Chapter 24: Wonderful!

July 19, 1989, Circleville, Ohio

"What did you do today?" Kris asked when she arrived home on Wednesday afternoon.

"Rachel and I hung out. I played my guitar, read to her, and we took a walk."

"How did your call with Doctor Mercer go this morning?"

"She capitulated," I replied. "And she agreed to support Angie's claims with the state licensing board, though as an error of judgment, not malpractice. But, with all the other facts, I believe that will be sufficient to cook Doctor Greenberg's goose."

"You mean he'll lose his right to practice?"

"I still think that's a longshot, but a formal reprimand is certain, and a suspension for a year is probable. And that information is public, so he won't ever escape it."

"And that would satisfy you?"

"Nothing will satisfy me because the situation can't actually be fixed, but it's the appropriate action by the State of Ohio. Call it a 'warning shot' to others not to make the same mistake. Sadly, I doubt it will be heeded."

"So, what can be done?"

"By me, very little except to try to encourage the psychiatrists I encounter to stop reflexively prescribing psychoactive drugs to create docile patients rather than doing the hard work of trying to help patients overcome their illnesses. Fundamentally, it's a product of Western civilization, and I'm not sure how to address it."

"Western civilization? How?"

"In a hunter-gatherer tribe, what triggers would Angie have had? And if she was quirky and celibate, she might well have been a seer or a medicine woman. The so-called barbarians would have treated her with respect and possibly even awe. Think also of the Russian tradition of 'Fools for Christ'. We so-called 'modern' and 'civilized' people treat her, and people like her, terribly.

"It's also the case for those tribes that nearly everyone engaged in some sort of labor that didn't require specialized knowledge, except that which was imparted from father to son or mother to daughter, and all of that revolved around food, shelter, clothing, and what passed for medical practice. If Angie is able to do data entry and practice Aikidō, she could certainly have been a productive member of the tribe. More so if she was a medicine woman or seer, things which were valued."

"Are you saying we should go back to that kind of existence?"

"I'm no Luddite!" I chuckled. "And I prefer my creature comforts. What I'm trying to point out is that progress isn't always positive, and there is much to learn from the ancients. Were you aware that there was reliable herbal birth control in Roman times?"

"No!"

"A plant called silphium was a very effective contraceptive. It's thought to be extinct, mainly because the demand for it was so high, because it also had other medicinal qualities. It was reported to be an abortifacient because it would induce menstruation whether the woman was pregnant or not. A single monthly dose was as effective as the pills you take every single day."

"Why not plant more of it?"

"From what I've read, it would only grow in a very limited region around the ancient city of Cyrene, in what's now Libya. They tried to manage the harvest, but as you can imagine, the demand was simply too great. That's not the only ancient herb or medicinal plant that was effective. Modern aspirin is synthesized, but it's based on an extract of willow bark, which was used as an analgesic.

"Coca leaf, which is chemically processed to make cocaine, acts as a mild stimulant and analgesic, and also suppresses hunger, and is not addictive, nor do users suffer from withdrawal if they stop using it. Of course, we moderns have developed a process to extract it, concentrate it, and make it addictive to the point where we no longer have what amounts to a natural remedy.

"And yes, Coca-Cola did originally use coca leaf in Coke, but they stopped doing that just after the start of the twentieth century, when they substituted 'spent' leaves that had no cocaine. A bottle of Coke made with the original formula and intended syrup to carbonated water ratio had around ten milligrams of cocaine, compared to a typical line of cocaine, which has around sixty milligrams, give or take."

"And that was legal?"

"Absolutely. Until the passage of the Pure Food and Drug Act in 1906, there were no effective limitations on what drugs could be sold or used. And that act only required proper labeling. Modern drug laws came about in 1938 with the Federal Food, Drug, and Cosmetic Act, and prescriptions became mandatory for listed drugs in 1951 with the Durham–Humphrey Amendment, which created two groups of drugs — prescription, also called 'legend', and over-the-counter. Interestingly, Senator Hubert Humphrey was a pharmacist by trade. He later on became Vice President under Lyndon Johnson."

