Chapter 22: I Didn't Call to Fight

July 17, 1989, McKinley, Ohio

"I can remove the cervical collar," I said after examining Mr. Gross' neck.

"It really hurts, Doc."

"Nothing is broken, and I don't feel any swelling," I said. "We'll give you some Tylenol 3, which will take care of the pain."

"Tylenol?"

"Tylenol 3 is actually a combination of acetaminophen and codeine, not the same thing you buy at the drugstore," I replied. "Let me speak with Doctor Williams, and we'll get it for you."

I removed the cervical collar and updated the chart, then Len and I went to find Doctor Williams, who was at the nurses' station.

"OK to present?" I asked.

"I thought it was minor, but go ahead."

"It is minor. No appreciable injuries; BP 120/70; pulse 72; PO₂ 99% on room air. Complains about 'extremely sore neck', but no appreciated tenderness or swelling."

"What are you not saying? Your tone of voice says there's something.

"When you came in, he asked about you, and I explained you were a senior physician, and he asked how long I'd been a doctor. When I explained I'd just graduated, he said 'kids' and freely shook his head. The paramedics reported he was arguing with the other driver on the way in."

"Ah. So why the codeine?"

"Because it is entirely possible he has a mild case of whiplash, and pain can't be proved one way or the other. He might actually be in pain, and given I see no indication he's drug-seeking, the standard of care is to provide pain relief. I'll discharge him with instructions to see his personal physician for a follow-up, but his chart will reflect my findings."

"So when he files his insurance claim, he comes up dry?"

"That'll be between him and his physician."

"Approved. Chart?"

He signed off and made notes, and I went to Ellie and asked for the drugs, showing her the signed chart. She retrieved two tablets for me from the Schedule Drug locker, and I took them to Mr. Gross.

"Len, a cup of water, please," I said when I returned to the room.

Len got the water and handed it to Mr. Gross, and I handed him the small paper cup with the two tablets.

"These will be very effective for pain relief," I said. "After six hours, you can take three regular Advil every six hours, and you should follow up with your personal physician within forty-eight hours. He'll manage any pain or whiplash symptoms."

Mr. Gross swallowed the tablets and handed the cup back to Len.

"I'm going to fill out your discharge papers. Is there someone we can call for you?"

"My wife," he said.

"Len, get the number and call Mrs. Gross, please. I'll be back in a few minutes.

Ten minutes later, Mr. Gross was shown to Patient Services.

"He was faking," Becky said.

I nodded and showed her the chart.

"WAIT!" Len protested. "He was faking?!"

Becky smiled, "I was pretty sure Doctor Mike caught it. I saw it in his eyes when the patient shook his head."

"Which you don't do if you have whiplash," Len said.

"Exactly," I replied. "Take a look at what I wrote on the chart."

Becky handed it to him.

He nodded, then read aloud, "'Patient claims neck pain but has no appreciable injuries or signs. Paramedics report patient combative during transport. Tylenol 3 PO, but no script. Follow up with PP'. Then why the pain meds?"

"What is the one thing we have no way of independently verifying under any circumstances?"

"Pain."

"And the standard of care?"

"Appropriate analgesia unless the patient appears to be drug-seeking."

"Correct. And if they appear to be drug-seeking?"

"Psych consult or social worker."

"Doctor Mike," Bob said, approaching with a chart. "Rule-out MI with heartburn ready for discharge."

"Did you perform an exam?"

"Yes, and I have an EKG strip for you. Cardiac enzymes negative on repeat test."

He handed me the chart, and I looked at the EKG strip, which showed textbook sinus rhythm and the patient's cardiac enzymes that were in the lower middle of the acceptable range. Nothing else was amiss, so I signed the chart and discharge form.

"Street him," I said, handing back the chart. "OTC heartburn medication and follow-up with his personal physician."

Bob took the chart and left.

"Thanks for stroking my ego," I said to Becky.

She smiled, "I actually meant it!"

"I believe I need more experience before that would apply."

Becky shook her head, "I didn't say you were the most experienced; I said you were the best."

