Chapter 17 — Tell Me About This Patient

_April 19, 1990, McKinley, Ohio_

{psc} "Doctor Roth needs to see you before you head downstairs," Kelly, the surgical charge nurse, said as I came out of the locker room on Thursday morning.

I checked my watch, and if the meeting lasted more than five minutes, I'd be late for my shift.

"Would you call downstairs and let Ellie know Doctor Roth requested a meeting and I'll be there as soon as possible."

"Of course. It's not disciplinary, but knowing you, you'll wish it was!"

"Wonderful. Thanks."

I hurried to Doctor Roth's office and rapped on the open door.

"Come in, Mike. Shut the door and sit, please."

I did as he requested.

"What's up?" I asked.

"I know for a fact you're going to hate this, but you were specifically requested by Cutter and Nels Anderson, and I can't think of a good reason to say 'no'. They want you as one of the two Residents on the oversight committee for the construction of the new surgical wing."

"Is someone _trying_ to drive me to drink?" I asked.

"Shelly wasn't happy, either. Nor were Bob Aniston or Penny Nichols. I figure if I have to do it, so should you four!"

"Misery loves company," I said, shaking my head. "What's involved?"

"Making sure that everything is completed to our satisfaction. Consider it similar to a building inspector. That's what your dad does, right?"

"He's the Director of the Property Division now, but yes."

"So, what do you say?"

"Nothing like being 'voluntold'," I chuckled.

Owen laughed, "That's awesome. Did you just make that up?"

"No. I heard it from Kellie Martin. In the Navy, officers would say, 'I need a volunteer!' then say, 'Martin! Thanks for volunteering!'. That meant she was being told to volunteer — 'voluntold'."

"Think she'll mind if I steal that?"

"Nope. Anything else, I do need to get to the ED."

"No. That's it. Thanks, Mike."

"You'll forgive me if I don't thank you for this assignment."

"I will, but you and I both know that you will make damn sure everything is done right and working right before you sign off. Just as the others will."

"You can count on it."

I left his office and hurried to the ED, where Mary was waiting. She looked at her watch, raised her eyebrow, and tapped her foot.

"You need to put your hands on your hips to have any effect," Ghost said to her. "Russian women have it down pat!"

"Speaking of Russian women, my cousin by marriage seems to be in no rush to have whatever my wife's cousin's kid would be."

"I think first cousin, once removed," Mary suggested. "But only by marriage, so not sure it's a thing for you, and I guess technically not for Rachel because there are no common ancestors, except by adoption or marriage."

"Thank you for the genealogy lesson, Miss Anderson!" I said with a grin. "Perhaps you'll practice medicine now?"

Mary laughed, "I'll get a chart from the rack."

"Kris said Oksana thinks she's going to have to be induced," I said.

"Me, too," Ghost replied. "So does Candace. She already scheduled us for Monday."

"Sorry to cut this short, but I need to supervise my soon-to-be Intern."

Ghost rolled his eyes and shook his head, clearly agreeing with me that Mary was capable of working with oversight, rather than supervision.

I followed Mary pushing a patient in a wheelchair into Exam 2. She helped the patient onto the treatment table, then moved the wheelchair out of the way.

"Jackie, I'm a Sub-Intern in training, and this is my supervisor, Doctor Mike. Doctor Mike, Jackie Barkhurst, seventeen, complaining of an ankle injury."

"Good morning," I said. "Mary, proceed."

"What caused you to come to the hospital today?" Mary asked the patient.

"As I told the nurse, I tripped last night when I was jogging. My ankle hurt, but I could walk on it. This morning, I couldn't put any weight on it, so I had my dad bring me in."

"Did you twist it or roll it?"

"I think I rolled it, if you mean my foot bent sideways, not rotated around my leg."

"Yes. Any previous injuries?"

"I had a pulled hamstring about six months ago."

"Did you see anyone about that?"

"My regular doctor, but his office doesn't open until 9:00am, and I couldn't walk."

"Do you know what grade he or she assigned the injury?"

"Grade 2. I just had to ice it and rest and wear an ace bandage. I was allowed to start walking longer distances after about a week and allowed to resume jogging after four weeks."

"Are you an athlete?"

"Volleyball, but it's a Fall sport."

"Any other complaints?"

"Besides my little brother?" she asked.

Both Mary and I laughed.

