Chapter 32 — Lord Have Mercy

_August 3, 1989, McKinley, Ohio_

{psc} At lunch on Thursday, I met Chancellor Evans from Taft at the diner across the street, hoping to not be paged, but knowing there were no guarantees.

"I'm sorry I've been remiss about having lunch with you," I said.

"It's understandable with your medical training, marriage, and family. How does it feel to be a doctor?"

"Fulfilled. Becoming a doctor was my goal since age ten."

"I'm happy we could do our small part in helping you achieve your goal! And that you're mentoring Antonne Jefferson."

"I haven't seen him over the summer, but we'll resume the mentoring sessions once school starts at the end of the month."

"I know your schedule is crazy, but would you be willing to meet prospective students in November and February? If so, we'd like to put together a 'pre-med' weekend. We'd invite Clarissa Saunders and Sophia Jackson as well."

"A lot will depend on our schedules, but I suspect we'll be able to make the time."

"If the hospital is amenable, we could have the students and their families come there, and perhaps observe."

"You'll need to take that up with Doctor Rhodes," I said. "I'm not sure what his position would be on observation by High School students."

"You're OK with it, though?"

"Yes, so long as you receive permission from the Medical Director. And obviously you'll need to ask Clarissa and Sophia. I should warn you that Sophia is seeking to match in the San Francisco Bay Area, and Robby is going to be at Stanford."

"That's not until next June, right?"

"Correct. Clarissa will be here as long as I am."

"I was reasonably certain that would be the case. If I may change subjects, how is your friend with schizophrenia?"

"Not good," I replied. "I'll be testifying before the Ohio Medical Licensing Board in two weeks, hoping to have her former psychiatrist suspended, though I feel his license ought to be revoked."

"What happened?"

"It's a long story, but the bottom line is that in my opinion, and the opinion of two mental health professionals, he committed malpractice in his treatment of Angie, which made her condition worse."

"I'm sorry to hear that."

"It's a bad situation and the hearing can't fix it, but it can ensure the psychiatrist understands how badly he screwed up."

Chancellor Evans nodded, "On a happier note, I'm looking forward to your concert at the end of the month."

"I enjoy those concerts very much."

We finished our lunches, agreed to meet sometime in September, and I headed across the street to the hospital.

The first task after lunch was to join Doctor Gibbs for evaluations for Bob and Len, both of whom received grades of 4, which were the norm for very good candidates, with scores of 5 being reserved only for the best candidates. After that, it was a busy, albeit routine, afternoon, and I met Clarissa for dinner. I let her know about Chancellor Evans' request, and she agreed she'd participate and thought the hospital was the correct venue.

The evening was quiet until just before 10:00pm when there were three EMS runs and five walk-ins within a fifteen-minute period, portending a night when I wouldn't get any sleep. Two admissions, five quickly streeted, and three being monitored, took us to midnight. I was just about to sack out when Doctor Gabriel asked me to handle a walk-in — a young girl who appeared to have been struck in the face multiple times.

"Hi, Amelia," I said, looking at the chart. "I'm Doctor Mike. Will you come with me, please?"

I escorted her to Exam 3, and we were joined by Mary, Tom, and Wendy.

"What happened?"

"I got into a fight," she replied.

"Who brought you in?"

"A friend."

"I'd like to do a quick exam — listen to your heart, your breathing, and look in your ears, eyes, nose, and mouth, then check your stomach, OK?"

"Yes."

I performed the exam, observing only glassy eyes, facial contusions, and a swollen lip. I appreciated no guarding or tenderness in her abdomen. I had two suspicions — the first was that she had taken some kind of drug, and the second was that her development did not match her claimed age of nineteen. If she was a day over fifteen, then I was Mikhail I, Tsar of All the Russias!

"Amelia, when is your birthday?" I asked.

"October 12th."

"What year?"

She hesitated just briefly before saying, "1970."

I decided on a gambit.

"Do you have your ID so we can put your address on the chart?"

She pulled her billfold from her purse and showed me what even I, as a layman, could tell wasn't her driver's license, as the facial bone structure of the girl in the picture didn't even come close to Amelia's. I ignored that for the moment and wrote down her address, noting her birthdate.

