Chapter 45 — Oh, Stop!

_September 6, 1989, McKinley, Ohio_

{psc} "Good morning," I said to the pretty blonde receptionist at the McKinley Free Clinic just before 7:45am on Wednesday morning. "I'm Doctor Mike Loucks."

"I remember you," she said with a smile. "But you were a medical student when you were here two-and-a-half years ago. Doctor Turner is waiting for you in his office."

"Thanks, Tamara. I remember where it is."

"Great! If you need anything, just ask!"

"I will," I replied.

I walked through the door and turned right, then walked down the short hallway to Doctor Turner's office.

"Good morning, Mike," he said.

"Good morning, Doctor Turner."

"Gale, please," he said, extending his hand.

We shook.

"Do you have your prescription pad?" he asked.

"I do. Doctor Gibbs reminded me yesterday that your rules are different from the hospital's."

"No pain medication and no controlled substances; generally, you'll only write scripts for birth control pills or antibiotics. Trina will write any scripts for diaphragms because they need to be fitted. You're authorized to do any of the procedures we do here, though I know you won't participate in an elective abortion."

"Correct."

"But you don't have a problem with our counseling policy, right?"

"Sure I do, but I'll still follow it."

"You're an odd duck, Mike."

"You are not the first person to say something like that! What's the drill?"

"See patients, assist the Nurse-Practitioners with procedures that require an MD, and generally be a doctor. That frees me for the things about which you have reservations. Use the small office next door, Nurse Michelle is assigned to you, and Exam 1 is all yours. Misty, at the front desk, will assign patients. Any questions?"

"I think I recall the procedures, but if I forget, I'll ask Trina."

"She's looking forward to seeing you. Let me know if you need anything."

"Thanks, Gale."

"Can I ask…"

"Why am I wearing a shirt and tie rather than my clerical robes?"

"Yes."

"You know what happened two years ago, right?"

"Yes."

"I chose to remarry, and the Orthodox Church doesn't allow clergy to marry. My options were to ask for release or take a vow of chastity."

"Say no more. Thanks for answering."

I left his office and walked down the hall to the small break room where Trina was sitting.

"Doctor Loucks, I presume?" she said when I walked in.

"I introduce myself and go by Doctor Mike. Everyone except patients and med students simply calls me Mike. How are you?"

"Good! You?"

"Good."

"No clerical robes?"

I gave her the same explanation I'd given Doctor Turner and then recapped what had happened in the thirty months since I'd trained at the clinic. A short, thin redhead came into the break room and Trina introduced her as Nurse Michelle.

"Trina," Misty announced, coming into the break room. "Your 8:00am is here. Doctor Mike, we have a walk-in."

"I'll bring the patient to Exam 1, Doctor," Michelle interjected.

She left, and five minutes later, to give her time to take the patient's vitals, I knocked and entered Exam 1.

"John Atkins, nineteen," Nurse Michelle said. "Vitals normal."

She handed me the intake form, and I quickly scanned it.

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

"I have a strange bump on my Johnson."

"Michelle," I said, "specific vitals?"

"Pulse 73; BP 120/60; temp 98.4°F."

"John," I said. "I'd like to start with a basic exam, then I'll examine your genitals."

He agreed, so I washed my hands, put on gloves, and ran through a basic exam, calling out the results to Michelle to add to the chart. I found nothing remarkable in my exam, and then asked John to drop his jeans and briefs, after confirming he was OK with Michelle staying in the room. Once I'd completed the exam, I had him pull up his briefs and jeans.

I had spent my free moments at the hospital on Tuesday reviewing my OB/GYN flashcards, as well as those on virology, and sexually transmitted diseases, and at home on Tuesday evening, I'd reviewed the plates of STD images to refresh my memory. This diagnosis was fairly easy.

"You have a genital wart," I said. "It's a relatively mild form of sexually transmitted disease, caused by a virus, specifically Human Papilloma Virus, also called HPV. Something like half the population in your age group has it, and the vast majority of cases show no sign and have no symptoms.