"They haven't taught me a procedure to resolve that," Mary said with a smile.

"Me, either," I chuckled. "And I'm a trauma surgeon. In my case, it was a little sister."

"Any other injuries or sickness?"

"No."

"Are you taking any medications, vitamins, or supplements?"

"I took Tylenol right after I hurt it last night; then again this morning. It helped last night but not much this morning. Otherwise, just birth control pills."

"Is there any chance you might be pregnant?" Mary asked. "I need to know because we'll most likely need to X-ray your ankle."

"I just said I'm on the Pill!" Jackie protested.

"Yes, but even with perfect use, three women in a thousand will become pregnant over the course of using the Pill. Have you had intercourse since your last period?"

"That's the point of the Pill, right?" Jackie asked with a smirk.

"Usually," Mary replied. "I started taking them at fifteen for bad cramps. That was convenient a year later when I needed them for their primary purpose! If you've had sex, we'll need to run a rapid pregnancy test before we X-ray you."

"Oh, that would simply make my day," Jackie said, shaking her head.

"I'd like to examine your ankle, please."

"Sure."

Mary washed her hands, put on gloves, then pulled the stool over and carefully examined Jackie's ankle. I saw severe ecchymosis, and even from where I was standing, I could tell the ankle was swollen. Mary carefully examined the injured ankle, then the healthy one for comparison.

"Doctor Mike, I suspect an ankle fracture," Mary announced. "I recommend an ankle series."

"Please verify no high fibula fracture," I requested.

"I'm not sure how to do that," Mary said.

"Palpate the calf proximally and check for pain or movement of the bone."

"Both legs, right? For comparison?"

"Correct."

Mary examined both legs in a manner I was confident was sufficient.

"Grossly normal," Mary said. "Rapid pregnancy test then ankle series. Once complete, orthopedics consult."

"Proceed," I said.

Mary wrote everything on the chart and handed it to me to sign.

"Jackie, can you give us a urine sample?" Mary asked. "That'll be quicker and easier than a blood test."

"If someone can help me," Jackie said.

"We'll send a nurse to help you. Once we see the results, we'll send you for your X-rays."

"OK."

Mary and I left the exam room, and she asked Ellie for a nurse to help Jackie with her urine sample. Ellie sent Becky and a student nurse to help, and six minutes later, Becky came out with the test container.

"Negative," she said.

"Thanks," Mary replied.

Mary called Radiology, and they could take Jackie right away, so Mary called for an orderly. Once the orderly arrived, Mary escorted Jackie to Radiology. Mary was back two minutes later and went to the waiting room to update Jackie's dad.

"They said about twenty-five minutes," she said when she returned to where I was waiting. "They'll send her back."

"OK. Good job on your assessment."

"I missed the high fibula check."

"No, you simply hadn't been taught it yet. I've seen enough ortho consults that I check right away so we don't have to send the patient back for further X-rays. Technically, it's an ortho thing, but it's simple enough to check that I prefer efficiency for the patient's sake. Nobody would have said a word if we hadn't done that, but it's better for the patient."

"Next chart?"

"Next chart."

Mary went to the triage desk, retrieved a chart, and went to the waiting room to call the next patient. We treated a toddler with an ear infection, and once he was discharged, Mary called to check on Jackie's X-rays.

"The radiologist says the wet read is a non-displaced fracture."

"Call Ortho for a consult. Non-displaced fractures almost always result in wrapping the ankle and referral to an orthopedic specialist for out-patient treatment."

That was the end result, and after showing Jackie how to use crutches, we discharged her. I could still do that on my own for two more days, so I simply signed the chart and returned it to the nurses' station.

"Mike," Naveen said. "I need a consult, please."

Mary and I followed him to Trauma 1 and confirmed the patient needed a cholecystectomy for significant gallstones. Unfortunately, Mary and I didn't get to scrub in, as it wasn't emergency surgery and would be done after the day's scheduled surgeries were completed.

"You did a good job on the ultrasound," I said. "And before you object, I didn't find gallstones the first two times without guidance. It's easier with the CAT scanner, but if we can diagnose with ultrasound, we do that because there is no ionizing radiation. It's also less expensive. Next time, you'll be more likely to find them. But remember, sonography has limits that CAT scans do not. What I'd _really_ like is a Magnetic Resonance Imaging scanner — MRI. They don't use ionizing radiation, so they're much safer."

