Chapter 20 — Popcorn?

_July 14, 1989, McKinley, Ohio_

{psc} By Friday afternoon, I was once again the walking dead, though it wasn't quite as bad as the previous week. Just before 3:00pm, Doctor Gibbs, Mary, Tom, and I left the ED to attend the M & M conference. Because of the timing, that meant several ED docs couldn't attend, as someone had to cover the ED, and it was possible that Doctor Gibbs might be paged, though that would only occur if a disaster protocol was activated.

When we reached the hallway outside the auditorium, I saw Clarissa waiting for us and started laughing.

"Seriously, Lissa?" I asked.

She smirked and asked with faux innocence, "What?"

"Popcorn?"

"It seemed appropriate! Other people bring snacks."

"Mike," Doctor Gibbs said. "One piece of advice — keep it completely clinical."

I nodded, "That was my plan. And while I didn't bring popcorn, I'll sit back and watch once Doctor Mastriano is in the dock."

We went into the auditorium, and while everyone else sat towards the back, I sat down in the front row, as I'd be presenting. I opened the chart and skimmed, doing one last check that I had the sequence of events correct in my mind.

"Good Afternoon," Doctor Jerry Rhodes said. "Our first case will be presented by Mike Loucks, surgical Intern. Doctor Loucks?"

I rose and went to the podium, took a deep breath, let it out, then began.

"Good afternoon. Just after midnight, on July 4th, an African American patient was brought to the Emergency Department in private transportation, and left in the waiting room. Upon exam, his breath smelled of alcohol, and it was obvious he had been in a fight. The triage team reported he was semi-coherent upon arrival, but then appeared to have fallen asleep. At intake, his vitals were typical of an individual under the influence of alcohol.

"The patient was transported to Exam 2, and my Third Year, a nurse, and I evaluated him. A banana bag was hung immediately. The primary exam was unremarkable save obvious contusions and lacerations to the patient's face, and his vitals were stable and consistent with inebriation. Blood was drawn for a trauma panel, as well as EtOH levels. The nurse recommended soft restraints, but I did not feel they were necessary.

"About ten minutes after the blood was drawn, which was about twenty minutes after intake, the lab reported EtOH at 0.19, confirming that the patient was, indeed, inebriated. At that point, a Sheriff's Deputy arrived and gave us the patient's name, and confirmed that he had been severely beaten by other patrons of a bar. The patient's injuries were all consistent with the reported beating. The Deputy asked if he could question the patient, but I reported that the patient was incoherent.

"While I was discussing the situation with the Deputy, I heard a crash from the exam room, and went in to find the patient on the floor, with his IV out, and a small amount of blood leaking from the IV site. The nurse reported that the patient had come to, pulled out his IV, and tried to get out of the exam bed, but fell and lapsed back into his unconscious state.

"The patient was moved from the exam room to a trauma room. Soft restraints were applied, and the IV was reinserted. On exam, the patient had minor bleeding from his nose, though it's unclear if he broke it during the fall or it had been broken during the fight. I instructed the nurse to pack the patient's right nostril with gauze to control the minor bleeding. I also apologized to the nurse for not listening to her recommendation of soft restraints.

"At that point, I determined that the patient needed at least a skull series, and noted that on the chart, along with the need to rule out a concussion, though the patient's inebriation would interfere with that determination. The nurse and I both conferred with the Deputy, who took brief statements about the injuries from us, and then left.

"About that time, the patient came to again, but was incoherent. I was concerned about that, as well as his lapsing in and out of consciousness, as his EtOH levels were not high enough to cause unconsciousness nor complete incoherence. The standard practice in such cases is to wait for EtOH levels to drop below 0.1, but given the blows the patient had taken to the face, and his fall, I felt an immediate neuro consult and CAT scan were indicated, and noted those on the chart.