"Thanks. How many times were you hit?" I asked.

"I don't know, maybe four."

Which matched her observable injuries.

"I'd like to get an x-ray to make sure no bones are broken," I said.

"Yes."

"Let me arrange that, please. Just relax here. Nurse Wendy will stay with you. Mary, with me, please. Tom, just wait here."

He gave me an odd look, but acknowledged my instructions, and Mary and I stepped out.

"What's wrong?" she asked. "Usually you would have Tom call radiology."

"She can't consent to the x-ray," I replied. "I either need two doctors with medical licenses to sign off with me, or her parents."

"She's nineteen, right?"

I shook my head, "I think she's fourteen or possibly fifteen. The ID she showed me is not hers."

"You know, she does look awfully young, but some girls look young. We had an undercover police woman at my High School who was twenty-three but passed as a Junior."

"Obviously not well enough if you knew!"

"I only knew after she busted the pot dealer. But then it made total sense why she never went on dates or hung out with kids after school or went to parties. So what do you do?"

"The discrepancy between her claimed age and what I observed is too great to simply ignore and pretend she's really nineteen. My thinking is to get Doctor Gabriel and Doctor Mastriano to sign off and treat her, but also see if you or I can build rapport with her and get her to admit her age."

"Then what?"

"Figure out if she's being abused or if she really was in a fight. The age mismatch suggests another possibility, too, based on a something a Sheriff's Deputy said this morning."

"I wasn't here, obviously. What?"

"They're looking for a pimp and drug pusher who runs underage prostitutes."

"I'll cut his balls off if I see him!" Mary declared fiercely.

"I think that was what Deputy Sommers was thinking as well. Let's go see Doctor Gabriel and see if he'll back our play."

We went to the Attending's office, and I was happy to see both Doctor Gabriel and Doctor Mastriano there.

"What's up, Mike?"

"I have a female patient who was battered. She has facial contusions, a swollen lip, and glassy eyes, suggestive of marijuana use. She claims to be nineteen, but after my gross exam, I believe she's fourteen or fifteen. She has ID, but it's clearly not her given the differences in facial bone structure and offset between her eyes compared to the picture.

"I want to get x-rays, but given I'm convinced she's under sixteen, I need you and Doctor Mastriano to sign off. I'm concerned that if I confront her, she'll leave AMA, and I'd rather get the tests done so we know that she doesn't have any fractures. I'll also draw blood for a tox screen."

"And then what?" Doctor Mastriano asked.

"Then we treat her, most likely with analgesics, and attempt to get her to tell us who beat her."

"You have a suspicion, Mike."

I nodded, "Deputy Sommers this morning said the Sheriff and the McKinley PD are looking for a pimp and pusher who runs underage prostitutes. Maybe the patient really did get into a fight, but I'd say it's more likely she was beaten by an adult male, given the bruising. Whether it's a family member, boyfriend, or pimp, she needs help."

"And if it's a fight?"

"We street her. If not, either a Psych consult or social worker. Given the hour, it'll be Psych."

"Alternatives?"

"Well, I precluded pretending she's actually over sixteen once I stated my suspicions to Mary and then to you. The other option is confrontation with the risk she bolts."

"Who brought her in?" Doctor Mastriano asked.

"A friend."

"Is the friend still here?"

"I don't know," I replied. "Mary, go check with the admit desk, please. Don't say anything, and be surreptitious, so you don't spook anyone. Just get a look at the person who brought her in."

"OK," she replied, and left the office.

"You couldn't let it go?" Doctor Mastriano asked.

"Not once it became obvious, she was lying about her age and with what the Sheriff's Deputies said this morning."

Mary was back a minute after she had left.

"Scruffy looking guy I'd guess was around thirty," Mary said. "Nurse Emily identified him for me without making it obvious."

"OK," Doctor Gabriel said. "I'll sign off on the treatment. Isabella?"

"Sure."

"Mike, get the x-ray and lab work and see if you can get her to admit what's going on. If it's what I suspect, I'll call the Sheriff. Isabella, you go with them, please, given we're treating an underage patient without parental consent."

