Chapter 12 — Then I Think You Know the Way Forward

_April 6, 1990, McKinley, Ohio_

{psc} "Would you do something for us?" Kellie Martin asked late on Friday morning.

"What's that?"

"Go to Personnel and fill out a religious accommodation request for your beard and ponytail."

"I don't need one," I said.

"You would if you wanted to accept Wernher's offer of an emergency medicine Residency. All you have to do is say you're considering it, but he said you had to shave and cut your hair, and you can't do that."

"I'm going to guess that will help the nurses in some way?"

"It'll make his unofficial policy public and put him on the back foot. It'll be one more thing he changed unilaterally, which is the main complaint the nurses have. The policy manuals simply say our appearances need to be 'professional' and 'neat', which has always been interpreted as properly groomed; no political or offensive slogans on clothing or buttons; no revealing clothing; and proper hygiene. I don't see any downside, and neither does Becky because he made the offer. All you're doing is asking for an appropriate accommodation."

"That actually makes sense, though I'm concerned Owen Roth or Shelly Lindsay will hear about it and think I'm actually considering it."

"Doesn't that work in your favor? They don't want to lose you, and it would wreck the entire 'trauma surgery' plan. Combine that with the rumor that you and Clarissa Saunders are leaving for Chicago, and you'll light a fire under Baker and Roth, not to mention the Attendings in the ED."

"I'll go see Personnel — well, I read the memo that it's 'Human Resources' now — right away.

Kellie left, and I walked down the long corridor to the Administration wing and went into the Human Resources office, which didn't appear to have changed in any way except its name.

"Good morning, Doctor!" a very pretty young woman said. "I'm Cassidy. How may I help you?"

"Good morning, Cassidy. I need to request a religious accommodation for my beard and ponytail."

"There are no hospital policies against either, except that you have to keep them neat, so no accommodation is necessary."

"The new ED Chief, Doctor Wernher, expressly said that he requires his male doctors to be clean-shaven and to have their hair cut short. Because of changes, I'm considering his offer to switch to a pure emergency medicine Residency."

"Doctor Wernher can't make that rule."

"Well, then someone needs to explain it to him because he was adamant, and he's instructed all the ED Residents and Attendings to shave and get haircuts."

"One moment, please. Let me speak to Mrs. Cartwright."

She walked away from the counter and down a short hallway. About two minutes later, Mrs. Cartwright, the Personnel Director — now the Human Resources Director — came to the counter.

"Hi, Doctor Mike. Cassidy explained the situation. You do not need any accommodation. Doctor Wernher is new, so he may not be aware of our policy. No other Chief has said anything, have they?"

"No."

"Good. Then I'm sure it's a simple misunderstanding. I'll take care of it and let you know."

"Thank you. I appreciate it."

"Any time! If you need anything, please call Cassidy, and we'll take care of you!"

"Thanks again."

"Have a good day, Doctor."

"You, too."

I left the Human Resources office and returned to the surgical lounge. I found myself in a strange situation, wishing for a severe trauma that needed my attention. It seemed so wrong, but truth be told, I was bored out of my mind and had to seriously consider my options.

I was paged just before lunch and was perversely happy that a patient needed a chest tube and then emergency surgery to repair a punctured lung. I was permitted to scrub in and assist, and we finished just in time for the M & M Conference. I'd been dreading it because it was a formal review of the events of February 20th and our patient care in the face of a violent attack.

I joined Clarissa, Shelly, Kylie, and Sophia and sat towards the back of the packed room. I was surprised to see Loretta brought into the auditorium in a wheelchair by Bobby and got up to greet her with a light hug before returning to my seat between Shelly and Clarissa.

Doctor Cutter took the podium, and after a brief intro, Bobby wheeled Loretta next to the podium and handed her the microphone. She recounted the basic events, and the response, including the armed security guards, and then asked for comments from the gathered doctors, nurses, and medical students.

