Chapter 16 — Getting To Know You

_April 17, 1990, McKinley, Ohio_

{psc} "What do you have?" I asked.

"Nineteen-year-old female with multiple contusions and a significant abrasion on her forehead. Claims the injuries are from Rollerblading, but I don't think so based on her demeanor and the VERY controlling vibe I get from the boyfriend who brought her in."

"Don't take this the wrong way, but by vibe, you mean intuition?"

"Girls know," Mary replied. "I know that's not medically defensible, but it's real. There are guys who give off a very creepy vibe. This guy sure does."

"I take it he insisted on coming into the room with her?"

"She insisted he come in, but her eyes kept darting to him as if she were seeking approval."

"Are they alone in the exam room?"

"No. Jamie is in the room with them. I figure if the six-foot black belt in Taekwondo can't control the situation, we'd need the Sheriff's HRT."

"What do you want to do?" I asked.

"Call the cops, but I don't have any actual evidence yet. I'm concerned that I won't get truthful answers from her, and I certainly won't with him in the room."

"If he won't leave and she doesn't want him to leave, we try a bit of subterfuge. Perform your exam and say that we want to send her to Radiology for a CAT scan. I'll call Jeannie Wilders or Amelia Clinton and ask them to put on a lab coat and meet us in radiology. We've used this ploy in the past because nobody is allowed in the room with the scanner or in the control room except medical staff. If the patient admits the abuse, the social worker can call the Sheriff. If not, all we can do is treat her injuries."

"That sucks," Mary declared.

"One lesson I had to learn, and with some difficulty, is that we have to leave things outside medicine to other professionals. There were times when I was still a clergyman when I wanted to do clerical things, but that wasn't my job as much as I wanted to do that. Doctor Gibbs made the point starkly — if I wanted to be a chaplain, then I had to be a chaplain and not a physician. It took quite a few whacks on the nose with a rolled-up newspaper for that to sink in, but it finally did. Let me make the call to the social worker now."

I picked up the phone and dialed the number for the on-call social worker, and Jeannie Wilders answered. I explained the situation and she agreed to my plan and asked me to call when we were ready to go to Radiology.

"All set," I said. "I'll call her when you take your patient to Radiology. Let's go see her, and be very careful how you present. We don't want to spook the boyfriend."

"Defib set to 300 to the groin will do it," Mary said.

"Ouch?" I said, shaking my head.

"Never thought about doing that?"

"Only to Residents or Attendings," I chuckled.

Mary laughed, "I promise not to do that to you! Rosenbaum…never mind."

"Did he act inappropriately towards you?"

"Yes, but before the new rules went into effect."

"Not since?" I asked.

"Not since," Mary confirmed.

"Then, sadly, there is not much I can do. Let's go."

We went to Exam 4, where Mary presented.

"Jill, this is my supervisor, Doctor Mike."

"Hi, Jill," I said.

The boyfriend, who was standing close to the bed eyed me suspiciously, and I had to admit to myself I had the same vibe Mary had. A quick look with Jamie confirmed he agreed.

"Hi, Doctor," Jill replied.

"Mary?" I prompted.

"Jill Morrison, nineteen. Multiple contusions and abrasions to arms, hands, and temple due to Rollerblade accident. BP 120/70; pulse 70; PO₂ 99% on room air. Reports significant right shoulder pain, and shoulder is tender to the touch, but does not appear dislocated."

"Jill, mostly your injuries don't appear to need more than irrigation – cleaning them with saline — and topical antibiotic. Your forehead scrape doesn't appear to be serious enough to require plastic surgery to prevent a scar. May I listen to your heart and lungs and examine your shoulder?"

"The lady doctor already did that!" the boyfriend protested.

"Mr…?" I prompted.

"Crowe. Drew Crowe."