"After consulting with the nurse, I went to present the case to my Attending, Doctor Mastriano, with my recommendations. I found her in the Attending's office and asked to present the case. I did so and made my recommendations. Doctor Mastriano countermanded my written plan based on the patient's EtOH levels. I repeated my concern that the patient would suffer neural deficits and possibly herniate. Doctor Mastriano stated clearly and firmly that I was to monitor until the patient's EtOH levels were below 0.05, so I asked her to write her order on the chart.

"I returned to the room and performed another set of neuro checks, finding no appreciable signs that were inconsistent with inebriation. Because of my concerns, I ordered oxygen by canula, as well as a glucose stick test, which showed 96. I instructed the nurse to perform another stick test, an ABG, and obtain EtOH levels every thirty minutes, and wrote that order on the chart.

"At that point, I was called for another patient who'd been brought in by his wife for a syncopal episode. While I was examining that patient, a nurse reported that the initial patient was seizing, so I ordered my medical student to wake Doctor Mastriano, and hurried to the trauma room where the nurse who I'd left with him had inserted a bite guard. I ordered 4 megs of lorazepam, IV push, which resolved the seizures.

"Postictal exam showed a blown left pupil and a sluggish right pupil. I ordered an immediate neuro consult. At that point, Doctor Mastriano entered the trauma room and asked what had happened. I presented, then ordered my medical student to hook up an EKG and monitor. Doctor Mastriano examined the patient and observed the same condition. She instructed me to call her after the neuro consult, but I asked her to stay as I was at the limits of my skills and abilities. She refused and left the room.

"I ordered new blood work, then went to check on my other patient. I returned when the neuro Resident arrived and presented the case. The most recent EtOH level at that point was 0.15. She performed an exam, including a Babinski, which showed normal flexor response. She proposed a diagnosis of a subdural hematoma and suggested a CAT scan, and I concurred.

"In order to take the patient with EtOH levels above the standard, she called and spoke to her Attending, who approved both the CAT scan and the admission. At that point, the patient was transferred to her care, and I went to handle an EMS transport of a car versus bicycle accident."

"Thank you, Doctor," Doctor Rhodes said. "Questions?"

"Mike," Doctor Strong said, standing up. "Why did you not want soft restraints?"

"Lack of experience," I replied. "The nurse was more than happy to point out that I should have listened to her, and I've learned my lesson."

There was laughter from quite a few attendees.

Doctor Javadi stood up and asked, "What made you think the patient had neurological problems?"

"He had been subject to a severe beating, and I was concerned about broken facial bones, though I didn't appreciate any. The autopsy report showed a non-displaced orbital fracture, which Doctor McKnight ruled was from a blow by a fist, not from contact with the floor. The contradiction, of course, were the high EtOH levels, but, as I noted, not high enough to cause unconsciousness in a typical adult male in their twenties."

She sat down and Doctor Roth stood.

"Why not just call neuro?" he inquired.

"Because absent some kind of significant neurological sign, they won't consult on a patient with EtOH levels above 0.1 unless the ED Attending on duty certifies the need and places the call to her counterpart. I had no signs or indications other than my gut feeling, so all I could do was recommend to Doctor Mastriano that the call be made."

He sat down and Doctor Taylor, the surgeon, stood up.

"Is it true that Doctor Mastriano was sleeping each time you approached her?"

"Yes."

"Is it also true she had given orders not to be disturbed?"

"Yes."

"How did she respond when you approached her about this patient?"

"She was annoyed."

He sat down and nobody else stood.

"Thank you, Doctor," Doctor Rhodes said. "Doctor Cohen?"

I returned to my seat and Doctor Cohen went to the lectern. She repeated her version of our interactions, which basically matched mine.

"Once he was transferred to our service, we took him immediately for a CAT scan, but he seized during the procedure. Neuro exam showed signs of significant brain injury, and despite administering mannitol, the brain swelling could not be controlled and the patient expired. I have very little more to say, as we didn't complete the CAT scan."

Nobody had any questions for her, as she really did have very little more to add.

"Doctor McKnight?"

