Chapter 26 — Let's Take a Walk

_July 24, 1989, McKinley, Ohio_

{psc} "That just seems so…cold," Len observed after we had moved away. "I mean the way you told her."

I nodded, "That's the standard, developed through years of experience. Our job in such cases is to clearly state that the patient has died. Emotional support, and everything else, comes from the chaplain, the social worker, or Doctor McKnight. I can't tell you why the patient died, and, generally speaking, doctors are not qualified grief counselors or spiritual counselors."

"You are, though, right?" Bob asked. "You were clergy."

I nodded, "I was a deacon, and I'm actually an appointed chaplain, though I can't do that here because it's literally not my job. That was one of the hardest lessons for me to learn during my clinical rotations, and I was reminded of that time and time again. Let's just say, I had my nose whacked with the rolled-up newspaper sufficiently often to convince me to stop peeing on the carpet, as it were."

"Doesn't it bother you?" Bob asked.

"Of course it does, which is why it took so many applications of the rolled-up newspaper. But it doesn't bother me enough to go into private practice or pediatrics or internal medicine where there is more personal interaction and the lines are a bit fuzzier. Don't work in the ED if you can't handle that. Think about all the shorthand we use, and how at times it's like an assembly line. We simply don't have the time to get involved.

"Going back to the monologue, that is something you need to memorize, and it's what you'll say each and every time a patient dies. You absolutely have to say 'he died' or 'she died' unequivocally, without euphemisms. And you don't give any diagnosis. It's almost always safe to say that the patient's heart stopped and we could not revive them, as that is, from our perspective, the sign of death. No heart sounds and nothing on the monitor is, for our purposes, definitive.

"With this patient, he was down for at least six minutes, and we don't know what his heart rhythm looked like before went asystole in the EMS squad. Two doses of epi, chest compressions, and a vent, with his pupils fixed and dilated, were sufficient to stop trying. At that point, there was literally nothing left in our toolkit, as it were, so we called it. It's up to Doctor McKnight to say what the cause was, assuming Mrs. Breckenridge agrees to an autopsy."

"It's not automatic?" Len inquired.

"No. When a patient dies in the presence of a physician, the death certificate can be signed at that point and it's up to the family to decide if they want an autopsy. When the patient dies outside the presence of the physician, the County Coroner holds an inquest, which always includes an autopsy. We also try to do them for patients who die unexpectedly, for our own purposes, but the family doesn't have to agree."

"Do you sign it?"

"No, because it needs to be signed by someone with a license. Attendings all have their licenses, but only some Residents do. Most get them during their second or third year of Residency, though surgeons sometimes wait, given it takes roughly eight years to be an Attending."

"How does that work for you?" Bob asked.

"I plan to take the licensing test late next year. I'll take my trauma boards around the same time, and then in about six years, my surgical boards as a general surgeon. While I'll be fully qualified, and be able to put FACS behind my MD, the vast majority of procedures I'll do will be chest tubes, pericardiocenteses, central lines, tracheotomies, and similar life-saving procedures. I will, at times, take a patient up to perform emergency surgery, but that won't be the main part of my job."

"Mike?" Nate called out. "EMS four minutes out with an electrocution. Use Trauma 3."

"Got it!" I replied, then turned to Len and Bob and said, "Let's go!"

We gowned, gloved, and went to the ambulance bay to meet the squad, which pulled up about four minutes later.

"Jerry Maclean, twenty-six; electrocution on a construction site. CPR performed by co-workers; tachy at 110; resps shallow at 16; BP 90/60; PO₂ 95% on five liters by mask; GCS 9; IV saline TKO; burns on both palms."

That indicated that the charge had gone across his chest.

"Voltage?"

"240."

"Trauma 3!" I ordered. "Bob, EKG and monitor; Len, CBC, Chem-20, ABG, and cardiac enzymes."

We began moving, and I called out to Ellie that I would need a nurse, and she sent Jenny with us.

"Jenny, switch the IV to Ringer's," I said. "Len, Foley; Jamie will draw the trauma and cardiac panels."