As expected, there were several objections to having armed security, even off-duty police officers, in the ED. I shook my head when Dutch Wernher stood up to speak. He hadn't been in the ED that day, and he hadn't lived in the area a week and hardly knew anyone in the hospital except by name. He certainly had a _right_ to speak, but a wise man would have kept his mouth shut and listened before addressing people he barely knew in a hospital he barely knew in a community he barely knew.

"I'm sure," he began, "that many of you don't lock your cars or lock your doors at home because you believe your community is safe, despite a gun battle in the ED and at least one previous incident where a doctor foolishly attempted to disarm a patient, and was fortunately rescued by an attentive Sheriff's Deputy."

"THAT IS NOT WHAT HAPPENED!" Ghost said vehemently, springing to his feet. "You weren't there, and you are mischaracterizing the events. Contrary to your claims, the Sheriff's Department wanted to award a commendation to that doctor for _preventing_ a patient from drawing a firearm by using a wrist lock."

"Doctor Casper," Doctor Cutter said. "Thank you, but please wait your turn to speak."

Ghost shook his head, "Not when an interloper with zero experience here and zero knowledge makes false statements."

There was applause, most especially from the nurses.

"Your input is noted. Please have a seat, and you'll have a turn."

"As I was saying…" Doctor Wernher started.

"Sit down!" a gruff voice called out, likely Tim Baker, but I wasn't sure.

"Yes! Sit down!" Becky demanded.

Suddenly, there was a clamor from numerous voices, male and female, all saying, 'Sit down!'. I simply kept my mouth shut, as did Clarissa, Shelly, and Sophia, as there was plenty of support. I hit on a course of action that would absolutely put Wernher in his place, all the while not saying anything he could point to as insubordinate. I stood.

"Fellow doctors and nurses," I said, standing up. "Please."

The room quieted.

"Doctor Wernher is entitled to his opinion, and we should at least politely hear him out. When he's spoken, I'm sure plenty of you will respond politely and one at a time. I certainly will. Doctor Wernher?"

I sat down, and Shelly leaned over,

"Nicely played," she whispered.

"Slick," Clarissa whispered.

"Thank you, Doctor Loucks," he said.

"Dutch, he goes by Doctor Mike," Doctor Cutter corrected. "Please use the name he prefers."

"Zing!" Clarissa whispered.

"My apologies, Doctor Mike. As I was saying, my experience in Chicago is such that I understand the need to provide medical care in a safe, efficient manner. The current ED is not configured for safety, though in looking at the plans for the new ED, I see the ambulance bay doors are properly configured to require badges.

"Armed security is standard in Chicago emergency departments and does not interfere in any way with patient care. It's private security, unlike here, where it's provided by off-duty law enforcement officers. Please do not dismiss patient and staff safety so lightly. Other changes should be adopted, including badges with photos that are color-coded by role and badge access for every door."

He sat down, and I immediately stood up.

"First, I want to welcome Doctor Wernher to his first M & M at Moore Memorial in his first week as Chief of Emergency Medicine. I do agree with his proposal for photo IDs color-coded by role, but beyond that, the events of February 20th were an anomaly in our community.

"Cook County Hospital, according to doctors who have served there, sees more gunshot wounds most _days_ than we see in a month. University of Chicago Hospital, where I know the Chief, has fewer than Cook County, but still an order of magnitude more than we have. We don't have a gang problem, and our drug problems are limited, though growing.

"What that means is that we do have to take security seriously, but it has to be in proportion to the actual threat. And, to be honest, armed citizens are the norm here in Hayes County, unlike Chicago, where handguns are largely banned, even for self-defense at home.

"If you walk into the parking lot, you'll see pickups with gun racks owned by Attending physicians, senior nurses, and just about any other role you can imagine here at Moore Memorial. Take a ride over to Hayes County High, and you'll see the same thing. We, as physicians, need to respect our community, and if we want to bring about change, we need to educate the public on the risks associated with handguns, which in our community is mainly suicide, not homicide.