He replaced Doctor Cohen at the lectern and began his presentation.

"An African American male, age twenty-three, presented with facial injuries consistent with being struck repeatedly with fists. Upon autopsy, I appreciated a non-displaced fracture of his left orbital socket, as well as a hairline fracture of his left parietal bone, both consistent with being struck with a fist. In addition, he had a fracture of his nasal bone, consistent with either being struck with a fist or impact with the floor. It's my opinion that the injury was initially from a fist, but exacerbated by striking his face on the floor. He had no remarkable injuries to any part of his body other than his face, though there were some defensive bruises on his forearms.

"Upon examination of his cranium, I found three large subdural hematomas, and the patient's brain had herniated. A thorough examination led to the conclusion that the injuries sustained from the fists were sufficient to cause significant bleeding in the brain, which led to herniation, resulting in the patient's death. I filed that report with law enforcement. Questions?"

"Would an immediate CAT scan have resulted in a different outcome?" Doctor Subramani asked, standing up.

"I'd have to be clairvoyant to answer that question," Doctor McKnight replied. "That said, the CAT scan would certainly have detected the hematomas."

Doctor Subramani sat down and Doctor Rosenbaum stood up.

"Did the fall in the ED contribute to his death?"

"I don't believe so," Doctor McKnight said. "The fall certainly didn't do him any good, but there was no indication of injuries except to his nose. As I said, it's my opinion that injury was initially sustained when he was beaten."

"But the fall _could_ have contributed to the outcome, right?"

"You know as well as I do," Doctor McKnight said, "that a minor bump on the head can cause a severe hematoma under the right circumstances. That said, there is zero indication that the fall had any significant impact on the patient's condition. In any event, such a fall could not cause hematomas in the regions where I found them. The laws of physics and what we know about the brain show that all three were the result of direct blows with fists."

Doctor Rosenbaum sat down and Doctor Gómez stood up.

"Did you confer with law enforcement?" he asked.

"Yes. The Sheriff's department confirmed that four men had set upon the patient and had beaten him up. Everything I saw was consistent with that, as was everything reported on the charts. I am absolutely sure the cause of death was the beating."

There were no further questions, and Doctor Rhodes called Doctor Mastriano to the lectern.

"Doctor, please explain your decision not to permit a neuro consult," Doctor Rhodes instructed.

"The standard of care," Doctor Mastriano said, "is that inebriated patients with no appreciable neurological signs, who are not in cardiac or respiratory distress, and who show no signs of internal injuries, are to receive IV fluids until their EtOH levels drop below 0.1, and if there are no indications of distress at that point, no further treatment until levels are below 0.05."

"Your Resident felt there was sufficient cause to discuss it with you and recommend a neuro consult and CAT scan."

"Interns don't have the experience to make those decisions, and I followed the standard of care."

"Does that include sleeping and demanding not to be woken up?" Doctor Taylor asked, standing up.

"On twenty-four-hour shifts, doctors are allowed to sleep," she countered.

"But isn't it true you gave express orders to both your Residents, and the nurses, to not wake you unless a patient was dying?"

"That's an exaggeration," she countered. "I left orders not to be disturbed unless necessary."

"How did you respond to Doctor Loucks' request to present?"

"I listened to what he had to say, and made a medical judgement based on the standard of care."

"Mike," Doctor Taylor said, "would you tell us exactly what transpired?"

I stood up and relayed exactly how Doctor Mastriano had responded each time I'd tried to speak to her.

"One more question, Mike," he said. "Did Doctor Mastriano attempt to put a formal reprimand in your file because she disagreed with the standing orders from Doctor Cutter and Doctor Northrup for your training?"

"I cannot speak to her motives, only her actions. She did state she was going to place a letter in my file because I obtained permission from Doctor Roth to do a surgical consult against her wishes, and then because I was asked to scrub in on an emergency surgery and didn't obtain permission from her."

"Thanks. Doctor Mastriano, who determines the training protocol for Interns and Residents?"

