Chapter 8 — What A Stupid Way to Die

_July 1, 1989, McKinley, Ohio_

"How was your first day?" Doctor Casper asked just before midnight.

"Routine, really. Fourteen walk-ins, with the only truly interesting case being the young woman with the migraines. I had mixed emotions about the MRI, hoping it would show something but dreading what it might show."

"That's a common reaction," Doctor Casper said. "You have a tentative diagnosis that you really hope doesn't pan out. I think you had a leukemia diagnosis in a college-age student."

"Yes. That sucked, though she recovered."

"How do you know that?"

"José married her best friend. It sucks that we don't have an answer for the migraines."

"Yes, but you asked Doctor Mastriano for a neurology consult and they took her, so you did your job. The last three times they simply sent her home after giving her analgesic cocktails."

"But the consult turned up nothing."

"Mike, what's your job? And don't give me any bullshit 'heal the sick' answer, either."

"That _is_ my job," I replied.

"No, that's your _calling_," Doctor Casper countered. "What is your job?"

"First line emergency care."

"Did you do your job?"

"Yes."

"Then as shitty as this sounds, that's a _good_ day. You cannot heal, cure, or whatever you want to call it, every single person who walks into the ED or is brought in by ambulance. And as shitty as it sounds, and feels, it's not your job. You job is to triage, treat or stabilize, then admit or discharge. You know the catchphrase."

"Treat 'em and street 'em. We've had this conversation before."

"And we're going to have it again until you get it through your thick head that the 'S' on your badge does not stand for 'Superman'!"

"I don't believe I'm Superman," I replied.

"Then don't try to _be_ Superman. How many of your patients walked out of the ED happy today?"

"Thirteen out of fourteen."

"That's a damned good day. How many died?"

"None."

"That's an _outstanding_ day. Days like that are right up there with the pilot's refrain that any landing you can walk away from is a good landing. Do you want to know my count for the past eighteen hours?"

"Go on."

"Eighteen treated, three of them resulted in a consult from McKnight. Want to trade days?"

That was another euphemism that was used in the ED to indicate a patient had died without saying it where other patients could hear.

"No."

"Then in ten minutes, let's get our showers, put on our street clothes, and go home. You're back on Monday, right?"

"0600 for a thirty-six-hour shift."

"You may be the last class of Residents who have those shifts."

"The Libby Zion case."

"Yes. Word is that the end result, when all the smoke clears, is eighty-hour weeks and no more than twenty-four-hour shifts, with at least eighteen hours between shifts."

"Fortunately, I have that, but I know some of the shifts work out to only twelve hours between thirty-six-hour stints."

"Hi, Mike!" Kylie said, coming into the ED.

"Hi, Kylie."

"How'd your first shift go?"

"I handled fourteen walk-ins. My board is clear."

"Excellent. I'll see you on Monday morning."

"See you then," I said.

_July 2, 1989, McKinley, Circleville, and Columbus, Ohio_

Just after midnight, Doctor Casper and I left the lounge and walked towards the locker room.

"I'm upstairs," I said.

"Cutter is really pushing the point, isn't he?"

"Yes," I agreed. "But so long as the turf war doesn't have any effect on my training, I can deal with the petty stuff."

He went into the locker room and I headed upstairs to the surgical locker room. I took a quick shower, dressed, then headed home, where Kris was waiting up for me.

"How was your first day being a doctor?" she asked after we exchanged a hug a kiss.

"Not all that different from my last day of being a Sub-Intern," I replied. "The main difference is I can do basic procedures without seeking permission every time, order tests, and prescribe non-schedule drugs."

"Narcotics, right?"

"Yes. Those I won't be able to prescribe until I actually have my medical license, which is after I pass my Boards, which is sometime after PGY4. In theory, I could do it in two parts, if Doctor Cutter would sign off on getting my basic license before I spend any time in the OR, but I'm not sure he will, given the turf war."

"Turf war?"

"A contest over who is actually in control of my schedule and decides the course of my training. Doctor Northrup tried to change things, and Doctor Cutter reacted. The only real effect of their little battle is that my locker is in the surgical locker room, and I wear red scrubs instead of pale blue ones. It's really no big deal from my perspective."

"So, now you have medical students to order around?" Kris asked lightly.

I chuckled, "Yes, but you know me. The key is teaching, not having someone to do scut."

"Male or female?"

"Today? Two females. I'm not sure who I'll have on Monday, but med students are limited to twenty-four-hour shifts, and mine are thirty-six, so I could have as many as six different students during that period, depending on the schedule."

