Chapter 69 — Accountability Partner

_December 24, 1989, Rutherford, Ohio_

{psc} On Sunday, Kris, Rachel, and I attended Matins and the Divine Liturgy in the morning, then Vespers for the Nativity in the evening. Once Vespers ended, we headed to my grandfather's house for our extended family Nativity dinner. I didn't relish the drive back and forth, as I had to be up at 4:15am for a 5:00am shift at the hospital, but it was the only way we could celebrate Nativity.

Before we arrived, we had an important thing to do.

"Rachel?" I queried.

"«Oui, papa?»" my daughter giggled.

I shook my head, and Kris laughed softly.

"Your «tante préférée» strikes again! Mama and Papa have something to tell you."

"What?"

"Mama is going to have a baby! You'll be a big sister!"

"I want a sister! No boys!"

I chuckled, "Papa is a boy!"

"Viktor is noisy and doesn't play nice!"

Viktor was, as the saying went, 100% boy, and did everything the way a male toddler was expected to do them — rough and tumble and very energetic. My daughter and Abby, on the other hand, were calm and gentle, though they had a habit of getting the giggles.

"Mama and Papa don't get to choose a boy or a girl," Kris said. "We'll love our baby no matter what, and you'll love your new brother or sister."

"When does the baby come?" she asked.

"June," Kris replied. "It's a long time away."

"How long is that, Papa?"

"Lots and lots of sleep times," I replied. "It's about six months."

I saw in the rearview mirror that Rachel looked confused, but that didn't surprise me, as her concept of time was limited.

"Want to live with Abby! Not a boy!"

Kris and I both laughed.

"This is going to be fun," she said quietly.

"Just wait until the kids start ganging up on us!" I replied equally quietly.

"We might have a baby girl," Kris said to our recalcitrant daughter.

"Yes!" Rachel declared. "Want a sister!"

"You have NO idea what you're asking for, little one!" I chuckled.

Kris smacked me lightly on the arm.

"You know my sister just does things to tease you, right?"

"Obviously. The same as my little sister!"

"I suppose your half-sister is too young to tease you!"

"Faith's teasing will be directed at Peter, not me!"

"We're still having dinner with them next Sunday evening, right? On New Year's Eve?"

"Yes. I had hoped to have the entire family together today, but Holly is still uncomfortable with my dad's side of the family. I suspect it will always be that way."

"Don't you think being the 'other woman' who breaks up a marriage would cause that?"

"Yes, though I wouldn't say Holly wrecked my parents' marriage. I'm positive it was already wrecked when he first slept with her, which, if I had to guess, was two years before she became pregnant."

"That's something you've never said before. Are you sure?"

"No, but all evidence points to the fact that they were involved when she was sixteen. It's not the age that bothers me, by the way, it's the cheating."

"I would think not considering you were betrothed to Elizaveta when she was fifteen and crowned to her when she was sixteen! And betrothed to me when I was seventeen!"

"Obviously. I think that answer is almost reflexive given the amount of grief we received on account of Elizaveta's age."

"How old would be too old? I mean, in terms of a relationship?"

"For me? Or in general?"

"Both."

"Well, first of all, for me, it's irrelevant because I'm married to you! But, to answer the question, you were right on the very edge, given I'm seven years older than you are. In the general case, I think it's up to the individuals to decide, not me. Ohio says a sixteen-year-old is able to consent to sex, and also to marriage with parental permission. At that point, it has to be up to the individuals."

"The law aside, you were OK with Liz and Paul?"

"No, because Paul was married and cheating. Had he been single, my response might have been different, but I'm not sure, because I'm a very different person from the one I was when all of that went down."

"It was moral outrage over the cheating?"

"That was a large part of it, yes. My honest opinion is that age difference matters more for teenagers than adults. The ten years from fourteen to twenty-four are far more meaningful than the ten years from twenty-four to thirty-four. But again, my problem with Paul was mostly that he was married and had a kid. That wasn't all of it, but Liz never once wavered about being in love with him, and you see how they are now."