"Mr. Crowe, Mary is a Sub-Intern, so I'll need to confirm her findings. She believes the shoulder injury is serious enough to require a CAT scan, and that will require my signature, and approval from the Chief of Emergency Medicine. In order for me to sign off on the test, I need to do an exam. Jill, may I?"

"Yes," she agreed, but only after looking for approval from her boyfriend.

Her heart and lungs were unremarkable on auscultation, but I was actually concerned about the shoulder, given how Jill winced when I touched it. I suspected some kind of deep ligament injury or possibly a ball-and-socket injury of some kind that hadn't resulted in a dislocation.

"She needs an X-ray and very likely a CAT scan," I announced. "Mary, please call Radiology, and I'll have Doctor Wernher sign off on the CAT scan."

"Why does it need three doctors?" Mr. Crowe asked.

"The hospital, like the military, thrives on red tape," I replied. "I'll be right back."

Mary went to the phone, and I left the room and walked to Doctor Wernher's office. He wasn't there, so I checked the board and saw he was in Exam 1, so I went there.

"Excuse me, Doctor Wernher, may I interrupt?" I asked.

"What do you need, Doctor?"

"Could you step out for a moment for a private conversation?"

"Two minutes," he replied.

I stepped back into the corridor and waited for him to come out, then explained what I wanted to do.

"Is that the usual protocol here for this kind of thing? In Chicago, we just called in a female police officer and social worker."

"We tend not to call law enforcement until we have some actual evidence, and usually it's left to the social workers to place those calls when we're treating battered women."

"X-ray first, and if it's not sufficient, then a CAT. Unless there's a break, it's most likely going to be treated outpatient, not by admission to Ortho or Surgery. Agreed?"

"Agreed."

"Proceed."

He went back into the room, and I returned to Exam 4.

"All set," I said. "Jill, we'll do an X-ray, you'll wait in Radiology while we wait for the film to be developed, and if it's inconclusive, we'll do an immediate CAT scan."

"OK," she agreed.

"Mr. Crowe, because both scans use ionizing radiation, nobody is allowed in the room except medical staff and the patient. There's a waiting room outside Radiology, or you could go to the cafeteria and get some coffee."

"I want to stay with Jill."

"The best we can do is the waiting room outside Radiology. It's simply unsafe for anyone to be in the room. Mary and I aren't allowed in there; only Radiology techs and the Radiologist, and they wear badges to measure the X-rays they receive despite the protective systems for the equipment."

He looked very unhappy, and I wondered if he'd insist Jill leave AMA.

"My shoulder really hurts, Drew," she said. "Please?"

"OK," he agreed. "I'll stay with you every second until they take the X-rays."

"Mary, go ahead and walk them down to Radiology, please."

They left, and I went to the phone and called Jeannie Wilders, who promised to go straight to Radiology wearing a medical coat.

"That asshole is beating her," Jamie said after I hung up.

"Mary figured that out. Hopefully, she'll talk to Jeannie. If she doesn't, our hands are tied."

"I'm a pacifist like you, Mike, but guys like that who abuse women…"

"Yeah."

We left the exam room and waited for Mary to return, which she did about five minutes later.

"The social worker is with Jill, but I'm not confident Jill is going to talk."

"All we can do is wait. You can get another patient while we wait."

"Mike?" Ellie called out. "EMS three minutes out; GSW to the chest."

"Mary, let's go. Ellie, I need two nurses."

"Jamie and Kellie."

All of us hurried to the ambulance bay for what was guaranteed to be a surgical admission.

"Mary, use the phone just inside the bay doors to call Surgery and let them know we have an inbound GSW."

"Right away, Doctor!"

The EMS squad pulled up, and Randy, a new paramedic, hopped out.

"Male, twenty-six; single gunshot wound to the right chest with no exit wound; BP 90/60; tachy at 110; PO₂ 94% on five litres; IV plasma and saline; 3mg morphine."

When he opened the back of the squad, Deputy Kenseth jumped out first, followed by Julie, he County's lone female paramedic.