"There is no vaccine or other treatment that will eliminate the virus, and in most cases, your body will simply clear the infection on its own. When symptoms do appear, such as genital warts, we generally use a drug called Podofilox, which is a topic cream. It will help clear the wart. I'll apply the first treatment and write you a prescription for it."

"My girlfriend gave me VD?!" he asked in surprise.

"Technically, yes, but HPV is in a different class from other so-called social diseases, such as syphilis, herpes, chlamydia, or gonorrhea. It's also possible you contracted it years ago, and there is evidence that it can be transmitted from mother to child when giving birth. It can also be transmitted via hands or objects. It might be transmissible by blood, but the jury is still out on that.

"The only action you can take at this point is regular use of condoms, otherwise you'll simply pass the virus back and forth with your partner. Your girlfriend is likely infected, even if she has no symptoms, which she might never have. You need to encourage her to see her gynecologist and have regular Pap smears. If she doesn't have a gynecologist, or can't afford to see one, she can make an appointment here."

"OK, he replied.

"Michelle, I need a tube of Podofilox, please, and an HPV pamphlet."

"Right away, Doctor!"

Fifteen minutes later, with the cream applied and instructions on how to use it, I handed John a prescription for another tube if the wart didn't clear with the first tube, the HPV pamphlet, and instructions to see his primary care physician for follow-up. Once he left, I asked Michelle to step back into the treatment room before our next patient.

"My preference is for vital signs to be expressly stated, please. Also, when we're not with a patient, just 'Mike' is fine. No need for the formal title."

"Sorry," she said.

"No need to apologize. Every physician has their own style."

"I'll go see what Misty has for us."

"I'll use my office to complete the chart and come back in about five minutes."

I removed my gloves, tossed them in the hazardous waste bin, and then went to the small office and completed the chart, putting it on the credenza behind me. One of Doctor Turner's duties was to review all the charts, and he'd take them home with him. That was one thing I appreciated about the ED — Attendings did all chart reviews, so I wouldn't have to worry about that for several years.

When five minutes had passed, I joined Michelle and a female patient in Exam 1.

"Katy Brooks, sixteen, seeking birth control pills," Michelle said. "Pulse 70, BP 110/60, temp 98.3°F."

"Hi, Katy," I said. "I'm Doctor Mike. Let's start with some basics. Are you sexually active?"

"I haven't, you know, gone all the way."

I looked over the intake form and saw she'd checked the box next to oral sex, and had written in '2' next to number of partners.

"Let me ask a different way," I said with a smile. "Have you done things which your _dad_ would consider 'sexually active'?"

"Uh, yeah," she replied, blushing slightly.

"And have you ever had a test for sexually transmitted diseases? What you might have heard called VD?"

"No."

"Do you see a gynecologist regularly?"

"Every year since I got my period when I was thirteen."

"And a regular physician?"

"I saw a pediatrician until I was twelve, now I just see my gynecologist."

"May I ask why you're here rather than speaking to him or her?"

"Her. She's my mom's gynecologist and if I make an appointment, my mom could find out. I, uhm, don't want to wait until my next appointment in May."

"You could tell them not to inform your mom," I said. "And they're required by medical ethics to honor that request."

"I couldn't afford to pay for the exam," Katy countered. "I don't work."

"And that's why we're here. What I'd like to do is perform a basic exam, which means listening to your heart and lungs, and checking your eyes, ears, nose, and throat, and check for swollen lymph nodes. You won't need to undress; just untuck your blouse and unbutton the top two buttons."

She did that I and checked her heart and lungs, then used the otoscope to check her ears, eyes, nose, mouth, and throat. That completed, I checked her distal pulses and then felt for enlarged lymph nodes in her neck.

