Chapter 1

It was the first week of my first year of residency. Five years earlier, I was employed at this hospital as a paramedic and decided I wanted to go all the way. I did well in med school, served my internship across town at University Hospital and felt incredibly lucky to have landed an emergency medical residency here. After all, there were only two positions available and the competition was stiff.

I'd just come on duty at 7AM, when the charge nurse told me I was wanted in the director's office. On a Sunday? I hurried down the hall and knocked on his open door. He was standing beside his desk in jeans and a T-shirt, reading a chart. The picture was completely out of character for the reigning god of EMS.

"Come in, Dr. Butcher. Please close the door and have a seat."

Dr. Peter O'Malley, author of three textbooks on emergency medicine and now Chief of Emergency Services, seemed all smiles and cordiality. For some reason, it didn't feel reassuring. He'd been very personable when he interviewed me for the position but I'd already been warned by one of the staff physicians and several nurses to beware of that pleasant demeanor because it could be intended to put me off my guard before he laid into me about some stupid little mistake I might have committed. I wondered again what in the world could have brought him into the hospital on a Sunday morning.

"Thanks, Dr. O'Malley. One of the nurses said you wanted to see me."

His smile broadened and that was even more ominous.

"That's right. First, may I officially welcome you aboard and congratulate you for persevering through medical school and your internship. I suppose by now you've heard every conceivable joke and pun about your last name and I don't doubt you'll hear the same trite remarks for the rest of your professional life. Still, I suppose it might have been worse; you might have chosen surgery as your specialty."

"Thank you, sir and, yes, I've heard that one too."

The smile wilted a bit.

He sat in the squeaky chair behind his desk and leaned forward, folding his hands like he was about to impart some nugget of profound wisdom. "I just wanted to give you a heads-up about one of your cases that will be reviewed at Tuesday's M&M conference."

He picked up the chart he'd been reading and leaned back, looking it over again for a few seconds. "Mmm, it says here that last Friday night, you saw a twenty-four year-old Hispanic female who was brought in by a friend, complaining of lower abdominal pain increasing in severity over three days. After the standard work-up and X-rays, you diagnosed pelvic inflammatory disease and discharged her with a prescription for antibiotics. Am I right so far?"

I recalled the case clearly. I remarked to the triage nurse about the woman overdoing it on the perfume and makeup and being dressed for business, if you know what I mean. She was practically a stereotypical hooker, although she never admitted to it. The diagnosis of STD's and PID was so common among her ilk that the treatment regimen was basic ABC's. I remember being a bit irritated because she was assigned to me right at the end of my shift, and I had to stay over an extra forty-five minutes to finish her chart. Normally, I wouldn't have minded, but I had to call my date and tell her I'd be late meeting her at the restaurant. She wasn't happy.

"Yes sir. The nurse did a vaginal swab and the lab confirmed chlamydia. I prescribed a course of doxycycline for seven days and told her to check in with the clinic if the pain wasn't better by tomorrow. She said she'd been seen at one of the satellite clinics about two months ago for similar symptoms and they told her she had gonorrhea. It cleared up with a course of antibiotics."

"So I see. And what was the patient's condition on discharge?"

"Well, she still had some supra-pubic tenderness, although it had eased up with NSAIDs and she was mildly febrile with a temp of 37.8. She had a pretty high blood alcohol level but the friend who brought her to the hospital said she'd make sure she got home OK. I gave her enough doxycycline for two days along with the prescription."

"Right. So far, so good. Um, tell me Dr. Butcher, what did her pregnancy test show?"

It bothered me that he kept calling me Doctor or Dr. butcher instead of my first name, giving the conversation a distinct air of formality, like this wasn't just a casual inquiry.

"Well, when I asked her about her last period, she said it had just ended a couple of days earlier."

"And?"

"Well, if she'd just finished her period, she wouldn't be pregnant, so I didn't order a test."

"Not even as a precaution?"

"Um, it didn't seem necessary. She didn't have any insurance and the test would have just piled on more expense."

He shot me a perturbed look, "Doctor, whether or not she had insurance is irrelevant. We're an emergency department, not a private clinic, and I'd call that kind of thinking penny wise and pound foolish. Now, as for her pregnancy status, apparently, you missed an important lesson way back in medical school. For your information, it isn't that terribly uncommon for a woman to menstruate or appear to menstruate after she's been impregnated. On another note, didn't you say she had a high blood alcohol level?"

"Yes, her BA was .16 if I recall correctly."

"And you say she appeared drunk."

"Yes sir."

He tossed the chart onto his desk, crossed his arms over his chest and glared at me. "So tell me, Dr. Butcher, in your vast experience as an emergency physician, do you consider intoxicated people to be reliable historians?"

"No, I guess not."

The old man rolled his eyes up toward the ceiling and I knew I was in for a verbal flogging. "You guess not. Let me offer you a little rule to live by, Dr. Butcher. When any woman of childbearing age presents with lower abdominal pain and tenderness not of traumatic origin, especially if she has impaired cognitive capacity, and especially if she has a recent history of a sexually transmitted disease like gonorrhea, she will be tested for pregnancy. That omission wasn't just a little brain fart, Doctor. And aside from neglecting to order an important diagnostic test, you violated a protocol by discharging a patient who was, by your own admission, clearly intoxicated."

