Chapter 22 — I Didn't Call to Fight

_July 17, 1989, McKinley, Ohio_

{psc} "I can remove the cervical collar," I said after examining Mr. Gross' neck.

"It really hurts, Doc."

"Nothing is broken, and I don't feel any swelling," I said. "We'll give you some Tylenol 3, which will take care of the pain."

"Tylenol?"

"This actually is a combination of acetaminophen and codeine, not the same thing you buy at the drugstore," I replied. "Let me speak with Doctor Williams and we'll get it for you."

I removed the cervical collar, updated the chart, then Len and I went to find Doctor Williams, who was at the nurses' station.

"OK to present?" I asked.

"I thought it was minor, but go ahead."

"It is minor. No appreciable injuries; BP 120/70; pulse 72; PO₂ 99% on room air. Complains about 'extremely sore neck', but no appreciated tenderness or swelling."

"What are you not saying? Your tone of voice says there's something.

"When you came in, he asked about you and I explained you were a senior physician, and he asked how long I'd been a doctor. When I explained I'd just graduated, he said 'kids' and freely shook his head. The paramedics reported he was arguing with the other driver on the way in."

"Ah. So why the codeine?"

"Because it is entirely possible he has a mild case of whiplash, and pain can't be proved one way or the other. He might actually be in pain, and given I see no indication he's drug seeking, the standard of care is to provide pain relief. I'll discharge him with instructions to see his personal physician for a follow-up, but his chart will reflect my findings."

"So when he files his insurance claim, he comes up dry?"

"That'll be between him and his physician."

"Approved. Chart?"

He signed off and made notes, and I went to Ellie and asked for the drugs, showing her the signed chart. She retrieved two tablets for me from the Schedule Drug locker, and I took them to Mr. Gross.

"Len, a cup of water, please," I said when I returned to the room.

Len got the water and handed it to Mr. Gross, and I handed him the small paper cup with the two tablets.

"These will be very effective for pain relief," I said. "After six hours, you can take three regular Advil every six hours, and you should follow-up with your personal physician within forty-eight hours. He'll manage any pain or whiplash symptoms."

Mr. Gross swallowed the tablets and handed the cup back to Len.

"I'm going to fill out your discharge papers. Is there someone we can call for you?"

"My wife," he said.

"Len, get the number and call Mrs. Gross, please. I'll be back in a few minutes.

Ten minutes later, Mr. Gross was shown to Patient Services.

"He was faking," Becky said.

I nodded and showed her the chart.

"WAIT!" Len protested. "He was faking?!"

Becky smiled, "I was pretty sure Doctor Mike caught it. I saw it in his eyes when the patient shook his head."

"Which you don't do if you have whiplash," Len said.

"Exactly," I replied. "Take a look at what I wrote on the chart."

Becky handed it to him.

He nodded, then read aloud, "'Patient claims neck pain but has no appreciable injuries or signs. Paramedics report patient combative during transport. Tylenol 3 PO, but no script. Follow up with PP'. Then why the pain meds?"

"What is the one thing we have no way of independently verifying under any circumstances?"

"Pain."

"And the standard of care?"

"Appropriate analgesia unless the patient appears to be drug-seeking."

"Correct. And if they appear to be drug-seeking?"

"Psych consult or social worker."

"Doctor Mike," Bob said, approaching with a chart. "Rule-out MI with heartburn ready for discharge."

"Did you perform an exam?"

"Yes, and I have an EKG strip for you. Cardiac enzymes negative on repeat test."

He handed me the chart, and I looked at the EKG strip which showed textbook sinus rhythm, and cardiac enzymes that were in the lower middle of the acceptable range. Nothing else was amiss, so I signed the chart and discharge form.

"Street him," I said, handing back the chart. "OTC heartburn medication and follow-up with his personal physician."

Bob took the chart and left.

"Thanks for stroking my ego," I said to Becky.

She smiled, "I actually meant it!"

"I believe I need more experience before that would apply."