"He's an excellent husband and father," Kris said. "Just as you are!"

"Thanks!"

When we arrived at my grandparents' house, my family was already there, including my uncle, his wife, and my cousin Jack. My cousin Diane was with her husband and daughter in California, where they'd moved. A few minutes after we arrived, my in-laws arrived, and my grandmother invited everyone to come to the tables to eat. It was crowded, but it was great to have everyone there, except for my dad, Holly, and their kids.

"We have an announcement," I said immediately after saying the blessing for the meal. "Kris is pregnant and we're due in June."

"Many years, Mike and Kris!" Stefan exclaimed.

Everyone quickly added their congratulations and my grandfather and Ignatiy began singing «Многая лета», or 'Many Years' in Russian, with those who knew that hymn in Russian joining in.

"Thank you," I said.

"Are you teaching Rachel to speak Russian?" my uncle Alexi asked.

"No. Obviously, she'll pick up some words here and there, and the few hymns we sing in Slavonic, but otherwise, no. She is, on the other hand, being taught French by a certain sister-in-law who finds it amusing!"

Rachel giggled then said, "«Je t'aime papa!»"

"I love you too, Rachel!" I replied. "Lyudmila, on the other hand…"

Lyudmila laughed and her eyes twinkled because she loved to tease me.

"Will you deliver your baby?" Elaine asked as everyone began eating.

"No. First of all, I'm not an OB; second, except in the most extreme emergencies, and when no other physician is available, it's considered unethical to treat members of your own family."

"Why is that?" my uncle asked.

"Mainly because of the risk that emotions might interfere with care, but also because there is potential for either risk avoidance or poor risk evaluation, such that you want someone who is thinking completely, clearly managing the patient's care."

"Like those two student doctors in New York?" my uncle asked.

"Don't believe everything you read in the papers," I replied. "There is far more to the story than the press is reporting, including a very interesting fact that an eighteen-year-old college Freshman had a _pediatrician_ as her primary care doctor. That's not normal in any way, shape, or form.

"He had prescribed drugs for her, erythromycin and chlorpheniramine, for flu-like symptoms. She was also seeing a psychiatrist, who prescribed phenelzine for depression, along with, among other things, imipramine, flurazepam, diazepam, tetracycline, and doxycycline. She also received Percodan from her dentist when she had a tooth extracted.

"The two Residents had no idea that she was taking, or had recently taken, all of those drugs, because the person who spoke to them was the family physician, who was neither the pediatrician nor the psychiatrist. Given the two Residents had no idea about the cocktail of drugs she was taking or had recently taken, it's hard to blame them.

"The problem lies in the fact that medical care is disjointed, and there isn't a unified collection of patient information. Each doctor keeps his own records, as does each pharmacy and each hospital. One of the biggest challenges I face is I see patients with no medical history other than what they can tell me, assuming they can even speak.

"The other problem, at least from my perspective, is that physicians are too free with their use of prescription drugs. That young woman was on at least eight different drugs when she was admitted to the hospital. Anything they gave her would have put her at risk, and the interaction that killed her was not understood at the time.

"On the plus side, I'm only working eighty-hour weeks with at least eight hours between shifts because of what happened to Libby Zion. Most hospitals haven't changed, and their PGY1s, that is, first-year Residents, sometimes called Interns, work thirty-six-hour shifts with no rules about time off between shifts."

"That's insane!" my cousin Jack declared.

I nodded, "Indeed it is. But shall we focus on the joyous time of the year, rather than the failings of medicine?"

"A good suggestion, Mike," my mom said. "Did you pick names?"

"Charlotte Michelle or John Michael," I replied. "John for Great-Grandfather Borodin, as Michael Michael just sounds goofy!"

Everyone laughed.

"Yes," my grandfather said, "Mikhail Mikhailovich would work, but not in English, and Ivan sounds too Russian."

"I'm glad you didn't use Dad's name," Liz said.

"We have a half-brother named Peter, and I didn't want to duplicate."

"Don't remind me!"

