Chapter 66 — You're a Difficult Case

_December 5, 1989, McKinley, Ohio_

{psc} Doctor Evgeni arrived and, after conferring with me and Perry Nielson, checked Mr. Gianis and found nothing remarkable. Mr. Gianis' labs were clean as well, so after ninety minutes, we discharged him, and Doctor Evgeni took him home.

"What happens now?" Kelly asked.

"Doctor Evgeni will coördinate Mr. Gianis' care. That's actually the best way to handle things that don't require hospital admission. Do you remember the term 'continuity of care' from your Practice of Medicine class? A GP is best situated to manage an individual's care. One of the most important things we do when we discharge someone directly from the ED is to refer them to their personal physician. Our role in the ED is, as we pithily put it, to treat 'em and street 'em, and if you can't street 'em, admit 'em."

"That seems awfully harsh," Kelly observed.

I nodded, "We have limited resources and our job is to stabilize patients and hand them off to other services or their personal physician. The biggest struggle I had initially was spending more time talking to patients than resources permitted. I push those boundaries further than most, but even I have to give in to the reality of patient volume. The one thing I was consistently called out for as a medical student was spending too much time with patients. Figuring out the correct balance was the challenge."

"Mike?" Paul Lincoln said, coming into the lounge. "I need a surgical consult."

"We'll be right there," I said.

He left, and my students and I followed him to Exam 2.

"Ms. Atkins, this is Doctor Mike, a surgical Resident. Mike, this is Jennifer Atkins, forty-eight, presents with durative colic in left upper abdomen for four days; deep tenderness in her left epigastrium without rebound pain; signs of peritonitis; CBC shows elevated white count; all other labs are normal. Dunphy's sign was absent. No other complaints, no history of abdominal pain or digestive problems."

"Hi, Ms. Atkins," I said. "I'd like to examine you, please."

"Of course!"

I performed an exam and confirmed Paul's findings.

"Kelly, I need an ultrasound cart, please."

"Right away, Doctor Mike!" she exclaimed.

"Ms. Atkins, we need to perform an ultrasound exam to see if we can determine what's causing your pain. We're a teaching hospital, so I'd like to have my student perform the exam. Would that be OK with you?"

"Sure."

Kelly returned with the ultrasound cart and I explained to both Kelly and Jenny how to set up the machine, then asked Jenny to perform the exam. I guided her through it and saw a strange shadow on the display.

"Stop there," I said. "Rotate the transducer about forty-five degrees and hold. Good!"

I pressed the button to freeze the image, then pressed 'PRINT' to get a physical copy.

"Do you see this, Jenny?" I pointed to a suspicious artifact on the display. "Any ideas?"

She shook her head, "That doesn't confirm to any anatomy I know."

"No, it doesn't. It appears to penetrate the descending colon and points toward the tail of the pancreas. You can also appreciate fluid accumulation in that area. Ms. Atkins, you're going to need immediate surgery to determine what that is."

"Surgery?!"

"Yes. I can't say for sure what it is, because the ultrasound can't show me sufficient detail. We'll take you upstairs for what's called a laparotomy. The surgeon who'll perform the procedure will explain in detail. OK?"

"What happens if I don't have the surgery?"

"The pain will continue, what appears to be peritonitis, that is, an infection, will worsen, and eventually you'll die from sepsis."

"I think I'll have the surgery," she said.

"Good choice!" replied with a smile. "Kelly, call upstairs, please. We need a surgical team for an emergency exploratory laparotomy."

Kelly made the call and after explaining what I'd requested, she hung up.

"About twenty minutes," she said. "They're prepping an OR."

"Ms. Atkins," I said. "Doctor Lincoln will arrange for you to be taken up to surgery. Do you have any questions for me?"

"No, I don't. Thanks."

"Then I'll leave you in Doctor Lincoln's capable hands. Kelly, please return the ultrasound unit to the alcove and wipe down the transducer with alcohol."

"Will do!" she exclaimed.