"Any interesting patients?"

"I treated patients who walked in, which means mostly minor stuff. The only really interesting one was a young woman with migraines, but in the end, all I could do was refer her to neurology. The MRI we ran showed nothing, so they gave her some stronger medication than you can buy over the counter. I suspect she'll be back. How was Vespers?"

"The same as it's been for over a thousand years," Kris said lightly.

I laughed, "OK, I deserved that. Shall we go to bed? We have to leave for Matins in just over six hours."

"Yes."

We headed upstairs and ten minutes later we were in bed, and two minutes after that, I was sound asleep. When the alarm rang early on Sunday morning, we got out of bed, quickly showered together, then fed and clothed Rachel, and the three of us headed to Dormition of the Mother of God Cathedral in Columbus for Matins and the Divine Liturgy.

Rachel wanted to be with Lyudmila during the services, which to me seemed to be one of her ways of showing independence. She still wasn't in a good mood, and I hoped going back to daycare would help, though I suspect it might take another few weeks until Abigail came home from Spain.

"You had your first day at the hospital yesterday, right?" Father Luke asked at lunch.

"Yes."

"I also heard from His Grace that you visited the man who murdered your friend in prison."

"I did. He was receptive to my visit, but he's locked into his Calvinist mindset and is convinced he's going to Hell."

"Just act in love, Michael."

I nodded, "I didn't take what might be considered his 'bait'. I'll see him again later this month to play chess. I did reach out to his daughter, who hasn't been to see him, but she hasn't returned my call. That could be because she elected not to, or because she's just starting her Residency in Kentucky."

"What's your goal?"

"To provide hope."

Father Luke nodded, and then moved on to speak to another parishioner, while I went to sit with Kris, Rachel, and the Korolyovs to have lunch. After lunch, Kris, Rachel, and I left the cathedral and walked out to the car for the drive home.

When we arrived, there was a message on the machine for Kris from Clarissa, and Kris returned it. I knew what it was about, and still wondered if what Clarissa intended was the right way forward, but I couldn't think of any real alternatives. I didn't know for sure how Kris would handle the revelation, but I hoped the 'privacy exception' would be sufficient to prevent serious problems between us.

Kris returned the call to Clarissa, and just over an hour later, Clarissa and Tessa arrived at the house. I wasn't surprised when Clarissa asked to speak to Kris privately, and they went into the study to talk.

"How do you think this will go?" Tessa asked quietly as we sat on the couch with Rachel playing with her dolls on the floor in front of us.

"Not as badly as if Kris somehow found out ten years from now, or whenever," I replied. "In the range of bad choices, this is the least bad. She's not going to mention you and me, is she?"

"No. I was adamant about that. It would serve no purpose except to create tension where none exists. Does Kris know about any of the other girls you were with?"

"Jocelyn and Tasha, because those two are, more or less, public. But she made it clear she didn't concern herself with what had happened before. And she doesn't see female friends as a risk the way Elizaveta did."

"Kris is very secure in who she is and views the world in a much broader way. Elizaveta was, and I mean no disrespect, very provincial where Kris is cosmopolitan."

"A very French way of putting it," I chuckled.

"But it's true, isn't it? Elizaveta was a very typical rural, religious person, whereas Kris is worldly, and mostly secular in her outlook, though also faithful. In other words, very much like you."

"I see the world through an Orthodox lens."

"Yes, you do, but how do you interact with the world? You're a scientist, not a monk. Think about your approach to miracles."

"I see your point," I replied, "but Elizaveta was growing in that regard, though she still had traditional conservative American values."

"And, as a deacon, that was what you needed. You need something different now."

"I don't disagree."

"Maybe Miss Cosmopolitan will allow you and Clarissa to conceive naturally!"

I laughed, "She's open-minded, but not _that_ open-minded!"

"Just think," Tessa smirked, "It might take _dozens_ of attempts!"

"Which actually wouldn't be as enjoyable for me as you might think, because I know how Clarissa feels about it."

"Weirdly, I believe you. Most guys would be happy to bang the hot lesbian!"

"Which is _not_ how I feel about it. I banged _you_, but not Clarissa, if that makes sense."

"Of course it does. You and me was just casual sex, and purely physical. It was awesome, but it was just sex. That was not true between you and Clarissa."

"Exactly."

A few minutes later, Clarissa and Kris came out of the study.

"We're going to head home, Petrovich," Clarissa said calmly. "See you at the hospital for lunch tomorrow?"