"I don't find anything that would preclude a prescription for birth control pills," I said. "I would like to have the nurse draw blood for an STD test, given you've had multiple partners with whom you've engaged in oral sex."

"Uhm, neither of them has gone all the way."

"Fellatio or cunnilingus are pathways for the transmission of STDs," I replied gently.

"Er, what do those words mean?"

"Oral sex. Fellatio is what you do; cunnilingus is what he does. Either way, you exchange bodily fluid, which is how STDs are transmitted. I'm not implying you have one, and I can't force you to have the test, but it would be a good idea. It's completely anonymous and we'll give you a code number so you can call without identifying yourself, and nobody could get your name by calling the number."

"Uhm, sure."

"Michelle will draw a tube of blood and I'll write your Prescription. I'll also give you a three-month supply, and after that, if you can't afford them, you can continue to return here for another three-month supply at little or no cost. Also, you should inform your gynecologist or primary care physician that you're taking birth control pills and you should begin having Pap smears each year."

"Wait! I have to tell the gynecologist?! I came here, so I didn't have to."

"Ethically, she can't say anything to your parents. That said, the Free Clinic does provide gynecological services. You can make an appointment with the desk, and in your situation, there would be little or no cost. The challenge there would be not seeing your mom's gynecologist, which would raise questions. It's my opinion you should continue to see the gynecologist and make it clear you do not want her to share anything at all with your parents. If she did, she could lose her medical license."

"You're sure?"

"Positive. Michelle, you can draw the blood, please."

She did that, properly labeling the tubes.

"Do you have any questions?" I asked. "Either Nurse Michelle or I can answer pretty much anything you can ask."

"I had health class," Katy said.

I smiled, "I suspect that was similar to mine and the amount of information conveyed was actually minimal. Let me ask you a question, which you can decline to answer if you choose. OK?"

"Yes."

"Do you expect your first time to hurt and do you expect to bleed?"

"Obviously."

"Actually, not so obvious. Do you play any sports?"

"Softball and soccer. Why?"

"Then the odds of you having an intact hymen are very small. By age sixteen, it usually either atrophies or is ruptured by athletic activity."

"WAIT! I'm not a virgin?!"

"A misconception perpetrated by ignorant people," I said. "If you haven't had intercourse, you're a virgin. But in the end, that's nobody's business except yours. It's literally impossible to tell if a woman has had sex or not. Anyone who tells you differently has no idea what they're talking about. There are outliers, of course, but even in those cases, the barrier is thin and mostly open, as otherwise you couldn't have a menstrual period."

Katy laughed nervously, "I didn't even think about that!"

"Most people don't," I replied. "As for it being painful, in girls who are over fourteen, that is nearly always because of lack of foreplay, nerves, or some other thing that inhibits lubrication. In addition to the birth control pills, I'll give you a pamphlet which explains all of this in non-medical terms, as well as a tube of lubricant. You apply that to your partner's erection and there should be no pain at all."

"You're sure?" Katy asked skeptically.

I looked to Michelle to confirm.

"He's telling the truth," Michelle said. "I was sixteen my first time, and we took our time and it was wonderful. There was no pain, and I didn't bleed. My friends who rushed, or who did it in the back seat of a car, had somewhat different experiences. Find someplace private, where you won't be disturbed, take your time, engage in foreplay, and use the lubricant, and everything will be wonderful."

"The only other consideration," I said, "is that birth control pills don't prevent STDs. Rubbers are the only effective way to reduce your risk, though having only one regular partner can limit your risk, assuming he also only has you as his partner."

"If my boyfriend cheats on me, the last thing he'll need to worry about is VD!" Katy growled.

"A sentiment I've heard expressed by various girlfriends over the years," I chuckled. "That said, you wrote on the form you had two partners."

"Uhm, the first one was at a party where we played 'Truth or Dare' when I was fifteen. That was before I started going out with Don."

"OK. Let me get your pills, the pamphlet, and the lubrication, and you'll be all set."