The three of us left the room with Kelly pushing the ultrasound cart. She did as I asked, while Jenny and I went to the lounge. About four minutes later, Kelly came into the lounge and Nate let me know that Nelson Burke needed to speak to me. I picked up the phone and pressed the only flashing button.

"Nelson, it's Mike."

"Any idea about that laparotomy?"

"I'd say foreign body," I replied. "Given the length and shape, my bet is an ingested toothpick. There are signs of peritonitis, including an elevated white count, so you'll likely need a lavage as well."

"OK. We'll be ready."

"Thanks, Nelson."

I hung up and sat down on the couch.

"Ingested toothpick?" Jenny asked.

I nodded, "It happens. I haven't seen one before, but I read an article in a medical journal about foreign body ingestion. The most common are kids swallowing something, especially coins. The most dangerous things are actually strong magnets, which can cause severe trauma if they pull different parts of the bowel together. Coins usually pass, but sometimes they're lodged in a way that they need to be surgically removed."

"You don't get to assist with the surgery?"

"Sometimes. In this case, I couldn't, even if it was offered, because I'm designated primary on trauma. It works out to about twice, sometimes three times a month. Depending on the circumstances, you and Kelly might be able to scrub in as well."

"But you just observe, right?"

"I've actually been allowed to close, most recently on a splenic rupture."

"As a PGY1?!" Kelly asked, surprised.

"Yes. It's all part of developing the trauma surgery Residency. There's resistance to it for various reasons, but Doctor Cutter believes that having a surgeon in the ED at all times will lead to far better outcomes, which so far has been borne out. I've advocated for quicker hands-on training, and I've had some success in making that happen because I have the doctor who invented the concept of Residency on my side!"

"But that's only your program, right?" Jenny asked.

"Yes, so far, but I'm doing the same thing with my students, so you two are doing more than typical medical students. My advice is to push hard in every rotation for the opportunity to do advanced procedures. There will be resistance, but don't let that stop you unless you're told in no uncertain terms to stop."

"But isn't that risky?" Kelly asked. "I mean, pissing off a Resident could really cause problems."

"It's a judgment call," I replied. "You need to be assertive and aggressive, but not to the point of pissing them off. I've misjudged that point a few times, but apologies go a long way to solve that."

"Mike?" Nate said from the door to the lounge. "EMS four minutes out with two victims from an MVA."

"Did they say how bad?"

"No."

"Let Doctor Nielson know, please."

"Will do," Nate replied.

Jenny, Kelly, and I left the lounge and headed for the ambulance bay, joined by Jamie. A few seconds later, Doctor Nielson came out with Bill Weathers, his Fourth Year, and Nurse Julie.

"I'll take the first one," I said to Perry.

"You are primary today, so your call."

It turned out that neither of the victims was critically injured, and neither required surgery, though the driver was admitted to Medicine for overnight observation due to severe cervical acceleration-deceleration, colloquially known as 'whiplash'.

The rest of the morning was relatively quiet, and my students and I handled a few walk-ins before noon, which was when John relieved Jenny. The afternoon was busier, with two MIs, two MVAs, and a broken leg. The MIs were both admitted, the MVAs were treated and released, and the broken leg was admitted to Ortho.

"Are you doing OK, Mike?" Carl Strong asked when I joined him at dinner after he'd admitted the second MI to his service.

"Who spoke to you?"

"You know the hospital is worse than any TV soap!" he chuckled. "Does it matter?"

"I suppose not," I replied.

"One of the jobs of senior Residents and Attendings is to help the young doctors cope with the reality of our jobs. Ghost said you sought spiritual counseling."

I nodded, "I did speak to my «старец». And Perry Nielson has ensured I climbed back on the horse."

"I'm sure you understand why that's necessary when there is absolutely no culpability, and sometimes even when there might be."

"I do."

"No depression?"

"Sub-clinical, but the conversations have helped, and the work has helped even more, which is, of course, why Perry did what he did."