Doctor Mastriano, Mary, and I returned to Exam 3.

"Amelia, this is Doctor Mastriano, one of my supervisors. We'd like to get some x-rays and draw some blood, and also get a urine sample to check, among other things, for blood. That's standard when someone's been in a fight."

"How long will it take?"

"It depends on Radiology," I replied, then turned to Tom, "Call for a facial series, please. Wendy, if you'd draw blood for a trauma panel, hCG, tox, and get a urine sample. Tom and I will step out as soon as he finishes the call. Do you want us to tell your friend what's going on?"

"Uhm, er, I guess."

"What's her name?" I asked, using subterfuge to not make her suspicious.

"It's a guy. Gary. He's wearing jeans and a black t-shirt."

Tom finished the call and let us know Radiology could take Amelia as soon as we were ready, so I asked him to step out with me.

"What's going on?" he asked once we were out of the room.

"We're pretty sure she's only fourteen or fifteen, and the guy she's with is around thirty. Come with me and we'll see if we can get any clues without making him suspicious."

"You think he's abusing her?"

"I don't know, but a guy of thirty isn't usually 'friends' with a girl who's fourteen or fifteen."

Which I knew from experience, though Paul hadn't been that old when he'd been with my sister.

"Statutory rape," Tom said. "Well, I guess it's Criminal Sexual Assault now."

We went to the waiting room, and I saw Gary, who was dressed as Amelia had said, though I realized that probably was not her name, given the phony ID.

"Gary?" I said.

"Yeah?"

"Doctor Mike Loucks. Amelia seems fine, except for the obvious bruises and fat lip, but we're going to take x-rays of her face to make sure no bones are broken. That will take about an hour."

"Can I see her?"

"Once the x-rays are completed, I'll ask if she wants you to come back, but it's up to her."

"She'll say 'yes'."

"Do you know what happened?"

"Some guy beat her up. She came to me and I brought her here."

"OK," I replied.

I didn't ask about calling the police because the last thing I wanted to do what make him suspicious. Tom and I went back into the ED and waited outside the exam room.

"He looks like a pusher," Tom said quietly.

"And possibly a pimp," I replied. "The Sheriff is looking for a guy running underage girls as prostitutes."

"Guys like that should be strung up."

"Mary suggested she'd perform an orchiectomy."

"Sounds about right."

Mary came out of the exam room with blood vials and a urine sample.

"Doctor Mastriano signed the order," Mary said.

"Tom, take everything to the lab, please. We need the results of the hCG before we run an x-ray."

"You think she might be pregnant?"

"A standard trauma panel for any female who is of childbearing years includes a pregnancy test."

"Got it."

"Mary, I'll leave you in the room and have you try to build rapport. Be very careful."

"You're sure I should do it?"

"Positive. I think she'll be more willing to open up to you as a medical student, but don't push too hard."

"What did the guy say?"

"That 'some guy' beat up Amelia and she came to him for help."

"Consistent with him being her pimp."

"Or pusher," I replied. "Or both."

We went into Exam 3 where I had Wendy draw the blood and had Tom take them and the order to the lab.

"Amelia, Mary is going to stay with you until the lab results come back."

"OK," she said.

Wendy, Doctor Mastriano, and I stepped out of the room.

"She's not nineteen," Wendy said quietly. "Fifteen at most."

"We're all in agreement on that," I replied. "And the 'friend' is a guy around thirty.

"Everything lines up except one thing that makes no sense," Doctor Mastriano said. "Why does the guy bring her and stay with her? In my experience in Los Angeles, the pimps and pushers never hung around, and with injuries like this, they never showed up in the first place."

"What's your theory, Doctor Mastriano?" I asked.

"I don't have one," she said. "I just pointed out something that didn't line up. That's not to say he's not her pimp or pusher."

"A girl my parents are fostering was involved with a guy in his forties at age fourteen and got pregnant," I replied. "She had a fight with her mom and her response was to go next door and screw her best friend's dad. He was arrested the day her baby was born. She'd concealed the pregnancy."