"The departmental Chiefs," she said.

"Do you believe you can substitute your judgment for theirs?"

"Doctor Taylor!" Doctor Rhodes said sharply. "Focus on facts, please."

"Sorry, Doctor. Doctor Mastriano, did you place a reprimand in Doctor Loucks' file?"

"Yes."

"And what happened?"

"It was removed and overturned by Doctor Cutter."

He sat down and Doctor Subramani stood up.

"In hindsight, do you agree that the neuro consult should have been ordered for this patient?"

"That's not the standard of care," Doctor Mastriano replied.

"With all due respect, Doctor, that wasn't my question. Your Resident felt the standard of care was insufficient in this case, and reported that to you, and wrote it on the chart."

"CAT scans are expensive, and I saw no indication that one should be ordered. I couldn't justify it, based on the standard of care."

"Then why not allow your Resident to call for a neuro consult?"

"Because with an EtOH of 0.19, they wouldn't have accepted him on their service."

"But that doesn't preclude a consult."

"Which would have shown nothing and achieved the same result."

"Mike, why did you think a consult and CAT scan were appropriate?" Doctor Subramani asked.

"The patient's neurological state did not conform to his EtOH levels."

"Thank you. Doctor Mastriano, isn't that a sign?"

"Everyone has a different response to alcohol, and a few hundredths of a percent difference is within the normal deviation."

Doctor Subramani sat down and Doctor Rafiq stood up.

"Doesn't it make sense to bring in someone experienced when there is a disagreement?"

"He's an Intern, and it was his first week in the ED. He doesn't have the experience to make that judgment call."

"Which is why he came to you, but you appeared to be more interested in sleeping."

"Doctor Rafiq!" Doctor Rhodes said sharply.

"I apologize," Doctor Rafiq said, sitting down.

Doctor Cutter stood up.

"Doctor Mastriano, did you tell a surgical Intern that they had neither the experience nor skills to make the judgments they were making?"

"Yes, of course, because it's true."

"Doctor Northrup and I obviously disagree, because we cleared Doctor Loucks for the procedures he's performing and set his training program. Are we wrong?"

"He's a PGY1 and has no business doing what he's doing."

"That's your judgment, Doctor. Are you perfect? Because if not, I find it odd that you do not care to listen to the opinions and judgments of others, whether they are junior to you or senior to you."

I was a bit surprised that Doctor Rhodes didn't intervene, but Doctor Cutter was the Chief of Surgery, and the most senior doctor in the hospital besides Doctor Rhodes, which I suspected gave him more leeway.

"That is not true," Doctor Mastriano protested.

"Did you tell Doctor Loucks that he was to obtain your direct approval before performing any procedures, including ones I personally approved for him to do?"

"That's the prerogative of the Attending who is supervising the Intern."

"And your comment to him that he was not allowed to touch a patient in the OR?"

"That's the norm."

"And your judgment overrides mine?" Doctor Cutter asked.

"As I said, decisions about what procedures an Intern is permitted to do are the prerogative of the Attending who is supervising him or her."

"No, Doctor, it's not," Doctor Northrup said, standing up. "Jerry, I'll handle this internally. I believe we've established that we failed this patient."

"Then this case is closed," Doctor Rhodes said. "Our next case will be presented by Doctor Bielski."

I listened to the case of an angioplasty gone wrong due to a severely weakened aorta, where the conclusion was that there was no negligence, and that not only had the standard of care been followed, but there had also been no indications of the problem prior to the insertion of the balloon catheter. The patient, under just about any imaginable circumstances, would have died with or without the attempted procedure, and the main lesson was that our imaging technology was not yet good enough to detect the problem encountered. A request was made for an MRI machine, and, as was nearly always the case with those kinds of requests, it was 'taken under advisement'.

There were no further cases, so the meeting was adjourned and Clarissa and I went to the cafeteria to get Cokes, a rare thing for me, but I wanted the caffeine and sugar to make it through the final ninety minutes of my shift.