"Sounds good."

I walked Clarissa and Tessa to the door, but couldn't discern anything from Clarissa, nor could I from Kris' demeanor when I returned to the living room.

"I never would have guessed," Kris said. "But it makes sense."

"Are you upset with me for not telling you?" I asked with a bit of trepidation.

"No. Clarissa pointed out that she swore you to absolute secrecy and it did fall under the exception I allowed for my 'nothing but the truth' rule. You look relieved."

"I am," I replied, after realizing I had been holding my breath. "I wasn't sure how you'd react. I thought you'd be OK, but I wasn't absolutely sure. You're OK with me spending time with Clarissa?"

"She made it clear that she could _tolerate_ doing that with you to make a baby, but has no interest in doing it with anyone except Tessa. I trust both of you."

"Thank you."

"Was it your idea for her to tell me?" Kris asked. "Or hers?"

"Hers," I replied. "I wanted to tell you, but it was something I wasn't allowed to share."

"Which I understand. Given how she feels about you, I don't see how she could have done anything else."

"Is there anyone who would concern you?"

Kris smirked, "Besides the nurse that has had the hots for you for four years?"

I chuckled, "Ellie will just have to make do with her fantasies."

"Did you ever consider it?"

I shook my head, "No, for several reasons, the most important of which was she tried to entice me to cheat, and that, in and of itself, precluded even thinking about it. That was before I'd formulated my rule about relationships in the hospital, which really didn't matter except in terms of ethical behavior and patient care, because I was married to Elizaveta. Once she reposed, I made two firm rules — I wouldn't date anyone who was on the same service and I would never even consider fooling around in the hospital."

"That happens a lot?"

"It does, unfortunately. And there are no rules against relationships, only against favorable or unfavorable treatment based on those relationships. The problem in my mind is that there is, in effect, no way to know unless someone makes a complaint. We all know about female students who use sex to gain advantage and male doctors who take advantage of female students, but it's difficult to prove. I would just ban any relationships where there was any supervisory or teaching relationship."

"It sounds as if you would prohibit relationships between students and doctors."

I nodded, "Completely. I don't see any way to allow that without opening the door to all sorts of potential ethical violations. Think about how easy it would be for a Resident to coerce sex from a student, given the doctor basically holds the student's medical career in their hands."

"Not quite as easy as playing a guitar," Kris smirked.

I laughed, "OK, but in that case, there is no ethical problem!"

"What will all those poor Code Blue groupies do now that José is married?"

"Cold showers," I chuckled. "Kim and Sticks get hit on, but not at the same level as José did."

"And you?"

"I was not lacking for attention," I replied.

Kris laughed softly, "Of that, I'm sure! Out of curiosity, was there anyone besides Ellie who wasn't a groupie who was persistent?"

"Erin Edwards," I replied. "She, too, was OK with cheating, which is, as I've said, an automatic lifetime ban, as it were. She did try to see me after Elizaveta reposed, but I was completely uninterested."

"Who is she?"

"The daughter of the President of the Hospital Board of Directors. I met her when she was a patient during my OB/GYN Clerkship. In those rotations, though, I couldn't touch patients, nor observe exams directly, if you get my meaning. She persistently hit on me despite me being married. The last time I saw her was about a year ago at Stirred Not Shaken."

"What is it with people willing to cheat?" Kris asked. "It makes no sense to me!"

"I agree. I mean, how could you ever trust someone who cheated with you? Well, I guess in Ellie's case, it's just sex, so that doesn't matter, but Erin strongly indicated she wanted a relationship, not just a roll in the hay. If I had to speculate, though, I'd say it's that the 'other woman' thinks she's so much better that she can hold on to the guy, but that's illogical."

"It makes sense you would see things through the eyes of logic, but attraction isn't based on reason, is it?"

"No. The heart wants what the heart wants," I replied.

"Or in their cases," Kris smirked, "the «minou» wants what the «minou» wants!"

"And you?"

"We could put Rachel down for her nap and you could find out!"

"Sounds great!"

_July 3, 1989, McKinley, Ohio_

"I hope you're happier after you see your friends in daycare," I said to Rachel as we walked into the hospital at 5:45am.

"Want Abby!" Rachel insisted.

"In about two weeks," I replied. "When she comes home from Spain."

"NOW!" Rachel demanded.

I suppressed a sigh because, as the quip went, the only difference between terrorists and toddlers was that you could actually negotiate with terrorists.