"So before that, anyone could take anything?"

"Yes, so long as they could find someone to provide it, and I don't mean just doctors or pharmacists. One of the reasons for the passage of the Pure Food and Drug Act was the availability of so-called 'patent medicines', which were, as the term goes, 'snake oil'. Coke, Pepsi, and Dr Pepper had their start as 'patent medicines'. Coke was sold as a cure-all for, among other things, morphine addiction, indigestion, nerve disorders, headaches, and impotence.

"Pepsi Cola was first marketed as a cure for dyspepsia, that is, an upset stomach. The name refers to the digestive enzyme pepsin, but the drink never included that enzyme, despite some people thinking it did. Dr Pepper was sold as a digestive aid and was claimed to restore 'vim, vigor, and vitality'. It, like Coke and Pepsi, was developed by a pharmacist and sold in drug stores, which, as you might guess, is the origin of the soda counter and soda 'jerks'."

"That's not a French thing at all, and I only know about it from things I've read or movies I've seen. Anyway, what's the plan for this evening?"

"Dinner, Vespers, and making love to my wife, if she's interested."

"She's interested! Shall we make dinner?"

"Yes!"

July 20, 1989, McKinley, Ohio

"Hi, Stranger," Lara said when I met her in the cafeteria for lunch on Thursday.

"We saw you and Nathan about a month ago!" I replied.

"And you and I saw each other nearly every day for the past seven years!"

"True, minus somebody's jet-setting during Summer breaks and my honeymoon with Elizaveta."

"How are you holding up?" Lara asked.

"Good, actually, despite being very tired. You won't believe what happened yesterday."

"What?"

"Doctor Mercer capitulated and agreed to write a letter stating that Doctor Greenberg had made an error in judgment by discounting clinically significant behavior."

"It was malpractice, and you know it!" Lara declared.

"It was," I replied. "But Doctor Mercer has to work within her community, so she couched it in terms that would help us but also protect herself. Saying that he discounted clinically significant behavior is sufficient to have him receive a disciplinary letter and will likely result in suspension. He'll have a permanent black mark on his record at that point. That is the best we can do and is better than what I'd expected."

"You know the attorney was instructed to push for revocation of his license, right?"

"Yes, and knowing how this works, he'll work out the equivalent of a plea deal and accept the reprimand and suspension in lieu of losing his license permanently, and the licensing board will agree. That said, if there were other incidents, things might be different. As far as I'm aware, there aren't, and revocation usually requires a pattern or some egregious act like performing surgery under the influence of alcohol or drugs or committing an illegal act."

"Sadly, that makes sense."

"Let's change subjects! How are things with Nathan?"

"I invited him to church, and he hasn't run away screaming!"

I chuckled, "He was at my wedding!"

"Which isn't three or four hours on Sunday morning!"

"True. And?"

"I think, with your blessing, I'll say 'yes' when he asks me to marry him."

"As much as I object to that entire idea of you needing it, you have my blessing."

"And you know I don't mean it in a patriarchal way, just that if you had anything negative to say, I'd listen carefully. I trust your judgment, Mike. It's been proven to be damned good for the past seven years."

"Minus a few significant mistakes."

"I think you've made fewer mistakes than you think, but that's bound up in your rigorist view of sin."

"As if there is any other option! I mean, for me, not how I apply it to others."

"You always did take the pre-Eucharist prayer literally."

"Yes and no," I replied. "It says I believe, O Lord, and I confess, that thou art truly the Christ, who camest into the world to save sinners, of whom I am chief. That's quoting the Holy Apostle Paul's First Letter to Timothy. And the point is to never, ever look down on another person because of their sin. It may disqualify them from ministry, but it is never to be lorded over them. It is not just to be forgiven but forgotten. That is, it should have no meaningful effect on how I perceive the person."

"Frank Bush," Lara said.

"As one example. I'm no better than he is in terms of sinfulness. He's paying an earthly penalty for his sin, but you know my take, right?"

