Chapter 67 — Emergency Procedures

_December 11, 1989, McKinley, Ohio_

{psc} On Monday afternoon, I received permission from Loretta to attend the Board of Inquiry for Doctor Mark King, though if the ED was slammed, I'd be paged and have to return. I wasn't surprised to see Carl Strong in the room and sat down next to him.

"How does this work?" I asked.

"They've all read Doctor Rhodes' investigative report, which is the primary evidence. King can make a statement, then call witnesses, both to facts and to his character. The Board could also call witnesses."

"Does he have any chance?"

"Five or ten years ago, it would be a sure thing; times have changed. I'd say he has no chance unless he can offer some kind of new evidence that he didn't sleep with Krista Sandberg or can somehow prove there wasn't a _quid pro quo_. That said, the only evidence they have is from Krista, and she's a known liar, which you demonstrated convincingly."

"That strikes me as a major problem," I observed.

"We'll see," Carl said as the Board members began taking their seats at a table in the front of the auditorium which normally hosts M & M Conferences.

"Good afternoon," Doctor Anderson, the Hospital Administrator said. "A Board of Inquiry has been convened to address a request for reinstatement by Doctor Mark King. The members of the Board are Doctor William Bielski, Doctor Paul Gilquist, Doctor Michelle Lindsay, Doctor Leila Javadi, and Doctor Marcie Baxter. Legal counsel for the Board is Mr. Leland Crowe. The Board has read the reports issued by the Medical School and the Medical Director following separate investigations.

"The findings of both investigations lead to the same conclusion — Doctor Mark King solicited sex from a medical student, Krista Sandberg, in exchange for improving her grade for her clinical rotation in Internal Medicine. These findings were supported by statements made by Miss Sandberg, as well as Nurse Nancy Rodgers, Nurse Karen Black, and medical student Patsy O'Meara. Per the rules for Boards of Inquiry, those individuals are here and may be questioned by Doctor Mark King. I'll now turn this over to Doctor Bielski, who is serving as chairman."

"Thank you, Doctor Anderson," Doctor Bielski said. "Doctor Mark King, would you please come forward and present your request?"

Mark King stood and moved to the lectern to address the board members, and I turned to look behind me and saw that Krista was in the auditorium, sitting in the last row.

"Good morning Doctors," Mark King said. "Thank you for hearing my petition for reinstatement. My request is based on one simple fact — the person making the accusations has proven themselves to be completely untrustworthy. It is also the case that her grade for her Medicine rotation was commensurate with her performance. And, this is not an admission, sexual relations between students and doctors were not a violation of hospital policy or the medical school ethics guidelines at the time of the allegations.

"With regard to the witnesses besides Miss Shephard, the evidence is mere hearsay, with regard to the specific reason for my suspension from the Residency program. None of the witnesses gave testimony about the alleged relationship with Miss Shepherd, and the actions to which they reported were not a violation of hospital policy or medical school ethics, as they stood at the time. I'll now address each of the witness statements.

"First, Nurse Nancy Rodgers. She has stated that we had a sexual relationship, and assuming for the sake of argument that is true, it did not violate any hospital policy. She was, at the time, she claimed we were involved, assigned to Cardiology, not Internal Medicine. Second, Nurse Karen Black made a similar statement. Again, assuming for the sake of argument that is true, it did not violate any hospital policy. She was assigned to Pediatrics at the time she claimed we were involved."

"Doctor King," Shelly Lindsay interrupted, "are you denying you had relationships with those nurses?"

"I'm neither confirming nor denying those claims as if they did happen, were not violations, and as such, have literally no bearing on the matter. According to both reports, their statements were used to corroborate Miss Shepherd's claim that she and I engaged in sexual relations. Even if ALL of that is true, none of it was a policy violation."

"If you wish this Board to take you seriously," Doctor Javadi interjected, "dissembling is not the correct approach. Did you have intimate relationships with those two nurses?"