"I've read about those; how long before we get one?"

"Ten years, I'd guess. First, we won't have room for one until the new surgical wing is built and the old building is remodeled. The surgical wing is scheduled for completion in 1993, and remodeling is expected to be completed around 1996. They'll leave space for an MRI scanner in the remodeled radiology area, but someone will have to come up with the money to actually purchase one."

"It always comes down to that, doesn't it?" Mary asked.

"Sadly. I've had this conversation with several doctors and friends. In the end, there are limited resources, and we have to figure out the best way to use them. My wife's solution is for all doctors to work for the government, all hospitals to be government hospitals, and all care to basically be free at the point of service, with everything paid for by taxes. But even then, there are limited resources, and you still have to ration care."

"Mike?" Ellie said. "Bounceback abdominal pain in Exam 3. He was seen by Paul last night around 10:00pm. Kellie is with him."

"Thanks, Ellie. Mary, how would you handle this?"

"Review the chart, then ask the patient questions."

"Reverse that."

"Why?"

"If you read Paul's notes, you'll have Paul's view and risk pre-forming an opinion. Conduct a full H&P and perform an exam. The patient may well tell you what Paul said, and that's fine. But do your own exam. Think about how consults work."

"They always do their own exam, even though we've already done one. I've never seen a single bounceback done the way you just said."

"But does it make sense?"

"Absolutely."

"Then let's go see him. You take the lead."

We went to Exam 3, where Kellie was waiting with the patient.

"Doctor Mike, this is Ken Webber, thirty-six," Kellie said. "He was in last night and saw Doctor Lincoln. Pulse 72; BP 120/70; PO₂ 99%; temp 38.1°C."

"Good morning, Mr. Webber," I said. "This is Mary, a Sub-Intern who I'm supervising."

"Hi, Mr. Webber," Mary said. "What brings you back to us?"

"The pain in my gut got worse. The doc last night said to come back if it did."

Mary conducted a proper H&P, then examined Mr. Webber, finding guarding when she palpated his abdomen, increaed pain when he was on his left side, and increased pain when he coughed. She finished her exam, and only then did she look at the chart.

"CBC, Chem-20," Mary said. "Then ultrasound."

"Approved," I replied. "Also, type and cross-match, please."

Kellie drew the blood while Mary went to get a portable ultrasound machine. The sonogram revealed exactly what I had expected — a seriously inflamed appendix.

"7 points on the scale and obvious inflammation," Mary announced.

"Agreed," I replied.

"Mr. Webber," Mary said, "you're going to need immediate surgery to remove your appendix."

"Why did they send me home last night?" he asked.

"I'll have to speak to Doctor Lincoln," I interjected. "Right now, let's focus on treating you. Mary, call upstairs. Kellie, a gurney, please."

They both did as I'd directed.

"Twenty-five minutes," Mary said. "She needs to page Doctor Flynn. It's OK to bring the patient right up."

"Do you have someone with you, Mr. Webber?"

"My girlfriend brought me in."

I discussed the procedure with Mr. Webber and had him sign the consent forms. With his approval, I went to the waiting room and found his girlfriend.

"Hi, I'm Doctor Mike. Ken is going to need emergency surgery to remove his appendix. I'll have a medical student escort you up to the surgical waiting room."

"Can I see him?"

"We're transporting him right now, so no. Just wait here, please."

I went back into the ED and borrowed Naveen's Third Year, Katy, and asked her to escort Mr. Webber's girlfriend upstairs. Five minutes later, we wheeled the patient into OR 4, the smallest and oldest of the operating rooms at Moore Memorial, which was only used for emergency surgery. But, given it was early in the morning, scheduled surgeries were in progress and couldn't be pushed.

"Doctor Roth said to scrub in," Nurse Julie said. "Both you and your student. Anesthesia will be here in five minutes, so you'll need to prep."

"OK. Blood type should be available in five minutes or so; remaining blood work in about fifteen minutes."

Mary and I quickly put on fresh scrubs, scrubbed in, gowned, and gloved. We quickly prepped the patient with help from two nurses, inserting a saline IV, affixing EKG pads, and administering IV antibiotics. The anesthesiologist, Doctor Ross Burnside, arrived as we finished prep.