"Trauma 1!" I ordered. "Jamie, type and crossmatch; Kellie CBC, Chem-20, ABG surgical stat! Mary, intubation, then five-lead."

We rushed the patient towards Trauma 1, with Deputy Kenseth following closely.

"Your handiwork, Deputy?"

"He drew on Scott Turner. That never ends well."

When we reached the room, we moved the patient to the treatment table, and I began my assessment. I moved the pressure bandage, observed the wound, then covered it again.

"Entry wound just below the right nipple," I said, then auscultated and announced, "Absent breath sounds. His PO₂ is OK, so I'll wait on a chest tube."

"O positive," Jamie announced."

I continued my exam, and once Mary had intubated the patient, she hooked up the EKG, and I didn't like what I saw.

"V-tach," I said. "And I don't like that pressure. He's going right up. Mary, make the call and tell them we're coming now. Kellie, get that blood to the lab stat. Jamie, we need a gurney."

Three minutes later, we were on the way to the elevators.

{_ "Code Yellow, Radiology! Code Yellow, Radiology!" _}

In the past, that would have brought unarmed hospital security guards; now, it was going to have an armed response by the off-duty police officer or deputy assigned to the hospital.

"He's not going anywhere, right Doc?" Deputy Kenseth asked, unsnapping his holster.

"Surgery then recovery," I said. "He couldn't get off the gurney if he wanted to."

"OK!"

He sprinted towards Radiology while we moved the patient into the elevator.

"That appears to have gone badly," Mary observed.

"Yeah. Let's get this guy to the OR."

"Will we scrub in?"

"Doubtful."

I turned out to be correct, and once the patient was in the OR, Mary and I returned to the ED.

"Mike," Ellie said, "Jeannie Wilders is in Exam 6. The patient's boyfriend punched her in the face."

"Wonderful. Mary, let's go."

Mary and I went into Exam 6, where Nurse Amy was with Jeannie, who was holding a chemical cold pack to her eye."

"Hi, Jeannie."

"Hi, Mike."

"What happened?"

"He was becoming belligerent, and I tried to calm him. I think he guessed who I was and punched me, then tried to break into the Radiology room. An orderly helped me here after the Deputies responded."

"OK. Let me take a look."

I performed a basic eye exam, then carefully touched around her eye.

"I don't think there's an orbital fracture, and I don't appreciate any injuries to your eye, but you're going to have a hell of a shiner."

"Eight years of school, and that's your diagnosis?" she asked with a slight grimace.

"Fine," I said flatly. "Periorbital hematoma of the _ocularis dexter_ due to blunt force trauma. Happy?"

Jeannie laughed softly, "Yes. Can I get something for the pain?"

"Can *I* get something for the pain in the butt you're being?" I teased.

"I'll ask Doctor Saunders for pointers so I can do better next time!"

"God help me," I chuckled. "Amy, two tablets of Tylenol 3 for analgesia. Ask one of the Attendings to countersign the chart for the Schedule Drug, please."

"Right away, Mike."

"Mary, go check on your patient and report back, please."

"Will do."

Mary left, and because Amy had left, I had to step out of the room until Amy returned.

"Did she admit he's beating her?" I asked once Jeannie had taken the Tylenol.

"No, she was sticking to her story, but it was obvious she was lying. Fortunately, the SOB showed his hand, so, at a minimum, he's going to jail to cool his heels, and I'll swear out the complaint. If she's admitted, Amelia or I will try to talk to her; if she's discharged, we'll send someone to talk to her. That'll be easier if the boyfriend is spending quality time with the Sheriff."

"OK. I'll sign the discharge form, but stay as long as you need. At home, you can take Tylenol or Advil for pain, and come see me on Thursday morning to check, sooner if you suffer any vision problems or dizziness."

"Thanks, Mike."

"You're welcome."

I filled out the paperwork, signed the chart and discharge form, then left the room. Mary arrived back in the ED about two minutes later.