"We all have those moments when you do exactly the right thing and there's an adverse outcome. I assume you know there will be an M & M?"

"I was sure that would be the case. After thinking about it, I'm not sure it will be helpful."

"From what I know about the case, there won't be a _medical_ finding, but that's not the only point of an M & M."

"Dealing psychologically with adverse outcomes?"

"Yes, of course, but the more important thing is not to hesitate when inaction guarantees a bad result. That's true even if you know what you're about to do is risky and might not change the outcome. Think about the implications of following your initial objection."

I nodded, "It had a chance of success, even if the probability was low, whereas the probability of death asymptotically approached 100% if nothing had been done."

Carl laughed, "Only Mike Loucks would answer that way! Wouldn't you say her death was certain?"

"Given the strange things I've seen in about thirty months of clinical rotations, nothing is certain. My primary example is the patient who codes in the OR due to a bad reaction to anesthesia, which nobody could predict in advance. I know that the random occurrences nearly always work against the patient, but then you have the tumor that shrinks or disappears for no known medical reason."

"Leaving aside your pedantic nature, would she have died if you hadn't performed the thoracotomy? Just 'yes' or 'no', please."

"I want to say 'in all likelihood' but you won't let me get away with that, because the answer you want is 'yes'."

"I won't argue with you that miracles and unexpected outcomes occur, but what I'm asking you is what the _expected_ outcome would be?"

"That the patient would die due to a combination of trauma, hypovolemia, cardiac tamponade, and lack of oxygen circulating to the brain and other organs."

"So, in the face of that _expected outcome_, a doctor needs to act, taking any reasonable action to attempt to preserve life, even if the chances of success are small."

"I agree, obviously."

"And that's the message that will come out of the M & M. The case will be discussed, and some jackass will claim that some different course of action might have had a better chance of success, but in the end, he wasn't there, faced with the dilemma that Ghost solved by instructing you to continue. Your options were to refuse, in which case she likely dies waiting for a surgeon who would perform the procedure, or to do the procedure, hoping that it buys enough time to save her."

"Logically sound, but my heart isn't logical."

"No, it's not," Carl agreed, "It's in the right place, but what you can't do is let your heart override your intellect and training. And, as rough as this sounds, you suck it up, deal with it, and move on. Or, get back on the horse, as the saying goes."

"I get it," I replied.

"I'm positive you do," Carl replied. "I just want you to be prepared for some jackass from Urology or OB to try to second guess you. There's always one. It won't be a surgeon or cardiologist. It'll be someone who pushes pills for a living."

I chuckled, "Because it takes steel to heal. Or in your case, angioplasty. Though you guys do recommend daily aspirin."

"A wonder drug! But you know our primary recommendations!"

"Stop smoking, limit drinking, eat a high-fiber diet, limit red meat, and exercise."

"Bingo. The drugs are mostly for people who haven't done that and show up in the ED or walk into a cardiologist's office. I believe you have an opinion on that."

I nodded, "If people would eat right, exercise, stop smoking, not drink to excess, wear seatbelts in cars, wear helmets on motorcycles, and have annual physicals, we wouldn't have a resource problem at the hospital! And we wouldn't need all the so-called 'wonder drugs' that mostly only compensate for poor lifestyle choices."

"Back to your patient," Carl said. "Do you know any more about what happened?"

"No. The only thing I know beyond her injuries is that they have her boyfriend in custody. Well, and McKnight discovered she was about four weeks pregnant."

"I think I know the answer, but what's your take on the death penalty?"

"I believe it serves no legitimate purpose. It's immoral, is ineffective as a deterrent, is fiscally unsound, and most importantly, denies the individual the opportunity for repentance."

"Charles Manson?" he asked.

"The poster child for the death penalty," I replied. "But I maintain that killing him in the name of 'justice' is contradictory, like…screwing to preserve virginity!"

Carl laughed hard, "I love that! Mind if I use it?"

"Sure. It's not original with me. I heard it at Taft."

