Chapter 53 — There Wolf! There Castle!

_September 26, 1989, Circleville, Ohio_

{psc} "There's a letter for you from the Pickaway County Clerk of Courts," Kris said after greeting me at home on Tuesday evening. "It's in the basket on the kitchen counter."

"I'll look at it after we say evening prayers, I read to Rachel and we put her to bed."

The three of us went to our icon corner, said our evening prayers, then I sat with Rachel and read her current favorite book — _Put Me In The Zoo_. When I finished reading to her, I took her to her room, changed her into a fresh diaper, put on a clean pyjamas, and then put her down to sleep. She was very good about going to bed and closed her eyes, so I turned off the light, left her room, and went downstairs. I went to the kitchen and retrieved the envelope, and opened it.

"A jury summons," I said aloud.

"How does that work with you being a doctor?"

"I'm not sure. Give me a minute to read this, please."

I read through the document and on the reverse were instructions on how to report, and instructions on how to request an exemption, though those were mostly vague.

"It says that exemptions are for verified medical or mental conditions…"

"Is this where Clarissa says something about you being mentally ill?" Kris interrupted with a smirk.

"Obviously," I replied, shaking my head. "And I've never denied being crazy, but I don't think I want to go on record with the state as being nuts!"

"Probably not!"

"It also states financial hardship, but I'm salaried and the hospital is required to give time off for jury duty. There is a statement that other hardships need to be described in writing, but I can't think of any. I mean, yes, the hospital will need to find someone to cover for me, but that would be true of anyone who has a job. The other listed exceptions, including being over seventy-five or having a felony conviction, don't apply. I won't try to be excused because it's my civic duty."

"When is it? And for how long?"

"October 23rd through 27th. It says I have to serve either five days or one trial. I report each day, and if I'm selected for a jury, I serve on it; if not, then I return the next day."

"Do you think you'd be chosen?"

I shrugged, "I have no idea. I'm fairly certain I couldn't serve on a jury if the case were about medical treatment, but otherwise, I suppose it would depend on what the attorneys on both sides think about me. We'll see what happens in a month. A questionaire is included that I need to fill out with basic information, so I'll fill that out and return it. I do have one other thing to tell you before we go to bed."

"What's that?"

"I had to give a deposition today about Krista Sandberg to the medical school and hospital attorneys. No big deal, and they talked to Shelly Lindsay as well. They'll also talk to Kellie Martin and Becky Compton."

"Why?"

"It's part of the investigation before they formally expel her, which will happen by the end of the week. It's also to know what might come up if she were to sue. There's a good chance she might, though her case is actually worse than the others who tried legal action. The same attorney has come after the medical school and hospital a dozen times in the past ten years, though he's always lost."

"And yet he keeps trying?"

"Because all he needs is one win, and that will open the floodgates. He did have one success with the negotiated agreement for Melissa Bush to repeat her Fourth Year, but that agreement created no precedent, and frankly, her expulsion was too harsh given the mitigating factors. It led the medical school to be less inclined to expel individuals for non-medical violations. That's why Jack Strickland was given a suspension, and not expelled, for his boorish behavior."

"Comparing a woman to a cadaver with regard to sex is more than boorish!" Kris exclaimed.

"I don't disagree, but that is how it was classified. And you've heard me complain often enough about the way women, minorities, and homosexuals are treated in the medical community. My complaints about what amount to sexual harassment and abuse are what got me into hot water with Doctor Northrup. He's apparently also not happy with the new rule the medical school put in place about sex in the hospital, but the more I think about it, that might be posturing."

"Posturing?"

"He wants to be Medical Director, and for that to happen, he has to overcome the institutional inertia of always appointing a surgeon to that role. By taking a position against interfering with doctors' private lives, he gains support of doctors who are jealously protecting their privileges."

"To sleep with their students!"

"From his perspective, it's about consenting adults, and he has a point, to a point. That said, I don't see a distinction between screwing in the hospital or going to a motel, with regard to propriety. I could make a distinction that in the hospital it disrespects other staff and patients, and despite believing that, I think it's more than that. I'm no prude, and I honestly do not care who sleeps with whom, until it affects medical training and patient care. Doctors are already prohibited from sleeping with their patients for ethical reasons."

"Kari?" Kris asked.