"You need to take the pills religiously," Michelle said. "Every day at the same time, and if you miss one, you double the next day, _but_ you have to use a condom until after your next period."

"Seriously? Why?"

Michelle looked to me to answer.

"The Pill works by regulating hormone levels, and even a period as short as twenty-four-hours can result in enough variation to allow pregnancy. The other thing to remember, and this is in the brochure, is that antibiotics and some herbal supplements can reduce the effectiveness of birth control pills."

"This is WAY more complicated than what they explained in health class!"

I nodded, "A common complaint. Any other questions?"

"No."

I left the room, got the pills, the lubricant, and the pamphlets, then returned to give them to Katy, along with the prescription and the form that would allow her to retrieve her tests results. She thanked us and Michelle walked her out. I returned to the small office to complete the chart, and Michelle came to the door.

"Someone just walked in, but they're filling out the intake form, so it'll be a few. You did a really good job with Katy."

"Thanks."

"I go home for lunch," she said with an inviting smile. "You're welcome to join me."

"I appreciate the offer, but if I did that, my wife would ensure nobody ever found my body!"

"Bummer, but I understand. The offer is there if you change your mind."

"Again, I appreciate it, but there is zero chance of that. And I'd appreciate it if we kept this professional and friendly, please."

"Sorry," she said. "I'll let you know when Misty lets me know the patient is ready to come in."

The rest of the day followed the pattern, and I saw a total of ten patients for a variety of sexual healthcare matters, with a break for lunch, which I ate alone in the break room. At 5:00pm, I handed the charts to Doctor Turner.

"How did things go?"

"No problems," I replied. "Michelle and I work well together, and Trina answered the one question I had."

"Great! Then we'll see you next Wednesday."

I left the clinic, headed to the hospital to retrieve Rachel from daycare, then headed home for dinner and Vespers at the Cathedral.

_September 7, 1989, McKinley, Ohio_

"How did things go yesterday?" Doctor Gibbs asked when she arrived in the ED at 6:00am.

"Other than a cute redheaded nurse propositioning me, just fine."

Doctor Gibbs laughed, "Nurses and doctors having affairs is so common that blatant requests to cheat are not out of the ordinary."

"Oh, I know. I declined and simply politely requested that we keep the relationship professional and friendly."

"Professional?" Doctor Gibbs smirked. "You're the last person I'd think needed to pay for it!"

"Oh, stop!" I chuckled. "I'd pay all right, and it's a price is too high.

"On a different topic, I'm sure it won't come as a surprise that Krista complained that she's not receiving enough procedures and isn't being given an opportunity to succeed."

"To whom?"

"Doctor Mertens. There's a meeting with her, Doctor Northrup, and me at 3:00pm."

"What did Paul Lincoln have to say?" I asked.

"That he reviewed her procedure book, and he's assigning her tasks appropriate with her training while looking for opportunities to expand her skills."

"That's the right approach," I said. "I suspect the crux of the complaint is that I take a more expansive view of what students can and should do. You know why."

"You've latched on to that Osler quote like a dog with a tasty bone."

"He wasn't, and isn't, wrong. You know my take."

"'I want more procedures!'" Doctor Gibbs said, trying to mimic my voice.

"The refrain of _every_ medical student, and with good reason."

Ellie came to the door to the office, "Sorry to interrupt. Paramedics are four minutes out with an MI."

"Give it to Mike," Doctor Gibbs said. "Go heal the sick!"

I left her office, gathered my students and Kellie, and the four of us went to the ambulance bay to meet the EMS squad. I knew how it was going to turn out as soon as I heard from the squad driver that a fireman doing chest compressions — at best a 5% chance of coming back. The four of us worked on the patient for fourteen minutes before I threw in the towel, as he'd been down ten minutes before he'd arrived in the ED. I had Heather bring his wife into the consultation room and presented the news and turned her over to the chaplain.

"I hate those," Heather declared as she, Jake, and I left the consultation room.

