Chapter 15 — A Wise Man Listens to Those With Knowledge and Experience

_July 4, 1989, Circleville, Ohio_

"DADA!" Rachel exclaimed when I walked into the house, dead tired after having been awake for over thirty-seven hours.

I scooped her up, hugged her, kissed her cheek, then carried her over to Kris.

"How are you feeling, Mike?" Kris asked after we exchanged a quick kiss.

"Beat," I said. "Dinner, then bed."

It'll be ready in five minutes," Kris said. "Come to the kitchen with me, please."

I followed her to the kitchen with Rachel in my arms.

"Was your afternoon better than your morning?" Kris asked.

"Nobody I was caring for died, so I think the answer is yes. Middle-age man with a torn ACL, teenage girl with a severe sunburn, four-year-old with a bee sting, and an offer to shower with a nurse."

"You'll need a trauma surgeon if you did that!" Kris declared.

"Something I understand quite well! It was Ellie."

"Does she ever quit?"

"Apparently not! But I used the surgical locker room, not the one in the Emergency Department."

"Did you get to see Clarissa at all?"

"No. Our breakfast, lunch, and dinner breaks didn't line up at all. We'll try for Thursday or Friday. Saturday is a bit easier because she can match her break to mine."

"How are your students?"

"Pretty good, but this is the first rotation for the Third Years and the first Sub-Internship for the Fourth Years, so I have to do the normal teaching plus the orientation stuff."

"But didn't they start in June?"

"Yes, but they were with Doctor Mastriano and she's not a very good teacher. I had a run-in with her about a patient; actually, a few patients. She wrote me up, but it'll be removed from my file and she's likely to be called on the carpet at a Morbidity & Mortality Conference because a patient gorked when she refused to allow me to call a neuro consult."

"Gorked?"

"Sorry. Suffered brain damage which is very likely irreversible. If you're OK with it, I can explain more tomorrow after I sleep."

"Yes, of course! Let me get dinner on the table. Put Rachel in her High Chair, please."

"NO!" Rachel declared forcefully. "DADA HOLD RACHEL!"

"Her Majesty, the Tsarina of All Russians, has spoken!" I chuckled. "I think I can manage the stew and bread one-handed. If she eats after we do, that's fine with me if it's OK with you."

"It is."

We ate, and I gave Rachel a piece of French bread to munch, and also fed her some of the stew, though not nearly enough for a normal meal for her. As soon as we finished eating, I handed a protesting Rachel to Kris, and with Kris' blessing, I went upstairs. I made sure the blackout curtains were closed, undressed, and put on my sleeping eye mask for extra protection against light, got into bed and instantly fell asleep.

_July 5, 1989, Circleville and McKinley, Ohio_

"How are you feeling?" Kris asked when I came downstairs just before 8:00am on Wednesday morning.

"Better," I replied. "Twelve hours of sleep seems to have helped. Where's Rachel?"

"She's on a playdate with Abigail. I set that up because I had no idea how long you would sleep. I'm leaving in a few minutes for class, and I'll pick Rachel up on the way home from OSU. Do you need anything before I leave?"

"Just a hug and a kiss," I replied. "What time will you be home?"

"About 4:00pm."

I walked Kris to her car, we hugged and kissed, and once she had driven away, I went back into the house. I made myself breakfast, and after I had eaten and cleaned up, I checked the menu for the evening, noted we needed a few things, and after I showered and dressed, went to Kroger to pick up a few things, then headed back home.

I really had nothing to do but relax, so around 11:00am I called Clarissa to see if she wanted to have lunch. She agreed, and just before noon, we met at Frisch's.

"I expected you to show up with toddler attached to hip!" Clarissa said when we met in front of the restaurant.

We exchanged a quick hug, then walked inside.

"Kris arranged a playdate for Rachel with Abigail because she had no idea how long I'd sleep. I woke up around 8:00am and Rachel was already at Abigail's house and Kris was ready to leave for her class at OSU."

The hostess seated us in a booth and when the waitress came over, we ordered right away.

"How does fasting work when you have your crazy schedule?"