Everyone acknowledged my orders and, with the help of the paramedics, we transferred Mr. Maclean from the gurney to the trauma table. I did a quick assessment and determined he was breathing OK and had a strong pulse, so immediate intervention wasn't needed. I began a more thorough workup while the others performed the tasks I'd assigned them.

"Foley is in!" Len declared. "Urine in the bag, and yellow."

"Take the blood to the lab; trauma stat."

"Right away, Doctor!"

"Arrhythmia," Bob announced.

"What do you see?"

"I'm not sure; I just know it doesn't look right!"

I looked up and nodded, "A-fib and irregular ST, both consistent with electrical shock. Put the unit in continuous print mode and call for a cardiology consult, please."

He did as I asked while I checked reflexes, all of which were nominal.

"What would you do next?" I asked Bob.

"Control the A-fib."

"Yes. Jenny, 1 meg digoxin IV push; 2 megs warfarin in the IV bag."

"1 meg digoxin, IV push," she repeated. "And 2 megs warfarin in the IV bag."

"Why those?" I asked Bob.

"Digoxin to control arrhythmia and warfarin to prevent thrombosis."

"Good. Now what?"

"Monitor; he'll need to have his INR checked daily to dose the warfarin."

"Correct. What about the burns?"

He moved to examine the patient's hands.

"Irrigate, debride, dress," he said.

"Yes. We'll wait for cardiology before we do anything else. What can you deduce from the burns?"

"He was holding wires?"

"Yes, but what stopped his heart? 240 will usually knock you on your ass, but not stop your heart."

"I'm not sure."

"The charge went across his chest. Think about that."

"Ah," Bob said, the answer obviously dawning on him, "similar to defib, only in reverse."

"Yes. What will we look for in the blood tests?"

"Elevated cardiac enzymes, which indicate damage to the heart muscle."

I nodded, "Specifically, the MB component of creatine kinase and troponin."

"Javadi, Cardiology," Leila Javadi said as she entered with a Third Year.

"Hi, Leila," I said.

"Morning, Mike. What do you have?"

I ran through the patient's vitals, my exam results, and the treatment so far.

"I don't like the fact that he's still out," I concluded.

"Let me do an exam, but we may want a neuro consult as well. We can do that upstairs, though, because he needs continuous monitoring."

"The EKG is on continuous."

"Thanks," she said, beginning her exam.

She asked similar questions of her Third Year as I'd asked Bob, and concluded by accepting Mr. Maclean on her service. In keeping with policy, she, Bob, and her student escorted the patient to Cardiology, and when I left the room, Nate indicated that there were walk-ins waiting.

"What do you have?" I asked at the triage desk.

"Take your pick — sprained ankle; abdominal pain, but without elevated temp; arm lac; alien infestation."

"Psych consult?"

"Either that or a Scientologist who failed to blow off his body Thetans with his e-meter!"

"Nice," I chuckled. "Who's been here the longest?"

"Psych consult."

"Let me take him and get him his psych consult and I'll come back for another. Bob can take the arm lac."

"Sold!" he said, handing me two charts.

I handed the arm lac chart to Bob, instructed him to evaluate and come see me, then we each called out to our patients. I escorted Nelson Thomas, who had aluminum foil on his head, to Exam 6, asking Kellie to join us.

"What brings you here today?" I asked.

"Aliens inserted tracking probes into my brain!" he said.

"When did this happen?"

"Last night. I put the foil on to block the signals!"

"How did they insert the probes?" I asked.

"Up my nose!"

"I'm going to do an exam," I said. "I'll leave the foil in place, and once we've run our tests, we'll call our alien expert to check you out."

He looked at me strangely, "You believe me?"

"I need to take your report seriously to treat you," I said.

"The alien expert is secret, right? You guys are government, so you don't admit it like they don't admit the alien bodies and ship they have at the Air Force Base in Dayton, right?"

"Right," I agreed.

Hangar 18 in Area B of Wright-Patterson Air Force Base purportedly had the wreck of a crashed UFO from Roswell, New Mexico, along with the bodies of the crew.

"Jenny, let's draw CBC, Chem-20, liver and metabolic panels, and tox screen."

"I'm not on drugs!" Mr. Thomas protested.

