Chapter 36: Inner Peace

August 8, 1989, McKinley, Ohio

"I thought someone dying before my eyes was the worst thing I'd see," Walt said after Lucy Leahy was admitted to pediatrics.

"Lumbar punctures on kids are rough," I replied. "I'll raise you third-degree burns and drowned toddlers."

"You've basically convinced me to stick to surgery," he said.

"Emergency medicine is not for everyone," I replied. "It's not the hardest specialty, and not even the hardest emotionally."

"Which one is that?" Serenity asked.

"In my opinion, it's pediatric oncology. In pediatrics, the little humans mostly get well and go home; in pediatric oncology, they don't. I believe that doctors and nurses on that service are automatically qualified for sainthood."

"I don't think I could do that," Serenity said.

"Me, either," I agreed.

"Is a lumbar puncture a procedure you could do?" Walt asked.

"No. It's a specialized pediatric procedure. For adults, it's done by Medicine. I've only seen four in two years and six weeks of clinical work."

"What's the worst procedure you'll have to do?"

"An escharotomy," I replied. "That's cutting down burns to minimize the damage from edema or to reduce pressure on the heart and lungs. You haven't smelled anything bad until you smell burnt flesh, and cutting into it is worse. I've observed but haven't done one. I will, eventually. And now I'm going to make a likely futile attempt at sleeping."

I went to the on-call room, and this time, I managed to sleep for an hour before I was woken to help treat two firemen and two civilians for smoke inhalation from a barn fire. None of them were serious, and their PO₂ levels weren't too low, nor were their CO levels high, so after an hour of oxygen therapy, they were all released.

"Take your meal break," Doctor Mastriano suggested.

I called up to Medicine, and Clarissa was able to take her break, so we met in the cafeteria. We got our food, then went to sit at a table by ourselves.

"How are your students?"

"Three good, one troublesome. You?"

"All four are pretty good. What's wrong with the troublesome one?"

"Her procedure book had about half the typical procedures for a Fourth Year, and when I questioned Leila Javadi about it, she said I should keep a very close eye on her AND shouldn't be alone with her."

"Uh-oh."

"Yeah. The most damning thing Leila said was that Krista was Felicity but without the skills or intelligence."

"Ouch!"

"I'm sure she'll bitch to someone about me taking my Third Year on the helicopter."

"Too bad you decided to re-marry! You could have been the Flying Monk!"

"Orthodox monks don't wear wimples!"

"What was it this time?"

"Hydrofluoric acid burns to arms, face, and neck. I didn't hear how it happened, but with 30% burns, transport to the burn center is recommended."

"How the heck do you treat that?"

"The firemen cut off all his clothes and flushed him with water, then we applied calcium gluconate gel and transported him. My biggest concern was his eyes, but OSU will have an eye specialist who can handle that better than we can at this point."

"No engine trouble?" Clarissa asked with a sly smile.

"Nope. And I slept on the way back. I figure if Kellie can be that calm, so can I!"

"Am I being replaced, Petrovich?" Clarissa asked.

"A harem of work wives! Now, there's an idea!"

Clarissa laughed, "You had that option! But all silliness aside, what are you doing about your student?"

"She'll have her chances. You know I don't believe in the 'all scut, all the time' treatment. And despite that, I'm sure she'll bitch given what Leila said and the fact that she objected when I insisted she learn how to read an EKG and said I'd give her a quiz on Friday. Fortunately, I only have her for twelve hours on my thirty-six-hour shift."

"I dread getting a rehabilitation assignment."

"This one wasn't intentional like Felicity or Tim; I went to Leila after seeing Krista's procedure book. I'll speak to Kylie tomorrow morning about it. Anything interesting on your service?"

"No, and that's exactly the way I like it! I like to have time to think, and my idea of a good day is not seeing forty patients for a few minutes and never seeing them again. You, on the other hand, are an adrenaline junkie!"

"And medicine needs both styles," I replied. "I'm happy to be a feeder service for your pill-pushing operation!"

"Now that's low, even for you, Petrovich!"

"Right," I chuckled. "Because you've never given me a hard time about anything!"

"Did you get any sleep?"

"On the helicopter, and then an hour. I take it you got more."

"About three hours total. I'm the one the nurses come to, of course, and I catch the consults as well. I heard there's no surgical Resident overnight in the ED when you're there."

