Chapter 33 — New Students

_August 4, 1989, McKinley, Ohio_

{psc} "A result of the hypovolemia?" I asked.

"That would be my guess," Shelly replied, "though we won't know for sure until McKnight examines her."

"The McKinley PD and Hayes County Sheriff's Department are investigating. Do they know she died?"

"I have no idea. I'm sure at some point they'll come speak to us."

"I think I better go inform them," I said. "See you next week."

I left the locker room and walked down the corridor to the far end of the building where Doctor Northrup's office was located.

"Excuse me," I said from the door. "Shelly Lindsay just informed me that Miss DeJong died in the ICU about fifteen minutes ago."

"Who was the surgeon?" Doctor Northrup asked.

"Bob Anniston," I replied. "Assisting were Lindsay, Wilson, and me."

"We'll need to speak to him, as well as the doctor in the ICU," Detective Rehling said.

"Mike, you can go," Doctor Northrup said.

I nodded and turned to leave, and as I was walking down the hall, Doctor Gibbs came up behind me."

"Did you run the trauma?" she asked.

"No, it was Perry."

"I heard you took over."

"She was clearly a surgical case, and there was no time to waste, so I simply gave the necessary orders. Did I do something wrong?"

"On the contrary, Perry said you handled it like a grizzled pro — decisive, authoritative, calm, cool, and collected, and with appropriate urgency. Most Interns can't or won't do that."

"I'm not most Interns," I said with a wan smile.

"No kidding," Doctor Gibbs replied flatly. "I just wanted to say 'good job'."

"I'd feel a whole lot better if we'd done something differently last night."

"Pete is beating himself up as well," Doctor Gibbs observed. "As Doctor Northrup has said, we're not social workers nor are we law enforcement."

"And yet we still somehow failed that young girl."

"They arrested her father," Doctor Gibbs said.

"The cops told you that?"

"Yes. As best I can tell, because they're being cagey, she revealed her pregnancy, and he threatened the boyfriend, which caused an argument, she said something offensive, and well, you can guess what happened next."

"Lord have mercy," I sighed, shaking my head. "But our concern was the guy who brought her in. That seems misplaced after what she said, though the cops sure like him for something."

"Their angle is she blamed her boyfriend, who's her same age, to protect the guy."

"He wasn't behaving the way I'd expect a guy who was at risk for a sexual assault charge would behave. Why bring her here and run the risk of people assuming he's the father?"

"Maybe he didn't think we'd do a pregnancy test, or maybe he didn't think about that at all."

"Or maybe it's as innocent as my relationship with Jenny Leonard."

"Who?"

"Little sister of an MVA two years ago who I counseled."

"Ah, OK. I recall the incident, but not the name. What _is_ your relationship with her?"

"Mentor. She stopped by the hospital to ask about her High School electives. She also wanted to see Rachel."

"Babies are magnets for teen girls!"

"Speaking of babies, who watches Bobby Junior?"

"Bobby's mom. Just be smart about that young girl."

"The bigger risk is medical students who don't care that I'm married."

"One of the ones assigned to you?"

"No. A Third Year who is friends with Sophia Jackson."

"I was surprised she changed her name. Most medical students and doctors don't."

"That was a thumb in her meddling grandmother's eye. 'You WILL teach your children Greek! You WILL send them to Greek school!' Sophia and Robby aren't having any of that and decided that abandoning the Greek last name was the right way to make a statement. Anyway, I need to get a shower and get home for dinner and sleep."

"We'll speak more on Monday, but great job."

"Thanks."

I returned to the locker room where Shelly was just about to leave, but she sat down to wait for me while I showered. Once I was dressed, the two of us headed for the parking lot.

"What did they say?"

"Nothing, really. They asked who led the surgical team, and I answered that question, then spoke privately to Loretta Gibbs. The cops arrested the girl's father."

"Wow!"

"Yeah. I was surprised you waited for me."

"I wanted to make sure you were OK."