"Doctor Javadi and Doctor Lindsay, with all due respect, I was taught that a gentleman never discusses that topic."

"_He's not doing himself any favors_," I whispered to Doctor Strong. "He should just admit it."

Carl nodded.

"While it's certainly true that I would not want a paramour revealing intimate details," Doctor Javadi replied, "the nurses in question have come forward to say that they had an intimate relationship with you. Please either confirm or deny their statements, or I will assume you have something to hide and take that into account during our deliberations."

"Yes, Doctor Javadi, I was involved with both nurses," Doctor King admitted. "May I continue?"

"Yes."

"During the time Miss O'Meara says that we were involved, she was assigned to Psych. Again, that was not against hospital policy, nor was it a violation of the student ethics code."

"Just to be clear," Doctor Lindsay asked, "you admit to having sex with a medical student and two nurses?"

"Yes, Doctor Lindsay."

"And with Miss Sandberg?"

"I'm involved in a civil lawsuit with Miss Sandberg, and on the advice of my attorney, I have to decline to answer that question."

"A criminal case would have delayed this inquiry until it had been completed," Doctor Bielski said. "But it's a civil case, so I think, Doctor King, that you have a stark choice. If you decline to answer our questions, we will decline to act on your petition with the result that the suspension would be confirmed, and you would be subject to dismissal from the Residency program."

I so wanted to turn to see if Krista was smiling, but I felt it was better not to do so.

"May I have two minutes to consult with my attorney, please?"

"Yes, of course."

Doctor King moved from the lectern to a woman sitting in the front row of seats and spoke quietly to her for about a minute, then returned to the lectern.

"Doctor Anderson, my attorney would like to speak with Mr. Crowe," Doctor King said. "We'd like a twenty-minute recess, please."

Doctor Anderson consulted with Mr. Crowe and then agreed to the recess.

"I wonder what that's about," I said.

"I suspect they intend to try for an injunction to prevent dismissal until he can answer the questions without risking anything in his civil suit. I'm no expert, but I'd say from what he's focused on — that nothing he did broke the rules and that Miss Shepherd received an accurate evaluation — he'll get it, and likely have cause to sue the hospital for wrongful dismissal."

"From what I've seen, a court isn't going to order them to take him back."

"No," Carl said, "but his suit for several million dollars would likely play well in front of a jury if he asserts he didn't break any rules and didn't raise her grade. He'd claim lost wages, and a ruined career."

"I think you might be right," I observed, "given there have been several complaints about unfair evaluations from Medicine in the past four years. But what if she says he threatened to fail her? I haven't seen the actual complaint."

"Me, either. Do you know anything about the settlement she made with the hospital and medical school?"

"No," I replied. "But one thing I'm sure of — no reinstatement given she lied in a sworn statement."

"There's no way she's coming back here, that's for sure," Carl said.

"She might have a chance at restarting medical school at another institution," I said. "A lot would depend on what the medical school agreed to in the settlement."

"What's your bottom-line assessment?"

"She's not cut out to be a physician," I replied. "I was leaning that way before the false accusation and before her other lies were exposed. I was giving her an absolutely fair shake, but I was suspicious that it was a wasted effort. She might have surprised me the way Felicity Howard did."

After about five minutes, Mr. Crowe consulted with Doctor Anderson, who stood up.

"This hearing is continued to a future date," he said. "I will provide appropriate notice as to when we'll reconvene."

"I suspect a deal was just stuck," Carl said quietly. "And they need to put it down on paper. I have ten bucks that say he's back to work by the end of next week."

"Shelly and Leila are going to be pissed," I observed. "And I'm not particularly happy."

"I hear you, but her claims were seriously weakened by trying to trap you. Had she not done that, you'd have testified on her behalf and made the hospital look VERY bad, and would have lent credence to her claims against Doctor King. Now, he can portray her as a liar, without that, he couldn't have. I bet any deal they strike will require him to settle with Miss Shepherd."