"So, yes, some response is in order, but a proportional one, not a disproportional one. I say this as a physician who saw a friend, Deputy Tracey Sommers, killed in cold blood before my eyes and who supported two of my colleagues who I count among my best friends, who were shot by the same assailant.

"Even having experienced that, armed security on the premises at all times is too much. The McKinley PD and the Hayes County Sheriff have committed to sending officers into the ED in response to incidents like the one that precipitated the events of the 20th. That, in my mind, is the proper proportional response."

I sat down, and the room erupted in cheers and applause.

"You skewered him good," Shelly whispered. "And he can't say a word about it!"

"Nice move, Petrovich," Clarissa whispered as Kayla Billings stood to speak. "First M & M; first week. You called him a «мудак» (_mudak_) without calling him a «мудак» (_mudak_)!" {green}("Asshole"){/green}

I nodded and listened to Kayla, who agreed with the ID proposal but rejected _all_ armed security, including police, in the hospital. I knew that would never fly because none of the officers would willingly surrender their firearms to enter the ED, and the Police Chief and Sheriff would never agree.

Several others spoke, with Shelly going last, reinforcing my point, though she objected to badged access to the ED for medical staff coming for consults. I understood her point, but unless we redesigned the hospital completely, there was no way to allow medical staff badgeless entry if access controls were in place. We could achieve what she wanted with no controls on interior entrances but with them on the ambulance bay and the waiting room. I suspected that would be the end result.

Once Shelly had finished, Doctor Cutter reminded everyone that Psych was available to help with any aftereffects of the shooting incident, then dismissed everyone. Kellie Martin came over to me and pulled me aside.

"In the military, we would say 'Sir' with a certain tone of voice that conveyed we thought the officer was a total asshole but in a way that couldn't land us at Captain's Mast or given NJP! You did the same thing here!"

"NJP?"

"Non-judicial punishment. It's a form of discipline short of a Court Martial, with the benefit of not being a criminal conviction. Punishments basically range from a reprimand to thirty days in the brig. A sailor or Marine could refuse, and then the officer has to decide whether or not to convene a Court Martial."

"Ever get called to Captain's Mast?" I asked.

Kellie laughed, "Once. I may have mooned a bunch of recruits one day when I was on a speedboat while off duty."

"May have?" I asked.

"May have. That's my story, and I'm sticking to it!"

"Reprimand?"

"Yes, and the Commander who held Mast was doing his best not to laugh the entire time. Nothing went into my service record."

"What was the charge?"

"Conduct unbecoming. Officers are not supposed to act «некультурный» (_nekulturny_)!" she smirked. {green}("Uncultured"){/green}

I laughed, "Nice. I take it you learned that word from Clarissa?"

"No, actually, from a Russian defector who addressed a seminar I attended during Medical OCS — Medical Officer Candidate School. I need to get back. But nicely done with Wernher."

"Thanks."

"Before I go, did you ask for your accommodation?"

"Yes, but no such thing exists because my beard and ponytail aren't against any policy. Mrs. Cartwright was going to explain that to Doctor Wernher."

"Which is exactly what I wanted to happen. He's now on record as trying to change the rules for nurses _and_ doctors without the authority to do so."

"You are a subversive, Miss Martin!"

"Takes one to know one, Mr. Loucks!"

She winked and walked away, heading towards the ED, while I caught up with Shelly on the way back to the surgical ward.

"You buried him," she said.

"Thanks to the setup from Ghost," I replied. "And I'm sure Ghost will understand."

"Everyone in that auditorium who knows you understood exactly what you were doing. And it was perfect."

"Thanks."

"You and Kellie Martin seem to be close," Shelly said with a hint of innuendo in her voice.

"Not that way," I said. "We hit it off, sure, but neither of us is a cheater, as you and I discussed. She's very unhappy that an ex-Navy man is acting like a complete jerk."