"Let's see if we can summarize," Clarissa said with a silly smile. "Something along the following lines…"

{_ 'You see, this bitch of an adulterous doctor apparently was so tired from screwing her lover in an on-call room, that she just wanted to sleep all night, and dismissed all the life-saving, logical suggestions I presented to her. And while it's true that neuro would have rejected my suggestion of a CAT scan, it would have been on them, not on non-specialists in the ED. She 'followed orders' like a good soldier and the patient still gorked and died. How about actually listening to people who know what they're talking about instead of sleeping, and also try looking at the pretty pictures so we know what the fuck is wrong with the patient?!" _}

"That's a bit harsh, Lissa."

"Is anything I said inaccurate?"

"No. But she won't get in any trouble for that. Not even a reprimand."

"Because she said the magic words 'standard of care'," Clarissa replied disgustedly. "Except the standard of care is a guideline, and there are exceptions."

"I agree, but they're going to nail her for substituting her judgment for that of Cutter and Northrup. And while it's cold comfort to the patient and his family, that's actually going to cause her more trouble than questioning her medical judgment on a case where nobody can say she didn't follow the standard of care."

"You'd never hide behind that!"

"You do realize that if anyone ever sues the hospital over a case in which either of us is involved, we will have no choice but to invoke that phrase, and that would be true in this case. In fact, I'd almost have to take the other side from what I've said about it so far."

"Do you know how fucked up that is? What about Angie?"

"I know. But the difference is that in her case, the psychiatrist ignored behavior that demonstrated marked improvement and was an indication that Angie could be one of the people who actually recover. In this case, what did we have? An inebriated patient who was in and out of consciousness. No clear indications, just my gut. With Angie, there were clear indications.

"Now you're defending Mastriano?"

"It's a fine line, Lissa. Think about the DUI MVA who had the pseudoaneurysm. I didn't order a CAT scan, which might have detected it. According to Doctor Lindsay, had I ordered it, the patient probably would have coded during the scan. So should I have ordered it? Maybe she doesn't code in the scanner and we save her life. A judgment call, and if push comes to shove, we followed the standard of care by rushing her to surgery and resolving the tamponade. I'm sure some smart lawyer could make us look like bad guys, but were we?"

"I see your point, but there's a difference between critical trauma and a case like the one that was reviewed today."

"Which is what makes it all a judgment call, but that judgment has to be based on what we observe. That's why Mastriano won't be reprimanded for refusing the CAT scan. That said, I bet she changes her overnight instructions."

"And will have her attitude adjusted in a 'come to Jesus' meeting with Northrup?"

"Yes. His statement that it's an internal matter means it's a disciplinary question, not a medical question."

"She and Rosenbaum are going to be gunning for you."

"Well, so far, it's Operation Foot-Bullet on their part. And with Doctor Gibbs back in the hospital, I think I'll be OK. Anyway, I need to get back."

"Dinner tomorrow during our shifts?"

"It's a plan!"

We left the cafeteria, and I headed back to the ED.

"Doctor Gibbs would like to see you," Ellie said.

I acknowledged her and went to the Attendings' office, where I shut the door and sat down.

"I assume you fed Vince Taylor all of those tidbits?"

"As my mentor," I replied. "I went to him for advice."

"He doesn't know about Mastriano and Rosenbaum?"

"Not to my knowledge. Other than you and Clarissa, nobody knows about my trouble with Rosenbaum except for the person who told me about it. Well, Elizaveta knew, but…"

I allowed my voice to trail off without completing the sentence.

"I just want to make sure, because I'll be asked, but did you coordinate with any of those doctors except Vince?"

"No, and I didn't 'coordinate' with Vince, I simply provided him the necessary information to advise me."

"Which is not how it will be spun by a cornered Attending."

"I'm not concerned," I replied. "My only error was not using the soft restrains."

"And admitting you should have listened to your nurse was a deft way to deflect fingers being pointed at that."