"Good morning, Rachel!" Marcie exclaimed when we walked into daycare. "We've missed you!"

Thankfully, Rachel gurgled happily as I handed her to Marcie.

"She's done with bottles," I said. "She's drinking exclusively from her sippy cup, and it has to be the purple one."

Marcie laughed, "OK. Is it in her bag?"

"Yes. Kris will pick her up around 5:30pm. I'm on until tomorrow evening."

"Ugh. Those shifts are terrible!"

"I do have a few hours off to play with my band at Milton Lake for the Fourth."

"But close to the end of the long shift, you're going to be beat!"

"I know. My goal is to catch a nap overnight, but there are no guarantees."

"We'll take good care of Miss Rachel!"

"Thanks."

I left my daycare and headed up to the surgical locker room to change, then reported to the ED for my shift.

"Morning, Mike!" Kylie said when she saw me in the corridor.

"Morning! How was overnight?"

"Sunday nights are usually quiet. Twelve hours down, twenty-four to go."

"Who's the Attending?"

"Doctor Taylor."

"Anything interesting on the board?"

"No. Sue Townsend, who's going off shift, just streeted her fender-bender. She's in the lounge."

"Thanks."

I went to the lounge and saw a short, stocky doctor with close-cropped brown hair.

"Sue Townsend?" I inquired. "Mike Loucks."

"Nice to meet you! Nothing to see here, so if you're set, I'm gone! I have a date with a bubble bath and a bed!"

"I'm set," I said. "Who are the students?"

"Bob Banks, Fourth, and Len Godwin, Third. They went to get breakfast."

"Thanks."

She left, and I went to the Attendings' office.

"Morning, Doc," I said to Doctor Taylor.

"Well, well, well, if it isn't Doctor Michael Loucks! How was your first shift?"

"Routine. I caught all fourteen walk-ins."

"You're on the regular rotation today, so you'll get a mix of cases. Check any procedures beyond the basics with me, please. I know you can do them, but we do need to follow protocol."

"Understood. OK to have Bob Banks do procedures he's had signed off in his book?"

"Yes. You can give Lawson a shot at the basics, too; he's competent."

"OK. I'll check in at the nurses' station and await my first case!"

"We're glad to have you here," Doctor Taylor said.

"Thanks."

I left the office, checked in with Ellie, and then went to the lounge. About five minutes later, two medical students walked in.

"Bob and Len?" I inquired. "I'm Doctor Mike Loucks."

"I'm Bob," a short, stocky guy with black hair said. "This is Len."

Len was tall and lanky and had blonde hair that was almost white.

"Nice to meet you both. Please call me Doctor Mike, I much prefer that. May I see your procedure books?"

They both handed them to me, and I flipped through them. Bob had done the usual procedures I'd expect a 'competent' Fourth Year to have done, while Len had far fewer, but that was no surprise, given this was his first clinical rotation.

"Have you decided on a specialty, Bob?" I asked as I handed back the books.

"Surgery," he said. "Doctor Roth said I should learn as much as possible from you."

"That should be true of every rotation with every doctor. And that means asking to do procedures, especially as a Fourth Year. I already cleared that with Doctor Taylor. You'll do as many as I can reasonably assign to you. Len, you'll have opportunities as well. Do either of you know how to read an EKG?"

"No," they both said.

"Len, during your Clerkship in cardiology, make sure you ask Doctor Strong to teach you. Bob, are you doing a Sub-I in cardiology?"

"Yes."

"Then do the same. I take it you know how to attach EKG leads?"

"Yes. I've done it."

"You should have written that into your procedure book," I said. "Next time, do so, and I'll sign off. Len?"

"I've seen several done, but haven't ever done it."

"Do you have a diagram in your notebook for the correct placement and lead colors?"

"No."

"Then the first time we do a twelve-lead, take notes, make a drawing, then study it. I'll expect you to know it by the end of the next shift."

"Got it."

"Doctor Loucks?" Nurse Jenny said. "EMS four minutes out with an MI."

"Doctor Mike, please. Which room?"

"Trauma 1 is open."

"Thanks. Meet us in the ambulance bay."

She left.

"Game time, gents. Bob, twelve lead EKG; Len, draw blood for CBC, Chem-20, and cardiac enzymes. Let's go!"

We left the lounge, put on gowns and gloves, and headed to the ambulance bay, where we waited with Jenny for the ambulance to arrive. I smiled when I saw the large white '2' emblazoned on the ambulance, and when it pulled up, Bobby hopped out.