"She'll need an Ortho consult," Mary said. "The Radiologist says he sees ligament damage consistent with hyperextension. I'd say she was yanked hard by the arm."

"While it's possible to hyperextend a limb by falling, that kind of shoulder injury is absolutely consistent with your observation that she was yanked hard by the arm. What happened to the boyfriend?"

"Per the tech, a nightstick to the back of the knee got his attention. Cuffed and dragged away. I'm sure the off-duty cop who responded will come to talk to Ms. Wilders."

"She said she'd press charges. Where's Jill?"

"An orderly will bring her back, accompanied by the off-duty cop."

Just as she'd said that, an orderly brought Jill back in a wheelchair and the off-duty McKinley Detective came over to me.

"Where's Ms. Wilders?"

"Exam 6. She said she'll press charges."

"Good. That'll keep the asshole off the streets for a bit."

He went to Exam 6, and I went to Exam 4.

"Mary, call Ortho, please," I said. "Then irrigate and apply triple antibiotic ointment and a clean dressing.

"Right away, Doctor."

"Jill, according to the radiologist, you have ligament damage in your shoulder. Mary will clean and dress your forehead abrasion, and then a doctor from Orthopedics will come talk to you after reviewing the images of your shoulder."

"What about my boyfriend?"

"You'll need to talk to Detective Miller. I'll let him know you asked."

I left the room and went to Exam 6 to let Detective Miller know Jill was asking about her boyfriend. He promised to see her as soon as he finished taking Jeannie's statement.

The rest of the morning was thankfully uneventful, and Mary and I saw a steady stream of patients. Clarissa wasn't available for lunch, but I ran into Sophia in the cafeteria, so I sat down with her. We had a good chat, and I expressed how much I was going to miss her and Robby when they moved to California. She had similar feelings, and when we parted, we hugged. I returned to the ED, and sent Mary for her lunch, then decided to call Gale Turner.

"It's Mike Loucks," I said when he answered.

"Hi, Mike. Back in the ED yet?"

"Yes, as of yesterday. How are things with you?"

"They offered a plea bargain — a single count of misdemeanor battery. I rejected it out of hand. They _know_ they were had and are looking for a way to save face. I'm not going to give it to them."

"That's good. What about work?"

"Once this is settled, I'm joining a practice in Cincinnati with a friend from medical school. He's like you — never believed a word of it, and there wasn't really any publicity in Cincinnati. Just one article about the clinic being shut down after allegations of sexual abuse. They didn't name me."

"That's good. Will there be any problems with the Medical Licensing Board?"

"My attorney doesn't think so. There's a chance someone will file a complaint, but if the police drop all the charges, it won't amount to much. I believe the protestors got what they wanted, and now they'll back off. At least they didn't firebomb the clinic."

"Thank God for small favors," I replied. "We're already seeing the results of the clinic closing."

"I knew that would happen, but without the grant, there's no way I could re-open. And you know the protestors would be back, making the same vile claims, or worse. And the pressure on the County Prosecutor would be intense to get me for _something_, and know how that works, I'm sure."

"'Show me the man, and I'll find you the crime'," I said disgustedly.

"I don't recall who it was who said that. J. Edgar Hoover?"

"It fits, but it's attributed to Lavrentiy Beria, the head of the Soviet Secret Police. It's drawn from a Russian proverb — «Была бы шея, а хомут найдётся» (_Byla by sheya, a khomut naydotsya_) which is roughly translated, 'If there is a neck, there is a collar', meaning the metal collar they used to put on slaves, and was about summary judgment by the Tsar's secret police. As they say, the more things change, the more they stay the same."

"I think you understand why I don't want to attract any attention."

"For sure. GP or OB/GYN?"

"GP. I can practice and basically be anonymous except to my patients. No hospital privileges necessary."

"Sadly, that makes sense. I hope you'll keep in touch."

"I will. You heard that Trina was hired by Medical Practice Associates, right?"

