Chapter 19: The Sleep of the Dead

July 7, 1989, Circleville, Ohio

"Papa!" Rachel exclaimed happily when I walked into the house.

I picked her up and kissed her forehead.

"I'm going to shower, eat, then fall into bed," I said to Kris.

"You don't look good at all, Mike," Kris observed.

"I need about two days of uninterrupted sleep."

"You have your shift tomorrow, plus band practice."

"I called Kim this afternoon and let her know I wasn't going to make it. I'll be back down in less than ten minutes."

I put down a protesting Rachel, then went upstairs, took a quick shower, put on shorts and a T-shirt, then went back down to the kitchen where Kris was putting dinner on the table.

"You're going to get sick if you aren't careful," she said.

"It's the after-effects of the adrenaline from the helicopter incident. Let's pray so I can eat, please."

I sat down, and Kris put Rachel in her high chair. Once Kris had sat down, I gave the blessing, put food on my plate, and began eating.

"I'm worried about you," Kris said. "It's only the first week and already you're so tired you can barely keep your eyes open when you come home."

"I know," I replied. "This is just something I'm going to have to find a way to get through. I'm not sure what the impact of the law that went into effect this week in New York will be here. It eliminates shifts longer than twenty-four hours and no more than eighty-hour work weeks, averaged over four weeks. But there's no requirement that Ohio hospitals follow that, and the Accreditation Council for Graduate Medical Education hasn't adopted those new rules. That's going to create a conflict for Residents at New York Hospitals who seek Attending roles elsewhere."

"How so?"

"They won't have the number of hours or procedures that other Residents will without extending their Residencies. The other challenge is coverage on the services. If our hours are reduced, they'll need more Residents to do the same work. The problem, as always, is money. Hiring three additional Residents means money has to come from something else, and the County Board just approved hiring six nurses to help cover triage."

"You know my answer!" Kris declared.

"Yes, and that would require completely restructuring our tax system, our healthcare system, and basically the entire federal system. So until then, we're stuck with current funding methods and systems."

"America is such a mess!"

I smiled, "As President Bush has said, that's the 'price of freedom'. And I'm in no mental state to debate that right now. Can we save it for Sunday?"

"Yes."

I ate quickly and, with Kris' blessing, went right up to bed. I closed the blackout curtains, stripped off my clothes, put on my sleeping mask, and collapsed into bed.

July 8, 1989, Circleville and McKinley, Ohio

I slept the sleep of the dead, only waking when Kris shook my shoulder at 10:00am.

"Your shift starts in two hours," she said. "Rachel and I will do the shopping after you go to work."

"OK."

"How do you feel?"

"Better, but not fully human."

"With you being male, I can understand that!" Kris teased.

"Climb into bed, and I'll show you the animal!" I teased.

"Rachel is in the living room."

"So put her in her playpen and come play with me! Unless you're not interested..."

"I suppose..." Kris said with a smirk.

She left and was back a minute later. She quickly stripped off her clothing and climbed into bed with me, and rather than our usual, slow, sensual lovemaking, we fucked for twelve headboard-banging minutes, then went to the shower.

"You certainly had plenty of energy!" Kris observed as we stepped into the spray.

"You're the one who accused me of being sub-human, so I decided to demonstrate!"

Kris laughed, "Very energetically! And that's fine on occasion, but I really do prefer our usual way."

"Me, too," I agreed. "Tomorrow evening after Rachel goes to bed?"

"It's a date!"

I managed to spend about thirty minutes playing with Rachel before lunch, and then I had to say 'goodbye' and head to the hospital. As I drove, I wondered how Doctor Mastriano would respond to my arrival. If I were in her position, and there was no way I'd ever be, I'd have done my best to make nice to try to gain enough camaraderie so as not to be thrown under the bus at the M & M.

With me, though, that wasn't going to work because I was simply going to recite the facts, which included her writing her order on the chart. Doing anything else would call attention to me, and that was the last thing I wanted to happen in an M & M. My goal was to present, then find a foxhole to hide in to avoid the shrapnel from the fire she was going to take.

In the end, though, I had to work with her, and that meant finding a way to get along, much of which would be on me as a PGY1. The problem was, there was open warfare between Doctor Cutter and Doctor Northrup, which was only exacerbated by the red scrubs. On the plus side, at least for me, those red scrubs and the 'S' on my badge meant I could do more procedures than any other PGY1 in the entire hospital.

"Morning, Luisa!" I said when I walked into the ED. "Is Doctor Mastriano in her office?"

"Yes. She said she wanted to see you as soon as you arrived."

"OK. I'm a bit early, so I'll see Doctor Billings before she leaves. If I end up stuck in Doctor Mastriano's office, have Doctor Billings come there so she can hand over any patients."

"Good luck."

"Thanks."

I walked to the door of the Attendings' office.

"You wanted to see me?" I asked.

"Come in and sit down. Close the door."

I did as she asked and waited for her to speak.

"I can't even begin to count the ways this is wrong, but you appear to be untouchable."