"Elizabeth," my grandmother admonished, "be kind."

Liz rolled her eyes, exactly as she had as a teenager, despite being almost twenty-four. Even so, she had become a wonderful young woman, despite all the challenges life had thrown her way as a teenager. And that made me wonder how things would develop with my children. My teen years had been, in a word, boring, pretty much the opposite of Liz, despite being raised in the same house by the same parents and attending the same school and the same church.

Elaine, whose experience in many ways mirrored my sisters, had matured significantly in the two years I'd known her, was a straight-A student, and was dating a Senior of whom my mom and Stefan both approved. At eighteen, I would have been very skittish about dating a girl with a two-year-old baby, but my mom said John, the young man, doted on April and was polite and respectful.

Thinking about Elaine and April made me think about April Nash and her daughter Chastity. I wondered how they, along with April's husband Rob Peters and their son Richie, were doing, but I'd basically lost touch with them right around the time she'd married. I only knew about her son through my mom, so I decided to ask if she knew.

"Mom," I said, "do you know how April and Chastity are doing?"

"No, though I heard that they're moving to Chicago."

"Who's that?" Kris asked.

"My girlfriend from Senior year of High School," I replied. "Not long after we broke up, she found herself in the family way. That was my first experience holding a baby or seeing a baby nurse and it had a profound effect on me, even though Chastity wasn't my daughter."

"I find it hilarious that April had a baby out of wedlock and named her 'Chastity'!" Liz opined.

"Perhaps a goal, rather than a statement," my uncle suggested.

"Obviously!" Liz smirked.

"Elizabeth…" my grandmother admonished again.

I found it very interesting that my mom kept quiet and my grandmother was the one gently reprimanding Liz. I wondered if it was an intentional strategy, or simply my grandmother wanting Liz to behave properly during family gatherings.

"How do you like being a doctor in the ER?" my uncle's wife, Caroline, asked.

"It's my natural element," I said. "One of my colleagues described working in the Emergency Department as insane, and my comment was that I fit right in!"

"Ain't _THAT_ the truth!" Liz smirked.

"Watch it, Lizard Breath!" I warned playfully.

"Hey, you admitted it, Mikey!"

"You two sound like you did when you were pre-teens!" Mom said, shaking her head. "Not like a doctor and the co-owner of a successful business!"

"Brothers and sisters never really grow up with regard to each other," Caroline said. "I've heard Alex and Rachel do the same thing!"

"AHA!" Liz exclaimed. "I knew it!"

Everyone laughed.

"Gee, thanks, Caroline," Mom said sarcastically.

"I believe she's simply doing what sisters-in-law do naturally," I chuckled.

"You love me anyway!" Lyudmila declared. "And if you don't, Rachel does!"

"That's what worries me," I chuckled.

"Love Papa! Love Mama! Love Lyuda!" Rachel declared.

"And Abby?" I asked.

"I love Abby mostest!" Rachel declared happily.

"Wow, Mikey, dissed by your own daughter!"

"Just wait, Lizard Breath! You have a son! I can't wait to have a man-to-man talk with him when he's about fourteen!"

"Oh, God," Liz groaned. "No!"

"I do believe you asked for it, Liz," Paul smirked.

"So this is intergenerational?" Stefan asked.

Mom and I exchanged looks and simultaneously said, "Yes!" which caused everyone to laugh.

We finished eating with a minimum of teasing, then after Kris and I helped my grandmother with the dishes, everyone gathered in the living room to open gifts. Once we'd done that, we had pie and coffee, and then, because I had to be up early on Christmas morning, Kris, Rachel, and I left to head home.

"Does my sister really bother you?" Kris asked once we were on Route 50 heading east.

"No. But I know it makes her happy when I respond, and I can think of a lot of things worse than my daughter being bilingual in an actually useful language."

"You don't think Russian will be useful given the changes in Europe?"

"English and French are far more important, and outside the Eastern Bloc, there are very few Russian speakers. I mean, how many people under forty at the Cathedral speak Russian?"

"You, my sister, and me, plus a few others."