"I am. I just wonder if we could have handled things differently last night, but as I'm routinely reminded, we're not social workers, nor are we law enforcement."

"And you know why that latter thing is important, right?"

"We don't want people to forego medical treatment because they think their doctor is going to narc on them."

"Which is why we'll almost always err on the side of not reporting things short of stabbings or gunshot wounds. And mostly we don't snitch on girls fourteen and up, even though technically it's sixteen."

"It was explained that the courts had ruled fifteen-year-olds could access birth control and pregnancy services without parental consent."

"Don't you find it odd that those limits are lower than the age of consent?"

"No, because age of consent laws, at least in Ohio, are structured to prohibit men over eighteen from having sex with girls under sixteen, not prevent girls under sixteen from having sex. If push came to shove, I'd say fifteen is the correct place to set the age limit, though I may change my tune in about thirteen years!"

Shelly laughed, "You sound like every other parent of a present or future teenage girl! Of course, you spent High School and college trying to get laid, right?"

"No comment," I chuckled.

"I'll take that as a 'yes'! I was certainly not a nun in college, though you wouldn't know it from medical school and Residency!"

"You're engaged, right?"

"Yes, but only as of about four months ago. You know what it's like for surgical Residents before PGY4."

"They basically never leave the hospital except to get a few hours' sleep."

"Now, I'm not pulling nights and I'm on a regular surgical team, and get to lead. That lets me have something of a personal life, finally. Oh, before I forget, Doctor Rafiq is transferring to a hospital in Dearborn, Michigan."

"Color me not surprised," I replied. "He's going to a city with a large Arab population. I think it's close to half."

"How do you know that?" Shelly asked.

"The Antiochian Orthodox Archdiocese, a sister jurisdiction, is Syrian, Lebanese, and Jordanian, and they have numerous churches in Michigan that are ethnically Arab. When is his last day?"

"The end of September. They had a Resident die in a traffic accident ten days ago."

"That was fast!" I declared.

"His uncle was hired there as an Attending in June after having worked in California for more than a decade. His uncle knew he was unhappy and called him."

"How did you get the details?"

"Through the surgical Attending grapevine. All the top guys know each other from conferences. Doctor Roth called a friend at that hospital to get an off-the-record scoop."

"So what happens here?"

"Privately? No great loss. Publicly, we'll accept a transfer, and if nobody applies, we'll draft an extra med student in March. Our Resident count doesn't specify how many in each year. You're a perfect example because you're ours, but you aren't in the surgical program, if you understand what I mean."

"I do."

"That said, great job today on the chest tube. You're signed off to do those, right?"

"Yes, and pericardiocenteses as well. I think that proves there's no reason a trauma Resident or Attending can't do them."

"Patience, grasshopper!" Shelly declared. "You're forging a new trail, and you know Cutter isn't going to authorize that at this point. You prove it can be done, and whoever fills the next slot in two years does the same, and then the argument can be made."

"When have you known me to be patient?" I asked with a grin.

"Never! I'm not, either. I was champing at the bit from the middle of Third Year to cut something, anything! You're way ahead of the game."

"Given emergency medicine as we know it is less than two decades old except for the Chicago and Baltimore programs, we've come a long way, but we have a long way to go."

"And we'll get there. Don't push too hard, or you run the risk of wrecking it."

We reached our cars, said 'good night', and each headed home.

_August 5, 1989, McKinley, Ohio_

On Saturday morning, Kris, Rachel, and I drove to Taft for band practice. We had a good practice, and I let Kim know about my schedule for September and October.

"Is there any time you could practice?" she asked.

"The only reasonable times would be Friday evenings or Sunday afternoons. Neither of those are very good, obviously, but the schedules are being set up to give us dedicated sleep periods, which is why I won't have thirty-six-hour shifts. The problem with Friday is that I have to be at the hospital at 0500 on Saturday, so I need to be in bed early. The problem with Sunday is that's literally the only day I'm with the family during the day."