"With «ekonomia». Health is always the primary concern. When I discussed it with Father Roman, we agreed I'd refrain from red meat on fasting days, but no other restrictions on what I need to eat to stay healthy. For marital harmony, Kris will follow the same rule."

"How are you handling church?"

"Just Sundays for now," I replied. "We could go Wednesdays, but we decided to entertain, and I have Father Roman's blessing on what amounts to minimal attendance, at least for the first few months. Obviously, I can't go on Saturdays, and tonight and next Wednesday, we're having guests. Anyway, how much sleep did you get?"

"About four hours, in a pair of two-hour stints, which I guess is far more than you had."

"You guess correctly."

"Did you have the drowning victim?"

"Yes. He was basically DOA, but you know the drill. That was right before I headed to the lake for our gig."

"Anything else interesting?"

"I asked a seventeen-year-old girl who needed an ankle x-ray if there was a chance she could be pregnant and she wanted to know if it was an offer."

Clarissa laughed, "And you can't be a pig in the ED!"

"Kris might have an objection as well! But you know me. I simply ignored the obvious flirting."

"Flirting? She was asking the cute young doctor to fuck!"

"Whatever," I chuckled. "Not the first and won't be the last. Did you have anything interesting?"

"Just the usual, and with the Fourth, no scheduled admissions or transfers, just the admissions from the ED. We have one interesting case where we're having trouble diagnosing. Doctor Subramani has a conference call with a specialist at Mayo and one at Emory tomorrow. I heard you had a run-in with the new Attending."

"Several, actually. Between you and me, and not to be repeated, she's lazy and I have strong suspicions about her ability to do the Attending job. She's going to get lit up at the M & M a week from Friday."

"Why?"

I explained what had happened with the guy who was beat up in the bar.

"You're covered because you made her write it on the chart," Clarissa observed. "No way she can throw you under the bus on that one."

"Probably not," I replied. "And I will acknowledge during my presentation of the case that I should have listened to my nurse."

"Ellie?" Clarissa smirked.

"She's obviously still interested, but she's also dialed it way back. It wasn't her, though, it was Becky, who's been a nurse nearly as long as I've been alive!"

"And your med students?"

"Mary and Tom are great; the other four are about what you'd expect. The one downside for Mary and Tom is that they were assigned to Doctor Mastriano during the interim period before the new PGY1s started, and she's not a very good teacher."

"Sleeps, can't teach, and lazy?"

"That's my assessment. Hopefully, the M & M will be a wake-up call. If not, the next year is going to suck. I'm on with her again on Saturday. On the plus side, the end result of one of our spats was that I was allowed to do a blind pericardiocentesis in the OR."

"You're not even a week into your Intern year!" Clarissa exclaimed.

"That was Doctor Mastriano's objection, though she called me a 'fucking intern'."

"Think about how rare it is for an Intern to do anything like that."

"And think about how DUMB that historical practice is! The advantage of the new program is that nobody has to 'do what has always been done' because it's never been done before."

Clarissa laughed, "Says the man for whom 'I have never seen it done that way before' is the ultimate reprimand for a clergyman!"

"If you think about it, we're priests and priestesses, and expected to follow tradition — what has been done always, everywhere, and by all."

"You're saying medicine is Orthodox?"

"I'm saying our rituals and traditions are handled _exactly_ the same way — anything new is viewed skeptically until accepted by the medical community at large. We have our deanery meetings every Friday, our medical conferences are like synods, and AMA meetings are, in a way, Ecumenical Councils."

"Oh, for the love of God!" Clarissa said, laughing hard. "Seriously?"

"The parallels are there," I said as the waitress brought our food.

I said the blessing, and we began eating.

"Have you heard anything about Kris' citizenship application?"

"Just that it was filed on the 3rd. I believe we provided everything they need, so the next step will be interviews, potentially as soon as next month, but it could be as much as six months."

Clarissa smirked, "That should be interesting. 'Does she swallow?'"

I chuckled, "While the attorney suggested those types of questions might be asked, he felt that Kris formally adopting Rachel would obviate such questions, given no sane person would risk losing custody of their kid for a sham marriage."