"Doctor Roth instructed me to put him under," Doctor Burnside said.

"Doctor Flynn should be here in ten minutes. I'll intubate as soon as you do that. Mary, connect the EKG leads, please."

Doctor Burnside asked the patient a series of questions, then administered IV anesthetics. Once the patient was under, I quickly intubated and connected him to the ventilator.

"Temp is up to 39°C," Nurse Barb announced.

That did not bode well.

"Etomidate and ketamine, then propofol, right?" I asked Doctor Burnside.

"Yes," he confirmed. "You have him on vancomycin, right?"

"Yes," I said. "Barb, call the lab. I want to know his white count."

"Right away, Doctor!" she replied.

"Let's get ahead of this," I said. "Deb, chemical cooling packs both underarms, please."

Nurse Debbie did as I asked, just as Doctor Flynn came into the OR.

"What do we have, Mike?" he asked.

"Ken Webber, thirty-six; bounceback abdominal pain from last night. Pulse 66; BP 110/70; PO₂ 99%; temp 39°C, up a degree after administration of vancomycin and anesthesia. Cooling packs in both underarm areas."

"I have the lab results," Barb announced. "Neutrophilia; everything else in range. A-positive."

"How high is that white count?" Doctor Flynn asked.

Barb spoke into the phone, then announced, "8.8."

"Mike, you're familiar with the procedures, right?"

"I've done two," I replied.

"As in assisted?" he asked.

"No, as in performed two. I recently assisted with one that ruptured, so I'm familiar with the lavage protocol."

"OK. Let's do this. Are you cleared to Bovie?"

"Yes."

"Who's your student?"

"Mary Anderson; she Matched here for trauma surgery."

"Miss Anderson, have you operated suction before?"

"Only once," she replied.

"I'll guide her, Josh," I said.

"Bobbie, I'll need you on retractors then," Doctor Flynn said to the most senior surgical nurse in the room. "Deb, hang a unit of A-positive."

"Ready, Ross?" Doctor Flynn asked.

"Vitals are stable, he's under. We need to keep an eye on his temp."

"Then let's go," Doctor Flynn said.

We worked quickly with Doctor Flynn cutting, Mary suctioning, and me using the electrocautery.

"Rupture," I observed when the appendix came into view."

"Peritonitis protocol," Doctor Flynn said. "Deb, hit him with another dose of antibiotics. Mike, let's get this out and clean him up."

"SVTs!" Doctor Burnside announced. "Run of six. Don't dawdle. Pressure and sats are still good."

"Deb, have adenosine ready, please," Doctor Flynn ordered.

He and I quickly removed the ruptured appendix, then I used three pitchers of saline for lavage, with Mary suctioning it away.

"PVCs!" Doctor Burnside announced. "Run of ten. Get this done, Josh!"

We worked quickly to close, and Mr. Webber didn't have any further cardiac events.

"Cease anesthesia," Doctor Flynn ordered. "Mike, I want you to sit with him in recovery, please. Keep him on the EKG and call cardiology if you see anything. Usual antibiotic protocol."

Before I could respond, the monitor blared.

"V-Fib!" I declared. "Paddles to me; charge to 150! Mary, pads!"

She quickly put the pads on Mr. Webber, and I positioned the paddles.

"CLEAR!" I commanded as soon as the machine chimed.

Everyone moved, Doctor Burnside disconnected the vent, and I pressed the buttons, causing Mr. Webber's body to spasm.

"No conversion!" Mary announced.

"Charge to 200!" I ordered, and as soon as the machine chimed, I called, "CLEAR!" and pressed the buttons.

"No conversion!" Mary announced.

"Begin compressions!" I ordered. "Charge to 250! Epi, IV push!"

Mary started chest compressions, Doctor Burnside re-connected the vent, and Deb injected the epinephrine.

"CLEAR!" I commanded

Everyone moved, and I shocked the patient again.

"Nothing," Doctor Burnside said as he re-connected the vent.

"Resume compressions," I said. "Charge to 250."

"CLEAR!" I commanded once the machine chimed.

"No conversion," Doctor Burnside announced.

"Deb, bicarb and epi!" Doctor Flynn ordered.

"Mary, continue compressions! Bobbie, atropine with a cardiac needle to me."

"Not usually indicted for V-fib, Mike," Doctor Flynn countered.

"Can it hurt?" I asked.