"What was the Russian word Clarissa whispered to you."

"«мудак» (_mudak_). It means a-hole."

"He's either going to get his poop in one group quickly or be out on his butt."

"I wouldn't count on that," I said. "He has support from the Hospital Board of Directors and indirectly from several County Supervisors. The best approach, in my mind, is the one I took in the M & M — find the common ground, act on it, and push back politely but firmly on the BS.

"The nurses chose flamethrowers; I chose rhetoric. Their way causes too much collateral damage, but I get it, given the County is being stingy with regard to paying them. I get that money is tight, but they can't take it out on the nurses without harming patient care. You and I both know we can make do missing doctors; what happens when we're missing nurses?"

"Nothing good."

"And losing candy stripers doesn't help, either," I observed.

"I did hear that the High School canceled the program after the County's liability insurer questioned kids under eighteen working in the hospital."

"Bureaucrats, whether in insurance companies or in government, are going to kill us all. Jefferson and Trotsky both warned about unaccountable bureaucrats and how they would betray their respective revolutions."

"Trotsky? Seriously?"

"Seriously. He had a lot of bad ideas, but being against bureaucrats wasn't one of them!"

As we walked into the surgical ward, my pager went off, showing three '999', indicating a consult in the ER, but not stat, which would have been six 9s. I walked to the lounge, found Nick, and the two of us made our way to the ED via the stairs. Ellie directed me to Exam 2, and we entered.

"Mike Loucks, Surgery," I announced.

"Hi, Mike," Naveen said. "Kristin Westbrook; sixteen; furuncle on her inner thigh, about 3cm below the inguinal groove; temp is 38.4°C; pulse 72; BP 110/70, PO₂ 99% on room air. First noticed about a week ago, now much larger despite warm compresses. Proposed treatment is lancing, topical antibiotics, and a course of oral antibiotics."

"Thanks, Naveen. Hi, Kristin. I'm Doctor Mike, a surgeon. How are you feeling?"

"Embarrassed!"

"I understand, but everyone in the room is a medical professional. How bad does it hurt?"

"It's pretty sore, and if I touch it, it really hurts."

"I'd like to examine you, please. I'll listen to your heart and lungs, then examine the boil. As Doctor Varma suggested, the usual treatment is a lance, that is, using the pointed end of a scalpel to puncture it. We'll drain it, wash it out with saline, and apply a topical antibiotic. Sounds good?"

"Do I get an anesthetic?"

"Honestly, a local would hurt more than lancing the boil. It'll just be like a pinprick. And the overall level of pain should go down once it's drained. May I examine you?"

"Yes."

I washed my hands, put on gloves, then had her sit up. I checked her heart and lungs, and finding nothing that would contraindicate the procedure, I had her lie down so I could examine the boil, which was about a centimetre below the elastic leg-opening of her panties. I saw no complications, and it was a simple furuncle — infection of a hair follicle, colloquially called a 'boil'.

"Becky, I&D tray, please."

Becky brought me a tray with a scalpel, a medium bore needle on a syringe, an irrigation syringe, a bottle of saline, a basin, a bottle of alcohol, and gauze. I decided to try to limit scarring and use the needle rather than the scalpel.

"Needle aspiration," I said to Becky. "Kristin, I'm going to use the needle to remove the fluid, as that's less likely to leave a scar than the scalpel. First, I'll wipe the area with alcohol, then insert the needle. I'll use it to suck out the fluid, then rinse with saline and apply a topical antibiotic. OK?"

"Yes," she agreed.

Becky and I worked together to perform the procedure, and ten minutes later, Becky taped gauze in place.

"Keep this dry for twenty-four hours," I said. "Then make sure you wash it well every day. Keep it covered with gauze for a few days to prevent chafing. If it's uncomfortable, apply warm compresses and take Advil or Tylenol. OK?"

"Yes! It already feels better!"