"Hi, Doc! Jerome McArthur, sixty-eight; complained of severe chest pains while at breakfast; pulse tachy at 110, BP 90/60; diaphoretic; PO₂ 94 on five liters by mask; no history of heart trouble; no known medications."

"Trauma 1!"

Bobby and Jim unloaded the gurney, and the six of us began moving towards Trauma 1.

"Mr. McArthur, I'm Doctor Mike. Where is the pain?"

"Chest and left arm," he said, his words muffled by the oxygen mask.

"When did the pain start?"

"During breakfast, maybe thirty minutes ago."

We moved into the trauma room.

"On my count!" I said. "One, two, three!"

We all lifted the sheet and moved Mr. McArthur to the treatment table. Jenny switched the oxygen supply from the portable bottle to the hospital system, and Bobby and Jim left.

"We're going to get you on an EKG, draw some blood, and do an exam," I said to Mr. McArthur. "Do you smoke?"

"No," he replied as Bob cut open his shirt and undershirt to gain access.

"Drink?"

"Socially."

"Exercise?"

"No."

"Are you taking any medication?"

"No. Aspirin if I have a headache, but not today."

As Bob attached the EKG leads and Len drew blood, I performed an exam and on auscultation, I heard 'distant' heart sounds. I called out the vitals to Jenny, who scribed them on the chart. Bob turned on the EKG and I looked at the screen.

"No ST elevation," I said. "Len, call for a cardiology consult, then get that blood to the lab, stat, please."

"What does that mean?" Mr. McArthur asked.

"ST-Elevation is a sign of the most dangerous type of heart attack. You don't show any elevation in the S-T segment of your EKG, which measures electrical activity of your ventricles. What I do see is something called a low-amplitude QRS complex, which measures both electrical activity and contraction of your ventricles. To put it in layman's terms, your heart is struggling to beat."

"Why?"

"That's what a cardiologist will tell us. You aren't in any significant danger right now. How is the pain?"

"Stabbing."

"Jenny, 5 megs sublingual nitroglycerin, please."

"Right away, Doctor!" she exclaimed.

"Jenny is going to put a tablet of nitroglycerin under your tongue, which will help with the pain."

We continued to monitor Mr. McArthur until the cardiologist arrived.

"Well, well, well," Doctor Alana Pace chuckled as she came into the trauma room with a female Third Year. "Pace, Cardiology. What do we have, DOCTOR?"

"Jerome McArthur, sixty-eight; complained of severe chest pains while at breakfast; tachy at 110, BP 90/60; distant heart sounds on auscultation; weak distal pulse in both legs; diaphoretic; PO₂ 96 on five liters by canula; no previous history of heart trouble; no known medications. 5mg nitro sublingual. CBC, Chem-20, and cardiac enzymes ordered. EKG shows low-amplitude QRS complex, suggestive of  pericardial effusion or infiltrative myocardial disease. Suggest transthoracic echocardiogram to confirm pericardial effusion."

"Good morning, Mr. McArthur," Doctor Pace said. "I'm Doctor Pace from cardiology. May I examine you?"

"Yes."

She repeated the exam I had done, then asked me to step out. I waved for Bob and Len to follow us into the corridor, as did Doctor Pace's student.

"How confident are you in your diagnosis?" she asked.

"Very," I replied. "He has the classic signs; the EKG and exams are consistent with pericardial effusion. We're waiting on blood tests, but I think the echo ought to be done right away."

"I agree. There's no need to wait for the blood test results. I'll take him, and we'll do the echo upstairs. Excellent diagnosis, Doctor!"

"Thanks."

"I see Cutter has you in red," she said.

"Does everyone know about that little battle?"

"I'd say so, given there was a heated debate at the Attendings' meeting that Doctor Getty told us about. He has no dog in the fight, so to speak, so he just sat back and ate popcorn."

"Of course!"

We went back into the trauma room.

"Mr. McArthur," Doctor Pace said, "Doctor Loucks and I agree you need to have an echocardiogram. That's an ultrasound of your heart and will help us confirm your diagnosis."

"Which is?"

"The most likely condition indicated by your symptoms is pericardial effusion, which is an accumulation of fluid around your heart. It's not technically a heart attack, but it could easily lead to one if not treated. Once we confirm, we'll most likely perform a pericardiocentesis, which means draining the fluid."

"What causes that?"

"Any number of things, and I can't really speculate until we do some tests. Once we confirm the fluid buildup, we'll look for the root cause."