"No. Debbie, atropine to Mike."

I had Mary stop compressions and injected atropine directly into Mr. Webber's heart, but it had no effect on his arrhythmia.

We worked on Mr. Webber for ten minutes, to no avail.

"Asystole," Doctor Burnside announced. "No electrical activity."

"Six shocks, three doses of epi, one of atropine," I said. "I don't think we're getting him back."

Doctor Flynn checked the patient's eyes and auscultated to his chest.

"Absent heart sounds; pupils fixed and dilated; time of death, 08:33am."

"Bobbie," I said. "Death protocol."

"Tell me about this patient," Doctor Flynn requested.

"Bounceback abdominal pain from last night, as I said. The chart showed a typical H&P for abdominal pain. Patient denied any medication or use of illicit drugs. No indication of alcohol on his breath. Patient was discharged with instructions to return if the pain increased."

"No surgical consult?"

"There wasn't one on the chart," I replied. "My shift ended at 2100, so it would have been Bob Hodges who was on call. Patient returned this morning at 06:18, and vitals were taken by both triage and Nurse Kellie Martin. Miss Anderson and I were called, a complete H&P was performed, and we observed Dunphy's sign and Sitkovskiy's sign. Appendicitis score was 7 indicating acute appendicitis.

"Ultrasound confirmed an inflamed appendix, and surgery was scheduled. Mary and I prepped, including saline IV and standard prophylactic antibiotics. Doctor Burnside administered anesthesia. Patient's temperature rose about 1°C post-anesthesia, so I ordered chemical cooling packs under each arm. That's when you arrived to begin the surgery."

"Why the cool packs?"

"I was concerned about an adverse reaction to the antibiotic or one of the anesthetic drugs."

"OK. McKnight will have to tell us what happened, if he can. Does he have anyone with him?"

"His girlfriend, Val. She's in the waiting room."

"You met her, right?"

"Yes. I had a student bring her up after explaining Mr. Webber needed emergency surgery."

"Then you and your student come with me to speak to her."

We removed our surgical gowns but left on our caps and masks, though we pulled down the masks. We walked as a group to the waiting room.

"Ms. Cartwright?" I said. "This is Doctor Flynn, the senior surgeon. Can we step into the consultation room so we can discuss the surgery?"

The three of us went to the consultation room, and as was the norm, Doctor Flynn and I sat down, and Mary stood behind us.

"Ms. Cartwright," Doctor Flynn said. "Your boyfriend was rushed to emergency surgery from the Emergency Department. Doctor Mike and I, together with Doctor Burnside and a team of nurses, performed an emergency appendectomy. Ken's appendix had ruptured, and we removed it.

"Just as the surgery was being completed, his heart began beating irregularly. We did everything in our power, but we were unable to correct the irregular heartbeat. Eventually, his heart stopped, and we were unable to revive Ken, and he died."

"NO!" she gasped. "NO! He was here last night, and you sent him away!"

"Neither of us where here last night," I said gently. "So we can't say for sure why that was. Is there someone I can call for you? The chaplain, a social worker, or a friend?"

"No," she said, tears streaming down her face. "Just leave me alone!"

"Mike, you and Mary can return to the ED," Doctor Flynn said.

I stood up and indicated the door with a nod. Mary followed me out of the consultation room, and we went to the locker room.

"Are there blue scrubs here?" she asked.

I smiled and nodded, "In the cabinet marked 'Rags'."

"Wow!" Mary said, shaking her head.

"I'm not sure who added the masking tape and the note covering the actual sign. But you'll get to wear red full-time in six weeks."

We both changed, I put on my baptismal cross and the chain with my wedding ring, and the two of us began walking towards the stairs.

"What do you think happened?" Mary asked.

"Some kind of adverse reaction to one of the drugs or an undetected heart problem. It's also possible the patient lied to Paul and to us, or there was some family history of which he was unaware."

"Lied?"

"Illicit drug use. We didn't run a tox screen because one wasn't indicated. That's not part of the standard protocol for pre-surgical labs."

"You sound as if you think it should be."

"It's one of those things that might catch something, but how often have you been fooled about illicit drug use?"

"It's almost always obvious."

"Even to a med student," I said with a goofy smile as we exited the staircase and turned left to head to the ED.

"You're a real sweetheart, Doctor Mike!"