"She was no longer a patient when we began dating, and I wasn't a doctor, so not bound by the same rules. Had she come back to the hospital for any reason, I wouldn't have treated her except _in extremis_. If I were a psychiatrist, then dating after she was no longer a patient would generally be an ethical violation."

"I suppose that makes sense. Did you make contact with anyone who could help the prisoner who isn't receiving proper medical care?"

"I spoke to the assistant in the office of the doctor in charge of prison medical care. That person flat out refused to do anything. I was invited to write a letter and they would review it and investigate. When I asked how long the investigation would take, they said ninety days, which is unconscionable. I'm trying an end run to see if I can have any success."

"End run?"

"From gridiron football, not what you call football!

"At least in _our_ football, you actually use your feet to advance the ball! It's illegal in your version! So silly!"

"Whatever! In any event, it means handing the ball to a back who then attempts to run to the outside of the offensive line. In general, it means to go around some obstacle, and in this context, to try to go around the bureaucratic process."

"How so?"

"By having Kurt Bowman name me as his next of kin, which gives me the right to contact the prison about his medical care. I did that, and also advised him to get aspirin from the commissary and take half a tablet a day, because the main cause of TIA is blood clots or plaque in arteries. That should help until I can have him properly evaluated. The problem is, the request for care will be evaluated by the same person who insists he's faking it."

"What can you do at that point?"

"I'm not sure. I think I might need to speak to an attorney."

"Your stepdad?"

"He specializes in family law. Mr. Winston, who my mom works for, is a generalist, so he's probably my best choice, at least to start. I'd say Jocelyn, but she's a brand new attorney similar to how I'm a brand new doctor."

"I can't believe they won't provide proper medical treatment!"

"I can believe it," I sighed. "People in prison are considered sub-human by many people, no matter why they're in prison. And a felony conviction basically screws you for life, even if you're completely rehabilitated and don't pose a risk to anyone or anything. It's made worse by ever-harsher penalties, over-criminalization, and stacking of charges. But now I'm getting way out of my area of expertise!"

"I know one area where you're an expert!" Kris declared with an inviting smile.

"Should we go upstairs and try to make a baby?"

"Yes!"

_September 28, 1989, McKinley, Ohio_

"Got a minute?" Bobby asked early on Thursday morning.

"Ambulance bay?" I asked, given the consultation room was being used and there were others in the lounge.

He nodded, and we walked out to the ambulance bay where his squad was parked.

"Is there anything thing I can say or do to get you to fix the situation between you and Lor?"

"To me? Or to her?"

"You are both as stubborn as mules!" Bobby growled.

"As has been said, the Borodin clan are a stubborn lot, but that said, do you know the true source of my problem with Doctor Gibbs?"

"'Doctor Gibbs'? Come on, Mike!"

"If you don't understand why I used her title and surname, that makes me suspect you don't know the true source of the problem."

"And what is that?"

"She refused, even in private and off the record, to admit that she, at one time, agreed with my position on relationships between doctors and medical students. She went from wholehearted support to refusing to admit that was ever her position. And that was after she threw me under the bus with Doctor Northrup by not backing my right to hold an opinion he doesn't like because it might interfere with his longshot chance of becoming Medical Director."

"That's not how she put it."

"Of course not. I'm positive she said I took umbrage at the double-secret probation, and while that's true, it's not the source of the problem. The double-secret probation bit was overturned by Doctor Cutter, but even after that, Doctor Gibbs refused to acknowledge that at one time she agreed with me. She's playing politics and places more value on that than on our friendship."

"Bobby, we have a run!" Sam called out from the cab of the squad.

"I'll find you later, Mike," Bobby said.

"OK," I replied.

He hopped into the squad and I turned and went back into the ED. I wasn't really surprised that Doctor Gibbs had focused on the 'rat fink' aspect of our interaction, because that had been my first complaint. That said, I'd backed off that and simply wanted her to acknowledge something she'd said in the past. Until she could do that, I didn't see a way forward except as professional colleagues.

"Doctor Mike, do you have a minute?" Al asked when he saw me walk in.

"Sure. What's up?"

"I know it's early, but I spoke with Doctor Mertens about my schedule for next year and she said Doctor Cutter would need to approve me for the Pathology Sub-I because of how limited they are."

"That shouldn't be a problem, given your surgical rotation is before the final choices have to be made. Do the same excellent work on that rotation, let your Resident and Attending know you want to Match for surgery, and we'll address it with Doctor Cutter once you have your evaluation. Remember, the trauma surgery Residency is officially a surgical Residency. And, worse comes to worst, not having the Pathology Sub-I won't hurt your chances at Matching here or elsewhere."

