, which may include vaginal and anal tears."

About two minutes later, Doctor Carmichael confirmed the tears I'd suspected.

"Foley?" she asked.

"I'm concerned about a ruptured bladder," I said, looking intently at the ultrasound. Let's leave that for the surgical team. She may also have uterine damage."

The phone range and Gabby answered it then hung up.

"Positive pregnancy test," Gabby announced.

"I'll go up with her," Doctor Carmichael said.

"Let me take a quick look," I said, moving the transducer.

"That doesn't look good," Doctor Carmichael said, looking at the screen with me.

"This?" I asked, moving the trackball to shift the pointer to a location.

"That looks like a uterine rupture," she said. "What monster did this?"

"Her husband," Detective Kleist said. "The dirtbag is next door. He fell down a flight of steps, trying to evade us."

I wondered about that, as there had been a few instances of suspects sustaining improbable injuries, but nothing had been proven against the McKinley PD.

"Callie," I said, "portable monitor, and you go up with Doctor Carmichael and her student. Gabby, grab a gurney."

The team worked quickly, and two minutes later, Ms. Rafferty was on her way up to surgery.

"Can I get a statement?" Detective Kleist asked.

"Doctor Carmichael did the most important part," I said.

"Understood, but you evaluated the other injuries."

We spent ten minutes with me describing the injuries I'd seen, as well as the ones I suspected, with Detective Kleist taking copious notes.

"Thanks, Doc," she said. "Buy you a beer at the end of your shift?"

"I don't get off until midnight, and then I'm going home to sleep so I can go to church tomorrow morning."

"Rain check, then!"

"With my work schedule and my family, I really don't have time."

She smiled, "We can always make time if we want."

She didn't wait for an answer, turning to head to the elevators that would take her up to the surgical ward.

"Let's not be _too_ obvious," Callie said quietly.

"She's recently divorced," Becky said, equally quietly. "Don't go there, Mike."

"No chance," I replied. "I'm a happily married man, and contrary to the stereotype, I do not play around."

"Good."

"Thanks, Mom," I chuckled.

"I'm not THAT old, you twit!" she protested.

"Older sister?"

"That works!"

"Callie, let's see what we have in the way of walk-ins."

"How do you do it, Doctor Mike?" Gabby asked.

"What?"

"Go from _that_," she nodded to the now empty trauma room, "to flirting and laughing."

"I wasn't flirting, she was," I corrected.

"Sorry, but you know what I meant."

"It's a primary trait for the best trauma docs and surgeons," Becky interjected before I could answer. "They compartmentalize, and leave the horror of trauma in the trauma room or the OR. If you have to _make_ yourself do that, think about a different specialty."

"What my _older_ sister said!" I added with a grin.

"Watch it, Doc, or I'll hand you a scalpel blade first!"

I winked, then turned to Callie, "Let's see what's waiting for us at the triage desk."

The next five hours were filled with routine cases, and I allowed both Callie and Gabby opportunities to handle cases, and just before midnight, handed things over to Doctor Lincoln before heading upstairs to shower and dress. I arrived home about 12:30am and found Kris asleep, so I undressed and quietly slipped into bed.

_July 16, 1989, Rutherford, Ohio_

"How have you been, Mike?" my grandfather asked after we sat down at his house on Sunday afternoon.

"Tired," I replied. "But I love my work."

"And you're attending services?"

"Wednesday Vespers and Sunday morning Matins and Divine Liturgy," I replied. "Kris and Rachel also attend Saturday Vespers, but I'm working, and don't get home until after midnight."

"And you start again tomorrow morning at 6:00am?" Stefan asked.

"Yes."

"And I thought new lawyers worked long hours!"

"Two weeks down, fifty to go before it lightens up a bit. As of next July, it'll only be about seventy-two hours a week."

"'Only'," he says," Paul said, shaking his head. "And I thought running my own business had long hours."

"Just tell my sister to take her feet off the coffee table, put down the bonbons, and turn off _Days of Our Lives_!"

"If you say that to her, you're a braver man than I am!" Paul replied.

"Brothers can get away with more than husbands," I replied.

"But not more than wives!" Stefan said with a wry smile.

"YOU married a Russian woman," I chuckled. "In fact, you married a Borodin! You have only yourself to blame!"