"I know!" I grinned. "But in all seriousness, we could use the logic that we have to account for every possible scenario, no matter how rare, but at what cost to patient care? At that point, we'd be paralyzed and inefficiently using our limited resources. Did you detect _any_ signs of illicit drug use?"

"No. His eyes were clear, his nose did not show any signs of inhaled stimulants, there were no lesions or anything in his mouth, and there were no track marks. He was well-groomed, his clothes were clean, he had good hygiene, and his speech was clear."

"Exactly."

"What did you mean by paralyzed?"

"Unable to act because we can't account for rare outcomes. Tell me about the use of etomidate for intubation. Why do we use it, as opposed to other drugs?"

"It has a standard, well-understood dosage for adults, it's fast-acting and fast-metabolizing, and allows for quick sedation. When combined with suxamethonium, it allows for rapid sequence intubation. Etomidate is one of the few sedation drugs that doesn't cause a drop in the patient's BP."

"Do you know the contraindications?"

"Basically none," Mary replied. "That's why it's the drug of choice for RSI."

"And that one patient in 100,000 who has a severe anaphylactoid reaction?"

"Of those, 90% are successfully resolved, leaving one in a million who die. The odds are that Moore Memorial will never see someone die from the use of etomidate, and an adverse reaction would happen once every fifty years or so given the number of intubations we perform in the ED and surgery."

"So, do we waste time and resources trying to prevent that?"

"No. I'm surprised you have that position."

"I had this conversation during Third Year. You and I briefly discussed it, though, with regard to innovation and progress. What would happen in an M & M if that one-in-a-million chance occurred."

"Everyone would agree it sucked, but there is literally nothing we could have reasonably done differently."

"Which is a lesson that had to be beaten into me in medical school. You have the advantage of me taking the beatings and transferring the knowledge."

"For which I'm grateful! How many patients have you lost?"

"At one point, I could have told you the number and recount literally every second of their treatment. I've had to compartmentalize it to stay sane enough to continue working. A few do stand out, either because of the victim or because something went wrong, and I wrote details into my notebook so I could make flashcards."

We arrived in the ED and went to Doctor Wernher's office. I rapped on the open door, and he beckoned us to enter.

"Bounceback abdominal pain, diagnosed with appendicitis, coded on the table."

"Name?"

"Ken Webber."

"Who saw him?" Doctor Wernher asked.

"Doctor Lincoln around 22:00 last night."

"Surgeon?"

"Doctor Flynn, assisted by me; Doctor Burnside was the anesthesiologist."

He made notes on a pad on his desk.

"OK. I'll get the chart and a report from McKnight. Was there anything obvious we missed last night?"

"Not from what I could see from the chart. There was no surgical consult, but that's a judgment call."

"I'll speak to Doctor Lincoln. Dismissed."

We left Doctor Wernher's office, and I asked Mary to get a chart.

"Is Doctor Lincoln in trouble?" she asked.

"The only thing with which I could quibble is the lack of a surgical consult. That might have caused the surgery to occur ten hours ago, but I'm a surgeon, and I know the outcome, so it's easy to say Paul should have asked for one. But that's me speaking with knowledge Paul did not have last night. That's not to say there won't be changes to mitigate the risk, but from what we saw on the chart, Paul followed protocol."

"One more question — you asked Kellie to type and cross-match. How did you know?"

"Bounceback abdominal pain is almost always surgical. Let's see another patient; I'm sure the waiting room is backed up because we were gone for ninety minutes."

The rest of the morning was routine, with two admissions, and at noon I had lunch with Clarissa, and I recounted what had happened with the appy.

"Why wouldn't he call for a consult?"

"You know it's a judgment call," I replied. "Wernher will talk to Paul and to Chuck Boyd, as well as whoever was on triage and the nurse or medical students. There was, in my mind, no medical reason to expect him to code, nor any indication from the H&P. Mary was extremely thorough, and I was in the room with her the entire time. I told you about that protocol, right?"

"No. What?"

"Wernher is more by the book, so I have to have an Attending sign-off on admissions or discharges; the only exception being emergency surgery. You know I'm the only one who was allowed to skate on that. Medical students have to be observed, not just supervised, except for suturing. That's not directed at Mary or me, and Wernher acknowledged we're exceptions, but he can't make exceptions if he wants to enforce the rules strictly. I honestly can't object to that."