"Thanks, Doctor Mike!"

"Any patients waiting?"

"No. The waiting room is a ghost town, and I just sent up the only overnight admit."

"You know what that means!" I said.

"Always calmest before the storm!"

"Bobby and Sam just had a call, so there's at least one incoming trauma."

"I'd like to be involved in more traumas," Al said.

"Me too!" I chuckled. "But my role actually works against that, given I need to be available for surgical consults, as there isn't a pure surgical Intern assigned to the ED when I'm on shift. That actually worked in our favor with that triple MVA, where we worked on all three patients. It's also the case that trauma interns handle walk-ins to allow more experienced staff to deal with traumas."

"Does it bother you?"

"Yes and no. Like you, I want more action; but I also signed up for this, knowing what it meant. As strange as it sounds, I was directly involved in more traumas on an average day as a Fourth Year than I am as a PGY1. You haven't done a cardiology rotation, whereas as a Third Year you'll tag along for consults, while Fourth Years stay in the ward."

"I'm missing the logic."

I smiled, "I did, too, at first. Think about it this way — a Fourth Year has the necessary experience to respond to an emergency that a Third Year would not. The Fourth Year at that point, being responsible for the ward, demonstrates he or she is ready to be an Intern, given that's what Interns do, besides consults."

"That makes sense. I have a question, but I won't be offended if you tell me it's none of my business — did you really tape record your meeting with Krista?"

"I did."

"You were obviously aware of her and Bill Schmidt in the on-call room."

"I think I need to decline to discuss this further until the investigation is complete."

"Got it. Sorry."

"No need to apologize. Students are expected to ask questions of their Residents. I'd prefer you asked whatever is on your mind than fail to ask an important question. If I can't answer, I'll say so. But the only way you're going to get that spot you covet is to ask questions, learn everything you can, and be the best student you can possibly be. That might mean being pushy; I certainly was. You want to be assertive right up to the point of being obnoxious, but not cross that line; I did, a few times, and it led to counseling by my Resident or Attending."

The entire morning was eerily quiet. The only trauma was a rule-out MI that Bobby and Sam brought in, and Naveen and I saw only one patient each. At 11:30, I called to see if Clarissa could take her lunch, which she could, so we met in the cafeteria.

"Guess who was chosen to be the first Medicine PGY1 to do an eight-week trauma rotation?"

"Doctor Atkins?" I asked, knowing full well that was not the right answer.

"No."

"Doctor Nelson?"

"You're being yourself, Petrovich!"

I chuckled, "Obviously. I saw the revised schedule this morning. I don't think Naveen is happy with two months in Medicine, especially given I get to skip because I'm a surgical Intern."

"But you think the rotations are a good idea, right?"

"I do. We'll also have a cardiology Resident in the ED starting next week, rather than have them come down only for consults or admits. The goal there is to ensure all the ED Residents and Attendings are up to speed on reading EKGs and treating MIs and strokes. The new system should also speed up admits to Medicine and Cardiology, which is important, given we're short beds at the moment and we're still about twenty months from the new ED wing being completed."

"Have you trained any paramedics?"

"No, that's being done by the Attendings, because that's a requirement for certification. Roy performed the first-ever Hayes County Paramedic field intubation the other day. As we push more and more advanced procedures to the field, which is good for patients, we diminish training opportunities. It means, for example, fewer opportunities for intubation by Fourth Years, which is a problem. It means, as I see it, that they'll need to do something like 90% of all intubations in the ED so they have the necessary experience when they're Residents."

"It's an interesting problem, but a good one to have."

"I agree. Anything further on Krista?"

"No, but I expect her to be formally expelled no later than Friday."

"Do you think she'll appeal to the Student Ethics Board?"

"If the rumors about her speaking with Arthur Braun are true, I'd say that's a lock."

"Could the tape be used as evidence in court if she sues?"

"I recall from High School that in Ohio you only need consent of one party to record a private conversation, and as I was in the conversation, the recording is legal. That, combined with her sworn statement, will sink her. Or should. And speaking of court, guess who was summoned for jury duty?"

"That should be interesting. When?"

"Late October. There is no guarantee I'll actually serve, though. The summons said you appear for five days, and if you aren't selected, you're done. If you are selected, you serve the length of the trial, and that could be civil or criminal."