"I had no idea if that was a contributing factor or not until I saw Doctor McKnight's report on Tuesday. It did concern me."

"In your position, I'd have been concerned as well."

"How do we change the standard of care?" I asked.

"Time," Doctor Gibbs replied. "As with everything else. Empirical evidence that we should do more CAT scans, for example. You provided one piece of evidence. The thing is, it's just one, and not to diminish what happened, but it's tough to make a case for a new standard from this case."

"Because he was just a drunk," I said disgustedly. "And drunks, like addicts, are treated as second- or third-class citizens. Add in the fact that he was African American, and it only gets worse."

"Doctors are human begins, Mike."

"And yet, we've taken an oath or made a vow to treat every patient with dignity and not allow our biases to influence medical decisions."

"Are you perfect, Mike?"

"No, of course not."

"Neither is anyone else. You have your biases as well, and they influence your behavior. I'm sure you know you have a reputation as a 'bleeding heart' and an idealist, and I'd wager you know that influences how people respond to you."

"Right," I growled, "loving my fellow man is a _bad_ thing."

"That's not what I said and you know it! My point is that there is a middle ground and you deviate far enough from it that people notice and that affects how they see you and how they receive what you say. Remember the discussions about your clerical garb? Same thing. You _know_ that's the source of Rosenbaum's opinion of you. You had permission to wear anything you felt necessary, and chose to wear your cassock. Yes, it was your right, but that doesn't mean there would be no consequences."

"You're blaming me?!"

"You're too tired to have the conversation now," Doctor Gibbs observed. "You're reacting emotionally instead of logically. That's my fault. I should have simply asked you about Vince, and left it at that. Finish out your shift."

"Medical training is totally fucked up when you say I'm too tired to have this conversation, then tell me to finish out my shift."

"As strange as it sounds, I'm confident in your ability to treat patients. That said, if you aren't confident, then we have a problem."

"I can do it," I said.

"Then go do it."

I got up and left the office and found Mary and Tom in the lounge.

"Everything OK?" Mary asked.

I nodded, "Yes."

"I had a call from Doctor Worth who confirmed the change to my electives. I'll be back in the ED in April."

"And Pathology?"

"Confirmed as well. The only potential sticking point is that nobody can make any commitments about the Match."

I nodded, "All you can do there is Match for surgery or trauma, and discuss it with the Chief once you Match. I'll add my two cents, but I can't make any promises, either, without getting in trouble with the National Match."

"Mike?" Kellie called from the door to the lounge. "Can you see a walk-in patient?"

"Sure. What do you have?"

"Nine-year-old male playing kickball head-to-head collision with another player. Significant forehead lac over the right eyebrow with significant bleeding. Vitals are otherwise stable and compression bandage in place."

"Put him in an exam room, please, and we'll be right there. I need to take a leak."

"Exam 3 when you're ready," she said.

I used the facilities, then Mary, Tom, and I went to Exam 3 to see the patient, who was lying on the exam bed with a compression bandage on his forehead.

"Eddie Connor, nine," Kellie said. "This is his mom."

"Hi, Eddie; Hi Mrs. Connor," I said. "I'm Doctor Mike. What seems to be the problem?"

"He ran smack dab into another kid," his mom said.

"Did you pass out, Eddie?" I asked.

"I, uhm, don't remember for sure what happened."

"Neuro consult," I said to Tom. "Eddie, I'm going to take a look at your forehead, OK?"

"Yes."

I washed my hands, put on gloves, and with Kellie's assistance, removed the bandage and examined the wound.

"That's going to require sutures," I said to Kellie. "Probably a dozen."

"Plastics?" she asked.

"No, there are good margins and I can approximate the edges. Let's prep him for suturing, please."

"Right away, Doctor."

"Mrs. Connor, Eddie needs stitches to close the wound. There will be some minor scarring over his eye, but given his age and the way he'll develop, it'll mostly be hidden by his eyebrow and will also fade. Did you see it happen?"