Becky shook her head, "I didn't say you were the most experienced; I said you were the best."

"And you can tell that after two weeks?"

"Would I lie to my little brother?"

I laughed, "Well, given how my little sister and I treat each other…"

"Good point! I have an older brother, and, yeah. Even now!"

"My mom and her older brother are the same way. My grandparents even commented on it at dinner yesterday."

"And my sister and me," Len said. "I think it's universal."

"Mike?" Ellie called out. "Walk-in teen with breathing difficulties. Bringing them to Trauma 4."

Len, Becky, and I saw Jamie bringing a teenage male from the waiting room in a wheel chair and we followed them into Trauma 4. It was a fairly straightforward asthma case, resolved with a nebulizer of albuterol, and I turned him over to Bob to discharge after two hours of observation.

We had a bit of a lull, then a series of routine walk-in cases, with no EMS transports. I sent Len and Bob to lunch at staggered times and then took mine at 12:30pm so I could meet Antonne in the cafeteria.

"How are things going?" I asked Antonne as we joined the line.

"Great, actually. My mom loves her job working for…how should I refer to him?"

"It's OK to call him my father-in-law," I replied. "The law may not see it that way, but he's Rachel's grandfather. Go on."

"Anyway, mom loves her job, as I said, and the housing here is far better than what she had in Cleveland, and it won't be long before she can get out of the subsidized housing. My brother and sister are both happy, though they miss their friends. That said, they're both glad to be out from the gangs. I'm working at Kroger stocking shelves. How about you?"

"The hours are brutal, but I love what I'm doing."

"I won't ask about interesting cases, because I'm positive the others will want to hear about them. Will you have time starting in August?"

"I'll make time," I replied. "I don't know what my schedule will be beyond the end of August. Until then, I'm on two thirty-six-hour shifts, one starting at 0600 on Mondays and the other 0600 on Thursdays, and then a twelve-hour shift on Saturdays, starting at noon."

"Military time?"

"All our schedules use military time, as do our charts, time of death announcements, and so on. It prevents any confusion. One major point is noon and midnight, which would both be twelve, where so many people mix up am and pm because you go from 11:59pm to 12:00am and 11:59am to 12:00pm. Both of those are by convention, too. With the twenty-four-hour clock, what you called 'military time' has no possible confusion because 2400 is never used in the hospital."

"I don't look forward to those shifts."

"There's a good chance you won't have to do them. New York passed legislation to limit shifts to twenty-four hours, with a maximum of eighty hours per week, and with a minimum of eighteen hours between shifts. That was in response to the Libby Zion case we discussed. That will likely spread, though it could take some time. That said, it's seven years before you're a doctor, so I'd wager you won't have thirty-six-hour shifts."

"Have you heard from any of the others?"

"No. I figured that would be the case, given a mix of how busy I am and the fact that none of them live in McKinley. Just remember, your break between graduation and med school is the last one you'll have until you've served your Internship."

"Are there any black doctors at this hospital?"

"Five, I think. Only one in the ED — Paul Lincoln. He's a PGY1 like me. For a brief period, Doctor Gibbs was the only female, but there are more now. Surgery is the true boys' club with just two female surgical Residents. Fortunately, McKinley Medical School's ratio of male to females is shrinking, but they're still lacking in minority applicants. I'm hoping all six of you apply there."

"You know Danika is going to go to Stanford, right?"

"I strongly suspect that's the case, but we'll see what happens two years from now. Maybe she'll meet the right guy and decide to stay in the area."

"YOU were her right guy!" Antonne declared. "And from what I understand, you felt she should go to Stanford."

"I didn't realize that was public knowledge."

"I wouldn't call it public, but everyone in the group knew it, just as they knew Conchita would have married you just to be Rachel's mom!"

I chuckled, "I got that impression, but I needed an Orthodox wife."

"How do you have time for church?"

"As with everything else that's important, I make time. It's when there are important things which conflict that tough choices have to be made."

"But medicine always comes first, right?"