"And you can tell that after two weeks?"

"Would I lie to my little brother?"

I laughed, "Well, given how my little sister and I treat each other..."

"Good point! I have an older brother, and, yeah. Even now!"

"My mom and her older brother are the same way. My grandparents even commented on it at dinner yesterday."

"And my sister and me," Len said. "I think it's universal."

"Mike?" Ellie called out. "Walk-in teen with breathing difficulties. Bringing them to Trauma 2."

Len, Becky, and I saw Jamie bringing a teenage male from the waiting room in a wheelchair, and we followed them into Trauma 2. It was a fairly straightforward asthma case, resolved with a nebulizer of albuterol, and I turned him over to Bob to discharge after two hours of observation.

We had a bit of a lull, then a series of routine walk-in cases with no EMS transports. I sent Len and Bob to lunch at staggered times and then took mine at 12:30pm so I could meet Antonne in the cafeteria.

"How are things going?" I asked Antonne as we joined the line.

"Great, actually. My mom loves her job working for ... how should I refer to him?"

"It's OK to call him my father-in-law," I replied. "The law may not see it that way, but he's Rachel's grandfather. Go on."

"Anyway, Mom loves her job, as I said, and the housing here is far better than what she had in Cleveland, and it won't be long before she can get out of the subsidized housing. My brother and sister are both happy, though they miss their friends. That said, they're both glad to be away from the gangs. I'm working at Kroger stocking shelves. How about you?"

"The hours are brutal, but I love what I'm doing."

"I won't ask about interesting cases because I'm positive the others will want to hear about them. Will you have time starting in August?"

"I'll make time," I replied. "I don't know what my schedule will be beyond the end of August. Until then, I'm on two thirty-six-hour shifts, one starting at 0600 on Mondays and the other 0600 on Thursdays, and then a twelve-hour shift on Saturdays, starting at noon."

"Military time?"

"All our schedules use military time, as do our charts, time of death announcements, and so on. It prevents any confusion. One major point is noon and midnight, which would both be twelve, where so many people mix up am and pm because you go from 11:59pm to 12:00am and 11:59am to 12:00pm. Both of those are by convention, too. With the twenty-four-hour clock, what you called 'military time' has no possible confusion because 2400 is never used in the hospital."

"I don't look forward to those shifts."

"There's a good chance you won't have to do them. New York passed legislation to limit shifts to twenty-four hours, with a maximum of eighty hours per week and a minimum of eighteen hours between shifts. That was in response to the Libby Zion case we discussed. That will likely spread, though it could take some time. That said, it's seven years before you're a doctor, so I'd wager you won't have thirty-six-hour shifts."

"Have you heard from any of the others?"

"No. I figured that would be the case, given a mix of how busy I am and the fact that none of them live in McKinley. Just remember, your break between graduation and med school is the last one you'll have until you've served your Internship."

"Are there any black doctors at this hospital?"

"Five, I think. Only one in the ED — Paul Lincoln. He's a PGY1 like me. For a brief period, Doctor Gibbs was the only female, but there are more now. Surgery is the true boys' club with just two female surgical Residents. Fortunately, McKinley Medical School's ratio of males to females is shrinking, but they're still lacking in minority applicants. I'm hoping all six of you apply there."

"You know Danika is going to go to Stanford, right?"

"I strongly suspect that's the case, but we'll see what happens two years from now. Maybe she'll meet the right guy and decide to stay in the area."

"YOU were her right guy!" Antonne declared. "And from what I understand, you felt she should go to Stanford."

"I didn't realize that was public knowledge."

"I wouldn't call it public, but everyone in the group knew it, just as they knew Conchita would have married you just to be Rachel's mom!"

I chuckled, "I got that impression, but I needed an Orthodox wife."

"How do you have time for church?"

"As with everything else that's important, I make time. It's when there are important things which conflict that tough choices have to be made."

"But medicine always comes first, right?"