"Are you sure the aliens didn't inject you with something?" I asked.

"Good thinking, Doc!" he said.

Once we'd completed the exam and the blood draws, I asked Mr. Thomas to lie down and wait. He complied without argument, and we left the room.

"You are strange!" Kellie declared.

"And what would have happened if I hadn't gone along with his delusion?"

"He'd have freaked out and wouldn't have cooperated, saying you were part of the conspiracy."

"Bingo. Now I just have to convince someone from psych to play along with my charade long enough to get him upstairs."

"Why the blood tests?"

"Because it's possible his delusions are based on metabolic or other problems. You know psych will only run those as a last resort in a case such as this one, or if he develops other symptoms."

"So wait for the results before we call Psych?"

"Yes."

"Unconventional, but likely effective."

"Thanks. I see Len coming, have him run the blood to the lab. I'll meet you in Exam 2 with the young woman with abdominal pain after I inform Doctor Gibbs. Bring her in, please."

She acknowledged my orders, and I went to see Doctor Gibbs, who was at the nurses' station.

"OK to present?" I asked.

"That goofy grin says you're up to something."

I laughed, "Busted, but I think you'll agree. I have a male patient, late twenties, who believes aliens inserted probes into his head last night. I humored him, ordered blood tests and once they come back, I'll get a psych consult."

"Humored him?"

"I didn't make him remove his aluminum foil hat, and said once we'd run the tests, I'd bring in our alien specialist to examine him."

She started laughing, as did Ellie.

"I also allowed that I knew about the alien spacecraft they have at Wright-Patterson."

"Psych is going to love you! And by 'love' I mean 'hate'!"

"The patient is calm, relaxed, and feels safe. Did I do any harm in accepting his delusions?"

"No."

"There you go. I did order complete blood work, including a tox screen, to rule out metabolic or other causes. I don't think he's on drugs, but there are things which manifest only as paranoid delusions or hallucinations. It's also the case that electrolyte imbalance, meningitis, and other ailments can cause mental confusion, including hallucinations and paranoia."

"And later when he tells people we believe in UFOs?"

"He won't be wrong," I replied.

"Don't tell me YOU believe in UFOs?!"

"We all do," I chuckled. "There are absolutely, provably, Unidentified Flying Objects. There's no proof they're alien spacecraft or any such thing, but the UFOs are actually real!"

"Give me your chart to sign, you clown!" Doctor Gibbs said rolling her eyes and shaking her head.

I handed it to her, and she scribbled a note and signed it. I winked, left, and put the chart in the holder outside Mr. Thomas' room, then went to Exam 2.

"Peggy Gibson, nineteen," Kellie said.

"Good morning. I'm Doctor Mike. What brings you here this morning?"

"My side hurts."

"More towards the front or the back?"

"The back."

"When did this begin?" I asked.

"Last night. I took two Tylenol, and that helped, but when I woke up this morning it hurt worse, and Tylenol didn't do anything."

"Did you do anything in the last few days which might have strained a muscle?"

"Not that I can think of. I went to class, studied, then hung out in the dorm common area."

"Taft student?"

"Yes."

"Did you pick up anything heavy?"

"Nothing heavier than my chemistry book."

"Did you eat anything out of the ordinary?"

"No."

"Any nausea, vomiting, dizziness, or imbalance?"

"No."

"Blurred vision, ringing in your ears, or strange smells or tastes?"

"No."

"Are you taking any medication or using any drugs?"

"Just the Tylenol."

"OK. I'd like to perform a basic exam. Just unbutton one more button on your blouse and untuck it, please."

She complied while I washed my hands and put on gloves. I auscultated her heart and lungs and found nothing remarkable, then checked her eyes, ears, mouth, and nose with similar results, and found nothing amiss with the glands in her neck.

"If you'd lie back, I'm going to examine your abdomen," I said.

She complied, and I palpated her abdomen and listened for bowel sounds, once again not finding anything remarkable.

I had her turn on her side and did a manual exam of her back, finding two spots where pressure caused her to wince, but which didn't indicate any masses.

"Any trouble urinating or any burning sensation when you urinate?"

"No."