"We are talking about you, Petrovich, and sanity was _never_ an option!"

"No kidding!" I chuckled. "But the government doesn't know that! Someone from INS will come to the house, see all the obvious signs of marriage and a family, and that should be it."

"And your «minou»'s politics?"

"Starting that again, are we?" I asked.

"Of course!"

"Being a socialist isn't a cause for denial of naturalization, only advocating the violent overthrow of the government. And despite flying the red and black flag on May Day, she hasn't advocated a _violent_ overthrow of the government."

"Sorry to bring this up, but how are you handling the memorial this year?"

"Viktor arranged with Father Nicholas to have the memorial that morning, which is a Saturday. Kris, Rachel, and I will be there. I'll still be on my current schedule, so I have to be at the hospital from noon to midnight, so we'll have to figure out our family birthday celebration for Rachel, and I'm sure the Kozlovs will want to do something. Kris and Lyudmila are planning a party with Rachel's friends from daycare and church, and that will be on Saturday afternoon while I'm on shift."

"Thereby avoiding a house full of toddlers and their moms!"

"One toddler is a challenge for the two of us! I can't even imagine a dozen little girls!"

"But when they grow up…" Clarissa smirked. "I recall you enjoying graduation parties!"

"That's even MORE reason to be out of the house! But seriously, at forty-two, I'd be ancient in their minds!"

"Mostly, but I think you'll be hit on by cute teenage girls for decades!"

"That does seem to happen to doctors right up into their forties."

"Speaking of one toddler being a challenge, are you still planning on having a baby next July?"

"If I have a baby in July, it'll be in every medical journal on the planet and I'll be famous!"

"You know what I meant, you nut!"

"That's the plan," I replied. "The timing coincides nicely with the end of the thirty-six-hour shifts and weeks longer than eighty hours, though I have a strong suspicion that's about to change."

Clarissa nodded, "Doctor Subramani said she spoke to a friend in New York who said the end result is going to be a limit of eighty hours a week and shifts no longer than twenty-four hours with at least twelve between them. Which means more Residents."

"Which requires more money, and that is a complex mess with federal, state, and local funding sources, plus patient fees and insurance receipts."

"I think we'll be bitching about lack of resources when we retire in forty years or so."

"I was thinking about that, and surgeons typically retire by sixty, or at least significantly reduce their actual surgeries and teach instead. I could work longer in the ED, as I could take regular shifts instead of trauma surgeon shifts, but I think at that point I'll hang out a shingle or work in a clinic. I just don't see retiring from medicine. Doctor Evgeni is nearly eighty and still sees some patients."

"You'd make a great teacher."

"I suspect so, but not seeing patients would frustrate me to no end. It's why I'll never take a job in administration. I'd rather be a _locum tenens_ on contract than Medical Director."

"There's no chance you'll be an eternal Resident! You'll get the Attending slot the second you pass your boards and can put FACS behind your MD! There's no way they'll risk losing you."

I smiled, "And yet, there is one thing that could take me away."

"Rutherford, right? If they become a teaching hospital and upgrade to a Level I trauma center."

"That would be it, and they're on that path, but who knows what will happen over the next decade."

"Want to make a wager?"

"On?"

"That Doctor Michael Peter Loucks, MD, FACS, will be the Chief of Emergency Medicine of Rutherford Hospital before the end of the next decade."

"And what would the bet be?" I asked with an arched eyebrow.

Clarissa laughed, "I can't make it _too_ interesting for you because your «minou» would object."

"Yeah, but if _that_ was what I would get for winning a bet that I wasn't going to have that role, do you think I'd take the job?"

Clarissa laughed, "There is no way you would trade one night with me for your ultimate dream job!"

"Are you _sure_ about that?" I asked with a smirk.

"Positive!" Clarissa declared. "Mainly because you could never collect."

"Truth. Despite the tragic events around Rachel's birth, I fully expect to grow old together with Kris."

"How are things going? And I don't want a flippant answer."

"They're good. We have our areas of disagreement, but they're peripheral, not core. Kris is very different from any girl with whom I've ever been involved and is more mature than most girls her age. We're going through what is likely to be the toughest time we'll ever have to, and she's handling it well. Rachel, on the other hand, is annoyed that she can't see me and alternates between clinging and giving me looks that remind me of Elizaveta when she was unhappy with me."