I nodded, "Yes, and even if I wasn't predisposed to that, it would be forced on me. As I've said, medicine is a harsh, demanding, jealous mistress, and she does not brook anyone or anything interfering with her demands."

"How does your wife handle it?"

"You'd have to ask her! But I made absolutely sure she knew what she was walking into before we married. Over the years, quite a few girls who might otherwise have been very interested took a look at the demands of medical training and Residency and chose not to pursue a relationship with me. Is there anyone special in your life?"

"There was a girl back in Cleveland, but she'll only be a Senior, and I don't think she's mature enough to handle the kind of life I'm going to have."

"My advice is when you find someone who can, you marry them. That's going to be FAR more important than being in love with them."

"Crazy."

"We are! It's the only way to stay sane!"

Antonne laughed, "That's so Zen!"

"I know you were raised Pentecostal, but I think you'll find a lot of wisdom in Eastern philosophy."

"You mean Buddhist?"

"Among other things. I'd recommend taking World Religions along with a philosophy class in your electives. It'll pay off."

"What about Latin?"

"It helped, but you can memorize the words by using flashcards. What language did you take in High School?"

"German, of course. This is Ohio, after all!"

"Given who I married, I probably should have taken French, but there was no way to know this is where I'd end up."

"Is Kris teaching Rachel French?"

"No, but my troublemaker sister-in-law is!" I chuckled. "I know Rachel's grandparents use Russian with her, and so do my grandfather and grandmother, but it's mostly English."

"Sisters are always troublemakers!"

I laughed, "I agree, and I just had that conversation earlier."

When we finished our lunch, Antonne left for a shift at Kroger and I headed back to the ED. The afternoon was busy with a mix of walk-ins and EMS transports, but nothing out of the ordinary. I admitted an MI and a diabetic, and streeted eight patients before Kris and Rachel arrived so we could have dinner together.

When I returned from dinner, Mary and Tom had taken over for Bob and Len. Almost immediately we had an EMS transport for an MI. I checked the board for an open trauma room, then we gowned and gloved.

"What are we doing?" I asked Mary as she, Tom, and Nurse Kellie waited in the ambulance bay.

"High-flow oxygen, EKG, and monitor. CBC, Chem-20, ABG, and cardiac enzymes."

"You have your cardiology rotation next, right?"

"Yes."

"Make sure you ask to be taught to read EKGs, and I don't mean just the basics. Doctor Strong is a good choice to ask, as he's an excellent teacher, as is Doctor Javadi."

"Already on my list of things to learn before this time next year."

The EMS squad turned into the driveway and, a few seconds later, pulled up in front of us.

"Art Nesmith, fifty-three; collapsed while dining; complaining of severe chest pain; diaphoretic; BP 180/120; tachy at 120; PO₂ 98% on nasal canula; history of hypertension according to his wife; taking Capoten; no IV due to hypertension."

Which was the right move, as adding fluids was the last thing a hypertensive patient needed.

"Trauma 3!" I ordered.

Three minutes later, after performing an auscultation and hearing no irregular heart sounds, I looked at the EKG and saw sinus tach, but no indication of an MI.

"What do you see, Mary?"

"Sinus tachycardia, but otherwise, no deviations."

"Differential?"

"With systolic of 180, hypertensive crisis."

"Mr. Nesmith, have you taken your medication today?"

"Yes," he replied, clearly in pain.

"First thing we need to do is get your blood pressure down. Have you been diagnosed with any liver problems?"

"No."

"Have you had a heart attack?"

"Just this one."

"I don't believe you're having a heart attack," I said. "Have you seen a cardiologist?"

"No. My doctor is treating my high blood pressure."

"Billie, sublingual nitro tab, then chlorpromazine, 50 megs IM, please."

"Right away, Mike!"

"Mr. Nesmith, the nitroglycerin will reduce the pain and help lower your blood pressure. The nurse will put a tablet under your tongue. She'll then inject you with chlorpromazine, which is an anti-hypertensive, that is, combats high blood pressure."

"OK," he said with a grimace.