"You can sit up," I said. "There are a few possibilities, the most likely of which is an ovarian cyst. Is there any chance you're pregnant?"

"Not unless two girls can get each other pregnant."

"So, no relations of any kind with a guy?"

"Never. Not even a kiss."

"Then you aren't pregnant, which narrows down the possibilities. I'd like to do an ultrasound to confirm."

"What else could it be?"

"Kidney stones would be a possibility, but you're awfully young to have those unless you've been diagnosed with some kind of renal disease. Any kidney problems?"

"No. What's the treatment for a cyst?"

"It depends on the size," I replied. "Small ones usually resolve on their own. Larger ones need evaluation by on OB/GYN and could be surgical. But let's check it out first before we speculate. Kellie will give you a gown to put on. You can leave on your bra and jeans, but you'll need to take off your blouse.

"I'm not modest. I can just take off my blouse."

"OK. We'll step out to get the equipment we need. Just take off your blouse and then lie on your left side with your back towards this side."

She acknowledged me, and Kellie and I stepped out. I stood outside the door while Kellie retrieved the ultrasound. Bob came to me to report he'd irrigated the arm lac, and felt it needed six sutures. I checked, confirmed that, then went back into the exam room with Miss Gibson. I performed the ultrasound and confirmed Peggy had a four centimeter cyst on her right ovary.

"You have a cyst," I said. "It's small, so for now, take three Advil every six hours, which should help, along with warm compresses. Make an appointment with your OB/GYN for followup."

"That's it?"

"That's it. If the pain persists beyond three days or gets significantly worse, and you haven't seen your OB, come back and we'll have an OB/GYN check you out and recommend treatment. Kellie will get you some Advil now, and I'll fill out the paperwork to discharge you."

"Thanks, Doctor."

"You can put on your blouse," I said. "We'll be right back."

Kellie and I left the room, and she touched my arm.

"You aren't going to ask for an OB/GYN consult or an Attending?"

"No. I've seen a number of these and she has no symptoms which warrant anything more than 'wait and see'. Her OB/GYN is best suited to care for her. I've also done other gynecological procedures, so I know Doctor Gibbs will sign off without an exam."

We went to the Attendings' office, and I asked Doctor Gibbs if I could present. She nodded, so I ran through my exam and diagnosis.

"No blood work?" Doctor Gibbs asked.

"No. There's no need to run extra tests at this point. All her symptoms line up."

"You're positive she's not pregnant?"

"Lesbian," I replied. "And I did confirm that she'd never had relations with a guy."

"Let me have the chart, please."

She made her notations, signed it, and handed it back.

"Street her, as you proposed."

"Thanks."

I filled out the necessary discharge information, completed the chart, then returned to the exam room to discharge Miss Gibson. Once that was completed, I took the sprained ankle, and finally received the results for Mr. Thompson's tests, all of which showed normal ranges, though with slight anemia, but that was insufficient to cause hallucinations or paranoid delusions. The tox screen was negative, though it didn't test for everything possible.

"The aliens are crafty!" Mr. Thomas said when I explained the nominal blood test results. "They don't use anything you can detect!"

I nodded, "That would make sense for an advance species of aliens! Let me place a call and have someone who specializes in this come see you."

"Thanks, Doc!"

I left the room, wondering which Psych Resident was on duty. I placed the call, and five minutes later, Leah Silver arrived with a Third Year in tow. I reviewed the patient's vitals, the exam results, and the blood test results.

"You seriously want me to pretend to be an alien expert?" she asked.

"My patient is calm and cooperative. I'd suggest maintaining the fiction until you get him upstairs, otherwise he's likely to fight you and have to be sedated."

"You know that's not protocol!"

"Hang the protocol!" I replied. "Our goal is to provide the best possible care, and if that means going along with his hallucination and delusion, at least in the short-term, so be it."

"Doctor Lawson will _never_ agree to that."

I shrugged, "You have my advice, but you're the psychiatrist."

I handed her the chart.

"Oh, this is going to go over great," she said, shaking her head. "Your Attending signed off on this?"

"Again, we have a docile, cooperative patient who thinks we're going to help him, as opposed to one who thinks we're in league with his enemies."