"Either way, it makes the point about contradictory ideas in an effective way. Back to you — have you felt hesitant in any way today?"

"No more than my usual mental review that I'm doing the right thing."

"OK. If you do feel hesitant, or feel unsure of yourself, talk to Shelly, me, or Ghost, please."

"I will. I appreciate the concern."

"You're a difficult case…"

"For MANY reasons," I chucked, interrupting him.

"True! But in this case, it's your usual stoicism, so it's not always clear to others when you're struggling. Just out of curiosity, is Doctor Saunders able to read you?"

"Like an open book," I chuckled. "Better than either Elizaveta or Kris, though with Kris, it's mostly due to the short time we've been together compared to Clarissa and me."

"Do you talk to her? Doctor Saunders, I mean?"

"Yes, though with our schedules and my family commitments, not as much as we have in the past. I actually spend more time talking with Shelly Lindsay."

"We're all here for you."

"Thanks" I replied.

I finished my meal, went to visit Nancy briefly, then headed back to the ED where almost immediately EMS arrived with a shooting victim.

"Three 9mm rounds to the chest," Roy announced before beginning the recitation of vitals, which indicated a patient in hypovolemic shock. I gave orders to Jack, Kelly, and Nurse Becky, and we rushed the patient to Trauma 1. I called out to Amy, at the nurses' station, that I needed another doctor, and once in the room, we quickly moved the patient to the trauma table.

"Becky, two units on the rapid infuser!" I ordered. "Kelly, get Doctor Mastriano, please! Jack, central line kit, then chest tube tray!"

The patient had lost so much blood that I thought it was hopeless, but I wasn't going to give up while he still had a pulse, as thready and weak as it was. First, I inserted the central line and hooked up the rapid infuser.

"What do you need, Mike?" Isabella asked, coming into the trauma room.

"Help me keep this guy alive long enough to get upstairs to surgery. He needs intubation, and I'm about to do a thoracotomy. Three 9mm rounds to the chest. A unit of plasma by the paramedics, two more on the rapid infuser, and whole blood on the way."

While I set about inserting the chest tube, Isabella intubated the patient and hooked up the ventilator. That would help, but the extra ventilation in his chest was not going to make it easy for him to breathe, even with mechanical assistance.

"300ccs on the floor," I announced as I made the incision.

I inserted the tube and hooked up the ThoraSeal, and saw blood.

"Blood in the ThoraSeal," I declared.

"Erratic heartbeat," John announced.

"Tamponade?" Isabella suggested.

"A good bet," I replied. "Becky, cardiac needle with a lead and an alligator clip, please."

"PVCs!" John announced. "Run of six!"

"Kelly, call upstairs; emergency surgery for three 9mm rounds to the chest, with no exits! Tell them we're still stabilizing the patient."

She moved to the phone while Becky brought me what I needed for the pericardiocentesis.

"Sats dropping, PO₂ down to 88%," John announced.

I performed the blind pericardiocentesis and aspirated fluid from the pericardial sac, which relieved the pressure on the patient's heart.

"They'll be ready in ten minutes," Kelly announced as a technician from the blood bank brought in two units of whole blood.

"Becky," I said, "let's get a unit of whole blood in and hang the second before we take him up. Isabella?"

"I agree," she replied.

"Kelly," I directed, "get a gurney, please. We'll take him up. He's too unstable for normal transpo."

Ten minutes later, Kelly, John, and I rolled the gurney from the trauma room and made our way to the surgical floor.

"What do you have, Mike?" Bob Anniston asked.

"Thomas Kincaid, twenty-four, three 9mm rounds to the chest. Intubated; chest tube; 150ccs from a pericardiocentesis; three units of plasma, one of whole blood, second running in now. BP 90/50; pulse 115 and thready; PO₂ 89%."

"You didn't bring me an easy one!"

I certainly hadn't, but we had no time to waste, and unless the damage was repaired, his vitals weren't going to come up further. He went into the scrub room, and my students and I returned to the ED.