"Because I'm the surgical Resident! PGY1s in surgery actually have less experience than I do because I did two trauma Sub-Is and a pathology Sub-I. Honestly, the new plan of having surgery and medicine Residents do eight-week stints in the ED during their first years is going to make a huge difference."

"And let you bums work no more than eighty hours!"

"The way I described it is that we now have programmed sleeping hours, and you know why."

"Libby Zion."

"It'll change on all other services over the next few years as they hire more Residents."

"How are things with Mastriano?"

"Fine. She's not trying to sleep all night, and she's treating me OK."

"Amazing what double-secret probation will do to an attitude!"

We finished our meals, and I headed back to the ED while Clarissa went back to Medicine.

The morning was fairly routine, with my students and I handling nine walk-in cases and one EMS transport. During the afternoon, I had my two Preceptorship students as well, though, as the rules required, they simply observed. When 6:00pm finally rolled around, I went to daycare to get Rachel, who had been dropped off by Kris that morning. She greeted me with a hug and a sloppy kiss on the cheek, and then we left the hospital to head home.

August 9, 1989, Circleville, Ohio

"What's your plan for the day?" Kris asked when we got out of bed on Wednesday morning. "Other than seeing the counselor?"

"I'll spend the day with Rachel. We have no place to go, and nothing planned after counseling except Vespers tonight."

I got Rachel from her bed, changed her diaper, and then the three of us went downstairs to have breakfast. After breakfast, we said our morning prayers, and then Rachel and I walked Kris to her car so she could head to OSU for her class. Kris and I exchanged a kiss, Rachel hugged her and kissed her, and then Rachel and I watched as 'Mama' drove away.

We went back inside, I dressed Rachel, then drove to the Korolyov's house to leave her with her aunt for the morning.

"I promise we won't get into too much trouble!" Lyudmila said in a lilting French accent similar to her sister's.

"Somehow, that doesn't reassure me," I chuckled. "I'll be back in about two hours to rescue my daughter!"

I hugged Rachel, and she immediately went to Lyudmila, and didn't look back. I rolled my eyes because I was chopped liver compared to her «tante préférée», who did her best to spoil her rotten. I figured if an aunt wasn't doing that, she was probably doing something wrong, and when my nephew Michael was a bit older, I'd do the same for him and any other kids my sister and Paul had. ("favorite aunt")

About twenty minutes after I left the Korolyovs', I walked into reception at Maryann Manning's office, and five minutes later, she brought me into her private office.

"No," I said.

"'No'?" she asked.

"The answer to your question two weeks ago."

"Are you always this annoying?"

"I'd say if you asked the people who know me best and for the longest time, you'd find the answer to be a resounding, unanimous 'yes'!"

She flipped through her notebook and nodded.

"You say that," she said, "but everything you've said indicates that's how you act now."

"Actually, I'll counter that and say it's how I react, not how I act. And it's all verbal, and I simply point out the things I find to be wrong. Do I push the edge of the envelope? Absolutely. Do I say too much? I'm sure that's the case. But I don't actually do anything that crosses the line."

"Your line."

"Other than spending too much time with patients and trying to work with patients with mental illness in a way that best suits them, not me, I don't cross the lines set by medical best practice."

"So, why did your mentor send you to me?"

"Because she's concerned that my idealism and my obsession with what happened to my friend Angie will lead me to burn out or become cynical, and that will impact my work and my personal life."

"That is often the case when idealism runs headlong into cold, hard reality. And the key thing is to find a balance where you don't lose your idealism but don't obsess over things you can't change."

"But I can't ignore them, either."

"It's about balance, Mike. There's a Swedish concept called «lagom», which means moderation, in a way where all things are in balance."

"Orthodox would call that 'inner peace', and it's achieved through 'Hesychasm', something my «старец» (staretz) has prescribed. Unfortunately, I'm not fastidious about it, and I'm still stuck at stage one." ("Elder")

"It seems to me, then, that you don't belong here, and you should see your «staretz» instead of me. When will you see him next?"

"The 10th of next month."

"Let's do this — see him, tell him everything you've told me, and see what he says. Perhaps he'll want to speak to me to gain some insight into treating a doctor who is devout enough to seek spiritual guidance from a monk."

"Perhaps," I replied.

"Call for an appointment after you see him."

"I will. Thanks, and I'm sorry I basically wasted your time."