Not to mention the situation with my sister, but I wasn't going to say anything about that, given everything else that had happened. Tom returned then and joined us in the corridor.

"So, are we taking bets?" Wendy asked. "Boyfriend? Pusher? Pimp? Trick? Friend?"

"Any or all of the above," I replied. "I do think Doctor Mastriano has a point about how a pimp or pusher would behave, but what's with the bogus ID and lying about her age?"

"If she claimed to be twenty-one, I'd say for bars," Tom said. "What does nineteen get you?"

"R-rated movies?" Wendy suggested. "Driving? And some clubs let you in at eighteen, but won't serve you booze."

"If Doctor Mike identified the license is phony, wouldn't a cop or bouncer?" Tom asked.

"It doesn't add up," I observed. "Let's see if Mary has anything for us when she comes out."

We waited about ten minutes, and Mary came out, and Wendy went in to stay with Amelia,

"She says Gary is her friend and that her boyfriend hit her."

"Did she admit how old she is?" Doctor Mastriano asked.

"Fifteen, and the ID is her older sister's. Her name is Amber. She doesn't want anyone to call the cops, so she pretended to be her sister."

"There are holes in the story," Doctor Mastriano said. "I think we need to call Social Services."

I nodded, "This isn't our area of expertise."

"I'm going to discuss it with Doctor Gabriel," Doctor Mastriano said.

"OK. Tom, go see what the lab has for us so far. I'm particularly interested in the tox screen and pregnancy test."

He left and was back five minutes later.

"Positive for THC and she's pregnant," he said.

"We need to tell Doctor Gabriel," I said. "Let's go."

The three of us went to the Attending's office, and I shut the door.

"Tom?" I prompted.

"Positive for THC and a positive pregnancy test."

"Mary?" I prompted.

"She admitted she's fifteen, says the guy who brought her in is a friend, and that it was her boyfriend who hit her."

"We can't x-ray her because of her pregnancy," Doctor Gabriel said. "Mike, do you actually suspect broken bones, or was it simply a precaution?"

"Precaution."

"OK. We need to call Social Services," Doctor Gabriel said. "The problem is, they won't see her until 7:00am tomorrow. We can't release her to an adult male who isn't her guardian, given she's under sixteen. There's no medical reason to keep her, so the only way we could do that is a Psych hold, which would obviously be a pretext or call law enforcement."

"What about calling her parents?" I asked. "We at least have an address for the sister. We could check the White Pages for surname and address match."

"Tom, do that," Doctor Gabriel said.

"Amelia DeJong," I said. "That's a Dutch name and isn't common in Ohio. 15 Custer Drive."

"Be right back," Tom said.

He left the office and came back a minute later.

"Charles DeJong, 15 Custer Drive," he said, "555-9898."

Doctor Gabriel pressed the speaker button on his phone and dialed the number. It rang five times before it was answered.

"DeJong residence," a man's voice said.

"Mr. DeJong, this is Doctor Peter Gabriel from Moore Memorial Hospital. Do you have a fifteen-year-old daughter named Amber?"

"She's fourteen. Is she OK?"

"Someone hit her several times, but we don't believe she has any broken bones or other injuries besides bruises. Do you know a man named Gary?"

"He lives next door. Why?"

"He brought your daughter here. We'd like you to come to the hospital so we can release her to you."

"My wife and I will be there in ten minutes!"

"Thank you, Mr. DeJong."

He pressed the button to disconnect the call.

"Do we tell her she's pregnant?" Mary asked.

"Yes," Doctor Gabriel said. "But before her parents arrive. We do not tell them. I'll put that on the chart."

Fourteen was iffy, but it was Doctor Gabriel's decision, and I felt given the unknowns, it was better to handle it the way he'd said.

"Mary should tell her," I suggested. "She developed rapport. Refer her to the Free Clinic?"

"Yes."

"Mary, let's go. Tom, go to triage and wait for her parents, then bring them to the consultation room and let us know."

"OK," Tom agreed, and he left.

Mary and I left the office, and I pulled her aside.

"If she asks why we ran that pregnancy test, you tell her it's a standard test before we run x-rays."

"And the THC?"