"Marry in haste; repent at leisure!"

I laughed, "That might be apropos for me! Where did you hear that one?"

"From another attorney who has a client with a very, very interesting past — former Navy Chief, former OSS and CIA officer, now a very successful businessman in Cincinnati. He has a son your age, despite being your grandfather's age."

"His youngest?" Paul asked.

"No, his oldest. I don't know the whole story, so I can't say what else happened in his life, though I do know his wife is twenty years younger."

"Paul, how is business?"

"Occupancy rates are good and we're turning a nice profit. We've worked out the deal for the restaurant and ownership will transfer on January 1st, 1991."

"That's great news. Why so long?"

"That's when the owners intend to retire, and we're in no rush. They'll take the note, similar to how Mr. Zhuravlyov handled the sale of the motel to us. That gives them income and we don't have to borrow from a bank."

"I'm happy for you. Have you heard from Emmy?"

"She stops by on every patrol," he said. "She's the kind of cop we need — laid back most of the time, serious when necessary. She cuts most people slack for minor stuff and doesn't write many tickets."

"I'm not surprised. Tell her I said 'hello'."

"When's the last time you spoke with her?"

"At her wedding a year ago. Why?"

"She's due at the end of January."

"Well, tell her congratulations for me. And Liz and I are going to have words about her not telling me!"

"You enjoy putting your head in the lion's mouth, don't you, Mike?" Stefan asked.

I chuckled, "Being her brother gives me certain advantages and immunities that Paul could only dream of! The same is true of the man married to my mother!"

Stefan laughed, "You Borodins are an interesting lot."

"You can say THAT again!" Paul chuckled.

"Dinner is ready," my grandmother announced.

My grandfather, Stefan, Paul, and I joined my grandmother, my mom, my wife, my sister, Elaine, and the three kids — Michael, April, and Rachel at the table.

"Would you give the blessing, Michael?" my grandfather requested.

I gave the usual Orthodox blessing, and we all began to eat.

"You seem to have failed to call me with important information," I said to Liz. "I had to learn from Paul that Emmy is pregnant!"

"You're never home even if I called!" Liz protested.

"There are these cool inventions called answering machines," I replied. "Not to mention an even older invention — the wife!"

Everyone laughed, including Kris, who also rolled her eyes.

"Emmy is the Sheriff's deputy, right?" Kris asked.

"Yes. Liz's best friend growing up, and she and I dated briefly before she decided my college roommate was more interesting."

"Because she's smart!" Liz said, sticking her tongue out at me.

"That's exactly the response I'd expect from Lizard Breath!" I chuckled.

"Did we somehow step into a time warp and go back ten years?" Mom asked.

"Because you and Alexi don't treat each other the same way even now that you're both grandparents?"

"Mom!" my mom protested.

"She speaks the truth, Rahil Mikhailovna!" my grandfather said with a twinkle in his eye.

"This is all YOUR fault, _doctor_!" my mom said to me.

I laughed, "Yes, because I somehow went back in time to when you were little and taught you and Uncle Alex to tease each other!"

"Your mother didn't need any help misbehaving," my grandmother said with a wink.

"So Mike comes by it honestly, then?" Kris asked.

"As does my great-granddaughter!" grandma said.

"She was certainly named correctly!" I said with a grin.

"You are all so silly!" Elaine observed. "My parents would never talk that way to each other! And certainly not in front of me!"

"How are you and April doing?" I asked.

"Great! She's almost two, which you know, and she and Rachel were playing really nice. I had all A's on my last report card, and I have a boyfriend."

"What's his name?" I asked.

"Tommy," she said. "He's going to be a Senior."

"What grade are you in?" Kris asked.

"I'll be a Junior," Elaine replied.

"He's a nice kid," Mom said. "And really dotes on April."

"A teenage boy doting on a baby? What's next? Cats and dogs living together?"

"You doted on April Nash's baby when he was born!" Liz said.

"So sue me! I like babies!"

"Dada love Rachel!" my daughter declared.

"I do," I said. "And I'll love any brothers or sisters you have."

"NO BROTHER!" Rachel said firmly causing everyone to laugh.

"Her Highness has spoken," Mom declared.

"Is that soon?" my grandmother asked.

"If all goes according to plan, a sibling will arrive next summer."