"Not the best part of my day, that's for sure," I replied. "This one was dead before he got here, but you know the EMS rule, right?"

"Not dead in the field unless there is obvious brain matter, obvious exsanguination, or the body is cold and not submerged in water."

"Decapitation is also on the list," Jake interjected.

"I dunno," Heather said with a sly smile, "most men seem to survive just fine without brains."

"Did you and Dale break up?" Jake asked.

"That obvious?" Heather asked.

"You usually don't get that down on men."

"He's been bitching about my hours."

"A girl from my former parish who I might have married made it clear she couldn't deal with the demands of medical training," I said. "It makes a complete mess out of relationships."

"How have you managed?" Heather asked.

"By finding the right woman," I replied. "One who could handle it."

"Guys do not accept it," she groused. "And you know how tough it is on women in medicine. I've heard you opine."

I nodded, "Medicine, and society as a whole, needs to get its head out of its butt. Look how long it took for even a tiny segment of the profession to admit that thirty-six-hour shifts are detrimental to patients AND to Residents. And there is serious pushback against the New York legislation as an 'overreaction' or 'political meddling'. But the situation was created by medicine, refusing to address the problem and take steps to fix it. The same thing will happen with the treatment of women, but unfortunately I might retire before things change in a significant way."

"Mike," Ellie called out. "There are five charts in the walk-in rack."

"Do your thing," I said to my students. "But this time, Heather, you do the assessment with Jake monitoring."

They went to get a chart, and I went to the lounge to get a drink of water. I sat down with _Lancet_ and read for about ten minutes until Jake came to get me.

"How'd she do?" I asked.

"Fine. I didn't confirm her auscultation, though."

"That's OK at this point," I replied

We went into Exam 2 and after Heather introduced me, she presented.

"Heide Burdick, seventeen; syncopal episode in gym class; BP 100/60; pulse 76; PO₂ 99% on room air; brief LOC. No recent illnesses, no medication. Nothing remarkable on exam."

"Hi, Heide," I said. "How are you feeling?"

"Still a bit woozy."

"Can you tell me what happened right before you felt faint?"

"We were playing soccer, and I suddenly felt lightheaded. I sat down, my gym teacher said I passed out, but I'm not sure I did."

"They didn't call 9-1-1?"

"I insisted my friend could drive me, and the gym teacher didn't argue."

"Any tinnitus? That is, ringing in your ears?"

"Right before it happened."

"Did you happen to cough or sneeze?"

"I had a small sneezing fit. I have allergies."

"What did you have for breakfast this morning?"

"The usual — a waffle, juice, and coffee."

"And dinner last night?"

"Steak, corn on the cob, and salad."

"Has your blood pressure been low?" I asked.

"My doctor says it's a bit low, but nothing to worry about."

"OK. I'm going to do a basic exam to check Heather's findings."

I did that, then excused the three of us so we could step out into the hall.

"Thoughts and next steps?" I asked Heather.

"Chem-20," Heather replied. "You ruled out blood glucose."

"Did I?" I asked.

"You asked about food and she ate, which means she shouldn't have hypoglycemia."

"Shouldn't," I replied. "Neither hypoglycemia nor hyperglycemia are ruled out, they're just unlikely. Continue."

"I don't have anything more."

"Jake?"

"OK to look in my book?"

"Yes."

He paged through his diagnostic handbook and, about a minute later, looked up.

"You suspect situational reflex syncope. That's why you asked about coughing."

"Yes. Keep going."

"She already has low blood pressure, she was exercising, and the sneeze triggered a syncopal event."

"So, what would you do?"

"Chem-20 to rule out some kind of electrolyte imbalance. If that's clear, then refer to neuro?"

"Check your book," I said. "One other test."

He looked in the diagnostic handbook.

"Hematocrit less than thirty. It also lists systolic less than 100."