"I'll handle that once you tell her."

We went to Exam 3, where Wendy was waiting with Amber.

"Amber," Mary said. "We can't take x-rays because you're pregnant."

"I know," she sighed.

"Let me give you a brochure for the Free Clinic."

"I know about it," she said.

"Amber," I said. "You also tested positive for marijuana. That's not good for your baby. Also, your parents are on their way to get you."

"NO!" she gasped. "They can't know I'm pregnant!"

"We won't tell them," Mary said. "But because you're only fourteen, we had to call them."

A few minutes later, Tom came to the door to let us know that Mr. and Mrs. DeJong had arrived and were in the consultation room.

"Was there a confrontation with the friend?"

"No. It appeared cordial."

"Stay here, please. I'll go speak to them with Doctor Gabriel."

I left the exam room and went to the Attending's office to let Doctor Gabriel know the DeJongs had arrived.

"Isabella, you speak to them with Mike," Doctor Gabriel said. "Remember, just tell them that she was hit, should see her personal physician, and leave it at that."

"OK," she said, and we left the office to go to the consultation room.

"Mr. and Mrs. DeJong," Doctor Mastriano said. "I'm Doctor Mastriano and this is Doctor Loucks. We examined your daughter and other than some bruises and a swollen lip, she's fine. You should take her to your family doctor for a checkup."

"Did you call the police?" Mr. DeJong asked.

"No," Doctor Mastriano said, "because we were able to get in touch with you."

"Can we take her now?"

"Yes. Doctor Loucks will take you to her and give you a discharge form."

"Thank you, Doctor."

I escorted the DeJongs to the exam room, explained the discharge instructions to all three of them. After they left, I went to find Doctor Mastriano, who was at the nurses' station.

"Could I have two minutes of your time in private, Doctor Mastriano?"

We went to the temporary Resident's office.

"What can I do for you?" she asked.

"I strongly prefer 'Doctor Mike'," I said. "I'd appreciate if you refer to me that way."

"I'd quote policy, but I don't think that would matter to you."

"You're Roman Catholic, right?"

"Yes."

"And you call your priests by their last name? Right?"

"Yes, of course."

"I'm Russian Orthodox, which I expect you know, and we call our priests by their first name. When I was a deacon, I was 'Deacon Mike' and my priest is 'Father Luke' and my bishop is 'Vladyka JOHN'. That's my tradition, and I think it's better. I'm not asking anyone else to use their first name, just that I be allowed to be Doctor Mike. May I draw another comparison?"

"I suppose."

"Would you be OK with me calling you Izzy instead of Isabella?"

"No. I've never gone by Izzy."

"And I've never gone by 'Doctor Loucks'. Just consider it, please."

"Or you'll run to Gibbs and tattle?"

"I asked you, politely, as a colleague," I said. "That's the end of it."

"Doctor Mastriano?" Nicki said from the door to the office, "EMS three minutes out with an MI. Doctor Gabriel wants you to handle it. Mike, he'd like to see you."

We left the temporary Resident's office, and I went to the Attending's office.

"You wanted to see me?"

"Angela said you and Mastriano were talking. What's up?"

I shook my head, "Nothing that needs your attention."

"You're sure?"

"Yes."

"Then get some rack time while it's quiet."

"Thanks, Pete."

_August 4, 1989, McKinley, Ohio_

I managed three twenty-minute naps overnight, which was a far sight better than what had been possible for Kylie. There hadn't been any critical cases, but we had two admissions and at 6:00am still had two awaiting discharge. I left Mary and Tom to watch over those patients and went to the cafeteria for breakfast.

"Hi, Doctor Mike!" Debbie Sherman said when I walked into the cafeteria.

"Hi! When is your trauma Sub-I?"

"December. I start my surgical Sub-I on Monday."

"I look forward to it."

I got in line and Debbie left, as she had already eaten. Once I had my breakfast, I returned to the ED and joined Doctor Gibbs for Mary's and Tom's evaluations. Mary received a rating of 5, as she was, in my mind, an exceptional candidate, and she was given a 'select for match' notation as well, while Tom received a rating of 4.