She shook her head, "I have to follow protocol."

I almost said 'Of course you do', but bit my tongue.

"Kellie, prepare five of Haldol," I said. "We're going to need it."

"Right away, Doctor," Kellie agreed.

"Leah, can we at least just say you're a specialist, and NOT say you're from Psych? Can't you see your way clear to maintain that tiny fiction?"

"You shouldn't have fed his hallucinations or delusions."

"Fine," I said flatly. "Have it your way. Just wait so I can have Len and an orderly standing by."

I had them stand outside the room when Doctor Silver, Kellie, and I went back into the room. I made one last-ditch attempt to continue the charade.

"Mr. Thomas, this is the specialist I was telling you about," I said. "She needs to talk to you about what happened last night."

The gambit paid off, and she simply introduced herself.

"Hi, Mr. Thomas. I'm Doctor Silver," she said. "Can you tell me what happened last night?"

She listened and asked questions, but it was clear from the tone of her voice and body language that she was skeptical, and Mr. Thomas picked up on that.

"You don't believe me!" he said accusingly to Doctor Silver.

"There are no such things as aliens, Mr. Thomas," she said.

"YOU'RE ONE OF THEM!" he screamed. "YOU'RE PART OF THE COVER-UP! HELP!"

He became more and more agitated, and I had no choice except to call in Len and the orderly to help me hold him down while Kellie injected him with the Haldol, which, thankfully, took effect quickly. I picked up the chart, wrote the Haldol on it, along with a note that the patient had become extremely agitated during the Psych exam, and signed it, then handed it to Doctor Silver, who rolled her eyes and shook her head.

"All yours," I said. "The orderly and Len will help you and your student take him upstairs."

"You'll hear from Doctor Lawson, I'm sure," Doctor Silver said.

"He can speak to Doctor Gibbs. She signed my chart and my orders."

Len, the orderly, and Doctor Silver's Third Year got Mr. Thomas onto a gurney, strapped him in with soft restraints and wheeled him out. I went straight to Doctor Gibbs to let her know what had happened.

"What is it Clarissa says?" Doctor Gibbs asked with a wry smile. "That she can't leave you alone for two minutes without you getting into some kind of mess?"

"She does say that," I confirmed. "But I still stand by the fact that Mr. Thomas was docile and cooperative until Doctor Silver stated flatly that there are no aliens. At that point, he accused her of being a collaborator and being involved in a cover-up. She made the point that she was going to tell Doctor Lawson that I hadn't followed protocol."

"And your defense?"

"Hang protocol when it's not in the best interest of the patient. This goes right back to the situation with Angie. That doctor followed protocol, too. I know I'm not a psychiatrist, and I wasn't trying to _treat_ Mr. Thomas' illness, I simply afforded him the dignity and respect every patient deserves. I fail to see how requiring me to administer Haldol was a positive development, when a small bit of fiction could have had him walk upstairs and begin treatment. He wasn't a danger to himself or anyone else, so I _could_ have streeted him. I guarantee that if I had suggested a _Psych_ consult, he'd have left. I'm sorry if this will cause you problems with Doctor Lawson."

"Do I sense some problem there?"

"Nothing I'd want to discuss on the record," I replied.

"I'll surmise from that you two spoke about Angie and he defended her psychiatrist."

"I can neither confirm nor deny the accurate speculation," I replied with a grin.

"Got it. Was this you tweaking him through his Resident?"

I shrugged, "Who knows what my innermost subconscious motivations were? My conscious motivation was what was in the best interest of the patient, and in my mind, that was him cooperating with his treatment, rather than fighting it. You realize he'll be drugged into a stupor now, because ANY attempt to wean him from the drugs will result in him losing it because he's been captured by collaborators and cover-up artists?"

"I'd say you have the surgeon's mentality about drugs, but it's deeper than that."

"While the phrase 'better living through chemistry' is true, we're far too anxious to prescribe some drug, especially long-term maintenance drugs, rather than seek alternative treatments. Part of that is people preferring pharmaceuticals to changing their behavior, part of it is laziness of physicians, part of it is the system, and part of it is the 'drug them into submission' theory of psychiatry."