"I think Mike will be OK without practice," José observed. "The rest of us can meet and Mike can run through his parts at home. Then we re-evaluate in October when he receives his next schedule."

"It probably won't get better until next June," I said.

"We knew this was coming," Kim said.

"And I have no problem with you guys playing gigs without me."

"Nah, we're all cool with limits for now," Sticks said. "Let's play Taft, Stirred Not Shaken, Newtown, and Goshen. Then we'll play only one or two Proms and July 4th. We can figure it out from there."

"That works for me," José agreed.

"And me," Kim said.

"It'll let me spend more time on my concert pieces," Kari added.

"Sounds like a plan, then," Kim said.

I packed up my things, then Kris, Rachel, and I headed home for an early lunch before I left for my shift at the hospital. Doctor Gibbs had come in so we could give Callie and Gabby their evaluations. I did the handover with Kayla Billings, then went to the Attending's office for the evaluations. Both were rated as 4, though Callie did not receive the coveted 'select for match'. I asked Doctor Gibbs about that afterwards.

"Neither Lewis nor Townshend felt she was worthy of that. Remember, it doesn't mean she won't be selected, it simply means she won't be actively recruited. We have a limited number of those to hand out, and I know you agreed Mary should receive one."

"Absolutely. And Bob as well."

"Was she better than Bob?"

"A judgment call that could go either way, but if push came to shove, I'd pick Bob and Mary as the two."

"Which is what we did, based on input from all the Residents."

"Any further fallout from yesterday?"

"No. The cops really do want to blame her older friend, but they have no evidence other than their moral outrage."

"Which I suspect they'd have directed equally at me when Elizaveta ordered me to marry her."

"That did turn heads, at least until people met her."

"The problem with making judgments based purely on age. I know plenty of twenty-year-olds who not only shouldn't marry but probably shouldn't even have driving licenses!"

"Did you hear the news about Mo Rafiq?"

"Yes. It didn't surprise me, really, as he didn't fit in here."

"I'm happy to see him gone," Doctor Gibbs said. "There are a few more Residents I'd be happy to see gone as well."

"Anybody on our services?"

"Besides you?" she asked with a goofy smile.

"I know you love me," I chuckled. "The women who love me the most give me the most grief!"

"Clarissa?"

"Obviously. My friend Jocelyn, my mom, my sister, Elizaveta, Kris, and as sure as the sun rises in the East and sets in the West, eventually Rachel!"

"Going back to yesterday, no real fallout. The cops just had a bug up their butts about her being pregnant at fourteen and our failure to call social services or law enforcement."

"Shelly and I discussed that, and the last thing we want is patients foregoing treatment because they're afraid we'll narc on them. It's always a tough call when we have an arrestee."

"There's discussion amongst the Attendings of creating a policy that requires law enforcement to stand outside the doors of the trauma or exam rooms, rather than be in the room. I think that Doctor Northrup will agree and propose it to the Medical Director."

"The cops are going to HATE that, but I like it. When?"

"It'll be proposed at the Monthly Attendings' meeting next Monday afternoon. Then it's up to the Chief. I hear you and Mastriano are getting along OK."

"I have minimal interaction with her, given every order she might give has to be countersigned. I just go to whoever is running the ED to cut to the chase. We'll see what happens once she's off double-secret probation."

"I believe she got the message. Anyway, I'm out of here. This is supposed to be my day off!"

"And I'm supposed to be working!"

"Then go heal the sick and I'll see you Monday with a fresh crop of medical students!"

Which meant two on Preceptorships on Tuesdays, and three Third Years and three Fourth Years on shift with me at various times. I'd looked at the schedule and didn't recognize any of the names of Third Years. I did know the Fourth Years, but I hadn't worked with any of them when they were Third Years. The only downside was that the Fourth Years would still have to cover the triage desk for August, as the new nursing schedule for covering triage didn't start until September 4th.