"And there are plenty who speak French, German, or Spanish. German is probably the most prevalent, then French, then Spanish, but Spanish is becoming more and more common."

"If Lyuda does start to actually bother you, let me know and I'll ask her to back off."

"It's fine," I said. "She's just practicing for when she's starts dating in about a year!"

Kris laughed, "Don't repeat this, but she has a boy she's seeing, though my parents don't know it."

"I'm not surprised, given she's fifteen. Personally, I think that's the age when it's appropriate to go on dates, but I totally understand sixteen, so long as that permits going to school functions like dances from age twelve or so."

"Fifteen is the right age," Kris confirmed. "Of course, we may change our mind in about twelve years!"

I chuckled, "The Tsarina and her best friend are going to be quite the duo!"

"Love Abby!" Rachel giggled.

"We're so dead," I said quietly.

"I know," Kris agreed with a smirk.

_December 25, 1989, Feast of the Nativity, McKinley, Ohio_

"Merry f-ing Christmas!" Isabella Mastriano said when I walked into the ED on Monday morning.

"What time did you come on?"

"4:00pm yesterday and I'm on until 4:00pm today. Being the newest Attending stinks!"

"You'll have at least some seniority in July, as will I."

"This is not a complaint, just an observation — you get better shifts than any PGY1."

"I'm also different from every other PGY1 at the hospital. These red scrubs aren't just to make me look good!"

"No kidding!" she smirked.

I laughed, "OK, I deserved that."

"Sexiest PGY1 in the hospital!" Kellie declared, walking up to us.

"Uh huh," I chuckled. "It's the red scrubs."

"If you weren't married, I'd prove it!" she said, her eyes twinkling.

"You're a troublemaker, Nurse Martin!" I declared.

"Of course! It's in my job description!"

I laughed, "Is that the 'other duties as required' clause?"

"Of course!"

"Morning, Mike!" Paul Lincoln said, coming up to me. "Only thing on the board is a rule-out MI in 2. Jenny and Kelly are with him, waiting on cardiology. Slightly elevated enzymes and T-wave inversion."

"Symmetric or biphasic?" I asked.

"Beyond my skill level! That's why I called for the cardiologist!"

"OK. I have it. Thanks. Merry Christmas."

"Merry Christmas. Doctor Mastriano, I'm out!"

"Merry Christmas, Paul. Have a good day."

He left, and I excused myself, asking Kellie to come with me to Trauma 2. I stopped to review the chart, then went into the room.

"Good morning, Mr. Crosby," I said. "I'm Doctor Mike."

"Hi, Doc. You the heart doctor?"

"No. I'm a trauma surgeon. I'm taking over for Doctor Lincoln so he can go home to his family. How are you feeling?"

"Like somebody put a hod full of mortar on my chest."

"Bricklayer?"

"How did you know?"

"Who, who was not a bricklayer, would know what a 'hod' is?" I asked.

He laughed, "You, obviously!"

"True! Jenny, run a strip for me, please."

She pressed the appropriate buttons on the EKG, and seven seconds later, handed me a strip. The inverted T-wave was symmetric, and unfortunately for the patient, it was on leads V₂ and V₃, which indicated a significant increase in mortality. I had just finished examining the strip when Patrick Shore came into the room with a female student.

"Merry Christmas, Mike. What do we have?"

"Merry Christmas, Pat. William Crosby, fifty-one; presented with chest pains. History of unstable angina; tachy at 110; BP 140/80; elevate cardiac enzymes; 3mm symmetrically inverted T-waves on V₂ and V₃, indicative of Wellens' syndrome. I believe he's a candidate for angioplasty for stenosis of the left anterior descending coronary artery."

"I could have stayed in bed!" he declared. "You or Paul?"

"Me."

"No surprise. Mr. Crosby, let me examine you, please. I'll confirm Doctor Mike's diagnosis and we'll very likely take you up for an emergency angioplasty to correct a narrowed coronary artery."

"All that from that strip of paper?" he asked.