"Yes. My GP, John Smith, is the Medical Director there. I also heard two of the nurses were hired here. Do you know what happened to the other two?"

"Michelle found a spot in Cleveland, and Patty found one in Cincinnati."

"Good. What about Tamara?"

"Decided to move to Indianapolis, where her parents live. I'm sure she'll find a job there."

"What happens with all the equipment and supplies?"

"There are companies that specialize in winding down medical practices. They'll sell everything they can, and the proceeds will pay any outstanding bills. Anything that might be leftover will go to charity."

"And the medical records?"

"To the County. They'll be sealed so nobody can see them unless a patient requests copies or law enforcement obtains a warrant. After seven years, they'll be destroyed."

"So if a patient comes into the ED and says they were treated at the Free Clinic, they can request their records?"

"Yes. Call the County Health Department and ask for their release forms, so you can just have the records faxed, if necessary."

"I'll mention that to Doctor Wernher. Let's have lunch next week."

"Sounds good. Diner across the street from the hospital?'

"Yes. How about 11:30am on Thursday of next week?"

"See you then."

We ended the call, and when Mary returned, we resumed seeing patients.

_April 18, 1990, McKinley, Ohio_

"I have another difficult case," Mary said early on Wednesday evening.

"Consultation room?"

"Yes."

She and I went to the consultation room, leaving the door partway open.

"I have a male, forty-three, who claims he has severe back pain and lost his medication. I'd swear he's lying."

"What did he say?"

"That he lost his bottle of Percocet."

"Is he local?"

"I actually didn't ask. There was no red dot on the chart."

"Go to the chart room and look to see if there are previous charts for him, then we'll go see him together. Just follow my lead, OK?"

"Sure. I'll be back in a few minutes."

I went to the nurses' station to wait for Mary, who was back about five minutes later.

"No patient with that last name and first initial."

"OK. Which room?"

"Exam 2."

I followed Mary to Exam 2, where she introduced me to the patient and presented.

"Jeremy Bledsoe, forty-three. Presents complaining of significant lower back pain. States he has a prescription for Percocet but lost his pills. BP 130/80; pulse 96; PO₂ 98% on room air; slightly diaphoretic."

"Hi, Mr. Bledsoe," I said. "How did you originally injure yourself?"

"Does that matter?"

"In order to prescribe Scheduled Drugs, we need a thorough medical history."

"I was working construction and threw it out about five years ago; ain't been the same since."

"May I ask what doctor you initially saw?"

"It was in West Virginia; I moved here about six months ago."

"Who prescribed your pills?"

"The Doc at the Free Clinic. I'd have gone there, but they closed."

He was lying, and I was sure of it because Percocet was a Schedule II drug. To my knowledge, Gale Turner had never once prescribed anything stronger than Schedule III drugs, and even those were rarely prescribed. Schedule II drugs also couldn't be refilled, as a new prescription was required each time, and the pharmacy had to keep the original on file. But, I needed to follow EMTALA and conduct an actual exam.

"OK," I said. "I need to examine you before I can dispense any Schedule II drugs. The exam is similar to a physical."

"OK."

I washed my hands, put on gloves, then performed the usual exam, finding nothing remarkable.

"Would you remove your shirt and lie on your stomach the table, please?" I requested.

He complied, and I felt no tension, guarding, or other trauma to his lower back or spine, though he made grunting noises whenever I pressed on his lower back.

"Would you stand, please?" I asked.

Mr. Bledsoe moved gingerly from the exam table.

"Try to touch your toes, please," I requested.

He nodded and began to bend over, grimacing, and stopped before his hands were level with his knees.

"That's as far as I can go," he said.

"OK. Would you lie on the table again, this time on your back?"

He did.

"OK. Would you please bring your right knee up towards your chest?"

Mr. Bledsoe did so without any obvious problems.

"And your left, please?" she requested.

He did that, too.