"No bet," I replied. "That would make perfect sense. He pays her off and is allowed to finish his Residency."

"On probation, most likely," Carl added. "And he won't be offered an Attending role here."

"With two years in Medicine he could apply for his license and hang out a shingle, so he wouldn't be completely screwed. I need to get back."

I got up and walked towards the back of the auditorium, noticing that Krista had left and was relieved she didn't try to talk to me. Unfortunately, my relief was short-lived.

"Doctor Mike, could I talk to you?" she asked as I walked out of the auditorium.

"My attorney said that's a bad idea," I replied.

"I'm not suing you," Krista protested, though her voice was calm.

"I know, but at least until all of this is over, I have to follow my attorney's advice. And right now, I need to get back to the ED."

"I am sorry," Krista said.

"I know," I replied. "I do need to go."

I walked away from her, turned left at the main corridor, walked quickly to the ED, and found Doctor Gibbs in the Attending's office.

"How did it go?" she asked.

"Doctor King's attorney spoke with Mr. Crowe, and Doctor Anderson agreed to suspend the Board of Inquiry. I suspect there's a deal of some kind in the works."

"That's going to go over like a lead balloon," Doctor Gibbs observed.

"Sure, but is Kristy a reliable witness? And is the hospital willing to risk a lawsuit that has actual teeth?"

"So he gets away with it?"

I shrugged, "I have no idea what kind of deal they might cut. Carl Strong speculated they'll reinstate him on probation and not consider him for an Attending position. I suspect he might bail after PGY2 and open his own practice. If you think about it, that could work for the hospital because they've already settled with Krista. Maybe they work out a multi-way deal with her to end the fiasco."

"Wait!" Loretta protested. "She might be back?!"

"I don't see that happening," I replied. "I was thinking more along the lines that King pays her off, and everyone signs non-disclosure agreements. If she's smart, she takes the cash, gets a Master's and PhD in biochem and becomes a researcher. That is literally perfect for her. She was a terrible clinician."

"AHA! You agree with me!"

"I _always_ agreed with you, Lor. The difference was, I felt she deserved a chance to prove it conclusively."

"Then why didn't you say something?"

"Because the one thing I won't ever do is prejudge a student. Yes, I checked to see why her procedure book was light, but that led me to think about what I could do to give her a final shot at success, not decide she was hopeless and relegate her to scut. That's not my style, which you know, and yet she was assigned to me. So…"

"You won that one, too," Loretta replied. "Per Cutter, effective January 1st, nobody is to be assigned pure scut, except for short periods. That's to be left to candy stripers and nursing students in most cases."

"That's good for students, and it also protects the hospital," I observed. "The other good change is the one the medical school instituted in rating Residents on their ability to teach."

"You would like that, given you received perfect scores on that, too."

"Have I received a less than perfect score on _anything_?"

Loretta smirked, "Clarissa Saunders outscored you on Step 2 of the MLE."

"Yeah, yeah," I chuckled.

"Mike?" Ellie said from the door to the office. "Paramedics four minutes out with a fire victim."

"Burns or smoke?" I asked.

"They didn't say."

"Let my students know. Which nurse?"

"Becky."

"Thanks."

"Go heal the sick," Loretta said.

I left the office, put on a gown, gloves, and goggles, and headed to the ambulance bay where I was joined by John, Kelly, and Becky.

"We don't know what we getting beyond their bringing someone in from a fire," I said. "John, be prepared to intubate; Kelly, EKG and monitor, though if the victim is burned, you might not be able to place the EKG leads; Becky, stat ABG, CBC, and Chem-20. I'll call out any changes if necessary."

The EMS squad turned into the driveway and, a few seconds later, pulled up in front of us. Bobby jumped out.

"Doc, it's Jim Greer," he announced. "Thirty-two-year-old male; floor collapsed during a rescue. Smoke inhalation and a fractured right leg; PO₂ 90% on ten liters; BP 130/70; pulse 80. Couldn't intubate; leg is splinted."