"I think I'll have the conversation with Doctor Lawson alone."

I nodded, "I understand."

"Don't worry, though. I signed your chart and I don't disagree with you in principle. May I give one piece of advice?"

"Of course."

"Creating adversarial relationships with other doctors in the hospital is not wise."

"I will point out that in each and every case, it's the other doctors who have taken exception to me doing what is right, or, in the case of Mastriano's paramour, simply being faithful. I can, and will, defend each and every response."

"I didn't say you were wrong, Mike," Doctor Gibbs replied with a smile. "Your usual style is disarming, but you rub some people the wrong way. They probably need it, but at some point, the volume of complaints is going to reach a level where somebody has to decide what's best overall for the hospital."

"So be it," I said. "I owe every patient the duty to provide the best possible care, and to be a forceful advocate for their treatment. The day I'm not allowed to do that is the day I can no longer be a physician."

"Please don't get dramatic."

"This is a private, confidential discussion, right?"

"Yes, of course."

"Then I stand by what I said. But I think you also know who my role models are."

"Men who refused to quit in the face of adversity, and who were wronged for doing the right thing."

"Exactly," I replied. "I'm no martyr, and I have no intention of giving up. That said, if I'm _ordered_ to act in a way contrary to a patient's best interest, you know exactly what I'll do. And so did everyone who voted to hire me as a Resident. What do you want me to do?"

"What I said. I'll deal with Lawson. Go heal the sick."

"Thanks, Loretta."

I left her office and went to check on Bob, who had finished suturing and had been waiting on me to review and discharge the patient. I signed off, and after giving the patient discharge instructions, Bob, Len, and I handled the ankle sprain, then I sent them to have lunch. While they were gone, I dealt with a broken finger which simply needed a splint, then went to have my own lunch.

The afternoon was busy, but relatively routine, with three ambulance runs and six walk-ins. Just before 6:00pm, when Mary and Tom arrived, I went to the cafeteria to have dinner with Kris and Rachel.

"Good day?" she asked.

"Mostly OK. I had a situation where I did the right thing, but likely created more animosity with Doctor Lawson in Psych."

"What happened?"

I explained the 'alien encounter' patient and the discussion with Doctor Gibbs.

"I don't see that you did anything wrong," Kris said. "And I'm not saying that as your wife, but as someone who agrees with you about dignity and respect. May I say something?"

"If you can't, who could?"

"Clarissa!" Kris declared mirthfully.

"Lissa!" Rachel exclaimed.

"She's upstairs!" I replied.

"No, she's not!" Clarissa announced from behind me.

"Sit down with us, Clarissa," Kris invited.

"If I'm not intruding."

"I believe our daughter would be quite cross with us if we didn't agree!" Kris declared.

Clarissa sat down and began eating.

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

Kris smiled, "That you wear your heart on your sleeve and are extremely sensitive to people with mental health concerns. I understand why, but perhaps you need to be more diplomatic."

"I was diplomatic," I replied. "As I said, I simply requested Doctor Silver to continue with the charade until they could take the patient upstairs. She's the one who insisted on going strictly by the book."

"What happened, Petrovich?" Clarissa asked.

I recapped the situation for her.

"I can't leave you alone for two minutes!" she said, shaking her head.

"Which is what Loretta said. But seriously, Lissa, all I did was treat the patient with dignity and respect. My approach was working, and he was docile and compliant. After Leah Silver did her thing, we had to physically subdue him and hit him with Haldol. Honestly, I'd have streeted him if I'd known that was going to happen because he was no danger to himself."

"You know you have to call for a Psych consult for something like that."

"I know no such thing!" I said firmly. "He was calm, responsive, and no danger to himself. Now, he's drugged and thinks the government is covering up and the doctors are part of the conspiracy. How does that help him? He was harmless. I should have checked him out and given him some kind of placebo."

"Oh, come on, Petrovich! You know darn well you could be dismissed if anything happened to him or he hurt anyone and you failed to call for a psych consult. I know you're sensitized to this subject because of Angie, but you can't continue your crusade or you'll ruin your career exactly the way Lawson said. And maybe that was what he was trying to tell you."

"I don't think so."