"That he should live a long life so he has a chance to repent of his sin and ask God to forgive him. And you've made him your personal mission in life. What do you gain by that?"

"Personally? Nothing. And that's the point. I don't want anything for me out of that, though I would obviously feel good if he were to acknowledge God's saving grace even while serving a life sentence without parole. But, in the end, I'll never know, at least in this life, if that happens. In the end, only God can see into Frank Bush's heart, and I'm certainly no «старец» (staretz) with the gift of insight into another person's interior life. My calling is to heal the body." ("Elder")

"So, is it just Frank Bush?"

"Long term? No. I hope to start a prison ministry that will also provide medical consultation. I'm sure I can find enough nurses to help."

"When you need funding, you know where to come."

"I appreciate it. Any idea when Nathan will ask?"

"I'd say before the end of the year."

"I'm happy for you," I said.

"I take it everything is OK with you, Kris, and Rachel?"

"Yes, minus not being able to see them as much as I'd like, but Kris and I knew that beforehand. Rachel is unhappy at times, but she enjoys our Wednesdays together."

"More soon?"

"Yes, Mom!" I chuckled. "We'll start trying in September."

"Did you receive your invitation to Maryam's wedding?"

"Yesterday. Kris and I plan to fly up on that Saturday and fly back late on Sunday."

"That's going to be very tight. What do you think about flying in a private plane? We wouldn't be bound to a specific flight schedule, and split four ways, it wouldn't be ridiculously expensive. I know someone with a Twin Beech who could fly us up and back. That means we could stay for the reception and still make it back so we could go to work on Monday morning."

"That would help," I replied. "I'd only have to trade a Saturday shift. Would you check into it and let me know how much it will cost? I think we'll likely leave Rachel with Lyudmila rather than try to take her along because I'm not sure how well she'd tolerate the trip."

"I'll check into it and get back to you."

"Thanks! Invite Clarissa because I'm sure she and Tessa received invitations."

"That will work. Six passengers will be fine."

"Great!"

We finished our lunch, hugged, and Lara left the hospital while I returned to the Emergency Department.

"Doctor Mike," Ellie called out as I walked towards the nurses' station, "Doctor Gibbs would like to see you."

I acknowledged her and went to the Attendings' office.

"You wanted to see me?" I asked.

"Come in, shut the door, and grab a seat."

I did as she asked and waited for what she had to say.

"Doctor Mastriano was placed on probation this morning," Doctor Gibbs said. "All her orders will need to be confirmed by another Attending until her probationary period has ended. There will be a memo published tomorrow, but Doctor Northrup asked me to tell you in advance. Doctor Mastriano claimed you set her up."

"And Doctor Northrup's evaluation of that claim?" I asked.

"That it is unfounded. She claimed you insisted on a written order for the express purpose of undermining her authority and that you failed to provide relevant details about the patient. The facts are not in dispute, and the charts from that night are definitive."

"I decline to respond to that accusation, and I'll stand on the facts and the orders on the charts."

"Which Doctor Northrup, Ghost, and I all knew would be the case, and why we didn't need to speak to you before Doctor Northrup concluded his investigation and determined the proper course of action. This will require a bit of juggling of schedules, as we'll need a second Attending overnight. Doctor Northrup does have an Attending slot open that he hopes to fill this week."

"What do you want me to do?" I asked.

"Keep on keeping on. You did exactly the right thing that night, and in your position, I'd have asked for the order to be written. That should have been her clue she might have misjudged the situation with the patient. And that's something to remember. If your Resident feels strongly enough to insist you write your orders in your own hand, that's the time to reconsider."

"Understood. On another topic, I may need to trade a shift in October; Maryam is getting married on October 15th and Kris and I will fly to Chicago on a Saturday and fly home late Sunday evening."

"OK. Let's discuss it when the schedule for September and October is published in August."

"Is there anything else? I saw patients in the waiting room when I walked past."

"That's all. Go heal the sick!"

I nodded, got up, and went to find Bob and Len, so we could handle some of the walk-ins.

July 21, 1989, McKinley, Ohio

"Mike, Doctor Lawson would like to see you," Ellie said just before noon on Friday.