"I'm going to complete the exam," I said.

I went through the usual exam steps, asking the usual questions. I wasn't surprised that Mr. Nesmith drank several cans of beer a day and smoked, and ate plenty of fried foods.

"Did your doctor discuss the effects of diet, alcohol, and smoking on your hypertension?" I asked.

"He's a pain in the ass!" Mr. Nesmith declared.

I decided I'd let Medicine deal with that, and simply let it go.

"We're probably going to need to admit you to get your blood pressure under control. Would you like your wife to come in?"

"Sure."

"Tom, would you see if his wife is in the waiting room and bring her in? Mary, call for a Medicine consult for hypertensive crisis, please."

Everyone followed my instructions and five minutes later my consult from Medicine arrived.

"Hi, Petrovich! What do you have?"

"Hi, Lissa!" I replied, then gave her the information.

"Mr. Nesmith, I'm Doctor Saunders from Internal Medicine. I'd like to examine you, please."

He agreed, and she performed her exam.

"No arrhythmia and stable, so I'll take him," Clarissa said, then turned to her student, "Jay, call for an orderly, please. When we get upstairs, you'll need to do the admission paperwork."

"Yes, Doctor," he agreed.

Ten minutes later, Mr. Nesmith, his wife, Clarissa, and Jay left the room to head up to medicine.

"Petrovich?" Mary asked.

"Mikhail Petrovich Loucks," I replied. "Or in English, Michael Peter Loucks. My dad's name is Peter, so that became my middle name, because Russians use patronymics instead of middle names. The 'vich' part means 'son of'."

"So, you're a son of a vich?" Billie asked with a silly smile, causing Tom, Mary, and me to laugh.

"ANYWAY," I said when I could after laughing so hard, "close friends call each other by the patronymic. Clarissa and I have been partners in crime since Freshman year at Taft."

"You're Russian?" Tom asked.

"«Да, товарищ»," I replied.

"I don't speak Ruski!" Tom declared.

"'Yes, Comrade'. Half, anyway. My dad is Dutch, from the time when Manhattan belonged to the Dutch. My mom's side of the family is Russian."

We left the room and Nicki waved me over.

"You had a call from a Doctor Fran Mercer in Milford. She left a number."

She handed me the message slip, I thanked her, then contemplated what to do. I decided I should return the call and went to the consultation room that served as an office for the Residents. I shut the door, sat down, and said forty repetitions of the Jesus Prayer before picking up the handset and dialing the number.

"Fran Mercer."

"Doctor Loucks returning your call. I'm on shift. What can I do for you?"

"I didn't call to fight, Mike," Doctor Mercer said. "I called to apologize."

"For?"

"How much time do you have?"

"I can't guarantee I won't be called for a trauma, so I can't really say."

"When would you have time to talk?"

"Wednesday during the day," I replied. "I'm on until 1800 tomorrow, sorry, 6:00pm, then I'll go home, eat, and collapse."

"Could you call on Wednesday morning at 9:00am?"

"I could. Your office or this number?"

"My office please."

"I'll call you on Wednesday."

"Thanks. Have a good evening."

"You, too."

I hung up and left the consultation room, wondering how far her apology might go. The fact that she had called at all was a good sign, given everything I'd said to her in the past. I was extremely curious about what she would say, but my duties in the ED had to take priority over my curiosity. I pushed those thoughts into the back of my mind and refocused on the ED.

"I heard Callie got to close an appendectomy," Mary said when I joined her and Tom in the lounge.

"Right place, right time, right circumstances," I replied. "Basically, all the planets aligned, and I did most of the suturing while she closed the epidermis. And that only happened because both Attendings and the on-call Resident were handling a traumatic amputation and the remainder of the staff was on the golf course for the annual golf outing."

"I'd…sorry, never mind."

I chuckled, "Give your eye teeth?"

"Yes, _that_ is what I was going to say because I'm my grandma!" Mary replied with a smile.