"No. The park is close to our house and one of his friends ran to the house to get me. I scooped him up and brought him in because we're only about five minutes from here."

"Is Eddie allergic to anything?"

"Baths!" she declared.

I smiled, "Normal for a diagnosis of a condition known as pre-teen boy! Has he had any local anesthetics?"

"No. No cavities, so not even that."

"What about family members?"

"Not that I'm aware of."

"Mary, lidocaine sensitivity test sub-cu on his forearm. Tom, let's get him on a monitor, please."

They both acknowledged my orders.

"We're going to do a quick test to ensure Eddie doesn't have a bad reaction to the anesthetic we use," I said.

"What could happen?" Mrs. Connors asked.

"The most common side effects are low blood pressure, headache, or dizziness. None of those are life-threatening. Truly adverse reactions are exceedingly rare, and what we're using is the same thing your dentist would use when filling a cavity, though they may call it by its trade name, Xylocaine."

"BP 110/80; pulse 90; PO₂ 98%," Tom announced.

"Eddie, I'm going to give you a small shot in your arm," Mary said. "You'll feel a small prick, and then it might tingle or feel warm."

"OK," he said.

Mary administered the quarter-dose of lidocaine, and while we waited to see if Eddie had a reaction, I performed my primary exam. I detected a slight delay in his response to the finger movement test, which indicated he might have a mild concussion, but it could also be a result of the splitting headache he certainly had.

"Hi, Mike," Doctor Cohen said, coming into the room.

"Hi, Rebekah. This is Eddie Connor, and that's his mom. Eddie had a head-to-head collision with another kid and has a five centimeter lac just above his right eyebrow. Admits confusion immediately following and loss of memory, so suspect brief LOC. Slight delay in eye response for the finger move test, indicating a possible mild concussion. Sub-cu lidocaine sensitivity test in progress."

"Hi, Mrs. Connor, I'm Doctor Cohen," Rebekah said. "I'm going to examine Eddie and make sure he doesn't have a serious head injury beyond the obvious cut."

"OK."

She began her exam, repeating much of what I did.

"BP 100/60," Tom reported.

"That reaction is mild enough that it's not a problem," I said to Tom. "Keep an eye on it, please."

Doctor Cohen completed her exam.

"I concur that it's likely a mild concussion," she said. "Monitor for symptoms for two hours after you complete your procedure, then release. If anything changes, call me."

"Thanks, Rebekah."

"Mrs. Connor," Doctor Cohen said, "I believe Eddie has a mild concussion. He'll need to rest for a couple of days, but that will coincide with Doctor Mike's instructions following the sutures. We'll keep Eddie for a few hours for observation, but then you'll be able to take him home."

"Thank you, Doctor."

Doctor Cohen left, and once a total of ten minutes had passed, I began to repair Eddie's laceration. The laceration required thirteen sutures, and once I finished, I ordered liquid ibuprofen for the headache and other pain, and had Kellie dress the wound.

"He'll need to keep the wound dry," I said to his mom. "Follow up with your family physician in a week, or bring Eddie back here for a wound check. If you see any redness, puffiness, or discharge that isn't clear, bring him in immediately."

"Why?"

"That would indicate an infection. You also want to watch for signs of nausea, confusion, dizziness, blurred vision, tinnitus, or abnormal drowsiness. If you see any of those signs, bring Eddie in immediately or call 9-1-1, as they would indicate that the concussion was more severe than we believe."

"Thanks, Doctor."

"You're welcome," I said, then turned to Eddie, who was sitting up. "How are you feeling, Champ?"

"My head hurts! But the stitches are COOL!"

"Boys!" Mrs. Connor said, exasperated. "He'd be happy to look like Frankenstein!"

Technically, it was Frankenstein's monster, but I wasn't sure how she'd respond to that correction.

"We men do have a different take on the world," I admitted.

"Now there is an understatement if there ever was one!" Kellie said brightly.