"Complete with hands on the hips?"

"A couple of times," I chuckled. "It was uncanny how much she reminded me of her…Elizaveta."

"You can say that to me, Petrovich. It won't cause any trouble."

"No, I can't," I countered. "I do not want to send mixed messages to Rachel or Kris. Yes, Elizaveta is Rachel's biological mom, but Kris is the only mom Rachel will ever know, even when she finds out about Elizaveta."

"She's almost two, and at some point, probably not too far in the future, she's going to ask about the icon and prayers. You don't display any pictures, right? I haven't been in your bedroom."

"Much to your chagrin!" I teased. "But no, no pictures. I have albums, of course, but the framed pictures were put away because I didn't want Kris to feel slighted in any way. And being Orthodox, it's the icon that truly matters."

"Theologically, sure, but you don't feel that way. Well, at least not a hundred percent."

"Yes and no," I replied. "The struggle for me is honoring Elizaveta and remembering her, without making Kris feel like my, and I'll use this term with you only, second wife."

"I think you've done a good job balancing things, and Kris has a good head on her shoulders. She accepts your relationship with Angie and your relationship with me, and didn't freak out over our desire to have a baby together. Any woman who can do that is a keeper!"

"And you keep your hands off, Lissa!" I said with a grin.

"I told you I think she's hot, but Tessa and I are as committed as you and Kris are."

"With one exception."

"You had your chance, Petrovich!"

"And you know that wasn't for me, and why."

"Well, if a threesome with Deb and Milena left you nonplussed, I'm not sure what would work besides a monogamous relationship."

"You, Tessa, and me did NOT leave me nonplussed!"

"Except that was all about you and me. Your pleasure with Tessa was directly related to me being there, participating and watching, not having a threesome."

"You might have a point. OK to change subjects?"

"Sure."

"I spoke with the attorney handling Angie's case and he thinks an official reprimand is likely, and that it's even possible we'll get Greenberg's license suspended."

"I hope that's the case! What happens now?"

"The complaint has to be submitted to the Medical Licensing Board. The attorney will interview me to get the details, from my perspective, and I'll testify in my official capacity as a doctor to his errors."

"Risky."

"I know, and I'm going to take the risk. Angie deserved better and while I can't fix what Greenberg did, I can certainly make sure he never does it again."

"Just be smart, Mike."

"Nobody in Surgery or Emergency Medicine is going to cause me trouble for doing the right thing, and I don't care what Psych says, or any other department, for that matter. My guess is that Doctor Greenberg files a _nolo contendere_ with the board in exchange for a reprimand. I won't like it, but it's better than nothing."

"Basically a plea bargain?"

"Basically. The other thing that happened is that Melissa Bush returned my call. She seems to be doing OK, but she's completely rejected Christianity, well, her version of it."

"Do you blame her? You reject it, too!"

"Yes, of course, be she claims to no longer believe in God and to be engaging in promiscuous sex with random guys on Friday nights."

"I don't believe THAT!" Clarissa declared.

"Neither did I, but she made the point that she's not the same person she was a year ago. I let her know I'd seen her dad, and her response was such that I don't believe she has any interest in getting in touch with him."

"Again, do you blame her?"

"No. Her comment was that he'd messed up her life, as well as her mom's and her brother's, and she basically expressed no sympathy for the Gospel message that everyone is redeemable."

"You are the lone voice in the wilderness on that one with regard to Lee."

"I know, but I have to be true to myself, even when it forces conclusions and actions I don't like."

"You're going to see Frank Bush again, right?"

"Yes. On a monthly basis. Maybe at some point I'll do some evangelism at the prison, but I need a sane schedule before I can consider that."

"So a year, at least?"

"Probably. At least at first, I'm just going to visit Frank and play chess with him. I did pre-order a book for him, which I think I told you about. Baby steps."

"I don't think I could do it, but I completely understand why you're doing it. It's you."

"Changing topics, have you and Tessa considered a commitment ceremony of some kind?"