The afternoon was routine, though busy, with a mix of walk-ins and EMS runs, but no critical injuries. I took my break about 4:00pm and used my AT&T calling card to call Father Roman. We had a good talk, and agreed that Kris, Rachel, and I would visit him on the second Sunday in September. Until then, he directed me to confess to Father Luke so that I could continue to receive the Eucharist.

After the call, we handled walk-ins until dinner, when I met Clarissa in the cafeteria.

"I heard you had a bad one yesterday," she said.

"We did," I replied, then explained what had transpired.

"And, of course, you're beating yourself up for that, right?"

"Shelly Lindsay and Loretta talked to me about it," I replied. "That doesn't mean I don't wish we'd done something differently."

"Sure, though with the competing priorities, you know what has to come first."

"Yes, of course, but did we do everything reasonable in our power to help her?"

"I'm not sure calling the cops would have turned out better, because her dad would still have found out she was pregnant."

"I'm still trying to sort out why she told him," I replied. "That's the one thing that makes zero sense here."

"You said you gave her the brochure for the Free Clinic. Maybe he saw that?"

"Possible," I replied. "But I would have thought she'd have been more careful, given she knew she was pregnant before she came in. The cops were fixated on the relationship with the older guy, and think she named her boyfriend as the dad to protect the older guy."

"What's your take?"

"That was actually my first thought, but by the end, I didn't get that vibe, which is why I didn't object to Doctor Williams' decision."

"You worked with Mastriano?"

"My problem with her is only laziness," I replied. "If she fixes that, I won't have any problem with her as a doctor."

"Just her cheating?"

"That's her business so long as it doesn't affect anything that happens at the hospital. I did get two pieces of good news."

"Oh?"

"First, the trauma Attendings are recommended banning cops from being in trauma or exam rooms in most cases. That's a good thing because patients are often reluctant to talk in front of the cops, which means we don't get the full story. It will require agreement by Doctor Northrup and the Medical Director, but I think they'll do it."

"That's good. And the second thing?"

"Doctor Rafiq is transferring to a hospital in Dearborn, Michigan."

"Wow! During his PGY2 year?"

"According to Shelly, they had a Resident die in a traffic accident, and his uncle, who is an Attending there, called him. There's a surgical Residency open for transfer as of September 1st, though if it's not filled, they'll draft another med student."

"Think he'll have better luck there?"

"Dearborn is about half Arab, which I think will work better for him, not that I'd ever want him to be my surgeon."

"I'd let Tessa operate on me before him!"

"But only after a thorough oral exam!" I teased. "Though patients don't generally examine their doctors!"

"Kari certainly did!"

"True."

"Sheila?"

"No comment."

"That's a 'yes'. I'd say Elaine was interested, and you shut her down quickly."

"Very. Though she did play it as marriage. But that was a mess I didn't need, and at that point, even eighteen was a question in my mind."

And yet…" Clarissa teased.

"We had this discussion!"

"You know I'm yanking your chain, Petrovich!"

"Obviously! How are things in Medicine?"

"No mysteries this week; just routine care. I'm OK with that, too, because I'm not an adrenaline junkie like you!"

"Fortunately, there is plenty of opportunity for both our styles."

"Mike Loucks, Chief of Emergency Medicine?"

"And Clarissa Sunders, Chief of Internal Medicine!"

"Someday, Lissa."

We finished our meals and headed back to our respective services.

"Mike," Carol, one of the weekend clerks, called out when I returned. "I was just about to page you. Doctor Gabriel needs a surgical consult in Trauma 3."

I hurried to the trauma room and announced myself.

"There's free fluid in Morrison's," he said after giving me the patient's vitals.

I quickly confirmed with the ultrasound machine and called up to the surgical scheduling nurse and booked an OR for an ex-lap for a patient who had sustained injuries in a bicycle accident. I called for an orderly, then escorted the patient up to surgery, where I turned him over to Doctor Burke, and returned downstairs to treat walk-in patients. I did that for the rest of the evening and at midnight, handed things off to Kayla Billings, then headed to the surgical locker room for a shower before heading home.