"I don't believe that's true," I said. "The same rules apply to me as apply to everyone. Residents perform procedures for which they are cleared by the Chief of their service. If you want to review my procedure book, I have it with me. If you have a problem with that, please take it up with Doctor Gibbs or Doctor Northrup, and they can take it up with Doctor Cutter. I'd prefer you didn't and that we find a way to work together."

"Unfortunately, I don't have a choice. Your fairy godmother made that clear."

"There is literally no need to fight, Doctor Mastriano. How do you want me to handle things today?"

"What I want and what I think is correct both appear to be irrelevant. Do what you want, but it's your ass if things go wrong."

"That means I will check with you, even if it means waking you up, if I think it's necessary. That's the best way to help ensure things don't go wrong."

"You have walk-ins today," Doctor Mastriano said.

"Then let me speak with Kayla about the handover and get to it."

She nodded, and I left the Attendings' office. I found Kayla Billings at the nurses' station updating a chart and asked about her patient load.

"Cooking burn in Exam 6 waiting on discharge, which I'm filling out now, and you'll handle one waiting on surgery for a badly broken ankle. Ortho said about 1:30pm. He's had Demerol IM with their approval and is resting comfortably in Exam 2."

"OK. Where are the med students?"

"Lounge. Gabby just came back from dropping off pre-op labs for the ankle."

"Thanks. Have a good day."

"Ten hours of sleep! See you!"

I left the nurses' station and went to the lounge to see Callie and Gabby.

"Doctor Mike, can I have a moment in private?" Callie asked.

"Sure. Let's see if the consultation room is free."

We left the lounge, and I was happy to find the room free, as it doubled as an office, though most Residents had resorted to using the lounge for paperwork. We went in and I shut the door about halfway.

"What can I do for you?"

"I'm friends with Heather Pratt, well, Doctor Pratt, now, at Northwestern in Chicago. She had good things to say about you when I asked before you started. Anyway, I heard some scuttlebutt and called Heather to ask about it because I wasn't sure what to do. She said I should just tell you one thing — Doctor Mastriano is having an affair with Doctor Rosenbaum."

Which would explain literally everything about Doctor Mastriano's attitude and would suggest the well was so poisoned that there would be no recovery. The consideration I'd given to finding a way to try to mitigate the results of the M & M went right out the window, though I'd been inclined against it.

"How sure are you?" I asked.

"Someone I trust implicitly has seen them together, including in the Pedes on-call room on multiple occasions. And another person I trust said you had a serious run-in with Doctor Mastriano, and a patient died as a result of her orders."

"I can't really discuss this with you, but I very much appreciate the heads up. You should come to the M & M on Friday. If you're off, come in special; if you're on, ask permission. It's usually granted, though in the ED, a lot depends on patient load, and both Doctor Mastriano and I have to be there. Let's go see our broken ankle, then see what we have waiting for us in triage."

We left the consultation room, collected Gabby from the lounge, and then went to see Mr. Miller, who had a shattered ankle.

"Hi, Mr. Miller," I said. "I'm Doctor Mike, and I'll be taking care of you until you go up for surgery. How are you feeling?"

"My ankle is throbbing, but the shot they gave me took the edge off."

I checked the chart and said, "I can safely give you ibuprofen, which will help, in combination with the Demerol. I don't want to give you more Demerol because you'll be going up for surgery in just over an hour. The anesthesiologist will see you before then, and they'll give you the pre-op meds."

"Which ones?"

"An anti-anxiety drug, usually Versed or lorazepam. The actual anesthetic depends on the preferences of the surgeon and anesthesiologist but is often a cocktail of propofol, fentanyl, and more of the anti-anxiety drug. The anesthesiologist will explain all of this to you when the time comes. Is there anything we can get you?"

"They said they called my wife, so she should be here."

"Callie," I said, "please check to see if Mrs. Miller is in the waiting room, and if so, escort her back."

"Right away, Doctor!"

She left and returned about a minute later with the patient's wife. Callie, Gabby, and I then left and went to the triage desk to get the next patient.

We handled a steady stream of mild injuries and illnesses, none of which technically needed an emergency room, but most GPs didn't work on Saturday, and despite the Free Clinic offering a complete range of services, most people associated it with gynecological services and therefore came to the hospital which had longer wait times and was more expensive.

I mostly avoided Doctor Mastriano, as the cases we handled were all so simple that I could have allowed Callie to run them unsupervised. On the plus side, it allowed me to give both Callie and Gabby opportunities to take the lead, which they very much appreciated. Things finally slowed just before 6:00pm, which let me take my dinner break with Clarissa.

"I think I might know what Mastriano's problem is," I said when we sat down at a table by ourselves. "She's having an affair with Rosenbaum in Pedes."

"Holy shit!" Clarissa exclaimed though she kept her voice low. "No wonder she had such a bad attitude with you."

I nodded, "It started off OK, at least as I saw it, but quickly devolved. I wonder if they had a convo after my Saturday shift. That would explain the apparent change in attitude."

"Now what?"

"Nothing, though I had considered trying to find a way to mitigate the damage from the M & M, but she's made her bed..."

"Cute, Petrovich! Cute! He's married and has a couple of kids."