"OK."

"Carol," Doctor Pace said to her student, "call for an orderly and bring Mr. Pace up. No need for an EKG during transport as he's not having an MI."

"Yes, Doctor," she replied.

Ten minutes later, Mr. McArthur was on his way up to Cardiology.

"You made a diagnosis straight from the EKG?" Len asked.

"A preliminary one," I replied. "But ultimately, what we found is secondary to the cause of the effusion. There are strong odds it's not a heart problem, so he might end up in Medicine once Doctor Pace performs the pericardiocentesis, assuming it's not some latent heart disease of which he was unaware."

"That happens?" Len asked.

I nodded, "Unless there are obvious symptoms, what happens today is the most common result — a trip to the ED due to onset of chest pains. Most effusions aren't symptomatic, at least in a way that the person suffering from them would notice. And if they're due to viral infection, they usually clear themselves with no intervention. Did you make your drawing?"

"Yes."

"Good. Bob, I'll sign your procedure book."

He quickly wrote in the procedure and I signed off, then said, "Let's report to Doctor Taylor."

We went to the Attendings' office, and I let Doctor Taylor know that I'd sent the patient up to cardiology. He reviewed the chart, scribbled a note and his signature, and handed it back. I thanked him, returned the chart to the nurses' station, and Ellie directed me to the triage desk.

"Morning, Alex," I said to the Fourth Year manning the desk. "What do you have?"

"Take your pick! Nothing critical. Toddler with an apparent ear infection; FF with back pain; carpenter with an infected finger."

"I'll take toddlers with ear infections for $500, Alex," I grinned, hoping someone else would catch the Frequent Flier drug seeker.

"Good lord!" Nurse Lily groaned. "That joke!"

Alex handed me the chart, and I went to the door to the waiting room and opened it.

"Ms. Lopez and Arturo?" I called out.

"Us!" a very pretty Hispanic woman called out, standing up and walking over carrying a crying toddler of about three.

I escorted her and her son into the ED, checked the board, and took them to Exam 5, the larger of the two makeshift exam rooms.

"I'm Doctor Mike and these two men are medical students I'm training. What brought Arturo to us today?"

"He's been crying a lot and started pulling on his ear a couple of days ago. This morning, he complained about pain, so my husband suggested taking Arturo to his pediatrician. They couldn't see him until late this afternoon and he's miserable."

"Let's get Arturo on the table and we'll check him out."

I was reasonably certain what I'd find — otitis media — but obviously I had to do a complete exam.

"Has Arturo had an ear infection in the past?"

"No."

"Any recent injuries or illnesses?"

"No. He's pretty healthy, except for the usual scrapes a little boy gets playing."

"How is his appetite? Any changes in the past few days?"

"He eats a lot, but he burns it up playing fútbol at the park."

I was positive she meant what we usually called 'soccer'.

"OK to examine him?"

"Yes, of course!"

I turned to the fussy little boy sitting on the exam table, who eyed me warily.

"Hi, Arturo. I'm Doctor Mike and I'd like to listen to your heart and breathing, count your heartbeats, look in your eyes, ears, nose, and mouth, and take your temperature. Is that OK?"

"Mama?" he asked.

"He needs to check you, Arturo." Ms. Lopez said.

"OK," Arturo replied, sniffing with a tear running down his cheek.

I washed my hands, put on gloves, and began my exam by listening to Arturo's heart and lungs, explaining each thing I was doing. I used an otoscope to check his ears and nose, changing the speculum between each ear and each nasal cavity. I used my penlight to check his pupils, and combined with a tongue depressor his tonsils.

Arturo's left tympanic membrane was red and bulging, which was a strong indication of otitis media. I checked his tympanic temperature in his non-infected ear, and determined he had a fever of 38.1°C, or just over 100°F. His pulse was elevated, at 85 beats per minute, but he had no other symptoms.

"I believe Arturo does have an ear infection," I said to Ms. Lopez. "Generally, they resolve without treatment beyond Advil or Tylenol to help with the pain. You should give him over-the-counter children's pain killers and follow up with his pediatrician in two days if he's still complaining about pain."

"No medication?" she asked.

"Most ear infections resolve in less than a week without medical intervention. In addition, it could be from a virus, which would mean antibiotics won't help. Except for infants, the best option is Children's Tylenol or Advil, and allow the infection to run its course. Your pediatrician will decide if further treatment is necessary."

"I could have just waited, then, right?"