My heart sank and I knew I had stepped right in the middle of it. "Oh no, don't tell me she came back!"

"Ah, but I'm afraid I must. Less than three hours ago, this young lady was brought in by ambulance and admitted with severe abdominal pain, hypotension and a hematocrit of 22. Had she waited until tomorrow to go to the clinic as per your instructions, she might well have bypassed it and gone right on down to the morgue. The attending physician read her chart from Friday night's visit and called me at home to express his concerns with your assessment and treatment."

I covered my face with my hands and groaned, "Ruptured ectopic pregnancy!" I hadn't made a stupid little mistake, I'd made a huge, potentially catastrophic mistake!

"Very good, Doctor! Your diagnosis is right on the money, even if it's two days late. Now, the good news is that she's doing reasonably well following surgery and a few units of blood. That's right, Doctor, you can breathe easier because she didn't die as a result of your mental lapse. The bad news is that you're going to present this case at M&M and then you're going to stand there in front of all those doctors, nurses and paramedics and take your medicine. It won't be pleasant."

M&M is medical-speak for morbidity and mortality conference. The emergency staff meets every Tuesday morning to review any cases that are particularly interesting, especially if someone (like me) did or didn't do something that turns out to be problematic.

As much as it embarrassed me to even think it, if the patient had been someone of a higher station in life and if I hadn't been in such a hurry to leave, I would have probably done the damned test and nailed the relatively straightforward diagnosis. Instead, here I was, practically brand new in the business and I'd already committed a stupid fucking boner that could haunt me for the rest of my career. My god, I thought, what if she had died?

I took a deep breath and said, "Yes sir. I see now, that I committed a serious error, and I can promise you it won't happen again."

There wasn't a trace of the smile left. His voice rose and his face began to turn red. "It had damned well better not happen again! If it does, you won't have to worry about presenting it at the next M&M because you won't be employed by this hospital. I won't tolerate sloppy work from my staff and that fact had better be firmly planted in your brain when you walk out that door! The only reason you're still employed at this moment is that your staff attending should have ripped you a new asshole for even thinking about cutting this patient loose in such a condition! Is everything perfectly clear to you now, Dr. Butcher?

"It is, sir."

He took a deep breath to calm himself, leaned back in his squeaky chair and reclaimed his crocodile smile. "Good! Now, at the end of your shift in the ER today, you will report to Dr. Jane Willard up in labor and delivery. She's kindly consented to give you some much-needed tutoring on everything you did wrong since you were either absent or asleep during the gynecology rotation during your internship.

"And one last thing, Doctor. As you must be aware, residencies in my department aren't easy to come by. Don't make me regret offering it to you. Now go away!"

Dr. Estep was waiting outside in the hallway. He was the staff attending that night and no doubt knew what he was in for. He avoided my eyes as I passed him on my way back to the ER.

I felt like a complete idiot. I owed the woman a profound apology, but I knew I dared not say a word to her. I had no idea if she had a clue that I'd screwed up, and saying anything to her could open me and the hospital up to some big-time liability. Shit! Double shit!

My shift in the ER wasn't all that eventful; one cardiac arrest that was too far gone to save, some multiple systems trauma from an auto/motorcycle collision and the usual collection of aches, pains, scrapes, cuts, drunks and dopers, most of whom should have been seen in one of the satellite clinics. Needless to say, Estep scrutinized every one of my cases with a very critical eye.

At 3:30, I showed up at Dr. Willard's office on the third floor for my remedial training in gynecology. Her door was open so I stepped in and introduced myself, "Hi, Dr. Willard. I'm Ken Butcher from the ER. Dr. O'Malley directed me to report to you for some tuning up."

She looked up from what she was reading and laughed, "Well, I suppose that's one way to put it." She waved toward a chair loaded with books and folders. "Just drop that stuff on the floor."

"Thanks."

"So, let's get off on the right foot, Ken. First of all, you can call me Jane since we're colleagues and secondly, I'm not planning to beat you up because, if I know Peter, he's already done that. That said, the mistake you made is the kind of thing that causes malpractice attorneys to have wet dreams. If Peter was angry, it's because he had a right to be. You put the patient, his department and the hospital at risk. The woman might have died."

I studied my shoes and admitted, "I can't say that I blame him for being pissed. There's no justification for the way I screwed up."

She at least made a stab at being conciliatory, "Ken, if this is the worst mistake you ever make in your career, you could be considered some kind of phenom. It's an unfortunate near-certainty that, as a medical practitioner, sooner or later you'll be at least partially responsible for a patient's death. You get no pats on the back because this one didn't die, but if you learn from your mistake, you'll be a better doctor. So tell me, Ken, what's the most common cause of ectopic pregnancy?"

"Um, STD's, primarily gonorrhea, if I recall correctly."

"Good! So, you're not completely ignorant. Now, let's talk about belly pain in young women."

So that's what we did for two hours. By the time I left to go home, I was wishing she'd been my professor of OB/GYN in med school. There was no way I was ever going to make that mistake again.

I headed down the hallway toward the elevator but impulsively decided to take a detour up one flight of stairs to the surgical floor to peek in on the woman who'd suffered from my mismanagement. I just had to satisfy myself that she was going to be OK. I checked in with the nurse and got a peek at her chart. Everything looked good.