"What do I need to do to receive a 5 for my Sub-I?" Tom asked.

"Be exceptional. I can't say specifically, except to say be the best in your class, or close to it. Honestly, I think your grade was a close thing, and if you continue the way you are, you'll have a good shot at earning a 5. I promise to do my best to help you."

"Thanks. I'm going to miss working with you. Well, except for the chopper incident!"

"Kellie made the comment that pilots say any landing you can walk away from is a good landing!"

"I still can't believe how calm she was."

"If there's a chance to be on a transport helicopter, take it," I said. "What do you have next?"

"Pediatrics."

"The key there is developing your bedside manner. It's the one service where you're absolutely expected to spend extra time with patients."

"Got it."

Mary returned and the three of us treated walk-ins until lunch. After lunch, we did the same, until just before 2:00pm, Nate called for me.

"Mike?" he called out. "Paramedics four minutes out with a stabbing victim. Doctor Nielson wants you with him."

"OK. Tom, get Mary and meet me in the ambulance bay."

He went to find her while I headed for the ambulance bay, grabbing a gown and gloves as I passed the stand. I joined Perry, Kellie, and Angela, and a minute later, Mary and Tom came out. The EMS squad pulled up and Bobby jumped out.

"Amber DeJong, fourteen; multiple stab wounds; BP 80 palp; tachy at 120; PO₂ 92% on ten liters; hypovolemic; one unit of plasma in."

"Lord have mercy!" I breathed.

"Trauma 1!" Perry ordered. "You know her, Mike?"

"She was here last night after being beaten up," I replied as we quickly moved her to the trauma room.

"Kellie, hang another unit of plasma on the rapid infuser; type and cross-match; Mary intubate; Tom, monitor but hold the EKG until we assess; Mike, wound assessment."

"She's pregnant," I said. "The facial bruises are from last night."

In the trauma room, the paramedics helped us move Amber to the treatment table and everyone sprang into action. I used bandage scissors to cut away Amber's t-shirt and bra and immediately saw four penetrating wounds.

"Three abdominal stab wounds, one chest," I declared. "Hemothorax, which we'll deal with upstairs. Tom, call upstairs and book an OR stat. She can't wait. Perry, she _has_ to go up as soon as the first unit of plasma is in. Kellie, that type and cross-match has to be stat and sent upstairs. Angela, get a gurney!"

"You heard the man!" Doctor Nielson said. "Move, people!"

"Tube is in!" Mary declared. "Hooking up the portable vent."

"OR 2 expecting us!" Tom announced.

"First unit is in," Kellie announced.

Angela came in with a gurney and on my count we moved Amber to the gurney, and immediately Tom, Mary, and I rushed her from the room, heading for the elevators.

"HOLD THAT ELEVATOR!" I yelled.

People in the corridor parted before us, and the elevator quickly emptied, with a nurse holding the button to keep the door open. A minute later, we pushed the gurney into OR 2, where Doctor Aniston, Doctor Lindsay, and Doctor Wilson were waiting with a full surgical team.

"Amber DeJong, fourteen; pregnant; multiple stab wounds — one to the chest, three to the abdomen; hemothorax; two units of plasma in; intubated; last vitals BP 80 palp; tachy at 110; PO₂ 94% on vent!"

"Mike," Doctor Anniston said, "your students can go back to the ED. Put in a Foley, then scrub in!"

"Tom, Mary, go!" I instructed. "14 French to me!"

As Doctor Anniston began assessing Amber, I picked up bandage scissors from the tray and cut off her shorts and panties, then inserted the Foley catheter. I connected it to the bag and saw it was tinged with pink.

"Blood in the urine in the bag!" I announced, then went to the scrub room, removed my scrubs and baptismal cross, then put on fresh scrubs. I scrubbed as quickly as I could and the scrub nurse helped me with gloves, my cap, and a mask.

"She's under!" the masked anesthesiologist declared. "5-lead shows sinus tach!"

"Mike, assist Doctor Lindsay on the chest," Doctor Anniston directed.

"Given the location and depth of the wound, we'll need to repair the lung," Doctor Lindsay observed. "I'll extend the wound, sew the lung, then close. You handle the retractor, and Penny will suction."