"Think he'll make it?" John asked.

"I'd say it's 50/50," I replied. "He's barely stable, and you heard what Doctor Aniston said. Anesthesia alone might cause him to arrest. The thing is, and this is a lesson to learn — sometimes you have no choice but to try something that has a low risk of success. Without surgery, he'll die. With surgery, it's 50/50. Which would you choose?"

"Surgery, every time."

When we arrived in the ED, Deputy McCallum and Deputy Kenseth waiting for me.

"Status?" Deputy McCallum asked.

"In surgery," I asked. "Who?"

"Turner," Deput McCallue replied. "Who else would score three out of three in the torso?"

"I'm surprised the three weren't all in the X-ring," I replied. "Of course, you wouldn't have brought him here in that case. Mind telling me what happened?"

"We went to pick up the perp on a New York warrant for dealing heroin and coke and pimping underage girls. We received a tip, showed up at the apartment, and he started shooting. Turner returned fire."

"Your guys and gals are all OK?" I asked.

"Twenty-something pimps are reliably bad shots and he didn't get lucky," Depty McCallum said. "Scott is a great shot."

"I'm just sorry I missed Emmy Nelson kicking his butt in the shooting competition."

"He won't live that one down," Deputy Kenseth declared. "Beaten by a girl!"

"I'll say nice words at your funeral if you say that to Emmy's face," I chuckled.

"Pass," Deputy Kenseth replied with a grin. "We'll head upstairs, but I doubt the perp is going anywhere."

"50/50 he ends up in the morgue," I said. "Does Deputy Turner go on administrative leave?"

"It was a righteous shoot, so it works out to a three-day vacation while it's reviewed. He'll have to speak to the headshrinker, but Scott won't feel bad for putting down a guy who was wanted for pimping fourteen-year-old girls and came out shooting."

"I think I understand why he came out shooting," I said.

"Yeah, guys like that do not do well in prison," Deputy McCallum said. "Justice at the end of shiv. Hell, he probably wouldn't even make it to trial if they stash him at Rikers Island."

"I hear that's one of the worst prisons in the country," I said.

"Technically, it's not a prison because they only hold prisoners awaiting trial or serving short sentences, but yeah, it's bad news — overcrowded and violent. Anyway, we'll head up and let you get back to your regularly scheduled heart attacks and MVAs!"

"Thanks, I think," I replied.

They left, and I went to see Isabella.

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

"No. They shot the guy?" she asked.

"Scott Turner did. The guy shot at him while a warrant was being served. The bad guy missed, the good guy didn't."

"Bad guy? That doesn't seem to fit your approach."

"Wanted on a warrant for, among other things, pimping fourteen-year-old girls in New York."

"Maybe we should have let the bastard bleed out."

"That is one thing I could never do."

"Oh, I agree, but we'd have saved the taxpayers of Hayes County some money, and the citizens of New York a ton of money."

"Good guys and bad guys both get our best, because it's not our job to bring justice. That said, I hope they nail this guy, assuming Bob Aniston can save him."

"50/50?"

"Yes."

"Mike?" Becky said from behind me. "Paramedics three minutes out with an MI."

"Let my students know, please, then come join the party!"

_December 6, 1989, McKinley, Ohio_

On Wednesday, as usual, I reported to the Free Clinic for my shift.

"Morning, Doctor Mike!" Tamara exclaimed. "Can I ask you a question?"

"Morning. Sure."

"Would you be interested in getting a drink after work?"

I smiled and held up my right hand, "Married."

"OK, now that's just not fair!" she exclaimed. "On your _right_ hand? How is a girl supposed to know?!"

"It's traditional for Orthodox to wear the ring on their right hands," I replied. "Sorry."

"Well, now I'm embarrassed _and_ bummed!"

"No need to be embarrassed! I'm flattered because you're a gorgeous young woman who is interested. I can't act on it, of course, but I appreciate the sentiment."