"EKGs are extremely sensitive," Pat said to Mr. Crosby.

"How bad is it?"

"Let me examine you first, OK?"

He performed the exam, then turned to his student, "Melinda, call upstairs and let them know we have an emergency angioplasty. Ask them to page the on-call Attending and let them know I'll prep and arrange for anesthesia."

"Right away, Doctor!" Melinda declared.

"Kelly, get a gurney please," I said. "You go with Doctor Short and Melinda, then come back once Mr. Crosby is in the cath lab."

"Yes, Doctor," Kelly said.

"Mr. Crosby, you very likely have a significant narrowing of an important blood vessel that we need to take care of immediately. Most likely we'll install a stent, which is a device designed to expand blood vessels to allow blood to flow freely."

"And that'll fix it?"

"It should," Doctor Shore said. "We'll do a complete cardiac workup once we solve this immediate problem and then discuss how to address it."

"What aren't you telling me?" he asked.

"This is very serious," Doctor Shore said. "But it's fixable."

"Mr. Crosby, is someone here with you?" I asked.

"My wife and daughter."

"Pat, I'm going to bring them in before you take Mr. Crosby upstairs."

We exchanged a look which expressed my concern about the mortality rate of patients with significant T-wave inversion on leads other than V₁ or V₄. I quickly left the trauma room and went to the waiting room where I saw a woman of about fifty with a younger woman who, I guess, was around twenty-five.

"Mrs. Crosby?" I asked, walking over to them.

"Yes," she said.

"I'm Doctor Mike. Your husband needs an emergency procedure. If you'll come with me, you can see him before he goes upstairs."

"What's wrong?" she asked, sounding very concerned.

"There's a cardiologist with him right now who will explain everything," I said. "May I ask your name?"

"Mary. And this is our daughter, Denise."

I almost laughed out loud as Denise Crosby was the actress who played Tasha Yar on _Star Trek: The Next Generation_. I led them into Trauma 2 and turned them over to Doctor Shore.

"Kellie, Jenny, with me, please," I said.

The three of us left the room and went to the lounge, as there was nobody in the waiting room.

"What did you do about Christmas?" Kellie asked after the three of us had poured ourselves coffee.

"We celebrated last night with our extended families," I said. "There wasn't really any other option, considering my shift today. You?"

"Last night as well, I came on at 10:00pm and I'm off at 10:00am. You'll have Stephanie, the new nurse who started a few weeks ago from when I go off until you leave. Have you worked with her?"

"No."

"She's also ex-Navy. Her dad is an Admiral. She was assigned to Bethesda Naval Hospital for her entire time."

"What brought her to Ohio?"

"Her husband is from Columbus. He was a Marine who was injured during a training exercise, and they met when he was in rehab."

"What's he do now?"

"He's a sergeant in the Ohio State Highway Patrol."

"She was an officer, and he was enlisted? I thought that was «verboten»!"

"How well do you think it will work if in about twelve years you forbid Rachel from seeing a boy she likes?"

"Not very!"

"Exactly! And they both had less than a year to go when they met. That was about two years ago. They married as soon as he got out."

"Are you trying to tell me something?" I asked with a smirk.

Kellie laughed, "No comment!"

"San Diego? I bet there was plenty of sun and sand while you served!"

"Possibly," Kellie said with a smirk.

"Doctor Mike?" Terry, a temp clerk who filled in when the regulars were off, said from the door.

"Yes?"

"EMS three minutes out with a possible MI," she said.

"Thanks."

"Merry Christmas," Kellie said.

"During my rotation in Cardiology, they said the time around Christmas was the worst with regard to heart attacks. Jenny, Kellie, let's go!"

The three of us made our way to the ambulance bay, donning gowns, gloves, and goggles along the way. Unlike the patient we'd just seen who appeared to be in relatively good health other than his unstable angina most probably caused by stenosis, the patient we received from this EMS run was the proverbial train wreck — morbidly obese, carrying a good 80 extra pounds and clothes that smelled heavily of cigarette smoke. His STEMI was such that he didn't even make it until a cardiologist could evaluate him, coding about a minute after we had him on the treatment table.