"His adultery is not my concern," I replied. "Nor who he's having sex with. What concerns me, obviously, is him poisoning the well."

"What are you going to do?"

"Nothing. As I said to Doctor Gibbs yesterday morning, I'll let the Attendings at the M & M deal with Doctor Mastriano. There's no need to bring her personal life into it."

"What do you think will happen?"

"I suspect it will end with a written note in her file and the usual opprobrium of her colleagues. It'll put her on notice that she's being watched, and her contract is in danger of not being renewed. This is another case where a doctor is able to rely on 'standard of care' to avoid the repercussions of their actions, even though their actions are arguably negligent."

"You mean because she insisted on waiting until the patient had lower EtOH?"

"Yes. That is the standard, but in my opinion, the CAT scanner has changed the standard of care. Before it, I would have to admit waiting was the right course of action, as without a CAT scan, we'd have to rely on X-rays, which are iffy at best. If asked, my argument will be to change the standard of care to not require the patient to be sober and obtain a CAT scan."

"It sounds as if you're blaming the system."

"In a sense, I am, but remember, I wrote I recommended a neuro consult so I could get a CAT scan, and wrote that on the chart. Doctor Mastriano specifically ordered me not to get a neuro consult and put that order in writing as 'monitor until EtOH is below 0.05'."

"I know you well enough, and so do others, to ask why you didn't override her order."

"Because you know exactly what the neuro Resident would have said given the patient's EtOH was 0.19. They'd have refused, per policy. And I can't order a CAT scan without an Attending's signature. With no neurological signs that couldn't be attributed to being inebriated, Doctor Mastriano wasn't going to sign off, and she refused my request for a neuro consult, so I had nobody to side with me until it was too late."

"I think you're right about the note in her file because she did follow the approved standard of care, especially given the CAT scanner is new here."

"I know it's expensive to use," I said, "but I think any doctor in the ED should be able to order a CAT scan if there's an indicated risk of brain trauma."

"I think you're right, but the bean counters probably won't. Changing topics, how were you at the end of the shift yesterday?"

"Tired enough that I skipped band practice this morning. I slept about fifteen hours."

"I slept twelve, but I also wasn't on that helicopter!"

"Honestly, it was really no big deal. Two ex-Navy pilots resolved a minor mechanical problem by safely landing on a baseball field. Imagine similar trouble on a passenger aircraft which has to make it to an airfield. And from what I read, most people flying commercial never know about mechanical problems."

"Back to medicine, how has your day been?"

"Mastriano has me on walk-ins. That's positive for Callie and Gabby because it allows them procedures they might not otherwise have a chance to do. We've been light on traumas today, anyway. How has your day been?"

"Routine, really, except for one mystery case. I've been doing research, but so far, nothing. I sent samples to Mayo yesterday, and I'll have a call with them on Monday."

"What do you suspect?"

"Mayo will test for Lyme disease antibodies, but the patient had no rash and claims not to have had a tick bite. That's what made us look for other things. If it's not that, we'll look at some of the rare autoimmune diseases. I honestly don't think it's Lyme, but I have to rule it out. Otherwise, we have a couple of pre-op patients, one waiting on a liver transplant, a pair recovering from surgery, one with COPD, and the TB patient."

We finished eating, and both headed back to our respective services. Callie, Gabby, and I continued to handle walk-ins, not fielding a trauma until just after 11:00pm, when there was a multiple-injury MVA. Doctor Casper took the first patient, and we took the second, and I had given advance orders to Callie, Gabby, and Billie.

"Joy Podesta, twenty-two; unbelted passenger; BP 110/80; pulse 110; PO₂ 98% on nasal cannula; forehead laceration; right lower leg and right lower arm fractures; GCS 9; IV saline TKO."

"Trauma 3!" I commanded.

We quickly moved the patient to the trauma room, lifted her to the treatment table, and began our choreographed motions to implement my treatment plan.

"Normal sinus rhythm," Callie called out once the EKG was hooked up. "BP 110/70; tachy at 110; PO₂ 98%."

"Foley, please," I said. "Pupils are sluggish, but lungs are clear and heartbeat is strong. No rebound or guarding."

"Urine in the bag," Callie said, having inserted the Foley. "No evidence of blood."

The patient appeared to be in no immediate danger, but with the head injury, I was going to play it safe.

"Neuro and ortho consults," I said to Gabby. "And portable X-ray."

"Calling now!" she confirmed.

"Ultrasound?" Callie asked.

"No indication for that," I replied. "She has a moderate concussion and a pair of fractures, but I didn't appreciate any abdominal injuries. You can throw a pair of sutures in that forehead lac."

"Nurse, suture tray, please!" Callie requested. "Irrigation kit and lidocaine times two."

Just before midnight, we transferred the patient to neurology and did the handover with Kallie before heading to the surgical locker room for a shower.

July 9, 1989, Circleville, Ohio

After Church on Sunday, Kris, Rachel, and I headed home to spend some time together as a family.

"It dawned on me this morning that Sundays are the only day we have significant time together," Kris said as we relaxed on the couch. "You spend most of your time at home sleeping."