"Marriage?"

"Use that term if you want," I replied. "You know my take on it."

"That so long as nobody tries to force your church to perform weddings for homosexual couples, you won't object, even if the government, at some point, permitted it."

"Exactly. I mean, why should you and Tessa have fewer rights and privileges simply because of something you can't control any more than I can control? It's not a 'lifestyle' despite the claims of some on the right."

"We haven't really discussed it. Hey, you could do the ceremony at this point!"

"I _could_ but that might get me the wrong kind of attention from Father Luke, Father Roman, and Vladyka JOHN. How is your dad taking everything?"

"I think he'll lose it when I announce I'm pregnant, but chill by the time I present him with a grandson or granddaughter. Speaking of that, how are things with the Kozlovs?"

"They're fine. Rachel will spend time with them on Saturday afternoons. She still doesn't like her cousin Viktor, mainly because he's so rambunctious."

"She does prefer girls…" Clarissa smirked.

"I don't think it's about sex at age two!"

"It's _always_ about sex!" Clarissa teased. "Wasn't that the primary goal of your life from Freshman year?"

"No. Being a doctor was more important. It did come a close second, though. But fourteen is different from two!"

"Except the interactions with the opposite sex start very young, and they're all practice for the future."

"Given my relationship with Jocelyn in kindergarten, I can't really disagree."

"Any progress with them on adoption?"

"They're very close, and once Jocelyn passes the bar next month, I expect them to receive a baby or toddler in a reasonable timeframe."

"I've heard there aren't that many babies or toddlers available."

"A lawyer and a nuclear physicist with a Master's and working on his PhD are basically the perfect couple."

"What is she doing?"

"Mostly studying for the Bar, but she also is writing briefs and handling motions and filings in simple cases."

"Have you heard from Maryam, Peter, or Nadine?"

"No, but I figure they're in the same boat we are, so I'm not surprised. I'm sure I'll hear from Maryam in the next few weeks with a wedding date."

"That fast?"

"They've known each other for close to ten years," I replied. "So it's not too surprising."

We finished our lunch and when we left the restaurant, we exchanged a quick hug and then got into our Mustangs. I decided to swing by Doctor Blahnik's house and see if she was home, but there was no answer at the door, so I headed back to Circleville. Once I arrived home, I put on some music, then went to the kitchen to prep the vegetables and peel the shrimp for the stir fry we were serving our guests, and put the rice in the rice cooker we'd been given as a wedding gift.

Kris arrived home with Rachel, and the three of us relaxed together on the couch while I explained what had happened with Doctor Mastriano as I'd promised Kris I would do.

"You're sure you aren't in any trouble?" she asked when I finished explaining.

"Positive. Well, not about that. The reason I insisted on her writing her orders on the chart was that she refused to even examine the patient, and I was concerned. As a PGY1, having written orders on a chart is a perfect defense. Someone might say I should have disobeyed Doctor Mastriano's instructions, but I can't get in any real trouble for not doing that."

"What would you do the next time?"

"Make a nuisance of myself until she checked the patient herself or I'd call for a consult and make my argument to the Resident from the consulting service. But in the end, the Attendings decide and they have the final say."

"But didn't you say you did things you were told not to do?"

"By Doctor Mastriano, but she's not my Attending — that's whoever is the surgical Attending. Yes, she supervises me and assigns my work, but in the end, I answer to Doctor Cutter, the Chief of Surgery. And that's what's caused the turf war, of which this is likely part."

"It all seems so silly."

"It is, but anything new in medicine causes tumult. On the plus side, I did get to do a surgical procedure — a pericardiocentesis, which is draining fluid from the sac around the heart."

"What causes that?"

"In this case, severe injuries from an MVA, a motor vehicle accident. The young woman hit her chest on the steering wheel."

"Did you save her?"

"I honestly have no idea. I performed the procedure and left her with the other surgeons, which is going to be a fairly common occurrence. And I don't have time to check on every admission."

"Dada?" Rachel, who was on my lap, said.

"Yes?"

"Git-arr?"