I nodded, "Yes, and even if I wasn't predisposed to that, it would be forced on me. As I've said, medicine is a harsh, demanding, jealous mistress, and she does not brook anyone or anything interfering with her demands."

"How does your wife handle it?"

"You'd have to ask her! But I made absolutely sure she knew what she was walking into before we married. Over the years, quite a few girls who might otherwise have been very interested took a look at the demands of medical training and Residency and chose not to pursue a relationship with me. Is there anyone special in your life?"

"There was a girl back in Cleveland, but she'll only be a Senior, and I don't think she's mature enough to handle the kind of life I'm going to have."

"My advice is when you find someone who can, you marry them. That's going to be FAR more important than being in love with them."

"Crazy."

"We are! It's the only way to stay sane!"

Antonne laughed, "That's so Zen!"

"I know you were raised Pentecostal, but I think you'll find a lot of wisdom in Eastern philosophy."

"You mean Buddhist?"

"Among other things. I'd recommend taking World Religions along with a philosophy class in your electives. It'll pay off."

"What about Latin?"

"It helped, but you can memorize the words by using flashcards. What language did you take in High School?"

"German, of course. This is Ohio, after all!"

"Given who I married, I probably should have taken French, but there was no way to know this is where I'd end up."

"Is Kris teaching Rachel French?"

"No, but my troublemaker of a sister-in-law is!" I chuckled. "I know Rachel's grandparents use a small amount of Russian with her, and so do my grandfather and grandmother, but it's mostly English."

"Sisters are always troublemakers!"

I laughed, "I agree, and I just had that conversation earlier."

When we finished our lunch, Antonne left for a shift at Kroger, and I headed back to the ED. The afternoon was busy with a mix of walk-ins and EMS transports, but nothing out of the ordinary. I admitted an MI and a diabetic and streeted eight patients before Kris and Rachel arrived so we could have dinner together.

When I returned from dinner, Mary and Tom had taken over for Bob and Len. Almost immediately, we had an EMS transport for an MI. I checked the board for an open trauma room, then we gowned and gloved.

"What are we doing?" I asked Mary as she, Tom, and Nurse Kellie waited in the ambulance bay.

"High-flow oxygen, EKG, and monitor. CBC, Chem-20, ABG, and cardiac enzymes."

"You have your cardiology rotation next, right?"

"Yes."

"Make sure you ask to be taught to read EKGs, and I don't mean just the basics. Doctor Strong is a good choice to ask, as he's an excellent teacher, as is Doctor Javadi."

"Already on my list of things to learn before this time next year."

The EMS squad turned into the driveway and, a few seconds later, pulled up in front of us.

"Art Nesmith, fifty-three; collapsed while dining; complaining of severe chest pain; diaphoretic; BP 180/120; tachy at 120; PO₂ 98% on nasal cannula; history of hypertension according to his wife; taking Capoten; no IV due to hypertension."

Which was the right move, as adding fluids was the last thing a hypertensive patient needed.

"Trauma 3!" I ordered.

Three minutes later, after performing auscultation and hearing no irregular heart sounds, I looked at the EKG and saw sinus tach but no indication of an MI.

"What do you see, Mary?"

"Sinus tachycardia, but otherwise, no deviations."

"Differential?"

"With systolic of 180, hypertensive crisis."

"Mr. Nesmith, have you taken your medication today?"

"Yes," he replied, clearly in pain.

"First thing we need to do is get your blood pressure down. Have you been diagnosed with any liver problems?"

"No."

"Have you had a heart attack?"

"Just this one."

"I don't believe you're having a heart attack," I said. "Have you seen a cardiologist?"

"No. My doctor is treating my high blood pressure."

"Billie, sublingual nitro tab, then chlorpromazine, 50 megs IM, please."

"Right away, Mike!"

"Mr. Nesmith, the nitroglycerin will reduce the pain and help lower your blood pressure. The nurse will put a tablet under your tongue. She'll then inject you with chlorpromazine, which is an anti-hypertensive, that is, combats high blood pressure."

"OK," he said with a grimace.

"I'm going to complete the exam," I said.