"Trust me, I know the feeling, and making deals with the Devil is not uncommon, but also not wise. The Devil always gets the best of you."

"Well, I want to know which god I offended so I can atone and get into the OR!"

"Unfortunately, I think Loki is in charge of the hospital!"

"The Norse trickster god?" Tom asked.

"Yes. Either him or Shiva."

"Which one is that?"

"The Hindu god of creation and transformation, but also known as 'the Destroyer'. Interestingly, both Loki and Shiva are associated with serpents, along with Moses, and we have a serpent on our badges on the Staff of Asclepius."

"So it's snakes all the way down?" Tom asked.

"Quoting Stephen Hawking in _A Brief History of Time_ quoting, supposedly, an anecdote by Bertrand Russell?"

"Yes! I laughed hard when I read that."

"It's related to the critique Russel made of the 'First Cause' argument for the existence of God, though in his words, the Indian guru asked to change the subject."

"What do you think of the argument?"

"I'm Russian Orthodox, so I don't. Given it is impossible to prove the existence of something which is outside the universe, and given no philosophical argument will ever satisfy someone who is convinced God does not exist, why waste time or energy? To rephrase something one of our bishops said — let the philosophers fight over proofs of God's existence, and let us worship the undivided Trinity who has saved us.

"As with so many conflicts between faith and science or faith and philosophy, we have no dog in that fight. From our perspective, the Scholastics did grave harm to the faith by trying to tie it all neatly up in a rigorous philosophical package, something we would maintain is impossible. Experience has borne us out on that belief. And this is where I stop talking theology on duty."

The timing was perfect because we were called for a walk-in hand lac, which I assigned to Tom, with Mary guiding him, and me standing aside and supervising.

"Is this like the government road crews?" Mr. Metcalf, the patient, asked.

I chuckled, "It might seem so, but this is how medical training is conducted. Tom is suturing and Mary is acting as his supervisor. I'm here to ensure everything goes well and to evaluate both of them."

"How long have you been a doctor?"

"I received my MD on May 25th," I replied. "But I have around 8000 hours of clinical experience, most of that from before my MD was conferred. Those clinical hours were exactly like what Tom and Mary are doing right now."

"But if you just graduated…"

"The same thing happens in complex traumas — I'll be assigned to work with a more senior doctor. There's an adage that, while not literally true, captures how medical training works — watch one, do one, teach one. I still need a senior physician, called an Attending, to sign off on some procedures, and to prescribe all Schedule II and Schedule III drugs, which is basically anything addictive. But for sutures and a tetanus shot, I have a notation in my procedure book," I held it up, "that authorizes me to do it without needing to be checked. Mary has a signature from me in her book for that, but until she's actually an MD, I'd have to check her work."

"Interesting. It almost sounds like my situation as a Master plumber."

"You're not as far off as some might think. We have Interns, Residents, and Attendings. I'd compare medical students to your apprentices or entry-level jobs. An Intern or Resident is akin to a Journeyman, and an Attending is akin to a Master. Training is partly classroom and partly hands-on. A friend of mine is an electrician, and that's how he's trained."

"Same for plumbers."

"I've had people compare an angioplasty to a roto-rooter job."

Mr. Metcalf laughed, "A snake through a blood vessel to open a blockage?"

"Exactly! And an arterial graft could be compared to fixing a broken or leaky pipe."

"Sign me up, Doc! I bet it pays better!"

I chuckled, "You'd lose that bet. My friend the electrician makes more as a Journeyman than I do. He'll make more than I do until I'm an Attending, which is about eight years from now. Mary and Tom are paying for the privilege of working."

"Get out of here!" he protested.

"I pay tuition," Mary said, "and don't get paid for working, so Doctor Mike is technically correct."

"I thought docs made big bucks!" Mr. Metcalf countered.

"Surgeons, especially plastic surgeons, do," I replied. "Also, Attending physicians at large hospitals or at research hospitals tend to be paid much higher salaries. Residents work for a relative pittance."

"You're an ER doc, right?"