"Time of death, 06:18," Isabella announced after I called her in to pronounce the patient after exhausting treatment options. "Any family?"

"I don't know," I replied. "Let me update the chart, and then I'll see if there's someone in the waiting room.

"OK," Doctor Mastriano said, then left the room.

"Kellie, get the death kit, please," I said. "Jenny, you're with me."

They acknowledged what I said, and I filled out the chart with what we'd done — EKG, ventilator, CPR, and multiple doses of epinephrine. He'd been intubated by the paramedics in the field, and they'd put him on a five-lead so they knew he was suffering a STEMI, which had saved us time, but to no avail. I completed the chart, signed it, then asked Jenny to come with me. I left the chart with Doctor Mastriano and we went to the triage desk.

"Anyone here for Kent Brown?" I asked quietly.

"His mother and his son are there," Nurse Tricia said, indicating a woman of about seventy and a man of around twenty-five.

"Thanks," I replied.

I couldn't wait for the chaplain as he wasn't in the hospital because it was Christmas morning, and the same was true for a social worker. That meant it was on me to provide a modicum of support, though I had to be careful not to overstep. Jenny followed me to the door to the waiting room.

"Mrs. Brown and Mr. Brown?" I announced.

Both of them stood up and hurried over to me.

"How is he, Doctor?" the woman asked.

"Let's go inside and I'll explain," I said.

I led them to the consultation room and had them sit. I sat down, and per protocol, Jenny stood.

"My name is Doctor Michael Loucks," I said. "I go by Doctor Mike. Your son and your father was brought in by the paramedics after suffering a severe heart attack. While we were treating him, his heart stopped. We used all of our capabilities and all of our skills, but we were unable to restart his heart and he died. I'm sorry."

"NO!" the son screamed. "NO! DO SOMETHING!"

"Unfortunately, there is nothing else we can do. We administered CPR and drugs, and had him on a ventilator, but the type of heart attack he had is routinely fatal. Is there someone I can call for you? A priest, pastor, or rabbi?"

"Can we see him?" the woman asked.

"Yes, of course. I'll take you to him, but I want to warn you that you'll see wires, tubes, and other equipment and supplies we used to try to save him, including a breathing tube in his mouth. I can take you now, or wait for your spiritual counselor, if you want me to call one."

"Kent hated preachers," she said. "So no, thanks."

"I was more concerned about you or your son," I replied with a smile. "But it's up to you. Shall we go see him?"

"Yes," she said.

"Grandma, they have to do something!" Kenny insisted. "It's Christmas!"

Sadly, there were no Christmas miracles this day.

"Kenny, you know he smoked, drank, and basically sat in his recliner full time," Mrs. Brown said. "Come with me to see him. It's important."

I stood and the two of them stood, then followed me to the trauma room, with Jenny following behind. They were relatively stoic while in the trauma room, and after about five minutes, they decided to leave. I offered once again to call someone, but they declined. I handed them a sheet of paper with the names of all the local funeral homes, and instructions on how to retrieve their loved-one's body. Once they had that, they walked slowly into the waiting room and Jenny and I went back to the trauma room to assist Kellie with the death kit.

"Christmas is going to be a lousy day for the rest of their lives," Jenny observed.

I nodded, "Yes, it is. Would you update the chart with what Mrs. Brown said about her son, please?"

Jenny agreed, and I began working with Kellie.

"You OK, Mike?"

I nodded, "I prayed when Bill and Jake handed him over to us, and again when he coded."

"I meant more about having to tell them their loved one died on Christmas."

"Mr. Worf to the contrary notwithstanding, is there a good day to die?"

"After a long and well-lived life," Kellie said. "Surrounded by children, grandchildren, and great-grandchildren."

"I'll take that for sure," I replied.

"What did I miss?" Kelly asked, coming into the room.

"A fatal STEMI," I replied. "Coded as soon as we had him on the table. How's your MI?"