"Just relax, Mr. Bledsoe. Let me go speak to my Attending, as they have to countersign any orders for Schedule II Drugs. It might take a few minutes."

"Thanks, Doc."

Mary and I left the room, and I went to the nurses' station, consulted my address book, and dialed a number.

"Gale Turner."

"Gale, it's Mike Loucks. Sorry to disturb you, but I have a patient claiming he obtained his Percocet from the Free Clinic."

"He's lying. You know we never prescribed anything stronger than Tylenol 3, and even that was rare. What's the guy's name?"

"Jeremy Bledsoe."

"Never heard of him, and he would have had to have come in sometime in the past thirty days because those scripts have to be renewed, not refilled. Trina's license didn't allow her to prescribe Schedule II or III drugs."

"Thanks. That's all I needed. I was positive he was lying, but I needed to check."

"You're welcome. See you for lunch next week."

We said 'goodbye', and I hung up.

"Lying?" Mary asked.

"Big time. I was positive that the Free Clinic had never prescribed Schedule II drugs, and Gale Turner confirmed that. The guy tried to take advantage of the fact we couldn't check."

"Or so he thought! Now what?"

"Psych consult, but he'll refuse. Let's go tell Mr. Bledsoe he's a liar, though not in those words."

We returned to Exam 2.

"Mr. Bledsoe," I said. "I verified that the Free Clinic never prescribed any Percocet, and Doctor Gale Turner does not know you."

"It was another doctor!"

I shook my head, "Only Residents worked there, and they don't have DEA numbers which authorize prescribing Schedule II drugs. I know because I worked there. Now, care to tell me the truth?"

"I am!" he protested.

"I'm sorry, but nobody here will write you a prescription for Percocet based on the information I have. Your only chance is to tell me the truth. If you want, I can have someone come speak to you about overcoming drug addiction."

"I'm no addict! My back really hurts."

"I can bring in my Attending to evaluate you, but even then the most that will happen is you'll be given two tablets of Tylenol 3 and directed to see your personal physician."

"You have to treat me!" he protested. "It's the law!"

"The Emergency Medical Treatment and Active Labor Act requires an examination and evaluation, and stabilizing treatment. Your vital signs are stable, you have no obvious injuries, no irregular heartbeat, and no fluid in your lungs. In other words, you don't qualify for treatment under EMTALA. Would you like me to call someone from Family Services or Psychiatry?"

"FUCK YOU!" he growled.

I picked up the chart, made notations, and filled out a discharge form with instructions to see his personal physician. He refused to take it from me and left the room as soon as he had his shirt on.

"Let's go talk to Doctor Wernher," I said.

Mary and I left the exam room and went to Doctor Wernher's office. We had to wait until Kayla finished before we could go in. Once we did, I related the facts of the case.

"He tried to pull a fast one on you," Doctor Wernher observed. "Good catch."

"Mary caught it," I said. "She came to me and said she was sure he was lying. I simply figured out how to prove it, given pain cannot be measured."

"Flag that chart. What's the protocol?"

"A red circular sticker on the inside of the binder for the patient's file."

"OK. Who signed the chart?"

"I did. Doctor Gibbs authorized me to sign charts for discharge late last year. I only need signatures for Scheduled Drugs and countersignatures for 'time of death' notations. I discuss any complex or difficult cases with Attendings."

"Miss Anderson, would you give us the room, please?"

"Yes, Doctor," Mary said.

She left and closed the door behind her.

"How hard are you going to push back if I ask you to clear discharges and admissions with Attendings?" Doctor Wernher asked.

"Me? I won't. The Attendings, on the other hand, will push back."

"Let me deal with them. This isn't about you, Doctor, but about not playing quite so fast and loose with the rules. You haven't given me a single reason to doubt your abilities, but if I don't apply the rules across the board, there will be dissension. You're the only one who basically operates as an Attending."

"I'm not going to fight you on that, Doctor," I said. "I do have a question about surgical procedures."