"I'm no home wrecker, so don't worry! I'm just annoyed because I checked your left hand each time you were here and never saw a ring!"

"Sorry," I replied.

I went into the clinic proper, said 'good morning' to Doctor Turner, then went to the break room where Trina was sitting with coffee and a small stack of paperwork.

"Morning!" she said brightly.

"Morning! What's with the paperwork?"

"Next year's budget."

"How bad?"

"It could be worse. We'll need to bump up the co-pays by about ten percent, but that's not too bad as less than half of our patients pay anything. Having the contract with the city and county for pre-employment physicals is huge, because we get paid in full for those."

"I take it the grant for the exchange program was renewed?"

"It would have expired at the end of May, but we have a commitment letter for another year, starting June 1st. I just wish we could keep you a day a week, but it's PGY1s only."

"And I won't have any moonlighting time for another five years, at least."

"When do you begin actual surgical training?"

"During PGY3, but I'm already authorized for central lines and thoracotomies."

"We don't get that kind of excitement here! You're an adrenaline junkie, like most trauma docs."

"Guilty as charged!"

"Doctor Mike?" Michelle said. "Your first patient is here. Employment physical. Exam 1."

I performed the physical, finding nothing that would interfere with the young woman working in the County Clerk's office, pending her urine test for drugs. I'd never see those results, as they were sent directly to the County Personnel office. I signed the form, handed it to the young woman, then went to the break room for coffee. About five minutes later, Michelle let me know I had a walk-in patient.

"Nineteen-year-old male Taft student who could be singing a Frank Zappa song!" Michelle declared, handing me the intake form.

"I doubt very seriously he caught from a toilet seat or that it jumped right up and grabbed his meat!"

Michelle laughed, "I knew you'd know the reference. Anyway, complaint of painful urination. I have a full STD test kit."

"Let's go see the poor guy," I said.

We went to Exam 1, where a good-looking young man was waiting.

"Hi, James," I said. "I'm Doctor Mike. What brings you to us today?"

"It hurts like a mother… when I pee."

"You marked 'sexually active' but didn't fill out the 'number of partners' line," I noted.

"I don't know for sure," he said.

"Give me an idea, please. More than five?"

"Yeah."

"More than ten?"

"Around there, I guess."

"You don't use rubbers?"

"Not every time. If the chick is on the Pill, we don't."

"You put yourself at serious risk for an STD with multiple partners," I said. "We'll do an exam and take samples for STD testing. I'll say up front it will not be comfortable, as we need to take swabs of your pharynx, which is the back of your mouth; your urethra; and your anus."

"I'm not gay!" he protested.

"It's part of the protocol," I replied. "Anal play is not limited to homosexuals. And just so we're clear, the urethra test means inserting the swab a short distance into your penis."

"What the fu…seriously?!"

"Seriously. Three swabs and a blood test. A woman would have four or five, depending on if there's a single cervical swab or a vaginal swab as well."

"You can't just give me a shot?"

"We will, but we're required to perform the test."

"My uncle who was in Nam said they just dosed anyone with a complaint with penicillin."

"I can't comment on what the military does in wartime; we follow the County Health Department guidelines. If you'll sit on the table, I'll perform a basic exam and swab your throat. Once that's done, we'll have you drop you pants and underwear for the other swabs."

"Is there any way of avoiding you sticking something in my dick?"

"No."

He sighed at sat down on the exam table. I put on gloves and performed a basic exam, changed gloves and swabbed his pharynx. I changed gloves and had him drop his pants and briefs and swabbed his anus, then changed gloves again, and pressed the tip of the swab into his urethra.

"Shit!" he growled.

"Sorry," I replied. "You can pull your pants up. Michelle will draw blood, then give you a shot of ceftriaxone, which is an antibiotic. You'll need to abstain from any kind of sexual contact for ten days, including kissing, oral, vaginal, or anal."

Kelly put on gloves and drew the blood, then administered the injection. I handed Jim a brochure on safe sex and one on STDs.