"Naveen, oral antibiotics are contraindicated — no carbuncle, no obvious skin disease."

"OK. Thanks, Mike."

"Anytime. Nicole, have a good day!"

"Thank you, Doctor!" she exclaimed.

I removed my gloves, tossed them into the bin, and left the exam room. Nick followed me from the room, and we headed back to the surgical ward.

"Can I ask a question?" he inquired.

"Sure."

"How would I explain that kind of thing to my wife? She'd have a fit if I touched a girl there."

"My wife, Elizaveta, was extremely uncomfortable with those kinds of procedures, especially Foley catheters, because you actually have to touch the woman's vulva to insert the catheter. All you can do is make it clear that medical procedures and intimate contact have zero to do with each other. As a doctor, it's just a body and just a medical procedure, period. That should have been drilled into your head by this point."

"It is. It's my wife's reaction."

"Be discrete and don't mention specific procedures. If it does come up, remind her that it's a medical procedure. How does she react to the co-ed locker rooms?"

"What she doesn't know can't hurt me!"

"You really do need to tell her because if she finds out later, there will be hell to pay. As for you, you simply need to turn off that part of your brain in every medical context, including the locker room. If you can't, go into research because you can't be a doctor."

"You were touching a hot girl's inner thigh, and you didn't think about that?"

"Not for a second," I said. "I was serious when I insisted you need to turn off that part of your brain. If you can't do it, you aren't cut out to be a doctor because, at some point, you'll end up in serious trouble."

"I'm not sure how you just turn it off."

"You just do. Train yourself. Remind yourself you're a physician. I'm not kidding about this. Got it?"

"Got it."

He said it, but I wasn't sure I believed him. When he walked into the lounge, I went to see Shelly Lindsay.

"What's up?" she asked when I appeared at her door.

"I have a question I need to ask in complete confidence about a medical student."

"Come in and shut the door."

I did and sat down.

"Here's the problem," she said. "No matter what I promise, if you tell me something I decide indicates patients are at risk or is about illegal activity, I can't keep the promise. This isn't a confessional."

"Understood. Let's try it this way. If a Fourth Year, who has already Matched, indicates that he was thinking about sex while observing an intimate exam, what's the correct action to take?"

"That's a huge red flag for a Fourth Year. Have you observed any inappropriate behavior?"

"No. This was in the context of a question of how to explain procedures a wife might find objectionable. I know about that because Elizaveta nearly had kittens when she found out about inserting Foley catheters for young women. I talked her off the ledge, and you and I have discussed the co-ed locker room, which was also raised, but in the context of hiding it from his wife."

"Another red flag because that means he potentially sees it as sexual in an inappropriate way."

"I was thinking the same thing. What's the approach?"

"You counseled him?"

"Yes, and he acknowledged what I said, but his body language and tone of voice made me doubt whether he actually internalized what I said."

"What specialty?"

"That's going to give it away in a way that neither of us can maintain plausible deniability."

"You don't have a choice, Mike. You didn't come here because you needed scintillating conversation or to bask in the glow of my greatness!"

I laughed, "Goddess Shelly?"

"Bow down, worship me, and kiss my feet!"

"I'll leave that to your future husband," I chuckled. "I already have two women at home demanding that from me in different ways, and a third one will arrive shortly!"

Shelly laughed, "Little girls tend to wrap their dads around their little fingers."

"She's trying, that's for sure!"

"Who?"

"Nick Duran."

"He Matched for oncology at Good Samaritan in the Chicago suburbs, a specialty without a lot of intimate contact. That said, he's going to be a physician. The protocol for a doctor with that problem is a psych eval, counseling, and close monitoring."

"My concern is that he voiced it as a question of how to handle it."

"Just a question? Why are you here?"

"Because he called the patient a 'hot girl' and mentioned me touching her inner thigh."