_August 6, 1989, McKinley, Ohio_

"My monthly should come at the end of the week," Kris said as we drove to the Cathedral on Sunday morning. "Do we still agree I should stop taking my pills?"

"There's no reason I can think of that would cause me to suggest waiting. It's really up to you at this point."

"No, it's up to _us_, Mike. A partnership. What do you want? And 'whatever you want' is not an answer."

"But it is, because making you happy will make me happy."

"While I'm sure that's true," Kris replied, "I also want to hear what you want."

"I want to have a baby with you."

"And I want to have a baby with you. So once my monthly begins, I'll stop taking my pills."

"Good."

"John Michael or Charlotte Michelle?" I asked.

"Those are the names we discussed, and I'm fine with them. What if the timing works poorly?"

"You mean it takes time to become pregnant?"

"Yes. Statistically, it takes six months to a year, though, as with all statistics, they don't mean much for any specific couple."

"How long did it take to conceive Rachel?"

"It was the second month after we began trying."

"So, perhaps you are very accurate!"

"You seem to think so!"

"I do! And all teasing aside, is there anything we can do to improve the chances?"

I chuckled, "If my schedule didn't interfere…"

"Yes, well, you signed up for that nearly twenty years ago!"

"True. In all seriousness, there are theories about body temperature variations at ovulation, but they're speculative, and they may or may not work for an individual. Given the window of opportunity, and the motility and lifetime of sperm, making love every day during the most likely fertile time is the best approach. And while I may regret saying this, multiple times per day doesn't significantly increase the odds."

"As if I would say 'no' to that!" Kris said with a soft laugh. "You know I very much enjoy making love with you."

"And I with you. My new schedule will make it possible for us to make a daily attempt, though that's not until September 1st."

"But if understand correctly, that would be the almost perfect time."

"It should. And you'll have about eight months to plan your class schedule from the time you miss your first period, which is more than sufficient. That only leaves the question of the Tsarina's response."

"I think she'll be fine."

"If we give her a sister. I think we'll be in deep sneakers if we give her a brother!"

"Deep sneakers?"

"Bowdlerization of the word for 'feces'."

"I take it you're careful because of our backseat passenger, not me."

"Correct. Can you imagine our darling daughter repeating a certain select group of words at the wrong time? She might give people at church a stroke! Right now, she has no sense of using 'proper' language. And speaking of our darling, did you arrange the celebration of her entrance into the world?"

Kris laughed, "Obfuscating your language?"

"That'll work for a short time. She'll figure it out soon enough."

"Yes. I spoke to Serafima, Alyssa, and Milena. And as I suggested, Lyudmila will help organize things. Sunday at 2:00pm at our house.

"I'll speak to Marcie at daycare about Rachel's other friends. Is this a 'girls only' soirée?"

"I think it would be difficult not to invite Viktor Gennadyevich and your brother Peter and nephew Michael and godson Michael."

"A good point."

"I'll speak to all the parents this week."

"You should invite Clarissa and Tessa, even though they don't have a kid."

"I'll do that. How are you handling the memorial service? You have to work, right?"

"Yes, and they're doing it after Vespers, which is right in the middle of my shift. Viktor knows and understands."

"What do you think I should do?"

"That's a difficult question, but I think, given I have to work, it's probably best if you simply follow your practice of going to Vespers with your parents and sister on Saturday evening. I mean no disrespect to Elizaveta, but our practice can't be bound to choices made by Viktor and Father Nicholas. They knew my schedule when they decided on the time for the memorial service. I'm sure you know that after the first anniversary, it's informal and up to the family.

"And as terrible as this might sound to others, our family is in this car. You're Rachel's mom in every sense of that word that matters. I loved Elizaveta with every fibre of my being, but I have to focus on you and Rachel, not on the past. We remember Elizaveta in our morning and evening prayers, and she's commemorated during the Great Entrance at both the Cathedral and Saint Michael."