"I'm actually training to be a trauma surgeon," I replied. "That's why I'm in red while Mary and Tom are in blue. Surgeons here wear red."

"What's the difference between you and a regular ER doc?"

"I'll be able to do minor surgical procedures during a trauma, including inserting chest tubes, central line IVs, and tracheostomies. Right now, a surgeon has to be called to do that. In the future, there will be trained surgeons assigned to the Emergency Department. I'm the first one at this hospital."

"Finished," Tom announced.

"Mary?" I prompted.

"Nice, even sutures, wound edges properly approximated. OK to administer the tetanus booster?"

"Yes."

She handed Tom the package and walked him through the process. Once that was complete, Mary filled out the chart and handed it to me to sign, which I did. Tom provided the discharge instructions and then directed Mr. Metcalf to Patient Services.

"Excellent work, Tom," I said once we were sitting in the lounge.

"Thanks. This Clerkship is the only one where I'll actually get to do procedures, right?"

"Generally speaking, yes. You'll monitor patients, take vitals, do wound checks, and so on, on the other services, but actually doing procedures is pretty much limited to the ED until you've graduated. There are some exceptions, such as Pathology or if you do a rotation at the Free Clinic."

"What was the coolest procedure you did as a med student?"

"Retrieving a lost condom with a speculum and forceps."

"Lost cond…wait! _Inside_?"

"If you don't hold on to them, they can slip off," I said. "And worse is allowing yourself to go soft before withdrawing."

"I bet that ruined their day!" Mary exclaimed. "Leaked?"

"Yes."

"How old?" Tom asked.

"Freshmen at Taft."

"Not quite as bad as being sixteen, but bad enough. How could you do that as a med student?"

"Because during my OB/GYN rotation, I participated in exams."

"And I thought you were going to say something along the lines of knowing your way around a pu…vagina!"

I chuckled, "That would be _exactly_ what Doctor Saunders would say to tease me! But she'd use the non-medical term you self-corrected away from, which I appreciate."

"If you two are so close, I'd have thought you two might…" Tom stared.

"She has a _girlfriend_, you idiot!" Mary interrupted, laughing.

"Oops," Tom said. "Sorry."

"No need to apologize," I said. "Clarissa doesn't hide it, but she also doesn't make a big deal about it."

"Mike?" Billie called out from the door to the lounge. "EMS four minutes out with a possible stroke. Doctor Taylor asked you to join him."

"Thanks. Let's go!"

We gowned and gloved and joined Doctor Taylor and Jamie, the male nurse, in the ambulance bay.

"Mary, how do you feel about intubation?"

"I can do it, Doctor Taylor," she said firmly.

"Do that. Tom, EKG, and monitor. Mike, supervise Mary, then peripheral muscle tone and reflex checks."

"Will do," I confirmed.

"Jamie, trauma panel; Billie, Foley. We'll decide on thrombolytics once we assess the patient. Mike, which drug would we use?"

"Off-label t-PA would be my choice," I said. "It's normally given for STEMIs, but has shown better success with strokes than streptokinase. Alternatively, streptokinase and heparin followed by ASA."

"Interesting," Doctor Taylor said. "Based on?"

"A recent article in _Journal of the American College of Cardiology_," I replied.

"We'd need approval from Doctor Getty and Doctor Northrup before we could do that. Neither of them are in the hospital."

"Then streptokinase, boosted by heparin, followed by ASA," I said.

The EMS squad pulled into the driveway.

"You're not wrong, Mike," Doctor Taylor said, "just a few years ahead of the game. We only started using t-PA with STEMIs in June."

The EMS squad rolled to a stop, and the paramedic jumped out.

"Bill White, sixty-seven; BP 170/90; pulse 110 and thready; PO₂ 99% on ten liters; vomited, then passed out; GCS 6; pupils sluggish; drooping left eyelid and facial palsy."

"Trauma 1" Doctor Taylor ordered.

"We're going to need a CAT scan as soon as we stabilize him," I said as we rushed Mr. White to the trauma room.