"If Owen Roth has cleared you, then do them. I'm simply asking you to have your charts signed by an Attending before you discharge or admit a patient."

"OK. Effective immediately?"

"Let's call it next Monday so I can speak with the other Attendings. You shouldn't be the one to tell them."

"Starting Monday."

"Thank you, Doctor."

"You're welcome."

"Do you have another moment to discuss your student?" he inquired.

"Yes, is there a concern?"

"You allow Miss Anderson to operate as if she has her MD and is a Resident."

"I know her very well and have taught her during several rotations. As you know, she's my student full-time as of June 1st. I trust her the same way Doctor Gibbs and Doctor Casper trusted me when I was in my second trauma Sub-I immediately before graduation."

"How will she react if I ask you to stay in the room with her?"

"Same answer as before. She'll follow whatever rules you set. I'm the one who would push back."

"And?"

"It's your ED, Doctor. Our conflict centered around…may I speak freely?"

"Yes, and you don't need to ask if the door is closed.

"The conflict centered around what I considered pettiness and unclear thinking. Neither of the things you just proposed are petty nor unclear. You also didn't ask me to violate Osler's principle of medical education. As much as it might seem like I don't know; I do know I am a Resident and I do know the limits.

"That said, it's my basic principle that medical students and Residents are responsible for their own training, and they need to be proactive and aggressive in ensuring they are properly trained. I think medical training moves too slowly from classroom to clinical, and that is exactly what Doctor Osler said about training."

"Do you truly feel you're ready to perform appendectomies?"

"Under close, direct supervision, I do. But more importantly, so do Doctor Roth, Doctor Anniston, and Doctor Lindsay. Doctor Roth cleared the training program with Doctor Cutter, and it is absolutely accelerated. It'll be accelerated for Miss Anderson as well. She, too, is capable. You saw my transcripts; did you ask yourself why I would select a Pathology Sub-I?"

"That one made no sense at all to me. Owen Roth explained it. A counter-intuitive idea that appears to have succeeded despite going against the flow. But then again, so does the entire program."

"You might call Al Barton at University of Chicago Hospital and ask him about it. He was one of the first to use Preceptorships, as well. We should do more and have students in the hospital for more than four hours a week. It was during my Preceptorship when I learned to read EKGs."

"Doctor Gibbs says you read them as well as most cardiology Residents."

"I probably spent sixty hours studying strips and flashcards. I still review them. I have a deck in my pocket at all times."

"May I see?"

I pulled a deck of fifty cards from the back pocket of my scrubs and handed them to Doctor Wernher, who removed the rubber band and flipped through them.

"How many of these do you have?" he asked.

"Just over 3500 across just about every possible topic. I started the first day of medical school. I haven't gone anywhere without a sample of the deck with me since then. Doctor Saunders in Medicine has done the same thing, as did the other members of our study group."

"Where are they?"

"Doctor Maryam Khoury is a cardiology Resident at Edward Hospital in Naperville; Doctor Fran Fredericks is an OB/GYN Resident at Riverside Methodist in Columbus; Doctor Peter Baldwin is a surgical Resident at Emory; Doctor Nadine Cross is a surgical Resident at UCLA. All of us except Doctor Cross graduated in the top ten, and she was in the top fifteen. She wasn't with us from the start and only joined us after Sandy Pierce took her own life near the end of First Year."

"Who chose the members of your group?"

"Effectively, it was Doctor Saunders when she, Doctor Fredricks, and I were undergrads at Taft, along with Sandy Pierce. Doctor Khoury recognized me as a Russian Orthodox clergyman and asked to join our group. Peter Baldwin and I met at the banquet for incoming students and asked to join. Then, after Sandy took her own life, Doctor Mertens suggested Nadine join our group because the group she was in was dysfunctional."

He put the rubber band around the cards and handed them back.

"We'll talk more. I'm sure you have patients to see, and I need to get home. Dismissed."