"Lord have mercy if it's a boy!" my grandmother said with a sly smile.

"She'll just have to deal with it! She and her friend Abigail are building a clique of little girls that in about fourteen years are going to terrorize the county!"

"Or at least their fathers," my grandfather said. "I know how that goes!"

"DAD!" my mom warned.

"Where do you think the white hair came from, Rahil?"

"Alexi!" my mom declared.

Grandpa laughed, "He got in his fair share of trouble, but you had no use for the 1950s view of women!"

"What is that supposed to mean?" my mom asked.

"I'm positive your outrage is because your son is here," Grandma said, "but I think he knows!"

"I give up!" Mom said, shaking her head.

"Wise," Stefan said.

"You have only yourself to blame, Mom," I said slyly. "Everything I know outside of medicine, I learned from you!"

"I should have given you to the Gypsies!" Mom said.

"They'd have returned him as being too much trouble!" Kris said.

"You go, girl!" Liz said.

"I am very happy we all love each other enough that no feelings are hurt by teasing such as this," my grandfather said. "I'm very happy to have all of you here."

_July 17, 1989, McKinley, Ohio_

"I heard a rumor," Doctor Gibbs said when I checked in with her early on Monday morning.

"What's that?"

"You did an appendectomy."

"Do you know REO Speedwagon's _Take It On The Run_?"

"The part about the tales growing taller down the line?"

"That's it. My students and I scrubbed in, and I _assisted_ Doctor Blake with the appendectomy because there were only four surgeons on duty and both Attendings and the on-call Resident were busy trying to reattach a traumatically amputated arm."

"Why not call in another surgeon?"

"I'm not sure how long it would have taken or what state they would have been in. They had the department golf outing yesterday."

"Say no more!" Doctor Gibbs said. "Surgeons take golf more seriously than anything except surgery! Retractors?"

"Yes. I might also have been permitted to close. I also might have talked Bill Blake into allowing Callie Newsom to make the final closure of the epidermis."

"I'd say the rumor wasn't too far off, given you're an Intern. What year is Blake?"

"PGY6," I replied. "But Residents who have passed their Boards are permitted to perform complete procedures without direct supervision. This was Blake's second solo appy."

"I have a written complaint from Mastriano about you being pulled out of the ED."

"Send it to Doctor Northrup without your endorsement," I said. "She won't like the results."

"I was simply going to reject it as Chief Attending, but you might have a point."

"Never interrupt your opponent when he is making a mistake," I said.

"Napoleon, right?"

"Yes. I say that based on two key points — first, both the reattachment surgery and the appendectomy had successful outcomes; second, Clarissa saw exactly one patient when she covered for me for about ninety minutes. It was one of those lulls that happen from time to time. Sure, it was chance, but in the end, the resources were applied properly. And you and I both know we're not going to get a larger headcount before the new ED opens, and even then, we won't keep up with the demand."

Doctor Gibbs nodded, "The Chief Attendings meet every other Friday and the biggest gripe is how often we have to shift doctors from Medicine or Surgery to the ED. And it's never the other way around."

"Oh, really?" I asked.

"OK, present company being the lone exception, but he's actually wearing the red scrubs of a surgical intern, so not included in that stat!"

"Did Doctor Mastriano say anything else?"

"Just her usual gripes about what she considers favoritism."

"May I make an honest observation?"

"Yes."

"I'd rather have Callie Newsom run a trauma that involved me than Mastriano. Callie at least cares, and that is important. The same is true for Mary Anderson."

"I heard Mary changed her schedule around."

I nodded, "She's interested in trauma surgery, but you know there won't be a Residency slot next year. She'll go the route of either ED or surgery and then apply for the open Residency slot after her Intern year."

"I take it you'd recommend we take her?"

"I have to see the entire candidate pool, but I'd certainly put Mary near the top of any list I was making."

"You, Bob and Len catch traumas today; Naveen and his students will cover walk-ins."

"No shifts at triage?"

"No. Naveen's students will cover."

"That'll make Mary very happy! Let me go speak to Kylie so she can get out of here."

I left Doctor Gibbs office and spoke to Kylie, who handed over three patients, all of whom were waiting on discharge labs or completing observation, and Doctor Nielson had signed the charts. Once we finished, I checked on each of them, then went to the lounge and sat down on the couch next to Ghost.