"Agreed."

The team quickly moved Mr. White to the trauma table, and Mary did a good job intubating the patient. As soon as I'd verified the breath sounds, I began checking Mr. White's extremities.

"Tobacco stains on his fingers," I said. "Consistent with the discoloration of his teeth."

"Did you notice a gag reflex on intubation?"

"Mary?" I inquired.

"Minimal," she said.

"Poor peripheral pulse, both lower extremities," I said. "Both flaccid and with some edema."

"Preliminary diagnosis is subarachnoid hemorrhage," Doctor Taylor said.

"Indicates no thrombolytics," I said.

"Agreed," Doctor Taylor said. "Let's get neuro down and see what they want to do. Tom, make the call, please. Mike, what do you see on the EKG?"

"PVCs and SVTs," I replied. "We want to try to bring down his systolic pressure, but we don't want to give him anything that's going to cause bleeding. And we want to address the arrhythmia."

"IV labetalol," Doctor Taylor said. "The contraindications are hypotension, bradycardia, and cardiogenic shock."

He gave the order to Billie, and she went to get the drug from the drug locker.

"More PVCs," I said. "He's decompensating. Recommend digoxin."

"Agreed."

When Billie returned, she administered the labetalol and Doctor Taylor ordered digoxin.

"Cohen, Neuro," Rebekah Cohen said when she came into the room with her student Joy.

Doctor Taylor explained the case, and she performed an exam.

"CAT scan," she said. "We'll take over."

"All yours, Rebekah," Doctor Taylor said. "Tom, stay and assist."

Josh, Mary, and I left the room. Over the next four hours, Mary and I, and eventually Tom, handled a steady stream of walk-in patients, none of which actually needed a trauma doctor.

"As useless as the idea likely is," I said to Mary just before midnight, "I'm going to try to take a nap. Naveen will handle anything that comes in for the next two hours, so you and Tom should try to get some rest if you can."

_July 18, 1989, McKinley, Ohio_

I actually managed thirty minutes of uninterrupted sleep before Billie woke me.

"Doctor Williams asked me to wake you," she said. "House fire with multiple victims. First transport is five minutes out."

"OK," I said.

I pulled myself from the bunk, took off my eye mask, and went to the locker room to empty my bladder. Once that was accomplished, I washed my hands, splashed a bit of cold water on my face, and headed to the ambulance bay where basically the entire medical staff was assembled.

"How many and how bad?" I asked Doctor Williams.

"Five, and pretty bad. Three of them are kids. Pedes was notified."

"Smoke or burns?"

"Both."

"Did anyone notify the air ambulance crew?"

"They're on stand-by."

The next ten minutes were pure chaos as the patients arrived — a family of five, with the father being the most severely injured as he'd rescued his kids before collapsing trying to rescue his wife, with both of them suffering significant smoke inhalation and moderate burns. Fortunately, none of them were burned badly enough to need to go to the burn center in Columbus, but three of the five — the dad, mom, and seven-year-old son were admitted to the ICU, while the five-year-old daughter and two-year-old son were admitted to Pediatrics.

"That could have been a lot worse," I said to Doctor Taylor about ninety minutes later when the last patient had been transported.

"Gutsy move going back into the house four times," Tom observed.

"There's a fine line between gutsy and foolish," Doctor Bill Schmidt, a PGY2, added. "He came damned close to crossing it."

"And if they were your kids?" I asked.

"That's why I said 'damned close'. I'd have done the same thing."

"Think they'll all make it?" Naveen asked.

"I'm worried about the dad," he said. "The pulmonary compromise was pretty severe, and CO levels high enough that the pulse oximetry was useless."

"Why?" Tom asked.

"Mike?"

"Carbon monoxide attaches to hemoglobin and the pulse oximeter cannot distinguish between it and oxygen. So with an ABG showing 10% carbon monoxide and 80% oxygen, you'd see a PO₂ of 90%, but that's a false number."

"How do you know?"