I went through the usual exam steps, asking the usual questions. I wasn't surprised that Mr. Nesmith drank several cans of beer a day, smoked, and ate plenty of fried foods.

"Did your doctor discuss the effects of diet, alcohol, and smoking on your hypertension?" I asked.

"He's a pain in the ass!" Mr. Nesmith declared.

I decided I'd let Medicine deal with that and simply let it go.

"We're probably going to need to admit you to get your blood pressure under control. Would you like your wife to come in?"

"Sure."

"Tom, would you see if his wife is in the waiting room and bring her in? Mary, call for a Medicine consult for hypertensive crisis, please."

Everyone followed my instructions, and five minutes later, my consult from Medicine arrived.

"Hi, Petrovich! What do you have?"

"Hi, Lissa!" I replied, then gave her the information.

"Mr. Nesmith, I'm Doctor Saunders from Internal Medicine. I'd like to examine you, please."

He agreed, and she performed her exam.

"No arrhythmia and stable, so I'll take him," Clarissa said, then turned to her student, "Jay, call for an orderly, please. When we get upstairs, you'll need to do the admission paperwork."

"Yes, Doctor," he agreed.

Ten minutes later, Mr. Nesmith, his wife, Clarissa, and Jay left the room to head up to medicine.

"Petrovich?" Mary asked.

"Mikhail Petrovich Loucks," I replied. "Or in English, Michael Peter Loucks. My dad's name is Peter, so that became my middle name because Russians use patronymics instead of middle names. The 'vich' part means 'son of'."

"So, you're a son of a vich?" Billie asked with a silly smile, causing Tom, Mary, and me to laugh.

"ANYWAY," I said when I could after laughing hard, "close friends call each other by the patronymic. Clarissa and I have been partners in crime since Freshman year at Taft."

"You're Russian?" Tom asked.

"«Да, товарищ» (Da, tovarich)," I replied.

"I don't speak Ruski!" Tom declared.

"I said, 'Yes, Comrade'. I'm half Russian. My dad is Dutch, from the time when Manhattan belonged to the Dutch. My mom's side of the family is Russian."

We left the room, and Nicki waved me over.

"You had a call from a Doctor Fran Mercer in Milford. She left a number."

She handed me the message slip, I thanked her, then contemplated what to do. I decided I should return the call and went to the consultation room that served as an office for the Residents. I shut the door, sat down, and said forty repetitions of the Jesus Prayer before picking up the handset and dialing the number.

"Fran Mercer."

"Doctor Loucks returning your call. I'm on shift. What can I do for you?"

"I didn't call to fight, Mike," Doctor Mercer said. "I called to apologize."

"For?"

"How much time do you have?"

"I can't guarantee I won't be called for an EMS run, so I can't really say."

"When would you have time to talk?"

"Wednesday during the day," I replied. "I'm on until 1800 tomorrow, sorry, 6:00pm, then I'll go home, eat, and collapse."

"Could you call on Wednesday morning at 9:00am?"

"I could. Your office or this number?"

"My office, please."

"I'll call you on Wednesday."

"Thanks. Have a good evening."

"You, too."

I hung up and left the consultation room, wondering how far her apology might go. The fact that she had called at all was a good sign, given everything I'd said to her in the past. I was extremely curious about what she would say, but my duties in the ED had to take priority over my curiosity. I pushed those thoughts into the back of my mind and refocused on the ED.

"I heard Callie got to close an appendectomy," Mary said when I joined her and Tom in the lounge.

"Right place, right time, right circumstances," I replied. "Basically, all the planets AND stars aligned, and I did most of the suturing while she closed the epidermis. And that only happened because both Attendings and the on-call Resident were handling a traumatic amputation, and the remainder of the staff was on the golf course for the annual golf outing."

"I'd ... sorry, never mind."

I chuckled, "Give your eye teeth?"

"Yes, that is what I was going to say because I'm my grandma!" Mary replied with a smile.

"Trust me, I know the feeling, and making deals with the Devil is not uncommon but also not wise. The Devil always gets the best of you."