"Assisted on an appy, I hear," he said.

"At least you got it right," I chuckled. "Someone told Loretta I'd actually done the procedure!"

Ghost laughed, "The day this hospital allows an Intern to do an appy is the day the state revokes our credentials! You were with Bill Blake, right?"

"Yes. Changing subjects, ready for Sunday?"

"As ready as any man is to get married!"

"I was ready," I replied. "Though the first time was basically at the command of my bishop, not that I objected in any way, shape, or form."

"Well, let's just say that marriage has some very specific benefits!"

I chuckled, "Indeed it does. I guess you'll be my cousin by marriage."

"Is that even a thing?"

"Who knows? But we will have one set of grandparents-in-law in common, which means any kids you have will be blood related to any kids Kris and I have."

"I hadn't considered that," Ghost said. "I mean, obviously I knew Oksana and Kris were cousins."

"Timing?" I asked.

"Well, given Oksana has her Associates in accounting, she's ready to start right away."

"And Kris and I are hoping to have our first next summer. The second cousins might be born around the same time."

"I'm not sure I'm ready for kids," Ghost said.

"If I could do it in med school, you can do it in your final year as a Resident!"

"Yes, but you're certifiably crazy!"

"I won't dispute that!"

"Because you can't!"

"Ghost, Mike?" Ellie said from the door. "Time to earn your pay! EMS transporting two MVA victims. Four minutes out. Not critical. Trauma 2 and 3."

"Time to go to work, kids!" Ghost declared.

Bob, Len, and I, along with Ghost and his students Jack and Stephanie, all left the lounge and headed for the ambulance bay, grabbing gowns and gloves along the way.

"First or second patient?" Ghost asked.

"You're senior, so it's up to you."

"I'll take the second one. You take Trauma 2 and I'll take Trauma 3."

"OK. Bob, Len, we'll assess what we need when we hear the bullet, but Len, for sure we'll need a basic monitor and vitals."

They acknowledged my instructions and about a minute later the EMS squad pulled up.

"Morning, Docs!" Bobby said jumping out. "Two victims of a low-speed MVA. Both complaining of neck and back pain. Patient one is a forty-two-year-old male; Patient two is a forty-five-year-old male. Both restrained. Both fitted with cervical collars. No other treatment except transport. Patient one pulse 90; BP 110/70; resps normal. Patient tow pulse 92; BP 120/80; resps normal."

"I'll take patient one," I said. "Name?"

"Karl Gross. Patient two is Randy Monroe."

He and his partner unloaded the gurneys, and we escorted the patients into the trauma rooms where nurses were waiting.

"Bob, would you handle the three patients waiting on discharge? Just bring me the forms to sign when you're ready."

"Sure thing, Doctor."

"Mr. Gross, I'm Doctor Mike. How are you feeling?"

"My neck hurts! I'm going to sue that bastard for every cent he has!"

"They were arguing in the squad," Bobby reported.

"Thanks," I said.

He left and Becky, Len, and I helped Mr. Gross move to the trauma table.

"What kind of pain are you having? Is it dull and throbbing? Shooting? Stabbing?"

"Dull and throbbing."

"On the sides or in the back?"

"Sides."

"Do you have a headache?"

"Yes."

"You were driving?"

"Yes, and that bastard just slammed into me! He wasn't paying attention!"

"Did you hit your head at all? Or did your chest impact the steering wheel?"

"No, I had my seatbelt on."

"Then let me examine you, please."

"Need any help in here?" Doctor Williams asked from the door.

"We're all set, Brent," I said. "Just possible whiplash from a low speed, restrained MVA."

"Holler if you need me," he said, then stepped away.

"Who was that?" Mr. Gross asked.

"One of the senior doctors on duty," I said. "He'd have heard there were accident victims and because I'm relatively new, he's checking on me."

"How new?"

"I graduated medical school at the end of May."

"God help me! Do you know what you're doing?"

"He's the best doctor here," Becky said. "I'd put my life in his hands."

"Thank you, Nurse! Mr. Gross, I'm going to examine you and see if we can remove that collar."

"Kids!" he said, shaking his head, giving lie to what I'd suspected — he was faking his injury.