"Yes. If either of those were the case, we'd admit her. If not, then she's not in immediate danger, so a better choice in my mind is to refer her to her primary care physician. He or she is a better choice to ensure continuity of care with a neurologist, cardiologist, or some other specialist. Not to mention the tests cost significantly less when ordered by the doctor outside the hospital."

"But she could pass out again, right?" Heather inquired.

"Yes, and I'll recommend she rest at home, which again is far more comfortable than here in the hospital. Let me ask you this — what treatment would we give?"

"That would depend on the underlying condition, right?"

"Yes. And that's what her primary care physician will investigate. Shall we go back in?"

We went back into the room and I explained our suspicions and our plan to Heide, Heather drew the blood for the Chem-20 and hematocrit, and we excused ourselves until the labs came back. Heather put the tubes of blood in the rack, where they'd be picked up by a student nurse who would take them to the lab.

"Mike," Nate called out. "Your patient's mother is in the waiting room."

"Thanks, Nate. Heather, check with Heide and if she agrees, bring in her mom. You can repeat exactly what I said to Heide to her mom, but don't embellish. If they have questions, let me know. Then come join us to present."

She acknowledged me and went to the waiting room, while Jake and I went to the lounge to wait. Two minutes later, Heather joined us, and the three of us went to the Attending's office to present the case.

"Heather, present your case, please," I directed.

"Heide Burdick, seventeen; syncopal episode in gym class following a sneezing fit; BP 100/60; pulse 76; PO₂ 99% on room air; brief LOC. No recent illnesses, no medication. Nothing remarkable on exam. Chem-20 ordered. Suspect situational reflex syncope. If hematocrit is over thirty, refer to primary care physician."

"Did you make the diagnosis?" Doctor Gibbs asked.

"It was a team effort," Heather replied. "I had a lot of help."

"Approved. Chart, please."

Doctor Gibbs made notes on the chart, signed it, and handed it back. We left the office and Heather returned the chart to the rack just outside the door of the exam room.

"Get the next chart," I directed.

We handled another four walk-ins before lunch, and discharged all of them, including Heide Burdick. I took my meal break and saw Sophia and her friends in the cafeteria and went to sit with them. Kelly Atkins flirted shamelessly as she had the previous time, and I simply ignored all the innuendo and double-entendres. When I finished lunch, I returned to the ED and had Jake and Heather take their meal break while I handled a walk-in with a sprained wrist with Kellie.

"You know," I said, once the patient had been discharged, "I never asked, and tell me if it's none of my business, but are you seeing anyone?"

"What?" Kellie asked with a sly smile. "Cheat on my work husband?"

I chuckled, "You'll have to fight Clarissa Saunders for that role!"

"Last I checked, you have disqualifying anatomy! Otherwise, you two would have married ages ago."

"True," I replied.

"I've been dating, but nobody I'd say is 'Mr. Right', at least at this point. You took yourself off the market before I met you."

"I'm pretty sure the concept of 'Mr. Right' is a myth," I replied.

"How so?"

"Nobody is perfect," I replied. "That is, a perfect match for the Platonic ideal partner. It's hard work, and if you don't put in the hard work, it ends in tears."

"It sounds as if you've seen that."

"My parents divorced during my first year in medical school. I didn't realize it growing up, but they didn't put in the effort necessary to make it work."

"Twenty-two years? Well, more, I guess."

"If my inferences are correct, based on things that were said, the trouble started before they got married and was never resolved. And without intervention by several close friends, that very likely would have been me. I didn't really get my act together until my Junior year at Taft."

"Not uncommon, especially for guys," Kellie observed. "I joined the Navy right out of nursing school."

"Twenty-one, right?"

"Yes. And after a six-year stint, here I am."

"You were at sea the entire time?"

"About four years, total, out of six. I had some shore duty, and of course, the _Nimitz_ was in port for part of the time. I left her when she arrived in Bremerton, Washington, last March. She had been based in Norfolk and now is based in Bremerton."