"I don't see how we can avoid asking for a Psych eval. I mean, we _could_ simply ignore it for another seven weeks, but if he's ever accused of inappropriate behavior and it becomes known we were aware of the risk and did nothing, we'd have liability. I'll speak to Owen, and he'll order the psych eval."

"That is unlikely to go over well," I said. "And it could very well cause students to not speak to me."

"Then tell me that you are one hundred percent unconcerned and you've decided it's unfounded."

"You know I can't."

"We can set it up so that none of it goes in his permanent record, so long as he completes the counseling I'm sure Psych will order. It'll be tight, but six weeks should be sufficient. Let us handle it, OK?"

"Yes."

My pager went off with '999999'.

"Stat ED consult," I said.

"Take Penny. Just say she needs the experience, and you can't take both. I'll go see Owen now."

"Will do."

I left the Residents' office and went to the lounge.

"ED consult," I said. "Your turn, Penny, given you haven't had a chance. Nick, confirm afternoon labs, please."

"Right away, Doctor Mike!" Nick agreed.

Penny and I left the lounge and hurried to the ED via the stairs.

"Why the stairs?" she asked.

"Partly exercise, partly to not occupy the elevators. I generally only used them when I escorted families as a med student or to transport a patient."

"What do I do?"

"Watch and learn," I replied. "Ask questions afterwards."

Ellie directed me to Trauma 1, where Ghost and Paul Lincoln were working on a patient.

"What do you have, Ghost?" I said.

"Connor Johnson; male, mid-30s, MVA, vitals in the tank due to hypovolemia. He needs a central line."

"Billie, central line kit to me, please," I said. "Mary, come stand by me, and I'll explain the procedure."

Billie got the kit, and Mary Anderson came to stand by me. I quickly inserted the central line, explaining each step to Mary as I performed it.

"Line is in," I announced.

Billie hooked up the rapid infuser and began running in blood, and the patient's vitals stabilized a bit, but he wasn't out of the woods.

"Hang out, Mike," Ghost said. "He's obviously surgical if we can stabilize him. Bleeders in his belly, most likely."

"Penny, call up and tell them we have an unstable ex-lap coming up right away. Ghost, pump in another two units, and I'll take him. He's sure as hell not going to get any better than he is now by lying here."

"Billie, two units on the rapid infuser," Ghost ordered. "Mary, get a gurney."

"I'd like Mary to scrub in," I said. "Can you see your way clear?"

"I'm already in Dutch up to my eyeballs, so why not?"

I couldn't help but laugh, and Billie laughed as well.

"You put Wernher in his place perfectly, Mike," Billie said.

"Doctor Roth and Doctor Lindsay are waiting on us," Penny announced.

Mary came in with the gurney, and as soon as the second unit of blood was in, the team moved the patient to the gurney, then Penny, Mary, and I rushed him from the trauma room.

"HOLD THAT ELEVATOR!" I called out as we hurried down the corridor.

As usual, everyone exited the elevator, and a nurse held the door open for us. Less than a minute later, we pushed the gurney into OR3.

"Mary, scrub in with us," I said. "I cleared it with Ghost."

"Yes!" she exclaimed.

We went to the locker room, where I removed my cross and ring, and Mary and Penny both removed necklaces and changed into clean scrubs. We left the locker room and went to the scrub room, and three minutes later, we joined Owen Roth and Shelly Lindsay in the OR.

"Train wreck," Ken Bernard, the anesthesiologist, said. "Owen, get in, find the bleeders, get out. He's not going to last long otherwise."

"Thanks, Ken. Mike suction. Mary, retractors. Shelly, let's get this done."

The surgery was as close to 'meatball surgery' as anything I'd ever seen in the OR. Owen and Shelly were operating like 'Hawkeye' Pierce and 'BJ' Honeycutt, and less than ten minutes later, they'd tied off three bleeders, removed the patient's spleen, and had begun closing.

"How's he doing?" Owen asked.

"Hanging in there," Doctor Bernard said. "We needed him off this table an hour ago!"