"The test results will be ready by Friday," I said. "Someone from the Clinic will call you, or you can call us after 1:00pm. You'll very likely be contacted by the County Health Department. They'll ask you for a complete list of your partners."

"Wait! Nobody said anything about reporting anything! I don't agree! And you have to keep my medical records secret!"

"Not in the case of STDs," I replied. "We're legally required to report that to the County Health Department. You acknowledged that when you signed the intake form. It's in bold type about an inch above where you signed. In any event, you should inform anyone you've had sex with about your symptoms, and advise them to be tested right away, even if they don't have symptoms. They'll also need to tell their partners, and so on."

"This sucks," he sighed. "I'm going to be a pariah!"

"There's nothing to be ashamed about," I said. "You were careless, but that's not uncommon for college kids. Just make sure you always use condoms, and you should be tested at least twice a year until you're in a monogamous relationship. Do you have any questions?"

"No."

"Then Michelle will show you out."

She walked him to the front desk, then came back to the break room.

"I think those conversations will be FAR more uncomfortable than a cotton swab in the tip of his urethra!" Michelle declared, sitting down next to me.

"No doubt," I agreed, "but you would think in 1989 kids would know better, especially with AIDS. You're about my age and things have changed significantly since we graduated from High School."

"I think I'm a year older, but yeah. I graduated in '80."

"'81 for me. What we called VD wasn't something we really worried about."

"Ditto. By the time I finished nursing school, AIDS was a thing, but we weren't calling it that."

"GRID even during my first year in medical school, which was '85. I even saw a patient with AIDS during my Preceptorship."

"Changing topics, when did you learn to play the guitar?"

"When I was at Taft. My friends suggested it and I decided to do it and took lessons."

"So it wasn't a way to get chicks in High School?"

"If only I had known," I chuckled.

The phone rang and Michelle got up to answer it. She listened, then hung up about thirty seconds later.

"Nineteen-year-old female walk-in with an arm lac. I'll bring her into Exam 2."

"Thanks."

I waited two minutes, then went to Exam 2 to see the patient.

"Doctor Mike, this is Jill Crawford; Jill, Doctor Mike."

"Good morning," I said to the young woman holding a blood-stained gauze pad to her arm. "Would you tell me what happened?"

"I was carrying a tray of beakers, stumbled, they fell to the floor and shattered and my arm landed on the broken glass."

"Empty? Or did they have chemicals in them?"

"Empty. They were clean."

"May I take a look, please?"

"Yes."

I washed my hands, put on gloves, asked Michelle for a gauze bandage, then examined Jill's wound.

"Michelle, I think there might be small glass shards in her arm. I need a pair of surgical loupes, please."

"We don't have them. We do have a large, lighted magnifying glass on a swing arm that connects to the exam table."

"That'll be perfect. I also need micro forceps. Jill, I'm going to step out for a moment while Michelle retrieves the magnifying glass."

Michelle and I left the exam room, and I shut the door behind us. She retrieved the swing-arm magnifier, and we returned to the treatment room together. There were, indeed, some small glass shards in Jill's forearm, and I carefully removed them with the forceps. Once that was done, I asked Michelle for an irrigation kit and washed the wound with clean saline. The laceration wasn't deep, so I used four Steri-Strips to close the wound.

"This shouldn't leave much of scar, if any," I said. "Keep it dry, and you can remove the Steri-Strips on Saturday. Keep it covered with gauze until it completely heals. If you see any signs of infection — redness, any oozing that isn't clear, puffiness, or it begins to hurt more, come back here, see your personal physician, or go to the Emergency Department at Moore Memorial."

"OK."

"When was your last tetanus shot?" I asked.

"I don't remember," Jill replied. "Maybe when I was fourteen?"

"Then I'd like to give you one today. They're usually good for ten years, but when you have a wound, we like to give them if it's been five years or more."

"Sure."

"Michelle will administer the shot. Do you have any other questions for me today?"

"Do you play in a band that has played at Taft?"