"In the cath lab, showing arrhythmia. Doctor Shore said they might not be able to proceed."

"I'm not surprised. What do you know about Wellens' syndrome?"

"I don't know what that is," Kelly said. "Sorry."

"Jenny?"

"No clue, sorry."

"OK. In a patient who presents with unstable angina, the diagnostic factors are as follows. First, progressive symmetrical deep T wave inversion in leads V₂ and V₃. Second, the slope of inverted T waves is generally between 60° and 90°. Third, little or no cardiac enzyme elevation. Fourth, limited ST elevation, but usually none. Fifth, no missing R wave. Generally, patients who present this way have at least 50% occlusion of the left anterior descending, or LAD, coronary artery. Around 25% have near-total occlusion."

"How do you know that?" Jenny asked. "No disrespect, but you're a trauma surgeon."

"I read an article by Doctor Wellens' in a cardiology journal during my Preceptorship and made note cards. What's the treatment?"

"Catheterization and a stent," she replied. "Doctor Shore said it could be fixed, but I saw you two exchange a look."

"Kelly, what's the nickname for the LAD?" I asked.

"The 'Widow maker'." she replied. "Without immediate treatment, an occlusion is always fatal; with treatment, it's fatal in more than half the cases."

"Why?"

"I don't remember."

"Jenny?"

"Our textbook said it was caused by coronary plaque rupture, but that's why even a small amount of plaque can cause a massive heart attack wasn't well understood. But it wasn't called Wellens' syndrome in our textbook."

"That's because it was only identified in 1982, so it won't hit the cardiology textbooks for several years, and the general textbooks a few years after that. This is a perfect example of why we have to read medical journals for our entire careers. We're obviously not cardiologists here in the ED, but of all the things I could study to provide better care, it's cardiology.

"We see more heart attacks than any other major ailments. With heart attacks, strokes, and major trauma, seconds count. Even if Cardiology arrives within five minutes, that could be too long. That's why I have gone out of my way to read EKGs and understand coronary symptoms. It's as vital as being able to intubate, insert a chest tube, or insert a central line."

"Is it OK to ask something that might be out of line?" Kelly inquired.

"Sure. What's that?"

"How is it that you're a PGY1 and you know more than some of the Attendings?"

"Emergency Medicine is evolving rapidly, to the point where someone who was a Resident even five years ago, would have been trained far differently than we're being trained now. Remember, the first Residency program in emergency medicine wasn't established until 1972 at the University of Cincinnati. If you think about that, that means any doctor who graduated medical school anywhere in the country before 1972 could not have had any specialized training."

"It was surgeons, right?" Jenny asked.

"Yes, supplemented by Internal Medicine. The trauma Residency program here didn't start until 1979, when the Emergency Medicine was recognized as the twenty-third medical speciality. The first certification was available in 1980. Given when the program stated here, the first Emergency Medicine Residents didn't graduate until 1982, and none were certified before then. Doctor Gibbs served her Residency here beginning in 1985, and even her training was significantly weaker than mine.

"Remember," Kellie interjected, "ten years ago, the county didn't have any paramedics. It was white-coated ambulance attendants performing 'scoop and run'. Mostly all thy could do was provide an oxygen mask and try to staunch bleeding. And you know about field intubation and EKGs, right?"

"They just started this year," Jenny said. "Doctor Mike, would you recommend me for trauma surgery?"

"Let's wait until the end of January when it's time for evaluations," I said. "You're doing fine, but I want more time to evaluate you. OK?"

"Yes," she replied.

We completed the death kit, and I asked Kelly to call an orderly to transport Mr. Brown to the morgue where he'd go into one of the cold lockers to await attention from Doctor McKnight, if anyone felt that was necessary. The rest of the morning was relatively quiet with a few lacerations, one automobile accident with only minor injuries, and a rule-out MI that turned out to simply be a combination of stress and indigestion.

At noon, I called Clarissa, and she and I met in the cafeteria.

"No Shelly today?" Clarissa asked.

"I'm the surgical Resident on duty," I replied.