I nodded, "Yes, though we prefer you err on the side of caution. You should take his temperature every three hours, and if it reaches 102°F, bring him back right away. I can get you the medication now, but honestly, it'll cost ten times as much if I get it for you as if you stop at the drug store just down the road."

"OK."

"Let me fill out the paperwork, and we'll get you on your way."

Bob, Len, and I left the exam room and went to the nurses' station where I filled out the chart and the discharge form, then took everything to Doctor Taylor for his review and signature.

"Any pressure to prescribe antibiotics?" he asked.

"His mom asked, but seemed to accept my answer that they weren't necessary."

"She'll get them from his pediatrician," Doctor Taylor said, writing notes on the chart and signing it and the discharge form. "But not much we can do about that. OK to discharge."

"Thanks," I said as he handed me the clipboard.

We returned to the exam room, I reminded Ms. Lopez about taking Arturo to his pediatrician, then asked Arturo what kind of candy he liked.

"Skittles!" he said.

I pulled a pack from a fanny pack I had purchased to use in the ED when I wasn't wearing a medical coat, and handed them to him, making his eyes light up.

"Doctor Houdini?" Ms. Lopez asked.

"I have a dozen different things in my pack plus spares in my locker," I chuckled, then turned back to my patient and said, "Arturo, you only eat those when your mom says it's OK."

"Arturo, thank the doctor!" Ms. Lopez said.

"Thank you," he said.

"Ms. Lopez, you can see Patient Services on your way out. It's the office next to the door to the waiting room. They'll get your insurance information and make arrangements for billing them."

"Thank you, Doctor!"

We all left the exam room and Ms. Lopez and her son went to Patient Services.

"I thought antibiotics were routine for infections," Len said.

"They used to be," I replied. "But their efficacy with ear infections is iffy at best, and as I said, if it's viral, they won't do any good. Overuse of antibiotics is a major problem, which should have been covered in your pharma class."

"It was, but they didn't say anything about not prescribing for ear infections."

"OK. Just something to remember."

"Why did Doctor Taylor say her pediatrician would prescribe them?"

"Because it's easy for us here in the ED to say 'no', but pediatricians often give into parental pressure because it's the path of least resistance, not to mention the guidance on antibiotics for ear infections is relatively new."

We went to the lounge and less than a minute later, Nurse Ellie came to the door.

"Doctor Mike?" she called out. "Multi-victim MVA. Doctor Taylor wants you with him and Doctor Foulks."

"On it!" I said. "Bob, Len, let's go!"

We gowned and gloved and met Doctor Taylor in the ambulance bay where Doctor Foulks and his medical students, along with two nurses were waiting.

"Any idea how bad?" I asked Doctor Taylor.

"Two critical," Doctor Taylor said. "One in arrest."

Which meant that a firefighter would be assisting with CPR and the chances of survival were low.

"Nick," Doctor Taylor said to Doctor Foulks, "we'll take the arrest. You take the other one."

"OK," Doctor Foulks agreed.

A minute later the first EMS squad came to a stop in the ambulance bay and a paramedic jumped out.

"Male, fifty-ish; unrestrained driver; cardiac arrest as we prepped him for transport; continue CPR and bagging; obvious head, chest, and leg injuries. IV saline TKO."

"Trauma 3!" Doctor Taylor ordered. "How long was he down?"

"It's been at least twenty minutes," the paramedic replied.

The gurney was removed from the ambulance and a firefighter got on, straddling the patient, performing chest compressions while the paramedic bagged the patient. Doctor Taylor, Bob, Len, Nurse Kelly, and I all rushed the patient to Trauma 3.

"Mike, EKG and monitor! Bob, Foley! Kelly, hang a bag of plasma, draw for a blood gas, type, and crossmatch."

I grabbed the bandage scissors and quickly cut away the patient's shirt while Bob did the same with his jeans. I began attaching the leads which required a bit of contortion on my part so the fireman could continue with compressions.

"Hold compressions," Doctor Taylor commanded.

He quickly listened.

"No heart sounds," he said. "Continue compressions."

I turned on the EKG and quickly scanned it.

"PEA!" I declared. "Atropine and sodium bicarb, IV push."

"Do it, Kelly!" Doctor Taylor ordered. "Mike, he needs a chest tube. You're wearing red and have the 'S' on your badge, and we can't wait for a surgical consult."

That wasn't protocol, but it was technically within the rules, as I was a surgical intern and I was being supervised directly by an Attending.

"Len, chest tube tray!" I ordered.