"Are you _sure_?" Clarissa asked. "I think you're blinded by your outrage about Angie's treatment, and you take everything Psych does as a personal affront."

"Maybe so, but that doesn't mean I was wrong in my handling of the case."

"And the Psych Resident decided otherwise, and she's the one responsible to the Psych Chief. This isn't the same as the Mastriano or Greenberg situations."

"Seriously, Lissa? A psychiatrist says something to a lucid, functioning patient that directly results in that patient being drugged into docility?"

"Mike," Kris said gently, "I haven't been to medical school, but I have listened to you and Clarissa, and I believe Clarissa is correct. What did Doctor Gibbs say?"

"Basically the same thing."

"End your crusade, Mike," Clarissa pleaded. "It will end in disaster if you don't."

"I can't let injustice go," I protested.

"So don't! But find a way to do it without antagonizing every psychiatrist on the planet and wrecking your career. You're going to hate me for saying this, but you can't bring Angie back, and she'd never accept you throwing away your career for her."

"You know what?" I said, standing up. "I'm going back to work."

"Mike, sit down and eat," Kris said.

"I'm not hungry. I'll see you at home tomorrow."

I kissed Rachel, then Kris, then left the cafeteria and walked down the corridor to the ED, and went to the triage desk because I needed to work to take my mind off the conversations.

"What do you have?" I asked.

"Twenty-eight-year-old male with abdominal pain."

"Any other symptoms?"

"Nausea, diaphoresis, and goose bumps."

"Any previous visits?" I asked.

"None in the current files."

"Any patients more in need?"

"No."

"OK. I'll take the chart."

He handed me the chart, and I quickly reviewed the vitals which showed a borderline tachycardia and borderline hypertension. I went to the door, opened it, and called for Mr. Nicholas Holt. He came to me and I escorted him to Exam 2, then remembered my students. I asked Mr. Holt to wait, then went to the lounge to get Mary and Tom, who returned to the exam room with me.

"What seems to be the problem, Mr. Holt?" I asked.

"I feel like shit," he replied.

"When did this start?"

"About four days ago and it's become worse every day."

"Tell me about that, please."

"It started with the shakes, then nausea and sweating, then my gut started hurting."

"OK, let me do an exam, and we'll draw some blood."

I completed the exam, and it matched the vitals which were on the intake form.

"Mr. Holt, the scar on your abdomen looks relatively recent. What surgery did you have?"

"I had my gall bladder removed."

"What did they give you for pain?"

"Dilaudid."

"How long did you take it?"

"Six weeks."

"It was refilled?" I asked.

"Twice."

"I strongly suspect you're suffering from hydromorphone withdrawal. You were on Dilaudid for a long time, and the symptoms you're experiencing are consistent with abrupt cessation. Is the pain different from the reason you were taking the medication?"

"Yeah. It's not the same place or the same feeling. How bad will this get?"

"It could get significantly worse, but I can give you a drug called clonidine that will alleviate the symptoms. It's not an opioid drug like Dilaudid, so it's not addictive. I'll give you a fast acting dose now, and then you'll take progressively lower extended release doses for the next two weeks. You'll need to follow-up with your personal physician, and he can adjust the dose, if necessary."

"That's it?"

"That's it. Let me get the paperwork done and have my boss sign off."

"Why?"

"I'm a Resident, so I don't have authority to write prescriptions just yet."

"But you're a doctor, right?"

"Yes. Give me five minutes on the first dose, which will take effect fairly quickly and relieve your symptoms. Once they resolve, which will be about an hour, we'll get you on your way with a prescription you can fill at the drug store down the street that's open until midnight."

Mary, Tom, and I left the exam room and went to find Doctor Nielson who had come on at 6:00pm. I presented the case, he signed the chart, and I asked Alice to get the first dose of clonidine. She administered it, and Mr. Holt relaxed in the exam room while it took effect. I assigned Mary to check on him, and Tom and I took a walk-in with a severe headache.

"Mike?" Doctor Shelly Lindsay said, sticking her head into the room. "Got a minute?"

"As soon as I finish the workup," I replied. "OK?"

"I'll be in the lounge."