"You were basically treated like a PGY1 when you were a Fourth Year, and like an Attending since graduation. How do you feel about that?"

"It doesn't bother me. Wernher and I are working well together. He's just more formal and, as I said, by the book, than Loretta or Brent. Doctor Simons was closer to Wernher, and Northrup was as hands-off as anyone could possibly be. That said, he was spending forty hours a week on the new ED, so it's hard to criticize him objectively. It's not how I would have done the job."

"How did Mary take it?"

"She's fine. She did get a kick out of the handwritten label on the cabinet with blue scrubs I told you about."

Clarissa shook her head, "That is SO like surgeons! Egotistical a-holes who cut first and ask questions later!"

"Says the doctor who pushes pills for a living!"

"Yeah, yeah. All kidding aside, you seem to be doing better with losing patients."

"As I said to Mary, it's about compartmentalizing. And adults don't affect me nearly as much as teens or younger kids."

"It's good to see you not obsessing. Anything from Oksana?"

"No. She and Ghost are frustrated with the ghostling refusing to be born!"

Clarissa laughed, "Nice. Induction?"

"Monday if the little guy doesn't accept reality by Monday."

We finished our lunches, then returned to our respective services.

_April 20, 1990, McKinley, Ohio_

"Ghost and Oksana are in OB," Ellie said when I walked into the ED on Friday morning.

"I'm married to her cousin, so guess who was called at 3:41am?"

Ellie laughed, "Did Kris go to be with her?"

"Yes. Miss Rachel is being spoiled rotten by her maternal grandparents today."

"That's their job!"

"Or so they believe," I chuckled. "Who's covering for Ghost?"

"Doctor Boyd is working a double."

"Morning, Doctor Mike!" Mary said, coming up to me. "Ready?"

"Never!" Ellie smirked.

"Do you think she'll ever stop?" Mary asked after Ellie walked away.

"No, and so long as it's only occasional flirting or teasing, I let it go. Get the first chart."

She went to the triage desk and came back empty-handed almost immediately.

"Nobody waiting. That scares me."

"Me, too!" I chuckled, "Let's go sit in the lounge.

We moved to the lounge, where we each got a cup of coffee, then sat down on the couch.

"I meant to ask yesterday, but who covers when you scrub in?"

"Whichever PGY1 or PGY2 is covering the ward. Most PGY1s do not get to scrub in."

"But we do?"

"Different job, different training regimen. Doctor Roth has considered giving PGY1s more chances, but our ORs are fairly small compared to what's considered appropriate for a modern ER with equipment they probably didn't even dream about when two ORs were built in 1964 and one in 1973. Think about what happened with the ED."

"We outgrew it long before the planned expansion, so they took away the Residents' office and one of the consultation rooms; and created the triage cubicles in the waiting room, but that made the waiting room cramped."

"I assume you've seen the plans for the new ED, right?"

"Six dedicated trauma rooms, fourteen beds in an open ward separated by curtains, two private exam rooms, a dedicated suture room which doubles as a treatment room, a centralized nurses' station, a waiting room that is twice as big as our current one, and a dedicated clerk's station. The new surgical wing will have eight ORs, four of which will be configured amphitheatre-style. We'll be able to do six simultaneous elective surgeries and two emergency surgeries. Of course, we have to be staffed for that, which won't happen right away."

"Money, right?"

"It's always money," I said resignedly. "The construction funds come from bonds, so that's covered. Operating funds come from taxes and payments for services. The more elective surgeries we do, the more services we can provide. It's the biggest profit center in the hospital, and makes up for the money we lose running the ED, and then some. Of course, EMTALA and the Free Clinic closing are going to have a serious impact."

"Limited resources every time."

"Yes. If you think about it, Hayes County lost about a million dollars in healthcare funds thanks to the false accusations against Gale Turner, which led to the grant being withdrawn."

"I hadn't thought about it in that way," Mary replied.

"Those protesters didn't either, or if they did, they felt wrecking healthcare in the county was an appropriate price to pay for eliminating reproductive health services."

"You're pro-life, right?"

"Yes, but that doesn't mean I should force my views on anyone. And despite claims to the contrary, abortions were less than 5% of what the Free Clinic provided. They performed more employment physicals for Hayes County and the City of McKinley than they did abortions. And for birth control, again, contrary to the protestors, more than 80% were for women eighteen and older."