He brought it to me, ripped it open, and I squirted Betadine onto the correct area.

"Atropine and bicarb are in!" Kelly called out.

"Cease compressions," I ordered.

Once the fireman stopped, I proceeded with the steps Doctor Rafiq had reluctantly taught me.

"Blood in the chest cavity!" I announced as blood came out of the tube.

"Heartbeat!" Bob called out. "Irregular, I think."

The firefighter climbed off the table and I looked over at the EKG and there was, indeed, indications that the patient's heart was beating. While I connected the ThoraSeal, Doctor Taylor auscultated and nodded.

"Faint heart sounds," he said. "Len find the on-call surgical Resident!"

The firefighter and the paramedics left, as CPR was no longer necessary.

"Thoracotomy?" I asked.

"If we can stabilize him," Doctor Taylor replied. "OK, heartbeat is weak but regular, let's intubate and do a full exam. Mike, tube him."

"OK to have Bob try it?" I asked.

"Once. First time or you do it."

"Kelly, intubation tray, please," I requested. "Bob, come stand by me."

"Are you sure, Doc?" he asked.

"I am, but if you aren't, stand aside, watch, and I'll do it and give you step-by-step instructions."

"Uhm, that's probably better."

"OK."

I intubated the patient and hooked the tube to the ventilator.

"Lindsay, surgery," Doctor Lindsay said, coming in with Jack Talbert, a Fourth Year.

It was odd for a Senior Resident to catch an early morning consult, but it happened from time to time. Most likely that meant her scheduled procedure had been canceled.

"Fifty-ish male; unrestrained MVA; arrested on site; CPR; PEA detected; revived with atropine and bicarb; pulse weak at 60; BP 80 palp; vent at eighteen with PO₂ 98%. Blood in the chest cavity; broken right tibia; severe contusion left temple; chest tube is in."

"Who did that?!" Doctor Lindsay asked, surprised.

"The surgical Resident!" Doctor Taylor said. "On my orders."

"Let me check that first, please. Hi, Mike."

"Hi, Doctor Lindsay. I followed Doctor Rafiq's technique."

She examined the tube, the ThoraSeal, and the sutures and nodded. "Looks good."

She did a quick exam and nodded, "We need to find the source of the blood, but he's unstable. Let's give him some pressers and blood and see if we can get his BP up. If not, he'll never survive me opening him up, and might not even make it upstairs."

"Kelly," Doctor Taylor said, "hang a unit; a meg of epi IV push, half a meg every five minutes."

"Yes, Doctor!" Nurse Kelly replied.

"Emergency thoracotomy?" I asked Doctor Lindsay.

"We don't have what we need here in the ED," she said. "You know the protocol."

I did, and when the new ED wing opened and I'd completed enough of my Residency, we would have emergency thoracotomy kits in the ED, but for now, we didn't, and couldn't, per hospital protocol.

The monitor blared, and I looked up.

"V-fib!" I said.

"Mike, charge to 150!" Doctor Taylor ordered.

I flipped the switches on the defibrillator, twisted the dial, then handed Doctor Taylor the paddles and squired gel on them.

"Charged!" I declared when the machine beeped.

"CLEAR!" he commanded.

I removed the vent connection and everyone stood back while he shocked the patient.

"No conversion!" I said once the EKG settled from the massive rush of electrical energy.

"Charge to 200!"

I did and Doctor Taylor shocked the patient again."

"No conversion," I said.

"250!"

I twisted the dial but before the machine beeped and the monitor tone went steady.

"Asystole!" I said.

"A meg of epi down the tube!" he ordered.

I grabbed the vial, as I was closest, drew the liquid into the syringe, then squirted it into the vent tube and reconnected the vent.

"Nothing," I said fifteen seconds later.

"There's no point in flogging him," Doctor Taylor said. "He's had three doses of epi, and another dose isn't going to make a difference. He was down for at least twenty minutes before he got here. Time of death, 0811."

"I'll get the death kit," Kelly said.

I turned off the EKG and monitor, waved for Bob and Len, and we left the room.

"Why give up?" Len asked.

"At some point, you decide it's hopeless," I replied. "With a potentially severe head injury, internal bleeding, and having been down for thirty minutes, it was a near miracle we got any kind of heartbeat at all. You know the survival rate for CPR, right?"

"Under 20%," he replied.

"And that's for heart attacks. While it won't appear on Doctor McKnight's report this way, his cause of death was not wearing a seat belt."

"What a stupid way to die," Len said.

"I agree."