"Is your life ever going to calm down?"

"It is calm! This is something a typical citizen does."

"OK, the jury thing, but all the other stuff at the hospital?"

"I don't think that's ever going to be calm! There are so many things that need to change, I'm never going to run out of people to piss off because I point out the flaws in the system!"

"Maybe give it a rest for a bit?"

"I think no matter how hard I try, things are going to find me. You know all the 'problem children' are assigned to me."

"I think that might change after this little fiasco because it backfired on them, even if it might turn out the way they wanted. You threw a hand grenade into their little harem scheme."

"They can still screw med students if they want, they just can't do it at the hospital without the med student being dismissed if they're found out. But that's a big win in my book."

"Changing subjects, any luck with getting treatment for that inmate with TIA?"

"No. I'm attempting an end-run, and we'll see how that goes. At a minimum, I want to get someone on the record rejecting my request."

"Then what?"

"I'll have to speak to Kurt Bowman's attorney or Public Defender at that point. I have no idea if there's any chance of success."

"Sounds almost like tilting at windmills."

"Maybe, but if there was ever a worthy cause, this is it. You know what the Gospel says about visiting prisoners."

"I do. And that is what motivates you. What's the guy in for?"

"Armed robbery. His story is that he lost his job, had no money, and was trying to care for his wife and kids. He was desperate and did something extremely foolish. He got twenty years, and he's served about half."

"Normal people don't resort to armed robbery, no matter how desperate they are."

I shrugged, "I wasn't making excuses, only relating what he told me. I'd do the same for Frank Bush. Heck, I did that, in a sense, when I helped treat him after he was assaulted in the County Jail. We took an oath, Lissa."

"I know. The point is, you can only do so much; stop trying to do everything."

"I will acknowledge I do take on more than most."

"Most are simply focused on not failing as a doctor, so that's not a high bar!"

"True. But I have to be true to myself."

"And if you burn out or burn bridges, you won't be able to help anyone, including yourself."

"The only trouble I have at the moment is Doctor Northrup and Doctor Gibbs. I'm pretty sure he'll leave as soon as they announce Doctor Cutter as the new medical director, and then Doctor Gibbs will chill."

We finished our lunches, and I returned to the ED. Jake, Heather, and I had a relatively quiet afternoon, though not as quiet as the morning had been. Just before 5:00pm, I called Southern Ohio Correctional Facility to request medical treatment for Kurt Bowman. A different nurse was on duty, and as best I could tell, the other nurse had not communicated anything to her.

"You say you saw him on Sunday?" she asked.

"Yes, and he reported symptoms which, as a physician, I am positive are signs of TIA, colloquially known as 'mini strokes'. They resolve, mostly, but he has lost feeling in his face. I'd like to have him evaluated by a physician, please. Let me also give you the symptoms."

I did that, and she repeated what she had written back to me.

"I'll fill out the appropriate form," she said, "have him sign it, then fax it to Columbus for approval."

"Thank you very much."

"You're aware that his records say he's faking, right?"

"I am, but I don't believe that to be true, based on medical judgment."

"OK, Doctor. I'll send this in tonight before the end of my shift."

"Thank you again."

We said 'goodbye' and I hung up, feeling I'd at least made some progress. Whether it would bear fruit or not was a very different question. About an hour later, I had dinner with Shelly Lindsay and Leila Javadi, then finished my evening, heading home just after 9:00pm.

_September 29, 1989, McKinley, Ohio_

"Did you review the evaluations for Jake, Heather, and Al?" Doctor Gibbs asked when she arrived on Friday morning.

"Yes. I made a few notations and put them in your office in a sealed envelope when I arrived this morning. I also verified that Jake, Heather, and Al turned in their evaluations at the medical school."

"Good. Do you believe Jake should be selected for Match?"

"He's an above-average student with 4 or 5 in every facet of the evaluation, so he'd be a good candidate."

"Thank you."

"You're welcome."

Al, who had stayed past the end of his shift, received his evaluation about fifteen minutes later, and was very happy. I asked him to check in with me from time to time, and after we shook hands, he headed home to sleep. Jake, Heather, and I had a busy morning, seeing eight patients before 10:00am, then things slowed down a bit. Just after 11:00am, Nate let me know I had a phone call.