"Mike, you and Mary go with him to recovery," Owen said. "Stay until he's stable, or you're relieved."

"Will do," I said.

Owen and Shelly completed the surgery, and the anesthesia was stopped. Mary and I scrubbed out and then came back to take the patient to recovery. Because of the time, I was going to be home late, so I asked Jane, a recovery nurse, to call the house and let Kris know I'd call when I could leave.

"Thanks, Doctor Mike," Mary said as we sat down next to Mr. Johnson. "Can I ask what might be an impertinent question?"

"Given I'm going to be your teacher starting June 1st, I'd say you're required to ask those questions."

"About that, with what Doctor Wernher is saying, how is it going to work?"

"The way Doctor Roth, Baker, and Getty want it to work. Just keep your head down."

"Why did you defend him in the M & M?"

"«Jūjutsu»," I replied. "Think about the position he's in now."

"He can't claim you're opposing him or being insubordinate."

"Exactly. Just let this play out, and everything should be OK."

"What about the rumor you and Doctor Saunders want to leave?"

"If the trauma surgery program were to be canceled, I'd have to consider that option."

"That would really, really suck."

"Yes, it would. I don't _think_ that's going to happen, but I need to think about what I'll do if that were to happen."

"I don't get it," Mary said. "Why kill a great program?"

"At the root, it's really a turf war. I, and the program, are simply proxies for Doctor Wernher to have more control over the ED. And I understand that point — once we move to the new ED, we'll be working towards Level I certification. That means the ED will need to be staffed with pediatricians, cardiologists, and surgeons. The current plan is for all of them to be members of those respective services."

"Suddenly, it all makes sense!" Mary declared. "Not his methods, but why he's doing it. There will be a dozen or more doctors from other services assigned to the ED who don't report to him."

"Yes. Right now, there is exactly one person in that situation — me. If he can win the battle and break the longstanding tradition that only surgeons supervise surgeons, he can win the war. If not, he's going to have to deal with staff who aren't his, per se."

"It's called 'matrix management'," Mary said. "It's very challenging because the employee has two bosses, and if they don't agree, the employee is caught in the middle. It can be a real nightmare if there are several levels of management before there is a common manager between the staff members."

"At least here," I replied, "the various service Chiefs report to the Medical Director," I observed. "I basically worked for Doctor Northrup and Doctor Gibbs, even though, officially, I was on Doctor Roth's service. It worked OK because they agreed on how things should work. The thing that surprises me is Doctor Cutter's role in this, but he's under pressure from the Hospital Administrator and both the Hospital Board and County Board over operating costs."

"Politics?" Mary asked.

"Something I swore I'd avoid like the plague, but that was a foolish notion because somebody has to raise the money for this public hospital, and guess who does that?"

"Politicians at all levels."

"Sadly," I replied. "Back to the patient — please check Mr. Johnson's heart and lungs. You're listening for crackles in the lungs and murmurs or regurge in his heart. You also want to listen for bowel sounds."

Mary performed the assessment, and I verified her findings of normal sounds.

"We should put temporary splints on his left arm and left leg," I said. "We didn't have time earlier. I'll stay with the patient; go to the ED, and get two adult male temporary splints — one posterior long arm and one posterior knee splint."

"Be right back."

She was gone about ten minutes, and when she returned, she, Nurse Camille, and I splinted the broken arm and leg. The patient would need an ortho consult, but that would have to wait until he was out of recovery. The question would be whether he went to the ICU or the CCU because he certainly wasn't going to a regular ward bed anytime soon.

At 7:00pm, Bob Hodges, a fellow PGY1, and his student Alan came to relieve us. Mary and I turned over the patient and left recovery. She returned to the ED, and I went to the locker room to change into my street clothes. Once I'd changed, I went to the lounge and called Kris to let her know I was on my way home and hoped for a quiet evening together, given the delay had meant we'd miss Compline and the Canon of Saint Lazarus at Saint Michael.