I handed Rachel to Kris and went to get my guitar. I played six songs for Rachel, ones I knew she liked, which included one I'd never play with Code Blue — _Baby Beluga_, a Raffi song. When I finished, Kris and I went to the kitchen to work on Dinner, and a few minutes later, the doorbell rang, signifying that at least some of our guests had arrived. Ghost and Oksana were at the door, and I saw Loretta and Bobby pull into the driveway.

Once everyone was inside, I offered a glass of wine to anyone who wanted one, and everyone except Loretta accepted. I poured the wine, gave everyone a glass, then began preparing the stir fry, cooking the shrimp first, then adding the vegetables and the sauce I'd made. When it was ready, Bobby helped me bring everything to the table, and we all sat down to eat.

"Ready to come back to work?" I asked Doctor Gibbs.

"I'm going slightly stir crazy at home, so yes, I am! Fortunately, Bobby's mom is available to watch Bobby Junior until he's old enough for the hospital daycare."

"Mike, did you see the scheduled for paramedic training?" Bobby asked.

"No."

"Starting September 1st, we'll work weekly six-hour shifts at the hospital until we reach fifty hours and you docs sign off that we can intubate and read EKGs. They also published the drug list, and we'll have lidocaine, succinylcholine, etomidate, and midazolam."

"Good. Chest tubes?"

"Not this round, because Doctor Cutter isn't ready to sign off on that."

I nodded, "That procedure is more complicated than intubation. It's rare for Fourth Year medical students to do it, and even Interns."

"Says the PGY who did one while he was a med student!" Ghost said.

"And who'll teach his Fourth Years who double on trauma to do them."

"Just don't feed his ego!" Doctor Gibbs ordered. "It's big enough already!"

"Mike isn't conceited!" Oksana protested. "He's the most humble person I know."

"Cousin, you don't see 'Doctor Mike'!" Kris declared. "He's a very different person from the one you saw at church or I usually see at home."

Ghost and Loretta looked at each other and broke up laughing.

"For sure!" Doctor Gibbs said.

"He's a surgeon," Ghost said. "Having a big ego is a prerequisite!"

"I have Clarissa for this kind of abuse," I chuckled. "I don't need it from all of you! Not to mention she's had eight years of practice! And if she's not sufficient, the Tsarina will absolutely point out every minor failing!"

"How are the wedding plans coming along?" Loretta asked.

"Who knows?" Ghost said with a smile. "I took Mike's advice and I'm just along for the ride! Oksana's mom is handling everything!"

"A wise man listens to those with knowledge and experience," I observed.

"Physician, heal thyself!" Loretta said, causing everyone to laugh hard.

_July 6, 1989, McKinley, Ohio_

"Morning, Mike!" Doctor Lindsay said when I walked into the surgical locker room on Thursday morning.

"Morning, Doctor Lindsay!"

"Shelly, please. I heard you did a blind pericardiocentesis on Tuesday."

"Drunk driver MVA," I said. "Any idea how she did?"

"Coded from an aortic transection. It blew about ten minutes after you left the OR."

"I missed it," I said ruefully as we began undressing.

"No, you didn't!" Shelly said firmly. "If the aorta had been completely torn, she'd have been dead before EMS arrived at the scene. There were no signs, and she bled out in seconds. McKnight said it was a pseudoaneurysm, which means short of a CAT scan, you couldn't have seen it, and maybe not even then. Had you ordered a CAT scan, the aorta would have blown while she was in the machine. There was nothing you could have done, Mike, unless you have a direct line to God and He was in the mood to grant a miracle of the type YOU don't believe occurs!"

She was right, but that didn't make me feel any better.

"It still sucks."

"Yes, it does," Doctor Lindsay said, taking off her skirt. "But you know what really sucks? Drunk driving. In this case, it was the driver. You know what usually happens.

"Some innocent person dies and the driver survives," I said, having stripped down to my underwear.

We each put on red scrubs and left the locker room. She stayed on the surgical ward while I headed down to the ED.

"Morning, Mike!" Nate said when I walked up to the clerk's desk to check in.

"Morning Nate. I see the board is almost empty. Quiet night?"