"God help us!" she smirked.

"Very funny, Lissa," I said sarcastically. "How many of YOUR Attendings are in the hospital?"

"Somewhere between zero and four, inclusive. I bet you can guess!"

"That would be 'zero'," I replied. "The only Attendings on duty in the hospital are in the ED and the ICU. Everything else is skeleton crews of Residents and medical students. Pat Shore had to call in someone for an emergency angio. That was the first MI; the second coded about a minute after we had him on the table. Morbidly obese smoker. His mother and son were here."

"How is the emergency angio?"

"Not sure. Kelly said he had arrhythmia shortly after they got him to the cath lab. You know what the LAD is nicknamed."

"Yeah."

"I did have to stifle a laugh when I met his wife — Denise Crosby."

Clarissa laughed, "And you immediately thought of Tasha Yar, of course."

"Of course! I was NOT happy when they killed her off. It made zero sense and I have to imagine the actress had some reason to leave the show."

"Are you objecting to killing main characters in general, or just that specific one?"

"That specific one. I felt killing Henry Blake on _M✶A✶S✶H_ made perfect sense, except that according to Mr. Black, a plane leaving Seoul would be too far from North Korean territory for the plane to have been shot down, and if there was a real risk, they'd have flown south and crossed the Korea Strait. Oh, and the entire North Korean Air Force was destroyed by the end of July 1950. And one more trivia point — by the end of the battle the Eighth Army had more air support than General Omar Bradley's Twelfth United States Army Group in Europe during World War II."

Clarissa rolled her eyes, "Artistic license!"

"Of course! But the problem is, they could have done it so many other ways and made it equally shocking. But anyway, I just think _Skin of Evil_ was a horrible episode. Back to reality — how many patients do you have today?"

"Seven, plus five in the ICU. How busy are you?"

"Not very. The two MIs, one with indigestion causing a panic attack thinking he was having a heart attack, an MVA with minor injuries, and a pair of lacerations. We'll see more heart attacks later."

"It's just you and me, Petrovich, so I want to ask if Kelly is behaving."

"She is. I suspect what happened with Krista Sandberg was a warning shot across the bow of every medical student who is interested in a doctor, and every doctor who might be interested in a medical student. Not to mention Sophia had a 'Come to Jesus' conversation with her after she made it clear she wanted to sleep with me even though I'm married."

"Just out of curiosity…" Clarissa smirked.

"There is only one person in this entire hospital besides you in whom I would be interested if I wasn't happily married to a sexy French girl!"

"It has to be Kellie Martin!"

"Right the first time! And it's mutual. Which is why I'm telling you."

"Accountability?"

"Yes. I don't see the risk, but Father Roman insisted I have an accountability partner. You're elected."

"It makes sense. I'm curious about Shelly Lindsay."

"Cute, but we click as colleagues, nothing more. It's similar to Leila Javadi. Doctor Gibbs is a colleague and a friend, similar to Ghost and Carl Strong."

"I have to ask about Kylie."

"We were fuck buddies," I replied. "And she has zero interest in married men. Honestly, I don't even really think about that part of our relationship."

"You're not spending time alone with Kellie, are you?"

"No. On the few occasions we've been in the consultation room, I've kept the door open."

"Which you always do if you need to speak to women privately."

"Except for you," I replied. "We always thought we were the risk, but we're not."

"No, we're not, which surprised me."

I shrugged, "I know who you are and I know that as much as I enjoyed being with you, you barely tolerated it. Well, not the cuddling part, which you liked, but the penetration. And I could never do that to you again."

"Not even to make a baby?"

"See, as much as we've discussed that, the one thing we didn't really cover is that it might be a dozen times a month for as long as two years. There is no way you could sign up for that."

"You're right," Clarissa sighed. "I didn't consider how long it might take."

"I think the way we're doing it is right," I said. "We're colleagues, best friends, and we're going to have a baby together. I'm very happy."

"Me, too."

We finished our lunch, and then Clarissa went upstairs to Medicine and I returned to the ED.