I got up, left his office, and went to the lounge.

"Let's take a quick walk," I said to Mary.

She followed me out to the ambulance bay, and we turned left towards the parking lot.

"What's up?"

"Starting Monday, I need to have an Attending sign all my discharges or admissions. It's not directed at me, but will apply to all Residents. Also, starting immediately, I need to supervise you more closely. Again, it's not about you; it's about medical students in general."

"So, fewer procedures?" she asked with a frown.

"No. He didn't say anything about what I allow you to do or not do; it's simply about adhering to the letter of the policy. Technically, the only thing medical students are permitted to do unsupervised is suture. As Doctor Wernher noted, I've been allowed to effectively work as an Attending, and I've permitted you to effectively work as a Resident.

"My strong suspicion is that he has concerns about other Residents and other students. He expressly said he did not have concerns about my abilities. I expressly said I have none about yours. Fundamentally, it's his ED, and he is the one who has to answer for anything that happens. That's especially true because you and I are both working on the license of the Attending who is supervising us. How much actual supervision do we have?"

"Honestly? None. Other than narcotics, you barely speak to Attendings about cases unless there's something very odd, and even then, you call for consults and decide treatment with other Residents."

"And if something goes wrong, it'll be Doctor Wernher left holding the bag. All of this came about because Northrup was completely hands-off. Doctor Wernher is not. Fundamentally, all that's going to happen is I'm going to sit in on your H&Ps and your discharges or admissions. I'll still be allowed to train you the way I see fit."

"You're sure there isn't a problem?"

"As sure as I can be. Nothing Doctor Wernher is doing is out of line with how things are normally done and how they were done during my Third Year."

"You know everyone hates him, right?"

I nodded, "I do, and I understand why. I simply chose to take the bull by the horns and figure out how to get what I wanted. I did that by appealing to his self-interest, a tactic that works with people like him. What he learned was that to appeal to my self-interest, he has to think about patient care first and foremost. I have what amounts to my dream job, and I have ZERO ambition to have his job! Or Doctor Roth's. Or Doctor Cutter's.

"The only question I ever ask is how what we're doing helps patients. That should be your only guiding factor. In six weeks, you're going to be a teacher, and I hope you'll instill that same attitude in your students. That means, at least to some extent, giving up procedures for your students the same as I've given up procedures for you. Keep Doctor Osler's precept for training students in mind at all times."

"Thank you for telling Doctor Wernher I detected the patient's lie."

"You're welcome. He needs to be confident in your abilities because you'll be seeing patients of your own starting June 1st."

"How will that work, exactly?"

"You'll have your students, and I'll have mine, and we'll both effectively be emergency medicine Residents similar to what I'm doing now. When there are surgical consults, we'll divide them, and I'll teach you the procedures. That means we have about six weeks to ensure you can read a sonogram or an X-ray so that you can handle consults."

"Twenty years of education, and I'll finally achieve my goal!"

"And still have another eight as a student, albeit you'll be Doctor Mary Anderson at that point. And the minute you have your diploma, you call me Mike."

"That's going to be really weird."

"It was for me, too. Attendings will tell you if they want you to call them by their given names or nicknames, but Residents always call each other by first name. One important thing — if you present to Doctor Wernher, or even just talk to him, don't use first names. He specifically corrected me on that. So it's 'Doctor Casper' not 'Ghost', even if every other time you use his nickname."

"Thanks for the tip."

"I have the utmost confidence in you, Miss Anderson. You're going to make an excellent physician."

"Thank you, Doctor."

"You're welcome. Shall we go find some patients?"

As we turned back towards the ambulance bay, I heard the telltale air horns and sirens of multiple EMS squads heading for the hospital.

"Sounds like patients are coming to find us," Mary observed.

We quickly walked back into the ED, and Ellie let us know that there were three MVA victims being transported. Mary and I gowned and gloved, then put on goggles and headed back outside to wait for the patients.