"A recorded voice said the call is from a prisoner at Southern Ohio Correctional Facility."

"Thanks. Which line?"

"Three."

I pressed the correct button and picked up the handset.

"Doctor Mike Loucks."

"This is Kurt Bowman. I saw a doctor today, and he confirmed TIA."

"That's very good. What did he prescribe?"

"Let me spell it — w-a-r-f-a-r-i-n; he said to stop taking the aspirin."

"You absolutely can't take those together. Did he tell you that you have atrial fibrillation?"

"Yes."

"Then I think he's on top of it. I'm not a cardiologist, but warfarin is the correct treatment for A-fib, and A-fib can cause blood clots, which can lead to the 'mini strokes' you were having."

"You coming back anytime soon?"

"In October," I replied. "I don't know which day yet, but likely a Sunday."

"I'd like to talk to you."

"I'll arrange it," I said.

"Gotta go. These calls cost a fortune!"

We said 'goodbye' and I hung up, and made a note in my notebook about seeing Kurt as well as Frank on my next visit.

"Mind if I ask?" Nate inquired.

"An inmate I saw as a chaplain last Sunday. He was having trouble getting medical attention, and I assisted him."

"I thought you resigned."

"I did. I'm a lay chaplain."

"I don't know how you do it!"

"At times, neither do I."

I picked up a chart, as Jake and Heather were scheduled for their evaluations, and Kellie and I treated and released a young man who had been bitten by a dog. When we finished, Jake and Heather, who were happy with their evaluations, got the next chart and we worked until lunch, which I ate with Sophia and her friends, though thankfully the flirty one wasn't with them.

The afternoon saw a steady flow of walk-ins, and at 5:00pm, I picked up Rachel from daycare, and we headed home for an evening with Subdeacon Mark and Alyssa, and Elias and Serafima and their kids.

_October 2, 1989, McKinley, Ohio_

"Morning, Mike!" Sophia exclaimed when I walked into the ED on Monday morning. "Sorry, Doctor Mike!"

"Hi! It's OK, given how long you've known me. Just be careful in front of patients, please."

"I will. I'm assigned to you, along with Nicole Lawrence, though she's only on until noon, when Marv Goldfeld comes on."

"I remember. Let me get the handover from Paul, then we'll get started."

I went into the lounge, poured a cup of coffee, then went to find Paul, who was in Exam 3, discharging a patient with a badly sprained ankle. He finished and then we walked over to the board.

"Four more for you," he said. "Last night was rule-out MI night. Five total, one we couldn't revive, three admitted, and one waiting on final labs to rule out an MI in favor of unstable angina. He's fifty-three, and in Trauma 1. Exam 5 is a twenty-year-old male with a concussion; mild symptoms, neuro said to monitor and discharge. Exam 6 is a suspected ovarian cyst, waiting on OB/GYN, but they say they're backed up."

"They're _always_ backed up to hear them tell it!" I groused. "That led to me delivering a baby back in August!"

"Better you than me!" Paul declared. "Final patient is in Exam 6 waiting on admission to Psych. Believes he's a werewolf."

"There wolf; there castle!" I said with a grin.

Paul laughed, "One of my favorite movies of all-time."

"Well, I don't have wolfsbane handy, and I doubt the Sheriff's Department issues silver bullets to the deputies, so I'll be careful. How did he say he contracted it?"

"Bitten by another werewolf, of course! But the bite mark appears self-inflicted. He's concerned because the next full moon is in thirteen days. So far, 2 of Haldol, and soft restraints."

"Restraints?"

"He demanded them because he's afraid he might bite someone. Doctor Samson felt it was appropriate to leave them on."

"With a waxing crescent moon? No risk! Give it two weeks, and then he'd risk changing and biting someone!"

Paul laughed, "How do you know so much?"

"Russian myths, including an incantation that will turn you into a werewolf if recited! The «заговор» is recited after wrapping a strip of animal skin around the person the warlock wants to turn into a werewolf. It can also be done by hiding the strip of skin under a mattress, and a husband and wife can both be transformed simultaneously."

"And you know the incantation?"

"Only roughly. My grandfather would never repeat it properly. I do know his modified version in Slavonic. Want to hear it?"

"Hell no! I have on a leather belt and leather shoes!"

I laughed, "Go home and get some sleep."

"Out of curiosity, is there a cure?"