"Thank you, Nurse," I said curtly. "That will be all!"

She laughed, "I'll get Eddie a small smock to wear because I cut off his shirt."

"Can I keep my shirt?" he asked. "It's cool with all the blood!"

"Oh, for heaven's sake!" Mrs. Connor exclaimed.

"That's up to your mom, Eddie," I said. "But maybe I can make a trade. What's your favorite candy?"

"Skittles!"

I produced a small package and held it up for him to see.

"Only when Mom says it's OK, but you have to listen to what she says about the shirt."

"Awww, do I have to?"

"That depends; do you want the Skittles?"

"Fine," he said, rolling his eyes. "Moms!"

I couldn't help but laugh, "I have one, too, so I know what you mean!"

I handed him the package of candy, and after Kellie returned with a scrub smock for him. Mary and I left, leaving Tom to monitor Eddie.

"Hi, Mike!" Kylie exclaimed. "I was in the back for the M & M! I think somebody is in deep doo doo, and it's not you."

"Better if I don't comment right now. I only have one patient, so let me fill you in.

I gave her the rundown on Eddie Connor, and then she and I went into the exam room.

"Mrs. Connor, this is my colleague, Doctor Baxter. It's time for me to go home, so she's going to take over. You'll be in very good hands with her."

"How long are your shifts? If you don't mind my saying, you look beat."

"Thirty-six hours," I replied.

"And you don't sleep?!"

"I managed to take two twenty-minute naps last night," I replied. "Which is about the norm."

"Do all doctors do that?"

"For their first year, yes."

"Wait! You're a brand new doctor?"

"Yes. I graduated from medical school in May."

"I would have sworn you were very experienced!"

I smiled, "I am. Mary and Tom are both medical students I'm training. I was trained the same way, so that by the time I graduated, I had hundreds of hours of clinical experience — that means treating patients."

"How old are you?"

"We're both twenty-six," I replied. "Mary is twenty-five, and Tom is twenty-four. To complete the picture, Doctor Cohen is twenty-seven, and my supervisor, Doctor Gibbs, is thirty-one."

"So young!"

"Most doctors in trauma are young," I replied. "It's grueling, but it's also the case that it's a very new specialty, only really existing for about fifteen years. Our most senior doctors are in their forties. Our Chief is in his fifties, and started as a surgeon."

"What are your normal hours? I mean, after your first year?"

"Twenty-four-hour shifts three times a week, and eventually twelve- or eighteen-hour shifts, depending. A normal work week is about ninety hours to start, going down to about sixty as a senior physician."

"Thanks for answering my questions."

"You're welcome. Have a good evening."

I left, and Mary and Tom followed me out, as Kylie would have her student monitor Eddie.

"Time for a hot shower, dinner, and bed!" Mary declared.

"Exactly!" I agreed. "I'm heading upstairs once I check out."

"See you on Monday," Mary said.

"See you then."

I checked out with Marjorie at the nurses' station, then headed up to the surgical locker room for a shower.

"Good job today," Doctor Lindsay said when I walked in.

"Thanks. Will there be an M & M for the DUI MVA?"

"No. McKnight confirmed to Rhodes that nothing could have saved her short of divine intervention."

"OK," I replied, stripping down to my briefs.

"How do you stay in shape?" Shelly asked, having stripped down to her briefs and sports bra.

"Before this rotation started, I ran and lifted weights. I haven't done either of those because, to be blunt, I'm dead tired and when I get home, I'm going to eat then fall into bed."

We both headed for shower stalls, where I removed my briefs, quickly showered, then wrapped a towel around myself. Shelly did the same, emerging just after I'd begun dressing. She turned her back to me, and I turned my back to her so she could put on her panties and bra without worry, and when we were both dressed, we left the locker room.

"See you Monday," she said.

"Monday," I replied.

I left the hospital, got into my car, and drove home where I greeted Kris and Rachel, ate dinner, then once again collapsed into bed.