"Do you love me?"

"With every fibre of my being," I replied. "You are the perfect wife and perfect mom."

"You might be exaggerating just a bit," Kris countered.

"I don't believe I am," I said as I pulled into the parking lot across the street from the Cathedral. "I do love you, Kris. And I can't imagine life without you."

"I love you and Rachel, and I'm happy we're going to spend our lives together and have more children."

I parked, we got out of the car, and walked across the street and into the cathedral. After we lit our usual candles, I let Subdeacon Nathaniel know I needed to see Father Luke for confession, and he went to the altar, then returned to let me know Father would hear my confession during the Psalms. About twenty minutes later, Father Luke came out from the altar and motioned me to stand with him before the icon of Christ. He said the opening prayers, then asked the usual question.

"What is on your heart, Michael?"

"I'm actually not sure if my behavior in a situation in the hospital with a patient was correct."

"First, did you act in Christian love?"

"I think that's the real question. A young girl died, and I feel, well, I suppose the only word I can use is 'guilty'."

"Can you explain without violating any confidentiality rules?"

I nodded and explained the situation with the fourteen-year-old girl, leaving out any names or even specific injuries.

"Lord have mercy," Father Luke said quietly when I finished relating the story.

"That was my response as well," I replied. "I still don't know if I did the right thing."

"I'm not sure what you might have done differently, except call Family Services or the Sheriff yourself, but from what I understand, you don't think she was abused, even if she was underage."

"As best as my medical student and I can determine, her baby's father was a close-in-age boyfriend."

"I think, in the end, you have no culpability here, and certainly could stand before the judgment seat and defend your actions. You didn't kill that poor girl, nor do I think you had sufficient reason to override the decisions of your superiors. I have a strong feeling that you'll encounter situations like this in the future."

"I'm sure I will."

"And you don't believe you made any medical errors?"

"I don't believe anyone did. It really does come down to whether or not some kind of intervention would have prevented her death. I'm not sure you can say confidently that is the case."

"No, I can't."

"I think, then, that the best answer is that it's OK to feel bad, but not to blame yourself. Is there some way I can mention the young girl during the Great Entrance?"

"I think, given her name was published in the _McKinley Times_, I think you can safely use it. Her name was Amber."

"Is there anything else on your heart, Michael?"

"Nothing that I feel needs confession."

"You're keeping your assigned prayer rule and fasting rule?"

"Yes, and I spoke to Father Roman yesterday. I'll see him in early September."

"Then I'll say the absolution prayers."

He said them, I kissed his _epitrachil_, then returned to stand with Kris and Rachel, who had been joined by my in-laws. Four hours later, after Matins, the Divine Liturgy, and a light lunch, we headed home for a quiet afternoon and evening.

_August 7, 1989, McKinley, Ohio_

On Monday morning, I checked in with Doctor Gibbs, then met with Jim Fitzgerald so he could hand over two patients waiting for admission. He also introduced me to Krista Sandberg, a Fourth Year, and Al Baker, a Third Year. When Jim left, I asked both Krista and Al for their procedure books.

I was disappointed in the limited number of procedures Krista had in her book, and that gave me pause. This was only Al's second rotation, so his limited experience was no surprise, given he'd been in Pediatrics for his first rotation. I returned their books, asked them to keep an eye on the two patients waiting on admission, and went to see Doctor Gibbs.

"What's up?" she asked when I came to the door.

"Mind if I come in?"

"No."

I went in, shut the door behind me, and sat down.

"What's the scoop with Krista Sandberg?" I asked. "She has about half the procedures I'd expect a Fourth Year to have after a Cardiology Sub-I."

"I honestly don't know. Jim didn't mention that."

"The very first thing I do with a new med student is look at their procedure book. It actually tells me more than an evaluation. Mind if I talk to Alana Pace or Leila Javadi?"