"Trauma 2!" I declared. "Kelly, find Doctor Gibbs! John, I'll handle the intubation, get the EKG hooked up. Becky, I need that ABG faster than stat!"

We rushed Lieutenant Greer into Trauma 2 and moved him to the table, and Bobby and Sam retreated to the corner of the room, rather than leave. Lieutenant Greer was wearing bunker gear, but someone had opened his jacket, which allowed John to cut away his shirt to affix the EKG pads. I grabbed an intubation kit myself and moved into position just as Loretta and Kelly returned to the room.

"I have soot around the nose and mouth," I said. "Intubation attempt in the field failed. Run it, Lor, while I try to get the tube in."

She began her examination while I removed the oxygen mask, placed Lieutenant Greer into the sniffing position, and inserted the laryngoscope. I placed the tube in the groove of the scope and began advancing it, but both visually and by feel I could tell his airway was partly occluded. I tried twice, but couldn't manage to advance the tube.

"Constricted airway," I said. "Lor, switch places and give it a try. I haven't done a crike!"

"PO₂ down to 87%!" John announced. "86%!"

"No time, Mike," Doctor Gibbs declared. "Do you know the procedure?"

"Yes, but I'm not signed off. Kelly, call for a surgeon!"

"PO₂ down to 85%!" John announced.

"Becky, crike kit to Mike! Mike, I'm authorizing it!"

Technically, that wasn't permitted, but there was no way I was going to allow Lieutenant Greer to die or have permanent brain damage while waiting for a surgeon. I put the oxygen mask back on him and moved to the side to I could perform the procedure which I'd seen twice, but had studied extensively.

"Kelly, assist, please. I need the neck hyper-extended."

She moved to where I'd been standing and adjusted Lieutenant Greer's head.

"PO₂ 89%," he called out.

Which meant that some oxygen was making into Jim Greer's lungs, giving me a bit more time to think through the procedure. With the open tray next to me and Becky standing to my left, I first tested the cuff of the tracheal tube balloon for leaks by using a syringe to inflate it with air. Once I was sure it would hold air, I deflated it.

"Becky, lubricate the dilator and balloon cuff, please," I requested. "John, I need you to sterilize the neck with Betadine, then drape!"

While that was happening, I filled a syringe halfway with saline. As soon as the drape was in place, I identified the cricothyroid membrane my moving my finger from the laryngeal prominence until I felt the step-off between the caudal end of the thyroid cartilage and the cricoid cartilage.

"Lidocaine!" I ordered.

Becky handed me the pre-filled syringe, and I made two injections near my planned incision site, then handed back the syringe. Using my left hand, I stabilized the larynx.

"Scalpel!" I ordered.

Becky handed it to me and I made a 2.5cm midline longitudinal incision in the skin and subcutaneous tissues over the cricothyroid membrane.

"Needle catheter!" I ordered. "Attached to the syringe."

Becky did as I asked and handed it to me. I inserted it through the cricothyroid membrane, aiming caudally at a 45-degree angle, kept back-pressure on the syringe plunger as I advanced the needle and catheter. I felt a bit of resistance and pop as the needle entered the trachea.

"Air bubbles in the syringe," I announced.

"PO₂ 86%!" John called out.

"Get a move on, Mike!" Doctor Gibbs ordered.

Having seen the air bubbles, I quickly removed the syringe from the needle, advanced the catheter, and withdrew the needle.

"Guidewire!" I requested.

Becky handed it to me and I threaded the flexible tip through the catheter and into the trachea. Once it was in, I removed the catheter, then carefully guided the dilator over the guidewire, ensuring it passed properly through the dilator. As I tried to advance it, I felt some resistance, so I rotated the unit slightly back and forth until the hub and flange of the airway catheter were flush against the skin.

"IN!" I ….