"You didn't. You spent time contemplating what I said, which is all that I can ask. The solution is found within you; all I can do is provide insight and guidance."

"I've heard that before from the counselor who worked with Angie. I'll call you sometime after the 10th."

We said 'goodbye', I left her office and headed back to the Korolyovs' to retrieve my daughter. When Lyudmila let me in, I saw Rachel playing with a teenage girl.

"That's my friend Cheryl. We're hanging out today. Rachel could stay if you had things to do."

"I planned to spend the day with Rachel," I said. "So I'd like to take her home."

"«Rachel, ton père est là!»" Lyudmila called out. ("Rachel, your papa is here!")

"Papa!" Rachel exclaimed.

"You're teaching her French?" I asked.

"«Mais oui!»" Lyudmila said with a twinkle in her eye. ("Of course")

"Go to your dad," Cheryl said. "He's a hunk!"

"And he belongs to my sister!" Lyudmila said, suddenly sounding like 'mama bear', but then turned to me and said, "Of course, not the better sister!"

I laughed and shook my head as Rachel came over to me. She reached up her arms for me to pick her up.

"Thanks for watching her," I said. "See you at church tonight."

Rachel and I left the house, got into the car, and headed home.

"What should we do now?" I asked my nearly two-year-old toddler after we walked into the house.

"Sing!" Rachel exclaimed. "Papa git'ar"

"I think we can do that."

"Raffi?" she asked.

"We can watch your Raffi tape as well," I said.

"Yes!" Rachel giggled.

We went into the house, and I got my guitar and sheet music and played Rachel's favorite songs. After I played for about an hour, I made some tea and gave Rachel a cup of juice and a sliced banana for her as a snack. With her happily munching her banana, we sat down to watch Raffi In Concert With The Rise And Shine Band, which contained her overall favorite song, Baby Beluga. When the tape finished, we went to the backyard to play with a ball, then took a walk. When we returned to the house, we had lunch, and then I put Rachel down for her afternoon nap.

Once Rachel was in her bed, I put on one of my Mozart CDs and sat down with the McKinley Times. I'd only read the first two pages before the phone rang. I got up and went to the kitchen to answer it.

"Korolyov-Loucks residence; Mike speaking."

"Hi, Mike. This is Leland Crowe from Moore Memorial. I'm sorry to bother you on your day off. Do you have a moment?"

"Yes. What can I do for you?"

"You keep diagnostic notes, correct?"

"Yes, I do."

"Do you keep those notebooks permanently?"

"No. I have them going back about six months. I retain them so that if a case reaches an M & M, I have my personal notes to supplement my memory and the chart. Which case?"

"Mary Josephson, age fourteen."

"I'm not surprised."

"Would you bring me that notebook when you come to the hospital? I'm positive the charts are accurate, and I have Doctor Gibbs' statement, but I want to make sure there are no landmines lurking."

"Absolutely. I'll drop it off at your office tomorrow morning."

"Just out of curiosity, do you ever remove pages?"

"No. And each set of notes is dated, with a time, and has the chart number."

"Perfect!"

"Is there an actual problem?"

Mr. Crowe laughed, "No attorney will ever give you a definitive answer to that, as no matter how obvious or cut-and-dried a case might be, there are no guarantees. In my professional opinion, there is no cognizable claim, but in the end, the courts would decide if they could bring a claim or not."

"Let me rephrase — is there anything you feel we did incorrectly?"

"No. Every step was defensible, and the decision to report the pregnancy to Family Services in compliance with the law provides an excellent defense. There is nothing to worry about from your perspective — you had a nurse in the room at all times, and you reported to Doctor Gibbs in line with hospital policy. I'll let you go."

"OK, I'll bring the notebook tomorrow."

"Sorry to disturb you on your day off."

"It's OK. Rachel is napping, and I was reading the newspaper."

We said 'goodbye', I hung up and went to the study, retrieved the correct notebook, put it in my bag, then returned to reading my newspaper. I finished not long before Rachel woke up, and after changing her diaper and giving her a snack of sliced apples, we went for another walk, then returned home so I could start dinner. Kris arrived home from school, we had dinner and then left for the Cathedral for Vespers.

After Vespers, we returned home, I read to Rachel, we said our evening prayers as a family, and then Kris and I put Rachel to bed. Once she was in bed, we left her room, and I touched my wife's arm.