"Cyanosis is the key," I replied. "If you see it in a smoke inhalation victim, you don't trust the oximetry numbers and get a stat ABG."

"Oxygen is the only treatment, right?" he asked.

"Yes," Doctor Williams replied, "with hyperbaric O₂ being the current gold standard."

"One more piece of equipment we don't have," I observed.

"It's been on medicine's 'wish list' for about five years, but there's no space for it even if we could get the funding. That should change in about five years when the new ED and surgical wings are completed. Remember, ten years ago this wasn't even a Level II trauma center. Most patients were transported to Columbus. Anyway, Naveen, you and your students grab a nap. Mike will cover walk-ins."

"Tom, go relieve Norm at the desk and we'll be right there."

Mary smiled at that, as that meant she'd get a chance to do procedures, rather than be stuck in triage. I went to get some coffee from the lounge, and Mary followed me.

"Thanks," she said.

"You're welcome. You take the lead and I'll kibitz as needed."

"Norm was complaining earlier about being assigned to Naveen and not getting nearly as many opportunities."

"All I can do is train my students and set an example. It's also the case that I don't know Norm well enough to judge if he should be given the same opportunities as you've been given. You have the personality and mindset for trauma. Without it, you wouldn't be given the opportunities."

"Can I ask something you might not be able to answer?"

"You can always ask."

"How does someone as high-strung as Doctor Lewis get a Residency slot?"

"I can only theorize that he interviewed very well. "He graduated in the top ten in his class in medical school. Let me ask you a question — should I reference Tom's panic attack following the helicopter incident in his evaluation?"

"I don't think that would be fair," she replied.

"There's at least part of your answer."

"You mean being cut slack for being inexperienced?"

"More or less. And, honestly, until you're actually baptized in fire, you don't know how you'll respond."

"You're cool as ice."

I chuckled, "And yet, I have nothing on Nurse Kellie who's only response to the incident was to say 'we have two engines'. I'd say my pulse was in the 150 range from all the adrenaline. I'd bet hers never hit 120, if it even broke 100."

"One more question, if I may."

"Sure."

"Is it wrong to be disappointed we didn't have to fly someone to Columbus?"

"I once observed that I wanted more procedures, but the only way that could happen is if someone was sick or injured, which bothered me tremendously. The way I balanced that in my mind was that the universe would provide patients whether I was here or not, and someone would have to treat them. I wasn't asking for more people to be sick or injured, just the opportunity to treat a higher percentage of them.

"To answer your question directly, every medical student in the history of the world has wanted more procedures and been disappointed when they missed out on something they truly wanted to do. That includes me, Doctor Gibbs, Doctor Javadi, Doctor Subramani, Doctor Saunders, and on and on. I could list the entire medical staff. So, no, don't feel guilty about wanting procedures.

"Before we go see Tom, I'll remind you what Sir William Osler, a co-founder of John's Hopkins and the creator of the first Residency program said — 'Medicine is learned by the bedside and not in the classroom. Let not your conceptions of disease come from words in the lecture room or read from the book. See, and then reason and compare and control. But see first.' Have you been in Doctor Getty's office?"

"No."

"He has a photo of Doctor Osler and that quote on his wall. It should be on the wall in every Attending's office. And every doctor in a teaching hospital should memorize it and internalize it. For the next ten months, you need to push hard for training and procedures. Don't take 'no' for an answer. Be proactive and make it happen. Let's go see what Tom has for us."

We went to the triage desk and Tom handed a chart to me, which I scanned, then passed to Mary.

"What do you want to do?" I asked once she had read it.

"Crying toddler pulling on his ear is a pretty good indication of otitis media," she said. "And Tom's exam confirms red, bulging tympanic membranes and a slight fever. So confirm, administer analgesics, and fend off the demand for antibiotics."

"What do you need to watch out for?"

Mary considered for a moment, "Confirmation bias. I know what I'm looking for so I'm likely to find it."

"And the antidote to that?"

"A complete exam and history, looking for any signs that I'm mistaken."

"Very good. Let's go get your patient."