"Did he say what he wanted?" I asked, despite having a strong suspicion about what it was he wanted.

"No, just that you should stop by his office between noon and three."

"I'll take my lunch now, then go upstairs."

I went to the cafeteria, ate my lunch quickly, then headed up to Psych to see Doctor Lawson. He was in his office and waved me in, indicating I should close the door.

"I had a call from Doctor Jules Greenberg. Your name appears on a witness list in a complaint against him filed by the parents of a patient. I believe we discussed this."

"We did," I replied. "And her family chose to proceed. I heard from their attorney, and if they do call me as a witness, I'll answer truthfully and forthrightly."

"You are unqualified to make any diagnostic comments."

"I have no intention of doing so and no need to do so. I will simply state my observations, which, by themselves, are damning."

"A doctor supporting a claim that revolves around diagnostic decisions and treatment choices will forever tarnish his own reputation. You can decline to testify."

I stood up.

"I reject your advice, Doctor, and I will not remain silent in the face of clear medical errors. I'm needed in the ED, so if you'll excuse me."

"You're throwing away your career, Loucks."

I left without another word because there was nothing I could say to him. The only decision I had to make was whether or not to make a complaint about Doctor Lawson. My initial inclination was to simply let it go, but my second thought was better — to wait for the outcome of Doctor Greenberg's hearing. And before I did anything, I'd need to speak to Clarissa, and, more importantly, Kris.

When I returned to the ED, I found Mary and Tom, and as there wasn't an active trauma, we went to the triage desk to take a patient. Before we could take a patient, Nate let us know that EMS was eight minutes out with an MVA with severe trauma. That ETA meant some distant part of the county and a long response and transport. The three of us gowned and gloved and went to the ambulance bay and a minute later, were joined by Ghost and Kellie.

"You run it, Mike," he said. "I'll only step in if you ask me to."

"OK. Who's covering for you next week while you're on your honeymoon?"

"Gómez from Medicine. A locum tenens is covering for him."

"Why not have the locum directly in the ED?"

"Doctor Northrup's policy. Only PGY3s from Medicine or PGY2s or higher from Surgery, as they're known quantities."

"Makes sense."

"Let's chat privately after this trauma."

"OK," I agreed.

About six minutes later, the EMS squad arrived and pulled up.

"Ian Barnes, twenty-two, MVA versus telephone pole; BP 80/50; pulse 110 and thready; resps labored and shallow; PO₂ 93% on ten litres; absent breath sounds on the left; crush injuries to both legs; severe head trauma; GCS 3."

"Trauma 1! Ghost, intubate," I ordered as we quickly moved with the gurney. "Mary, EKG and monitor; Kellie, trauma panel. Tom, call the surgical Resident. The patient will need a chest tube, and I can only do it with an Attending present."

"Tom, get Doctor Gibbs," Ghost countermanded. "This guy can't wait!"

"Also, get the ultrasound," I said.

In the room, Ghost, the two paramedics, Mary, Kellie, and I, moved the patient from the gurney to the table and began our work. As I assessed, Ghost intubated the patient.

"Tube is in!" he exclaimed.

I quickly auscultated the patient's lungs and announced, "Absent sounds on the left, but all signs point to a collapsed lung, not a misplaced tube."

"What do you have, Mike?" Doctor Gibbs asked as she came into the room.

I quickly repeated the vitals, taking the PO₂ and pulse from the monitor Mary had hooked up, and asked for permission to insert a chest tube.

"Do it," she declared. "I'll complete the assessment."

"Kellie, chest tube tray!" I ordered.

Four minutes later, the patient's lung was re-inflated, and I supervised Mary putting in several sutures to hold the tube in place.

"That didn't resolve the thready pulse," I said. "Ultrasound, please!"

I did a quick assessment and determined the patient needed a pericardiocentesis, and with Doctor Gibbs' assistance, performed it, which improved the patient's heartbeat. Next up was an ultrasound of the abdomen, which detected fluid in Morison's pouch.