_April 7, 1990, Monastery of the Dormition of the Mother of God, Rives Junction, Michigan_

"Father, bless!" I said when I walked into Father Roman's small office on Lazarus Saturday, having driven up after attending the Divine Liturgy at Saint Michael the Archangel.

I cupped my hands, he made the sign of the cross, and I kissed his hand, then we exchanged a typical Russian greeting.

"I see you have on your cassock," he observed.

"I have permission from His Grace to wear a standard black cassock here and at the prison. I also have leave to wear the _sticharion_ when I'm assisting Protodeacon Ivan with the Typika at the prison. And, finally, His Grace asked me to teach Sunday School once a month, and I'll start in August."

"How is Kris?"

"She's fine; she simply didn't feel up to traveling."

"Understandable. And Rachel is well?"

"Yes, she is."

"Let's take a walk around the grounds and talk, if that's OK?"

"It is."

We left his office and began our walk.

"What's on your heart, Michael?"

"Things at the hospital are unsettled, and for the first time since I started medical school, I didn't want to be there."

"What happened?"

I explained everything that had happened with Doctor Wernher and how I felt about it.

"At the risk of feeding your ego, you handled that meeting with Doctor Wernher perfectly and made good use of your prayer rule. What you did at the…what did you call the assembly?"

"An M & M – a Morbidity and Mortality Conference. It's used to review any negative outcomes, but this time was about the shooting incident."

"What you did there was cynical, even if it had the desired outcome. You showed him up with false humility."

"I can't dispute that, nor that it felt good to do so."

"The problem, Michael, is not your actions but your heart. That's almost always the source of sin, which I'm sure you know."

"I do. And I reveled in my colleague approving my actions and even pointing out I had used false humility to show him up."

"Had you been motivated by love rather than animus, there would have been no problem."

"It always comes down to that, doesn't it?"

"Yes, it does. Any tool can be misused, and it is not the fault of the tool but of the person who is using it improperly. Remember, it's not that you were wrong in anything you said, just in your motivations. You felt…let's use 'picked on' rather than 'persecuted', and used your rhetorical skills to get even."

"I did. Not to defend the problematic thinking, but what I said needed to be communicated."

"This is always the challenge. Is 'the ends justify the means' valid thinking?"

"Generally not. I wasn't thinking that way, though. I felt my response was justified based on my analysis of the situation."

"I agree, Michael. The problem here is not what you said or did, but where your heart was. Do you think you can deceive yourself?"

"Yes, of course. I'm struggling with the need to do the right thing, even if my heart isn't completely right."

"That, my young friend, is the essence of the struggle to live the Christian life. We're very quick to try to find justification for our actions, and it's simple to deceive ourselves into thinking that because we did what was right, our motivations do not matter. Or, and I know you've experienced this, that what we did was wrong, but we excused the behavior in some way."

"My promiscuity while I was single and after I became a widower."

"Yes, but all of that has been confessed, and thus you shall have 'no further care'."

"I don't beat myself up about it, but I do use that as an object lesson in how easy it is to justify or excuse sin."

"Yes. I want you to contemplate how you might ensure your heart is right before you act."

"I know the answer, Father — it's prayer, especially Hesychast prayer. The challenge is that my role is one where immediate, decisive, confident action is necessary for success. When I know the right thing to do, I do it immediately."

"And your motivation?"

"To provide my patients the utmost in medical care — with God's help, I do everything possible to repair their injuries and save their lives."

"And that motivation so thoroughly permeates your spirit that you don't have to think about it, and nothing can deter it, correct?"

"Yes."

"That is what you need to do in every area of your life, Michael. Get your heart right first, so that when you encounter situations such as the one at the M & M Conference, you are acting in Christian love. In your one-on-one with the doctor, you stopped to pray. Did you do that at the conference?"

"No, I didn't."

"Then I think you know the way forward."

"I do."