I withdrew the guidewire and removed the dilator, then inflated the balloon cuff.

"Vent!" I ordered.

Kelly passed me the ventilator tube, and I connected it.

"Set the pressure per the card," I directed.

She adjusted the ventilator controls and Doctor Gibbs auscultated Lieutenant Greer's chest.

"Good bilateral breath sounds!" she declared.

"PO₂ 91%…92%…93%!" John announced.

"Becky, secure the unit with tape through the catheter flanges."

"Great job, Mike!" Doctor Gibbs said. "Kelly, call for Ortho and Pulmonology."

The first three minutes had been frantic, but things calmed down after that, and after the consults, John, Kelly, and I escorted Lieutenant Greer to the ICU for overnight monitoring. His CO₂ and CO levels weren't dangerously high, but with the crike, they'd keep him sedated until it could be removed.

"You two go back to the ED," I said. "I'm going to turn myself in."

"Huh?" John asked.

"Remember when I said I wasn't signed off? Doing the procedure is a dismissible offense."

"But Doctor Gibbs authorized it!" he protested.

"Technically, she can't. I'm sure I'll be OK, but I need to make sure Doctor Cutter hears it from me, not anyone else."

They turned to take the stairs down to the ED and I continued along the corridor to the surgical wing, heading for the Chief Surgeon's office. His assistant said he was on the phone, so I sat down to wait. About five minutes later, she saw the light go out on the phone and went to the door of the inner office and announced me, then waved me in.

"What's up, Mike?" Doctor Cutter asked, his voice friendly.

"I performed a procedure for which I didn't have sign off," I said.

"What procedure?" he asked, suddenly serious.

"A percutaneous cricothyrotomy," I said.

"I know you well enough that you aren't a cowboy, so tell me what happened and why."

I describe the situation in detail, including who the patient was, and Doctor Gibbs' order to perform the procedure.

"OK. First, let's go see your patient."

We left his office and walked in silence to the ICU, where he checked my work and reviewed the chart. We left the ICU and returned to his office.

"Textbook work, as I'd expect. I'm sure you know why the rule is in place. There is some leeway in an extreme emergency, but if things go wrong, it opens the hospital to significant liability. In this case, you'd likely be safe, but Loretta risked her job ordering you to do that. I understand why, and I'd probably have done the same thing in the same situation. I need you to fill out an incident form, have Loretta sign it, and bring it to me."

"Yes, Doctor," I replied.

"Given the circumstances, that will be the end of it for you. Without an adverse outcome, I have thirty days to turn the incident form over to the Medical Director, to allow me to do an investigation. I believe my investigation will take three weeks, given the holidays."

I suppressed a chuckle because that meant turning the report over to himself, as he would be Medical Director as of January 1st.

"Is Loretta in any trouble?" I asked.

"No. She's the Chief of Emergency Medicine and she had a surgeon perform the procedure."

"And if there had been an adverse outcome?"

"Then I have three days to complete the investigation and it goes to the Hospital Administrator, Legal Counsel, and Medical Director. But that didn't happen."

"And if you have to make that referral and there's an investigation?"

"The totality of the situation is taken into account. Given the extreme likelihood of death or severe brain injury due to oxygen deprivation, I doubt any medical review board would find either of you acted improperly, even though it was a technical violation of policy. Life-saving has to be our primary goal.

"But a word of caution, Mike — this has to be a very rare occurrence. It was, in my view, completely warranted and defensible in this case. If you find yourself in a similar situation in the next two years, ask yourself if what you think you need to do, or your being ordered to do, is worth the risk to your career. Go right up to that line, and you're fine. Cross it, and all bets are off."

"Understood."

"Do you have your procedure book?"

"It's in my locker," I replied.

"Bring it to me with the report. I'll sign off on authorization for you to perform an emergency percutaneous cricothyrotomy."

"Thank you, Doctor."

"I want the report on my desk before you go home, please."