"I find it interesting that the carrier is named for Chester Nimitz, but you say 'her'."

"All ships are 'her'," Kellie replied. "I don't actually know why."

I thought about it for a moment, then smiled because I had an idea.

"In Latin, the word for 'ship' is _navis_, which is a feminine noun," I said.

"I've heard that, but the problem with that theory is that in the derivative languages, that is Spanish, French, and Italian, the noun is masculine."

"Oops," I chuckled. "So much for that theory!"

"I asked the Commander who was responsible for the nurses about it, and that's how I know about the problem with that theory. She had more than twenty years in when I showed up. She retired the same time I left the service."

"Mike?" Nate called out. "EMS three minutes out with a non-responsive toddler pulled from a swimming pool. Use Trauma 4."

"Lord have mercy," I said aloud.

Jake and Heather had returned, so the three of us, with Kellie, gowned and gloved and headed to the ambulance bay. The squad rolled to a stop, and Roy jumped out of the cab.

"Trey Washington, three, found in a swimming pool by his mom; CPR performed; pulse 120 and thready; BP 80/40; PO₂ 86% with bagging; GCS 4; vomited twice en route."

The fact that they'd got him to us with any kind of pulse was a good sign, but there was no way he was out of the woods. He might well have aspirated his vomitus, and was at risk for hypoxic ischemic brain injury, as well as acute lung injury or acute respiratory distress due to water in his lungs.

"Trauma 4! I'll intubate; Kellie, pediatric etomidate and succinylcholine, then stat ABG; Jake, five-lead and monitor; Heather, you bag until I'm ready to intubate!"

We moved quickly, and as we passed the nurses' station, I called out, "Ellie, I need a nurse!"

"Mary! Go!" Ellie ordered.

"Mary, pediatric intubation tray!" I instructed, as she joined us.

In the trauma room, we quickly transferred Trey to the treatment table and the orders I'd given were followed while I used bandage scissors I carried in my pocket to cut away Trey's shirt, then began a primary exam.

"Weak heart sounds," I reported. "Pulmonary edema, both lungs."

I moved into position to intubate, verified with Kellie that the etomidate and sux were in. She confirmed, and Heather stopped bagging and moved away. Kellie, having drawn the blood, left to have a nursing student carry it to the lab for immediate results.

"Sinus tach!" Jake reported. "PO₂ 85%."

"Do you feel confident you can insert a Foley in a toddler?" I asked.

"I can do it," he said.

He went to the cabinet to get the correct catheter as Mary was assisting me. Fortunately, I was able to pass the endotracheal without difficulty, and Mary hooked up the respirator while I checked for breath sounds.

"Bilateral sounds," I replied. "Now we wait and deal with any complications or symptoms."

"Foley is in; urine in the bag."

"Good job, Jake. What's the target PO₂ for drowning recovery?"

"Between 92% and 96% he replied."

"And the risks?"

"Severe brain injury due to hypoxia; pneumonia; long-term lung injury."

"Mike?" Ellie said. "His mom is having a meltdown in the waiting room."

"Bring her to the consultation room," I said. "I'll speak to her."

"Right away!" she acknowledged.

"Heather, you come with me; Kellie and Jake, stay with our patient."

Just then the phone rang and Mary answered it. She listened, then hung up.

"pH 7.30; PₐO₂ 55; PₐCO₂ 48; HCO⁻₃ 20."

"Put those on the chart, please. Jake? Interpretation?"

He shook his head, "I don't remember off the top of my head."

"He's slightly acidotic. Treatment?"

"For slight acidosis, oxygen via vent," he said.

"Good."

"How's it going?" Doctor Gibbs asked, coming into the room.

"Immediate CPR got him here with a pulse and respiration," I replied. "ABG shows slight acidosis; PO₂ 85%; sinus tach at 120; vented; being monitored. I was about to go talk to the frantic mom."

"I'll stay," she said.