"You either strip the skin off the werewolf or remove the strip of skin and recite a different «заговор» calling on Yogory the Brave, or a prayer to Saint George."

"I doubt we can skin this patient!"

"Well, we can't remove the strip of skin or amulet, because he contracted it by being bitten! See you tonight."

Paul left, and I went back to find Sophia and Nicole, and we checked on each patient in turn, with the 'werewolf' last.

"Cuckoo!" Nicole said when we left the room.

"Is that your medical diagnosis?" I asked with a slight smile.

"He's what my psych prof at OSU would call 'Just Plain Nuts'!"

"Sophia?"

"The tox screen says MDMA, so some kind of paranoid psychosis?"

I nodded, "That would be my guess as well, but we'll let psych deal with this one, as he appears to be a danger to himself and others. Sophia, get the first chart from the rack, and conduct an H&P; Nicole, you observe. Pay close attention, because I'll give you a shot soon."

They left, and I updated the charts for the patients Paul had handed over, then went to the lounge to wait for Sophia to let me know they were ready.

"Morning, Mike," Ghost said, coming into the lounge. "I hear you have a werewolf!"

"This one I'm happy to give to Psych! According to Paul, he asked to be retrained because he was afraid he'd bite someone. But if he _really_ understood lycanthropy, he'd know he wasn't a risk for another twelve or thirteen days when the moon is full!"

Ghost laughed, "Why am I not surprised you're conversant with the intricate details of being a werewolf?!"

"I could tell you about vampires, too! There's a book my grandfather has, which was published around 1970, _The Songs of the Russian People, as Illustrative of Slavonic Mythology and Russian Social Life_, that contains all manner of information about Eastern European myths. Mostly, though, I heard them from him growing up. I find those things fascinating as they give a glimpse into pre-Christian Russia."

"Mike?" Ellie said from the door to the lounge. "Doctor Silver is here for your werewolf."

"Thanks, Ellie."

"Ever hear of the stories of the succubus?" Ellie asked with a sexy smile.

I chuckled, "Oh, I have, and I might be fired for saying what I know about them out loud!"

I got up and went to Exam 6, where Leah Silver was waiting just outside the door.

"Hi, Mike. Not feeding this one's delusions?"

"Mr. Alien Encounter was no danger to himself or anyone else. Anyway, you might want to introduce yourself by your first name, not your last."

"Why is that?"

"Werewolf? Silver bullet?"

"What is it with you and feeding these delusions?" she asked, sounding exasperated.

"Fine," I said flatly. "He's had 2 of Haldol and is in restraints based on Doctor Samson's evaluation. He's all yours. I'll sign the chart because Paul went off shift twenty minutes ago."

She handed me the chart, I signed it, and left the patient with her and her student. I simply did not understand the — I almost laughed out loud at the thought — insanity of saying or doing things that would serve only to agitate a patient. I returned to the lounge to wait for Sophia and Nicole to complete their intake.

"Mind telling _me_ about the succubus?" Ghost asked.

I chuckled, "One myth is that they need regular doses of semen to survive."

Ghost laughed, "I can see why you didn't say that to Ellie! And if the shoe fits…"

"Yeah," I chuckled.

About a minute later, Nicole came to get me and I followed her to Exam 3, where Sophia was waiting with a female patient.

"Crystal, this is Doctor Mike," Sophia said. "Doctor Mike, Crystal Knowles, nineteen, student at Taft. Complains of being lightheaded. BP 110/70; pulse 80; PO₂ 99% on room air. No recent illnesses; no medication; between six and seven hours of sleep each night; no muscle weakness; no inflammation of lymph nodes. Symptoms first began about ten days ago; no variation in diet. Not induced by standing up or other physical activity."

"Thanks, Sophia. What would you propose to do?"

"CBC, Chem-20, and a pregnancy test."

"Impossible!" Crystal declared.

"When was your last menstrual period?" I asked.

"About ten days ago, but I've never had sex, so I can't possibly be pregnant!"

"I would agree," I replied. "But as of today, we have a new policy that requires us to perform a pregnancy test on any woman of childbearing age who presents in the Emergency Department."

"But why, if I never did it?"

"I believe you, but our policy is to always run the test out of an abundance of caution. Anything else, Sophia?"

"Not until I see the results of the blood work."

"I agree we need to see the blood work, so draw for that, but let's get a twelve-lead EKG immediately."

"EKG?" Crystal asked.