"Not at all. Residents discuss med students all the time, even outside their service."

"Thanks. It's calm at the moment, so I think I'll run upstairs and see which of them is available before rounds."

"Fine with me!"

I left her office and went upstairs to Cardiology and found Leila Javadi in the Resident's office.

"Hi, Leila," I said. "Do you have a few minutes to discuss a student?"

"Come in; which one?"

I closed the door and sat down.

"Krista Sandberg. Her procedure book is pretty sparse for a Fourth Year starting their second Sub-I."

"Remember Felicity Howard?"

"Yes."

"Similar attitude, but without the skills and intelligence. I'm not saying Krista is not intelligent, but she's not as smart as she thinks she is, and feels the world owes her everything she wants. She's quick to complain about discrimination and unfair treatment, but it really was a reflection of her knowledge, skills, and abilities. You turned Felicity around, and she's started a Cardiology Sub-I today. She'll be treated as the above-average student she is."

"In your opinion, is Krista dangerous?"

"Let's just say I would keep a close eye on her at all times. A very close eye."

"Wonderful."

"How are things going otherwise?" Leila asked.

"Good, except for the fourteen-year-old girl."

"I heard. This morning's paper suggested to me the police don't know for sure what happened."

"I think they're barking up the wrong tree with the older guy. Mary Anderson was confident the patient was being truthful about the father of the baby being a boy who was about a year older. I do need to get back downstairs, and thanks for the heads up on Krista."

"You're welcome. One more piece of advice, off the record."

"Off the record," I confirmed.

"Don't be alone with her."

"Thanks."

I left Cardiology and headed back down to the ED, checked to see that Clarissa had admitted the two patients, which she had, then went to Doctor Gibbs' office.

"Leila Javadi compared Krista to a Third Year I was paired with during my Cardiology Sub-I. Do you remember discussing how to handle Felicity Howard?"

"Vaguely."

"Cutting to the chase, Leila advised, not to leave Krista alone with a patient."

"Then you need to be the best teacher you are able to be, watch her like a hawk, and make your own evaluation. And don't let her kill any patients."

"I'll do my best. Anything further on the DeJong case?"

"No. We're out of it unless someone tries to bring a malpractice case, but Mr. Crowe says that's a longshot because there's no legal obligation for us to call the police or Family Services if a fourteen-year-old is pregnant by a close-in-age boyfriend, and there's no sign of abuse."

"OK. Let me go see what I can do with Krista."

I left her office and went to the lounge where my students were waiting. I wanted to speak to Krista alone, but I also needed to heed Leila's warning.

"Your procedure book seems a bit light," I said to Krista. "Who was your Resident for Cardiology?"

"Abbott was the main one, but also Javadi."

Abbot was a good teacher, and if she didn't trust Krista to do procedures, I'd have to be extremely careful, as Leila had suggested.

"How comfortable are you doing triage?" I asked.

"It's pretty simple, right? Basic exam and bring anyone who has cardiac or breathing problems straight in. Why?"

"You'll be on the triage desk with Nurse Libby on afternoons this week. We'll catch walk-ins this week, though we'll handle traumas if necessary. Let's go see what they have for us now."

The new procedure for the triage desk was that charts were placed in a rack near the clerk's desk, and the clerk would ensure that they were handled first-come, first-served based on the priority set by the triage desk. The point was to limit the ability of Residents to cherry pick cases. I picked up the first chart and reviewed it, then handed it to Krista.

"We'll use Exam 3," I said to Nate, who wrote it on the board. "Krista, bring the patient in, please."

She went to bring the patient in, and as they walked past us, I signaled Al to follow me. In the exam room I waited for Krista to introduce me, but she just stared blankly, so I held out my hand for the chart.

"Hi, Mr. Sanchez," I said to the twenty-three-year-old man. "I'm Doctor Mike and my students are Krista and Al. What brings you in today?"