"OK. Jake will stay here, and Heather will come with me."

Heather and I left the room and went to the consultation room where a clearly distraught woman in her twenties was waiting.

"Hi, Mrs. Washington; I'm Doctor Mike and this is my student Heather," I said. "We're treating Trey."

"How is he?" she asked frantically.

"His heart is beating, and he's breathing," I said. "We have him on a ventilator, and he's being closely monitored by my Chief and a nurse while I speak with you."

"Will he live?"

"I can't make any promises, but when a drowning victim arrives at the hospital with a heartbeat, the odds are very good."

"Can I see him?"

I considered how she might react to being told 'no', as well as how she might react to seeing him on a vent, with EKG leads on his chest. I decided that seeing him alive, even with life support and monitors, would be a good thing.

"Yes," I said. "I'll take you in, but you can only stay a minute."

"Thank you, Doctor."

I led her to Trauma 4, where her son was lying naked, with only a modesty cloth over his groin, a vent tube in his mouth, and EKG leads on his chest.

"My poor baby!" she gasped.

"PO₂ is up to 87%," Jake announced.

"That's a promising sign," I said to Mrs. Washington. "Heather, would you escort Mrs. Washington to the waiting room, please, and make sure she has coffee, water or whatever she needs to drink? Mrs. Washington, I'll update you as soon as I have more information."

"Mrs. Washington," Heather said. "If you'll come with me, please."

Heather left with Mrs. Washington and I performed a basic exam.

"Pupils are sluggish," I said. "But reactive. His sinus tach has resolved. I'd say the odds are he makes it, and might even have no deficits. Whoever performed CPR immediately saved this little boy's life."

"I'm going back to my office," Doctor Gibbs said. "Let me know when he wakes up and if you need a neuro or respiratory consult."

"Will do," I said. "Thanks, Loretta."

"Good job, Mike."

"Thanks," I replied. "As I said, it was the immediate CPR. You know the odds if they arrive without a pulse unless it's a hypothermic situation."

"Infinitesimal."

She left, and I instructed Jake to stay with Trey, while I left the room. Heather came back from the waiting room a minute later and walked over to where I was standing at the clerk's desk.

"How is Mrs. Washington?" I asked.

"She seems OK," Heather observed. "I got her a bottle of water from the lounge."

"Thanks."

"How do you stay so calm?" she asked. "You intubated a toddler like it was nothing."

"If you want trauma, you need ice water in your veins," I replied. "And you need supreme confidence. Remember what I asked Jake about the Foley?"

"If he could do it?"

"No," I said with a smile. "Think about the exact words I used."

"I don't remember."

"On that, you need to find a way to remember literally everything that happens in a trauma. You won't always have time to write things on the chart until later, and if there's ever an M & M, you'll be asked what you observed. What I asked Jake was if he felt _confident_ about inserting the Foley. Not if he could do it, but was he _confident_ he could do it. Confidence is even more important for intubation.

"That said, there's a fine line between confidence and arrogance. You have to be willing to admit you aren't confident in your skills or abilities, or that you don't know something. That's especially true for next year when you're a Sub-Intern, and it's true for me, too. The entire point of calling for consults is that we don't, and can't, know everything. Your task for the next twenty months is to ask questions, build knowledge, gain skills, and become confident."

"What if Jake had said 'no'?"

"In this case, I'd have instructed him to do it, because I was confident he could do it, or I wouldn't ask. The question was really a 'gut check' for him. But remember, too, there is no harm and no disgrace in saying you don't feel ready to do something. That's a clue to your teacher to up their game, and if they don't, for you to press them to help you."

"I hope I'm assigned to you for my trauma Sub-I. I learn more from you because you take the time to explain _how_ to learn, not just what we need to do."

"Thanks. One thing I learned was something I've said many times — you, and only you, are responsible for your medical training. Follow my prescription and you'll be successful. Get the next chart, please. We have more sick to heal."