"OK," I replied.

The phone rang, and a nurse answered and was given a blood type of 'O+' and Beth, a Fourth Year, was asked to retrieve two units from the refrigerator. The nurses hung the blood, and we began the surgery while the other team was performing an ex-lap to locate all the internal injuries.

"Penetrating wound to the uterus," Doctor Anniston announced. "Fetus is not viable."

Doctor Lindsay successfully repaired the would which had caused the hemothorax and began closing.

"Chest tube tray to Mike!" she ordered.

"16 French," I requested.

"Infrarenal aortic rupture!" Doctor Wilson declared. "Lap pads and suction!"

"No pressure!" the anesthesiologist declared. "She's bleeding out!"

I prayed silently that the surgical team would have the skills necessary to save Amber.

"Two more units!" Doctor Anniston ordered. "Pump them in!"

"Asystole!" the anesthesiologist called out.

"Starting compressions!" Doctor Lindsay declared.

I stopped working on the chest tube because of the chest compressions and watched as Doctor Anniston and Doctor Wilson tried to repair the infrarenal aorta.

"Repair complete!" Doctor Anniston declared. "Keep that blood coming!"

"Stopping compressions," Doctor Lindsay declared. "Mike, auscultate."

"Faint heart sounds," I said. "Getting stronger."

"Pressure coming up," the anesthesiologist declared.

"Sinus rhythm!"

"OK," Doctor Anniston said, sounding relieved. "Let's continue."

I put in the chest tube and confirmed good bilateral breath sounds.

"Hemothorax repaired, chest tube is in," Doctor Lindsay announced.

"Shelly, come run the bowel while I repair a liver lac. Mike, Mary, observe. PGY2s need to know the procedure for running a bowel."

Mary and I were both PGY1s, though I wouldn't be in surgery regularly for nearly two years. I watched as Shelly manipulated the bowel, looking for any injury or leaks, while Doctor Anniston repaired the liver laceration. The final repair was to the uterus.

"Mary, we'll need an OB/GYN for a D&C once the patient is out of the ICU. Let them know."

The surgery was completed, and Mary and I took Amber to the ICU, then returned to the surgical locker room to change.

"Any idea what happened?" she asked as we changed scrubs.

"All I can really say is that she was in last night after being beat up. She was released to her parents, and then EMS brought her in about two hours ago."

"I thought we were going to lose her."

"Me, too," I agreed. "She's not out of the woods yet."

I finished putting on clean scrubs, then headed back to the ED.

"Mike," Nate said. "You need to go to Doctor Northrup's office."

"About?"

"The stabbing victim."

I nodded and returned to the elevator and went to Doctor Northrup's office. I didn't like the fact that it wasn't directly adjacent to the ED, but that would be rectified once we moved into the new building.

"Go right in," Mrs. Andrews, his secretary said.

I went into the office and saw Doctor Northrup, Doctor Williams, Doctor Gibbs, Doctor Mastriano, and Detective Louise Rehling from the McKinley PD and Sarah Vaughn, an investigator with the Sheriff's Department. Mr. Crowe, the hospital legal counsel, was also in the room.

"Have a seat, Mike," Doctor Northrup said.

I sat down and waited.

"Did she make it?" Doctor Gibbs asked.

"Touch and go. She coded on the table due to hypovolemia but we got her back. She's in the ICU and I'd say it's no better than 50/50."

"Doctor, you received the victim last night, correct?" Detective Rehling asked.

"Yes," I said, taking my notebook from my pocket.

"Would you tell me what you observed and what she said?"

I pulled my notebook from my pocket and read my diagnostic notes to her.

"Do you document every patient that way?" she asked when I finished.

"The amount of detail varies, but every patient I treat goes into my notebook, with at least a single line. It's a habit from when I was a student and I had to keep a procedure book. I continued it once I started my Residency. There are no names, though."

"When you discovered Miss DeJong was pregnant and underage, why didn't you report it?"

"I did, to Doctor Williams and Doctor Mastriano."

"Why did you run a pregnancy test?"