"What do you say to a bubble bath, lovemaking, and then sleep?" I suggested.

"I say 'yes'!"

August 10, 1989, McKinley, Ohio

"Morning, Lor," I said when I arrived in ED on Thursday morning.

"Morning, Mike. Did Mr. Crowe reach you?"

"Yes. I have my diagnostic notebook. I'll take it upstairs at 8:30am so I can hand it to him or his secretary directly."

"Don't worry about this. He'll swat it away without working up a sweat. I've seen several complaints like this, and I'm positive the only reason it's come this far is that the dad is an attorney."

"I'm not fretting over it," I replied. "I just wanted to let you know. I need to go do the turnover with Kylie."

"Go heal the sick!"

I left the Attending's office and found Kylie in the lounge and received the handover of two patients waiting on admission — one to Pediatrics and one to Medicine. She asked to speak to me privately, so I followed her to the locker room.

"What did you do to Krista?" Kylie asked as she began undressing.

I turned so I wasn't looking directly at her.

"I noticed her procedure book was light, then spoke with Leila Javadi, who warned me that she's Felicity without the intelligence and skills and also warned me not to be alone with her."

"OK, I didn't get that angle, but she certainly thinks you're sidelining her. She bitched about Al getting procedures and getting the helicopter ride. She said she thinks you're sexist."

"That would be her best line of attack, but I'm not going to put her on pure scut, even though that's the norm for someone like Krista. How did she do during the past twelve hours?"

"I think Leila's analysis is accurate," Kylie said. "Krista doesn't know as much as she thinks she does, nor does she know as much as she should."

"Fixable?"

"Probably not by you because of how she feels about you, and I honestly don't think she's worth the effort. Give her the procedures she can do, challenge her to learn, but in the end, it's on her."

"That was my initial strategy," I replied. "I challenged her to study the EKG section of the cardiology book and that I'd quiz her today. I also instructed her to find out who Sir William Osler was."

"Your hobby horse! Not that I disagree with you about the implications of that quote."

"I plan to suggest his seminal work be made mandatory."

"You just love to stir up the hornets' nest! Now I need a shower, so unless you're going to join me..."

"You know the answer to that."

"Of course!"

She went to the shower, and I left the locker room and went to the lounge, where Krista and Al were waiting.

"Good morning," I said. "Krista, who is Sir William Osler?"

"He founded Johns Hopkins and created the first Residency program."

"Yes. Did you discover anything else about him?"

"As in?" she inquired.

"His methods?"

"You mean learning in the wards, not in the classroom?"

"Yes. That was the point I made earlier. I'd maintain that actual learning begins with clinical rotations. Being able to pass tests is what allows you to actually start learning to be a doctor. Did you review the EKG sections in your cardiology textbook?"

"Yes."

I pulled three sample strips from my pocket and handed them to her.

"Describe these, please. Just in general terms, not a diagnosis."

She looked at them for about a minute before answering.

"This one is sinus tachycardia," she said. "And this one has ST elevation. And the last one is V-fib."

"Good. Those three things are the most likely arrhythmias that you'll see. At this point, you don't need to know the specific causes, just be able to call out what you see. Al, did you memorize the pad placement and leads for a five-lead?"

"Yes. Right side, white; left side, black; fourth intercostal, brown; right below the ribs, green; left below the ribs, red."

"Very good. A good way to remember them is smoke over fire, clouds over grass, chocolate on the chest."

"That's cool! Thanks."

"Al, check on the admissions; Krista, get the first walk-in chart, get basic vitals, and confirm their presenting complaint. Al, you can meet us after you check on our patients."

While I wasn't going to give Krista pure scut, I was going to give her opportunities with walk-ins where, for the most part, she couldn't do any real harm. I waited five minutes, then headed to Exam 3, stopping to receive an update from Al about the admissions, both of whom would go up in the next ten minutes. He followed me into the exam room.

"Mr. Harrington, this is Doctor Mike Loucks," Krista said.

"Good morning, Mr. Harrington. Krista?"

"Tom Harrington, fifty-eight; tachy at 116; diaphoretic; complains of headache, fatigue, lightheadedness, and blurred vision."

"Thanks, Krista. Mr. Harrington, when did these symptoms start?"

"I've felt tired the last few days, had the headache last night, and when I woke up this morning, I felt lightheaded and had blurred vision."