"Yes, Doctor."

"Dismissed."

I left his office, returned to the ED, and let Doctor Gibbs know what Doctor Cutter had said.

"OK. I'll cover anything that comes in while you fill out the paperwork. Bobby and Sam want to give you a medal, and asked me to extend an invitation to dinner at the firehouse."

"I was just doing my job," I replied.

"Now you sound just like the firemen!"

"Good! Do you have the form?"

She opened a credenza behind the desk and handed me a triplicate form. I took it from her and went to the consultation room, which doubled as the Resident's office, and sat down to complete the report Doctor Cutter had requested.

The form was fairly straightforward and had a number of blanks to fill in regarding the incident, then a section for prose to describe what had happened. The instructions stated that only factual information should be provided, something I realized was to ensure that the form didn't provide additional information to any would-be litigants.

Once I completed the form, I signed it, then took it to Doctor Gibbs for her signature. She read through it, concurred that I'd accurately reported the events, then signed it. I took the complete form up to surgery, stopped at my locker to retrieve my procedure book, and then walked to Doctor Cutter's office. He had left for the day, so, with his assistant's permission, I put the form and my procedure book in the middle of his desk, then returned to the ED.

When I took my dinner break, I called Clarissa to see if she was available, which she was, and she met me in the cafeteria, where, after we had our food, I explained what had happened.

"And the pattern continues," she teased. "I leave you unsupervised and you're going all Father Mulcahy!"

I chuckled, "I didn't use a pen knife and an eyedropper!"

"Do you think that's possible?"

"It was risky for me to do with the proper tools," I replied. "There are numerous blood vessels that have to be avoided, and only my extensive knowledge of anatomy made that possible."

"Oh, you have extensive knowledge alright!" she teased.

"Not THAT anatomy, Sveta!" I countered with a grin.

"You haven't called me Svetlana Yakovovna in ages! I think the last time when I was teasing you on your wedding day!"

"I don't use much Russian these days, other than calling my grandfather «Дедушка». It seems French has replaced Russian in my home!"

Clarissa laughed, "You like French!"

"Yeah, yeah," I chuckled. "Any way, I think it might be possible to do what Father Mulcahy did, but the chances of success are almost nil. That said, when death is the alternative, you do what you have to do."

"Are you in any real trouble?"

"No. Given the outcome, it'll simply be recorded as a necessary emergency procedure. And if there were any real fallout, it would land on Loretta. I might be reprimanded and reminded of the policy, but that would be it. I'd seen two of them, and I'd studied the procedure, and all joking aside, I know my anatomy."

"I think you just demonstrated why we have to continue to review our flashcards and notes even now, after we're out of school."

"Formally out of school, yes, but we're in a training program that doesn't require classroom work."

"And yet, we still study!"

"Because we can't afford to not study," I replied. "I've added at least a hundred flashcards since graduation, because there's always something new to learn."

"It's more critical for you, given you don't have time to look things up or discuss them with colleagues. I honestly don't know how you do it! Even Medicine can be hectic at times. The ED is simply insane!"

"Which is a perfect fit for me," I chuckled.

Clarissa laughed, "So true! I heard that the Board of Inquiry didn't finish."

"I think King is trying to make some kind of deal that allows him to complete his Residency. Carl suspects he'll come back on probation, but truth be told there is no chance he'll land an Attending role here."

"How the heck?"

"How reliable do you think Krista is? And can you imagine if King were to bring suit against the hospital? They dismiss him based on uncorroborated statements from a known perjurer? Think how that plays in front of a jury."

"Badly. But what about the nurses and the other med student?"

"Circumstantial, in that sure, he was fooling around with them, but that proves nothing about what happened with Krista. Having sex wasn't a policy violation for him, nor an ethical violation for her. Now it would be. But you can't do anything _ex post facto_ in that regard. He'll be the poster child for the policy, but the policy can't be used against him. He also made the argument that her work during her Medicine rotation was accurately reflected in her grade. She had a 3 on the old scale, and it's pretty hard to score less than that."