"They claimed it was encouraging teen sex, right?"

"Among other counterfactual claims. Going back to the question of abortion — you're going to be a physician in less than six weeks. Do you think anyone other than your patient and you should decide on treatment?"

"Hell no! I've heard the horror stories about insurance companies and Medicaid."

"That's my point. It's not my place to interfere in a patient's relationship with another physician and their joint choices of how best to care for the patient's health. As I've said to a few people, I don't approve of abortion, so I won't have one. What anyone else does has to be up to them."

"What about counseling one?"

"My firm rule is to not participate in an elective abortion; beyond that, I will discuss the options but not recommend an abortion. My strategy in the past was to refer them to the Free Clinic, but that's no longer possible. The closest clinics are in Cincinnati, Columbus, or Dayton, and who knows how long those will last. The problem with the Pro-Life movement is they don't consider the overall ramifications of their actions."

"The needs of the many?" Mary asked.

"Close, but more throwing the baby out with the bathwater. The problem is that many in the Pro-Life crowd object to teen sexuality and think denying them birth control will stop it."

"Right, because no teenagers ever fucked before 1960!" Mary said, rolling her eyes. "It's not like condoms were impossible to get, either. My aunt said men's rooms usually had a machine, so you didn't even have to go to the pharmacist!"

"Yes, but I'm sure you know about _Griswold v. Connecticut_, right?"

"I do, and I bet you anything teens in Connecticut were fucking anyway!"

"I suspect you're right," I replied.

"Mike?" Becky said from the door. "The triage desk has walk-ins."

"Be right there!"

Mary and I got up, and she retrieved the first chart and brought in a broken arm who, after an ortho consult, was admitted to have the bones properly set. That began a steady stream of patients which didn't let up until 2:30pm when Mary and I took a late lunch. When we returned to the ED, Ellie told us that Oksana had finally delivered.

"John Gregory Casper was born at 2:24pm," she said. "Mom is tired, but otherwise, everything is fine."

"Fantastic!" I said. "I'm going to go up to OB and see Oksana and Ghost. Mary, you can tag along if you want, given you can't take an H&P without me observing."

"Dumb rules," she groused quietly.

"I sympathize, but it's not directed at you."

We left the ED and took the stairs up to the floor with OB/GYN. We made our way down the corridor, I checked the board and saw which room 'Baby Ghost' was in, and we walked towards it.

"Baby Ghost?" Mary tittered.

"I suggested 'ghostling' to Clarissa yesterday."

I rapped twice on the door, waited a few seconds, then went in.

"Many years!" I exclaimed.

I walked over to Father Nicholas and asked his blessing.

"Mary and I just popped in to say 'congratulations'," I said.

"Thanks, Mike," Ghost said. "Finally!"

"Oh, stop!" Oksana exclaimed. "You just had to sit there! I did all the work!"

"He did help about nine months ago," I chuckled.

"Yes, only fun for him! Work for me!"

"Was Kris here with you?"

"Until she had to leave for class. She'll be back in about an hour. She said she'd stop in and see you."

"OK. We won't disturb you further! Is 'Baby Ghost' in the nursery?"

"Yes, and the nurses are having fun with the nickname."

"We'll stop and see him."

Mary and I left the room and went to the nursery, where we saw John Gregory wrapped in the typical hospital baby blanket, sleeping quietly.

"What was the thing you did with the priest?" Mary asked when we left the nursery a few minutes later.

"It's the usual way of greeting major clergy," I replied. "One supplicates by cupping one's hands, the priest or bishop makes the sign of the cross, and we kiss their hand. It's a cultural tradition that is just second nature to me after twenty-seven years. Think about how Russians greet each other."

"Do you do that?"

"I have, in the past, but most of my mom's family has Americanized and has mostly American sensibilities."

"I think my pastor would have flipped out if someone tried to kiss his hand!"

"Different traditions," I replied. "You know, like Lutherans and Jell-O molds!"

Mary laughed, "For the Free Church, it was always a hot dish — some kind of casserole usually, but it could also be in a crockpot."

When we reached the ED, Nate let me know I had a visitor in the waiting room. I walked out, saw who it was, and walked over.

"Hi, Jenny! What's up?"

"Do you have a few minutes?"

"I do. Come on in."