"Yes. I'm lead singer for Code Blue."

"I thought I recognized you but I wasn't sure. I thought the scrubs were just a costume!"

"In a sense, they are, because I wear red scrubs when I'm working at Moore Memorial. Freshman or Sophomore?"

"Sophomore."

"What are you studying?"

"Music, with Doctor Anicka Blahnik."

"She's a very close friend, and she taught me to play guitar," I said. "My wife and I are friends with her daughter as well, and her granddaughter is my daughter's best friend."

"You must be married to the blonde girl you sing with at the end, because I know Kari isn't married. What happened to the dark-haired girl you used to sing with?"

"She was my first wife and died shortly after giving birth to our daughter.

Jill's hand flew to her mouth, and she gasped.

"Oh, I'm so sorry!"

"It's OK. You had no way of knowing."

"I feel about two inches tall," Jill said.

"It's OK," I soothed. "Really. Any other questions?"

"No."

I filled out the chart, Michelle administered the tetanus shot, and then showed Jill out.

"She's a bit upset about asking you that question," Michelle said when she returned to the break room.

"Unfortunately, there's not much I can do about it. Do we have another patient?"

"No walk-ins, but your next scheduled appointment is in an hour — birth control pills."

The rest of the day was routine, with six walk-ins along with three scheduled appointments, and at 5:00pm I headed home to have dinner with Kris and Rachel, and then attend Vespers at the cathedral.

_December 8, 1989, McKinley, Ohio_

"Morning, Shelly," I said as I walked into the surgical locker room.

"Morning, Mike. Did you hear the news?"

"Which news?"

"Mark King is demanding to be reinstated and asked for a Board of Inquiry. Guess who was nominated?"

"You?"

"Unfortunately. They needed a senior female Resident who isn't in Medicine or the ED. Leila was chosen as well, and so was Marcie Baxter from Psych. The two Attendings are Bielski from Cardiology and Gilquist from Endocrinology."

"When is the hearing?"

"Monday afternoon."

"How does it work?"

"We hear evidence, then make a recommendation to Doctor Anderson, the Hospital Administrator."

"I'm not up on legal tactics," I said, "but if he loses before the board, doesn't that hurt him in the lawsuit Krista brought against him?"

"I'm no legal expert, but given the hospital and medical school are settling and paying her off, he's screwed no matter what. I think he's counting on doctors giving him a fairer shake than a jury. In the past, that would have been a good bet, but they stacked the deck against him."

"Three females, all of whom very likely experienced harassment by male Residents and Attendings."

"Exactly," Shelly confirmed. "The previous boards were all male, and in nearly every case, cleared the doctor, no matter what the charges were, medical, professional, or ethical.'

"You know my take on that."

"It was obvious from your pursuit of the psychiatrist who harmed your friend. Also, you'll hear officially from Doctor Cutter later today, but you and Ghost will be presenting your stabbing case at the M & M two weeks from today."

"I assumed that would be the case."

We both finished changing, and I left the locker room and headed for the ED while Shelly headed for the surgical lounge.

"Morning Mike!" Kayla Billings said as I walked into the lounge. "Four to hand over to you."

"Busy night?"

"Nonstop walk-ins and EMS runs. None of us had a wink of sleep. And it's not even the full moon yet!"

I chuckled, "Confirmation bias! But what do we have?"

"Forty-year-old drunk male brought in by the PD, but no charges, on a banana bag and sleeping it off in Exam 6; fifty-three-year-old male snow-shoveling non-STEMI waiting on admit to cardiology in Trauma 2; sixty-one-year-old male with diabetic neuropathy and foot ulcers waiting on admit to Medicine in Trauma 3; twenty-two-year-old with sutured temple lac being observed until 7:00am in Exam 1. And with that, I'm out of here!"

"Have a good day. Where are my students?"

"Babysitting!" Kayla declared. "Jenny is with the MI and Kelly with the diabetic."

She left, and I collected the four charts to review the cases Kayla had turned over to me.