"Because it was my intent to x-ray Miss DeJong for facial bone fractures. It's standard practice to perform a pregnancy test on any female patients who are of child-bearing age, which is twelve to sixty, based on menarche and menopause, before x-rays."

"Did you ask her who the father of her baby was?"

"No."

"Did you see who brought her in?"

"A guy named Gary. He had what appeared to be a cordial conversation with her parents when they arrived."

"Did he say anything?"

"Just that 'some guy' beat her up. My medical student spoke to Amber, and she said that her boyfriend beat her up and that Gary was just a friend."

"Do you find it normal for a thirty-year-old male to befriend a fourteen-year-old girl?"

"Excuse me, Detective," Mr. Crowe said. "Doctor Loucks stated that he reported the situation to his supervisors, which is hospital policy."

"That's not what I asked, Mr. Crowe."

"But that is the answer you'll receive. Doctor Loucks is an Intern. If you have questions about how this was handled, those are for Doctor Northrup and Doctor Williams. Do you have any other questions about treatment that Doctor Loucks can answer?"

"Not at this time."

"Mike, you can return to the Emergency Department," Doctor Northrup said.

"Yes, Doctor," I replied.

I left the office and headed back to the ED and found Mary and Tom.

"Did the police talk to you?" I asked.

"They wanted to, but Doctor Northrup and the hospital attorney wouldn't allow it," Mary said. "I'm not sure they can actually prevent it. How is she?"

"She coded on the table due to hypovolemia but we got her back. She's in the ICU, but it's 50/50 at best. She lost the baby."

"Don't you think she should have had an abortion?"

"My opinion on that is complicated, but it should have been her choice, not whoever stabbed her."

"I heard they arrested her dad," Tom said.

"Unless the cops told you that directly, it's a rumor, and you shouldn't repeat it."

"Sorry."

"No need to apologize. That's simply personal advice. What's not advice is not to talk to anyone about the patient unless Doctor Northrup or Mr. Crowe give their approval. Obviously, you have to talk to the cops if they insist, but your answer should always be that you're a medical student and are not qualified to make any medical judgments or observations, and it is, at least in some cases, illegal for you to do so."

"Why?" Tom asked.

"Mary?"

"We're forbidden from making any medical judgments and we're only allowed to say things approved by our Resident or an Attending. Anything else could be construed as a violation of the rules against practicing medicine without a license. Though prosecution is unlikely, saying the wrong thing to the wrong person could lead to dismissal from the program."

"Exactly," I replied. "Tom, can I speak to you privately?"

"I'll go get a Coke," Mary said.

She left the lounge.

"You want to know how to score a 5? Be able to answer the question you asked. The answer is in the study material for Practice of Medicine and in the student guide."

"Sorry."

"Another thing," I said. "You're too quick to apologize. It's better to say that you'll study and know the answer next time, or something similar. Remember what I said about your surgical Clerkship?"

"Find out the surgery and memorize the steps; if we don't know, admit it and state that we'll do better."

"And then you have to back that up. You've copied the flashcards, now you have to study them. And review your material for each rotation regularly. Keep a notebook, not just for procedures, but for each service with literally everything you're taught and study it. You've started doing that; keep doing it."

"How did you get perfect scores for every rotation?"

"I studied. All the time. There was never a time I didn't have my flashcards or a book. Standing in line at the BMV, I reviewed flashcards. Standing in line at Kroger, I reviewed flashcards, and so on."

"Thanks."

"I'll see over the course of the next year, I'm sure, and then I'll see you on your trauma Sub-I. Do what I've said and I promise you'll get all the procedures you can handle."

"I appreciate it."

"Hi, Mike," Kylie said, coming into the room. "The board had nothing with your name."

"I ended up in emergency surgery for two hours."

"Lucky dog! Then I suppose you can take off and I'll see what's waiting out front."

"Thanks, Kylie."

I said 'good night' and headed up to the surgical locker room where, as usual, I ran into Shelly Lindsay in her panties and bra.

"She coded in the ICU about fifteen minutes ago," Shelly said. "They couldn't bring her back."

"Lord have mercy," I sighed.