Chapter 10 — 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.