"Yes," I replied. "Syncope is caused by lack of blood flowing to the brain, and your answers to Sophia's questions make it less likely that it's what's called 'orthostatic syncope', which is usually caused by standing up too quickly or even something as simple as urinating or having a bowel movement. It's also not likely 'neurally mediated', as it wasn't caused by seeing blood, being frightened, or some other neurological effect. That leaves us with the most likely cause being cardiopulmonary; that is, your heart or circulation."

"My heart?!"

"Let's not get ahead of ourselves," I said. "Most of the time, it's something very minor. Nicole, draw the blood please, and then Sophia will hook up the EKG."

"Twelve, not five?" Sophia asked.

"Yes, please."

Nicole drew the blood and took it to the Clerk's desk, then returned. Sophia had Crystal unbutton her blouse and lie down, and hooked up the twelve-lead EKG. She turned on the machine, and after about ten seconds, I saw an anomaly.

"What do you see, Sophia?" I asked.

"Sinus rhythm," she replied.

"Print a strip, please."

"What's wrong, Doctor?" Crystal asked.

"Just give us a minute, please."

Sophia printed the strip, which was actually closer to a full-size sheet of paper, and then I excused myself and my students and stepped into the corridor.

"What do you see now," I asked.

"Same thing," Sophia said.

"Look closely at the QT interval. What do you see?"

"I'm sorry, but I don't know this well enough."

"The QT interval is longer than 480ms," I replied. "Do you know about Long QT Syndrome?"

"No," Sophia admitted. "I haven't had a Cardiology Sub-I."

"OK. The primary symptom is syncope, and it can be caused by hypokalemia, hypocalcemia, hypomagnesemia, antibiotics, antipsychotics, antiarrhythmics, heart failure, or genetics. In other words, the most likely causes will be ruled in or out by the blood work you ordered."

"Why did you run the EKG?" Nicole asked. "Did you know?"

I shook my head, "I didn't know, but given everything else, I decided to run the EKG that I strongly suspected we'd need. Given everything you know now, what would you suspect is the cause?"

"Young female adult? Low blood calcium would be my first thought."

"I agree. Let's go back in and I'll explain what we found."

The three of us went back into the exam room.

"Crystal, your EKG shows something called Long QT Syndrome. That's a minor variation of your heart rhythm and is likely the cause of your syncope. In most cases, it has to do with low blood calcium, low blood potassium, or low blood magnesium, and we'll know for sure when the blood test results are available, which will be about thirty minutes from now."

"A heart attack?!" she asked, sounding worried.

"No, just what's called arrhythmia — a variation in your heart rhythm. The EKG doesn't show any reason for me to suspect any damage to your heart, and as I said, the most likely causes are low calcium, low potassium, low magnesium, and in your case, given everything we know, most likely low calcium. Once we see the blood test results, I'll call a cardiologist to confirm the results, then propose treatment. OK?"

"OK."

"Nicole, it's OK to remove the EKG; Crystal, just relax and we'll check on you in a few minutes."

"OK," she said.

Sophia and I stepped out into the corridor while Nicole began removing the EKG.

"At times I feel like I have no business being a doctor in eight months!" Sophia said quietly.

"You're fine," I said reassuringly. "In your chosen specialty, you won't need to be able to interpret EKGs. It's an important skill in the ED, given otherwise we'd have to wait on a cardiology consult, which could take fifteen minutes. That's time we often don't have here. You're not going to find yourself in that situation doing prenatal and neonatal surgery. You'll have a team of specialists with you in the OR. This is something I do every day. I couldn't tell you the first thing about prenatal or neonatal surgery."

"Why does it seem so easy for you?"

"It's not. You know how much I studied, and I still do that. I carry my flashcards and review them all the time. I review my cardiology textbook fairly often as well. You, on the other hand, are studying OB/GYN materials I should never need!"

Sophia laughed, "And yet…"

"I know. I loved delivering that baby, but that was also a perfect example of the system breaking down."

"But also of it working," Sophia countered. "Healthy mom and healthy baby, despite things not working as they should have. And you have the Polaroid to prove it!"

"True. What I'm trying to say, though, is that you're going to make an excellent physician. I just wish you and Robby weren't moving to California. I'll miss you guys, and not just because of Code Blue."

"We're going to miss you guys, too."

"All set," Nicole said, coming out of the exam room.

"Then get another chart, please. I'll be in the lounge."