"I work landscaping and stepped on a rake and it went into my foot."

"Do you know when you had your most recent tetanus shot?"

"No."

"OK. We'll examine you, clean your wound, suture if necessary, dress it, and give you a tetanus shot. Can you remove your shoe and sock, or do you need help?"

"I can do it."

He removed his left shoe and sock and after I washed my hands and gloved, I checked his foot. The injury wasn't too bad and simply needed to be irrigated and dressed. I did that, explaining to my students each step, then had Kellie administer the tetanus shot. Once the patient was walked to Patient Services, I asked both Krista and Al to join me in the consultation room, as there was no Resident's office to use.

"I treat my students as trainee doctors," I said. "And I want things done a specific way. First, when you bring in a patient, you give their name and their presenting complaint."

"I didn't know," Krista said quickly.

"Now you do. Once I'm comfortable with you, I'll have you run patients and do minor procedures under supervision. Impress me, and I'll allow you to do them without me watching."

"Third Years, too?" Al asked.

"Irrigating wounds, suturing, blood draws and injections. You learned how to do all of those during Second Year. Now is the time to start on live patients."

"Excuse me, Doctor," Krista said, "but shouldn't I get preference as a Fourth Year?"

"Absolutely, and you will, and if you demonstrate to me that you can do those things, despite having a thin procedure book, then you'll learn to intubate. Are you able to read an EKG?"

"I know how to hook them up, and I know what a normal rhythm looks like, but that's all."

"Did you ask Doctor Abbott or Doctor Javadi to teach you to read them?"

"No."

"Then you're going to learn. Get your cardiology textbook and read the two chapters about EKGs. There will be a quiz on Thursday."

"Seriously? This is a trauma rotation!"

"And nearly every trauma has an EKG. I could read them as a Third Year."

"Shit," Al swore under his breath.

"Don't sweat it. You haven't had a cardiology rotation yet. When you do, ask your Resident to teach you. If you want a head start, read the textbook and I'll help you."

"But I get a quiz?" Krista asked indignantly.

"This is your eighth rotation, and you've had two cardiology rotations; Al has had one rotation, and it wasn't cardiology. You're going to be a doctor in ten months, he has twenty months. My job is to make sure that on June 1st, when someone says 'somebody call a doctor', you can respond as a doctor. This rotation is when it gets real. What specialty are you planning?"

"Internal Medicine."

"Everything you learn here will be relevant to working in Medicine. You need to prove to my satisfaction that you're ready to be a doctor. That's true of every Sub-I, especially Medicine."

"Can I speak to you privately?" she asked.

I considered, then said, "Al, step out into the corridor, but leave the door open."

He stepped out and moved to the other side of the corridor.

"What did you want to say?" I asked.

"Why are you riding me?" Krista asked.

"It's my job to teach you, and I shape my methods to the needs of the student. With limited procedures in your book and an admission that even after a cardiology Sub-I you can't read an EKG, I decided that the best course of action is to challenge you and see if you can live up to my standards."

"Yours?"

"Mine. My job is to teach you, but also to discuss your evaluation with Doctor Gibbs. There is nothing easy here, and you're going to have to step up and fill your procedure book, because interview committees are going to want to see it. If it's as light as it is today, they won't list you for the Match, and you'll be stuck Scrambling, or possibly fail to Match. That's the trajectory you're on."

"You know that from a minute with my procedure book?"

"It's the permanent record of what you've done. I also spoke with Doctor Javadi."

"She didn't treat me fairly!" Krista protested.

"Even if that's true, you are still responsible for learning. I had a Resident treat me like crap and assign me as much scut as possible, because they didn't like me. I did everything requested to the best of my ability and found opportunities to learn from other doctors."

"You obviously don't like me."

"Whether I do or not, I'm going to teach you if you're willing to learn, and give you the procedures if you put in the effort. It's up to you. What do you want to do?"

"Learn."

"Then let's go."