"Mostly. You know the new EMS protocol started yesterday, right?"

"Yes."

In order to free up nursing resources, the ED clerks were going to answer EMS calls, and soon, we'd have an EMS radio, similar to the setup they had on _Emergency_, so that the paramedics could talk directly to us. That would allow them to get advice from doctors directly, rather than work through dispatch, and eventually, the EMS squads would radio directly when they were on their way, which would give us a few extra minutes' warning on their arrival.

"Morning, Mike!" Doctor Casper said.

"Hi, Ghost! Haunting the ED today?"

"Keep your day, night, and day job!"

"Morning, Doctor Mike!" Len Godwin said. "We have a seventy-two-year-old bowel obstruction waiting to go up. Otherwise, our board is clear. Surgery will take him at 8:00am."

"Last vitals?"

"EKG is clear; BP 130/80; pulse 80; PO₂ 99% on nasal canula. Surgery saw him at 0500."

"Orders on the chart?"

"Monitor vitals; IV Ringers; NPO."

"Did you and Bob have your breakfast?"

"Yes. Doctor Baxter sent us right after the surgical consult."

"OK. Where is she?"

"Sacked out in the on-call room. She said you should wake her when you arrived."

I went to the on-call room and saw only Kylie, so I simply called her name. She sat up almost immediately.

"What do we have?" she asked, pulling off her sleeping mask.

"A tired doctor in need of sleep! My prescription is to go home, sleep, and have a nice warm bath."

Kylie laughed softly, "Now, if only you could keep me warm and take that bath…"

"Time to go home, Doctor," I said. "Len gave me the scoop on the bowel obstruction."

"Sorry," Kylie said.

"It's OK," I replied. "I appreciate the sentiment."

"These shifts are WAY too long."

"I was basically dead on my feet on Tuesday evening."

"I believe it!"

We left the on-call room, and I went to Exam 3 to check on the bowel obstruction, then went to the lounge to get some coffee, where Len and Bob joined me.

"We're catching walk-ins," Bob said. "I'll be at the triage desk."

"OK," I said.

Bob left, and once I finished my coffee, Len and I went to the triage desk.

"LOL, weak and dizzy all over," Bob said, handing me a chart.

"Huh?" Len asked.

I kept my voice low to ensure I wasn't overheard, "Little Old Lady, near-syncope, with trouble standing."

I scanned the chart and had Len get a wheelchair before we went out to the waiting room to where the woman was sitting with an elderly man.

"Mrs. Valerio?" I said. "I'm Doctor Mike and this is Len, my student. Let us help you into the wheelchair, please. Mr. Valerio, you're welcome to come with us."

Len and I helped Mrs. Valerio into the wheelchair, and Len pushed her into the ED, where I directed him to Exam 3, then asked Ellie for a nurse. She sent Wendy, who had a nursing student with her, to help. Between the four of us, we helped Mrs. Valerio onto the exam table.

"What brought you to us today?" I asked, handing Len the chart to scribe for me.

"I got up early, as we always do, went downstairs to make breakfast, and I had just started the Mr. Coffee when I felt dizzy and could barely stand. Julius insisted I come here."

"Are you still feeling dizzy?" I asked.

"A little, yes."

"Anything else bothering you? Or anything else that's not normal for you?"

"My chest feels a bit heavy."

"Wendy, portable EKG, please," I said. "Mrs. Valerio, I'm going to examine you and put you on a heart monitor to see if we can figure out why you're feeling dizzy."

I got up to wash my hands and put on gloves, then returned to the exam table. I had a suspicion that Mrs. Valerio might have had a mild heart attack. The signs and symptoms for women were different, and often less pronounced than in men. For women, in many cases, only cardiac enzymes were definitive to rule out an MI as EKGs were not as reliable for women as they were for men. That meant I'd do the primary exam first, get blood drawn, and then do a history.

"Karen," I said to Wendy's student, "Chem-20, ABG, and cardiac enzymes, please."

"Right away, Doctor."

"Mrs. Valerio, I'm going to listen to your heart and lungs," I said. "Then Karen will draw some blood."

"What do you think is wrong?" Mr. Valerio asked.