"What was her grade going to be for trauma?"

"A 2 or 3, based on what I had seen so far, but there was a clear risk of failing, even apart from lying to me. She could easily have told the truth because it wasn't against the rules for the medical school or hospital. Trying to hide it only made things worse for her and led directly to her trying to save herself by lying about me."

"That would have been a disaster! She's not part of the deal, is she?"

"I think there might be a payoff from him to her to settle the case, but nothing can bring her back because she was dismissed for making a false sworn statement. She did try to talk to me today, but I declined on Melody's advice."

"Wise. What do you think she'll do?"

"As I said to Doctor Gibbs earlier, if Krista is smart, she'll take her settlement money, earn a PhD, and go into research. She'll be good at it. She was a terrible clinician."

"Do you think she could get into a post-graduate program after being expelled?"

"I'm not privy to the details of her settlement, but it wouldn't surprise me if she was allowed to say she quit, so long as she doesn't try for another med school."

"Was her attorney at the Board of Inquiry?"

"I didn't see him, no. She sat in the very back, by herself."

"She's a pariah," Clarissa observed.

"Self-inflicted," I replied. "But enough about her!"

We chatted about other things as we ate, and when we finished, he hugged, and each returned to our service to complete our shifts.

_December 14, 1989, McKinley, Ohio_

"I hear you're being released today," I said to Nancy when I visited her on Thursday morning.

"Finally!" she exclaimed. "Four freaking weeks in the hospital!"

"Mind if I look at your chart?"

"Why not?" she said with a smirk. "You've seen everything else!"

I chuckled and picked up the chart. I'd looked at it each time I'd visited, but I wanted to see the final discharge notes from the physical therapist. Nancy was making excellent progress, though it would be a few months before she'd have the cast removed from her leg. She'd had her final surgery on her arm, removing some of the hardware that had been installed when they'd reconstructed it.

"Looks good," I said. "How does your arm feel?"

"It throbs, but Tylenol solves that. The cast is crazy uncomfortable and I itch."

"I'm glad the double-vision cleared," I said. "Concussions can be lifelong problems."

"Me, too! That was driving me completely nuts, even more than you did!"

"Ouch," I chuckled.

"I'm teasing, Mike! We had our ups and downs, and despite the problems, it was good. We just weren't meant for each other. Mom was disappointed, but she likes Matt, and she spoils Matty to death!"

"I believe that's the job of grandmothers and, apparently, little sisters!"

"Yours? Or your wife's?"

"My wife's, of course. I don't even want to think about what my little sister might teach my daughter! Being taught French is bad enough!"

"That's right, you told me your wife is a recent immigrant from France. And I would have figured you were teaching her Russian."

I shook my head, "No, we're American through and through. The French is only to annoy me, though, ultimately, her being able to speak French is probably far more useful than Russian. That said, with what's going on in Eastern Europe, you never know. Russia might become an ally once again, but this time without a communist government. It's really only since the end of World War II that Russia hasn't been a US ally."

"I take it you plan more children?"

I nodded, "We do. Can you keep a secret? I mean, from everyone?"

"Your wife is pregnant?"

"Due in late June. We plan to announce it at Christmas dinner."

"If I recall correctly, you have to work holidays."

"I do. We'll have ours on the 24th after Vespers. I already received permission from the bishop for «ekonomia» for both families to have our celebration that night because I have a shift from 0500 to 2100 on Christmas day."

"Er, I don't do military time."

"Sorry. That's 9:00pm. The trick is that if it's before 1200, it's AM and if it's after 1200, it's PM, and you subtract twelve. We use it because it reduces confusion as to when your shift starts or ends, especially when it's a thirty-six-hour shift!"

"Ugh! How do you do that?!"