Fifteen minutes later, after Doctor Cohen had come down for a consult, I went to the lounge.

"Let's take a walk," Doctor Lindsay said.

"Who called you?" I asked.

"That transparent?"

"Yes."

"Clarissa. She actually called Vince at home and he called me because I'm here."

"Let me tell Perry I need fifteen minutes."

I did that, then Doctor Lindsay and I walked out the doors of the ambulance bay and along the entrance road to the sidewalk.

"Clarissa was concerned, and she said your wife is concerned as well."

"How much do you know?"

"I called Loretta. Let me start by saying I sympathize, but you're allowing your visceral hatred for your friend's psychiatrist to affect every interaction you have with Psych. If you don't let it go, you're going to destroy yourself."

"How the heck can I let it go? Her life was ruined by that, that…"

"Doctor," Shelly said, completing my sentence with a word I wouldn't use. "Mike, nothing can fix that now, and wrecking your career won't help her. What possible good can you do with this Quixotic quest? You're tilting at a windmill. Is there a problem? Yes. Will your righteous anger fix it? No. How many patients are alive because you were there for them? How many _thousands_ will be alive if you're there for them?"

"There are other doctors," I countered.

"And how did that work out for Krissy Sumner?"

I sighed, "Not well."

"And who would have advocated for Peter Firth?"

"A fat lot of good that did!"

"While the outcome was bad, what happens to the next Peter Firth? And what happens to your friend in the future if you don't have 'MD' behind your name? And the countless other patients who will have improved outcomes because Michael Loucks, MD, is there for them?"

"I just…"

"Have to let it go," Shelly said firmly. "Look, I know you're operating on minimal sleep, and there isn't anything anyone can do about that now, and it's affecting you in a number of ways — emotionally, psychologically, and probably spiritually, given what I know about you."

"I'm handling my cases properly," I protested.

"That is what Loretta said, and I don't doubt it. But it's also caused you to walk away from your wife and daughter because Kris and Clarissa were telling you the truth and giving you good advice. For most doctors, I'd recommend going home and taking sick time, but not only would you not do that, I think it would be counterproductive. Worse would be Doctor Gibbs or Doctor Northrup questioning your judgment. If that happens, they'll _send_ you home, and a note will go into your file. That is the _last_ thing you want, Doctor."

"It's not fucking fair," I sighed.

"If you mean what happened to your friend, I agree with you, but you aren't helping by allowing your disgust with the psychiatrist to cause you to behave irrationally. You realize he wins if you do that, right? Rosenbaum and Mastriano win. You lose. Your family loses. And your future patients lose. Does that sound like a good outcome?"

"No."

"You're going to do two things. First thing tomorrow you're going to make an appointment with a counselor I know in Columbus. She specializes in doctors, and she's not a psychiatrist. You'll also find she agrees with you about mental healthcare. Second, you're going to discuss this with either Vince or Ghost, and keep them apprised. Do you drink?"

"Occasionally, but I abide by the rules, and when I do drink, it's a glass of wine with a meal."

"Never at other times?"

"Not since start of third year."

"Ever take or consider taking narcotics?"

"No."

"You're wound awfully tight, so you need to be accountable to Vince and Ghost about that. I'd mentioned the other typical self-medication, but given your faith, I don't think that's necessary."

I laughed, "Surely you jest! My primary means of self-medication after Elizaveta died was sex because both drugs and booze would have resulted in me being dismissed from the program. A lot of sex."

"You could knock me over with a feather on that! Your reputation is pristine!"

"I studiously avoided even a hint of that at the hospital and refused to even consider the usual hanky-panky that goes on. Weirdly, I'm also capable of completely controlling these desires. I simply chose not to."

"I'll leave it to your wife to hold you accountable on that one."

"Which she'll do."

"Are you going to call the counselor?"

"I'd ask if I had a choice, but I know I do."

"We all do. Mike, the entire point of this is to keep you from making a serious mistake, either with professional relationships, or worse, with a patient. Right now, as tight as you're wound, I'm not sure you'd survive that."

"I'll call the counselor in the morning."

"I'll give you her card when we go back inside. The hospital will cover the costs. You OK to keep working?"

"Yes."