"Right now, I don't know," I said.

I listened to Mrs. Valerio's heart and lungs, but didn't detect anything except minor crackles in her lower lungs, which might, or might not, be a sign of cardiac trouble. I had Len take her blood pressure, which was slightly elevated, then Karen drew the blood. For the EKG, Mrs. Valerio would need to take off her dress, so all of us except Wendy and Karen left the room. Normally, they would have left as well, but given Mrs. Valerio needed help, they stayed.

"All set, Doctor," Wendy said coming out the door about five minutes later. "Leads are attached, along with the monitor."

"OK. Please have your student take the blood to the lab. I want those cardiac enzymes stat."

"Right away, Doctor."

Len and I returned to the room, and I looked at the EKG, which was showing what appeared to be a normal sinus rhythm, though she was a bit tachy at 110, and her PO₂ was a bit lower than I preferred to see it at 95%.

"What's it show?" she asked.

"Your blood pressure is slightly elevated and your heart is beating a little fast," I said. "Your blood oxygen levels are a bit low, so out of caution, we're going to put you on oxygen via a nasal canula, which is a tube that sits right under your nose. Wendy?"

She hooked up the oxygen and a minute later, the monitor showed 98%.

"Are you taking any medication?" I asked.

"Naproxen for my arthritis," she said. "Plus a multivitamin with iron."

"Are you anemic?" I asked.

"Not since I started taking the vitamins about a year ago."

That could account for the low oxygen saturation I'd seen on room air, and might account for her other symptoms, if her anemia had worsened.

"Did you have another diagnosis?"

"What do you mean?"

"Sorry, did your doctor tell you what was causing your anemia?"

"No. He said it was mild, and I wasn't showing having any problems besides my arthritis."

"Have you had any health problems at all, besides your arthritis, in the past six months?"

"I have trouble falling asleep some nights, but otherwise, no."

Insomnia was a common problem that came with advanced age, and given Mrs. Valerio was seventy-eight, occasional insomnia wasn't a problem.

"Do you get any exercise?" I asked.

"Not since my arthritis started acting up about two years ago. The Naproxen lets me do my daily stuff around the house, but we don't take our walks at the mall the way we used to."

"What do you think is wrong?" Mr. Valerio asked.

"Everything your wife has said is consistent with her anemia worsening, but I want to wait for the blood test results before I say for sure that's it."

And I didn't want to worry them needlessly with my suspicion she might have had a heart attack, or even a mild stroke. Nothing I had seen so far called for a cardiac or neuro consult, though I could call for a gerontology consult without a specific reason for any patient over seventy-five, just as I could call for a pediatric consult without a specific reason for any patient under age fourteen.

"Mrs. Valerio, when was the last time you saw your physician?"

"February, just after my birthday. He said my anemia was under control and my arthritis was being controlled by the pills."

"How's your diet?" I asked.

"I don't eat as much as I used to, but I make sure I get plenty of fiber to keep things moving."

"Balanced?"

"Yes. I try to eat a good mix of meat, vegetables, and fruit. I take Metamucil for fiber every morning."

"I'd like to do a complete exam, if that's OK."

"Of course," she said with a sly smile. "I was a dancer in a cabaret when I met Julius almost sixty years ago, and I'm wearing more now than I was in front of an audience!"

"I was in the Navy," her husband said. "I went to a show, took one look at her, and said to myself I was going to marry her! Two months later, I did!"

I had a vague idea of what 'burlesque' had been like in the late 1920s, and her comment about her clothing strongly indicated she had been a striptease artist. And with her husband being in the Navy in the 1920s, I was sure they both had some very interesting stories to tell.

I performed the exam, noting nothing out of the ordinary, with her distal pulse and muscle tone being typical for someone who was nearly eighty and suffering from arthritis. I had just finished when the phone rang. Karen answered, then hung up.

"Lab results are ready," she said. "I'll go get them."

She left the room and returned about two minutes later and handed me the printout with the results. The results were basically what I'd expected, showing slight anemia, but also showing elevated cardiac enzymes.

"Mrs. Valerio," I said. "I believe you've had a mild heart attack."