"Fortunately, I don't. The Emergency Department switched to eighty-hour weeks, with no more than twenty-four hours per shift and at least eight between shifts. There was a situation in New York attributable to overworked and overly tired Residents at the end of a thirty-six-hour shift with little sleep, and that's caused some hospitals to change their scheduling practices."

"What happened?"

I explained the basics of the Libby Zion case to Nancy, who just shook her head.

"Sorry to cut this short, but I need to get back to the ED. I just wanted to come say 'hi' before you're released."

"Thanks! Mom wants to have you and your wife to dinner. Is it OK for her to call you?"

"Absolutely. Let me write down the number."

I wrote my name and number on the scratch pad next to the bed, then said 'goodbye' to Nancy and headed back to the ED.

_December 17, 1989, McKinley, Ohio_

On Sunday, after Matins and the Divine Liturgy, Kris, Rachel, and I had lunch with the congregation, and then I met with Bishop JOHN.

"I'm sorry I didn't have time to speak last week when you asked about Nativity," he said after we sat down in his office.

"It's OK, Vladyka," I replied. "I totally understand, and I cannot monopolize your time!"

"I enjoy speaking with you, Michael! How are things at the hospital?"

"There's been a bit of drama surrounding a medical student and a doctor having an affair and an allegation that her grade was improved because of that affair."

"I find it hard to believe it's not against the rules for what amounts to a teacher being intimate with a student."

"It is _now_," I replied. "As a direct result of that situation. I've been pushing for that rule for two years, and things finally were serious enough that the medical school and hospital both instituted rules limiting that."

"Limiting?"

"There is a bit of leeway for students and doctors who are not on the same service, but it has to be disclosed."

"Knowing you, I have to ask — how involved were you?"

"Up to my eyeballs, of course! The student was a troubled one who was assigned to me when everything went down. She was dismissed for making false sworn statements and the doctor in question is suspended pending a completion of the investigation."

"What was your part?"

"The false accusation was leveled against me, but I'd taken steps beforehand to ensure a claim like that wouldn't stick."

"Now I have to ask — did you do anything at all questionable?"

"Not in the way you mean," I replied. "I did speak to Father Herman about my response to some of the tension that was created because of the internal battle over the rules change and the responses to the situation."

"May I ask what steps you took?"

"On the advice of one of my mentors, I began carrying a pocket tape recorder and recorded a meeting with the student. Her characterization of the meeting was directly at odds with the tape recording, which led to her dismissal."

"That could have gone very badly," Bishop JOHN observed.

"It was actually that meeting that caused her to make the false accusation because I confronted her with other lies she'd told. I was also careful to have a trusted nurse stand in a strategic spot so she could see the student and me."

"Perhaps you should start at the beginning and explain, as best you can, without violating any hospital rules."

I nodded and gave a complete rundown of the situation, beginning with Felicity Howard and running through the hearing the previous Monday. Bishop JOHN listened intently, but didn't ask any questions until I finished the story.

"You discussed this with Father Roman?"

"Most of it, yes. I'm seeing him face-to-face the first Sunday in January."

"Good. How are things otherwise?"

"Very good. I'll tell you now, as I won't have a chance to do so before the usual gossip brings it to your attention — Kris is pregnant and we're due towards the end of June."

"Wonderful news, Michael! When will you make it public?"

"We'll tell our families on the Eve of Nativity at the dinner for which you granted «ekonomia»."

"Of course, Michael! Your schedule is such that accommodation is totally warranted. I assume you've modified your fasting rule?"

"Yes. Father Luke, Kris, and I worked out a rule for any time she might be pregnant, and I believe she informed him in confession that she was pregnant. The one place, besides your office, completely immune to gossip!"

"If there was one thing I could end with the wave of my staff, that would be it! How is Rachel taking it? Or does she know?"

"We'll tell her right before we tell our families; toddlers are not known for discretion or keeping secrets!"

"Nor many adults, sadly! I'm very happy for you, Michael."

"Thank you, Vladyka."