Chapter 37: At Least

August 10, 1989, McKinley, Ohio

"He's McKnight's now," Doctor Strong observed. "Any next of kin?"

"Not that we know of," I replied.

"Wendy, death kit, please," Doctor Gibbs ordered.

"Al, Krista, stay with Wendy and observe," I said. "I'll check on our other patients. Kellie, with me, please."

The doctors filed out of the room, and first, I went to check with Nate, who had the labs for Mr. Harrington. I quickly reviewed them and saw literally everything except his blood glucose and A1C were mid-range, but both the A1C and glucose were very low. I picked up the phone and called for an endocrinology consult, then asked Nate about the pregnancy test for Becky, which was negative.

"Nate, call for an orderly with a wheelchair for Ms. Matthews. I'll see her as soon as I speak to Mr. and Mrs. Harrington."

"On it!" Nate declared.

Kellie and I went into Exam 3 to see Mr. Harrington.

"I have your blood test results," I said. "Everything except your blood sugar is within normal ranges, and most of them are right at the midpoint. I've called for a doctor from Endocrinology to come down to do an exam and give us an opinion for the next steps."

"What do you think?"

"All we know right now is something appears to be causing your body to produce too much insulin. I'm not a specialist in that area, so I don't want to speculate. I'll be here when the endocrinologist examines you, and we'll discuss the possibilities. I'll be back in about two minutes, as I need to see another patient."

Kellie and I left and went to Exam 1.

"Good news," I said with a smile. "You aren't pregnant. An orderly will come with a wheelchair to take you to Radiology for X-rays, then someone from Orthopedics will come down to decide what to do next."

"You can't just pop it back in?"

"I could," I said. "But that could result in nerve damage or other complications. Let's see what the X-rays and the orthopedist have to say. OK?"

"OK."

We left and returned to Exam 3 just as Doctor Matt Keller, an endocrinology Resident, arrived and announced himself.

"Hi, Matt," I said, then reviewed my findings with him.

"Hi, Mr. Harrington," he said. "I'm Matt Keller from endocrinology. I'd like to examine you, and then we'll discuss the next steps."

Mr. Harrington agreed, and Matt began the exam.

"Doctor Mike?" Patty, a nursing student, called out from the door. "The family of the MI, the Noonans, is here. They're in the consultation room. His name was Jack."

"Thanks, Patty. Mr. Harrington, I need to speak to a patient's family. Doctor Keller will speak to you once he's done and fill me in."

I left the room and asked Patty for their names, then went to the consultation room.

"Hi, Mrs. Noonan," I said. "I'm Doctor Mike Loucks. Would you have a seat, please?"

"How's my dad?" a teenage boy asked.

"Please sit, and I'll explain."

They both sat down, and I did as well.

"Mrs. Noonan, your husband was brought in by the paramedics and firemen who were performing CPR. A team of doctors and nurses made every possible attempt and used every skill and ability in an attempt to revive him, but we were unable to do so, and he died."

"What?!" she gasped. "He's only forty-four!"

"My dad died?" the boy, who I guessed was about fourteen, asked.

"I'm sorry, yes. His heart was not beating when he was brought in, and we continued CPR, administered drugs, put him on a ventilator, and used several procedures, but to no avail. His heart simply wasn't pumping any blood."

"But how?" Mrs. Noonan asked. "He's so young!"

"An autopsy will determine what happened," I replied. "All I can say is that when the paramedics and firemen reached him, passers-by were performing CPR on him. I can take you to see him, if you like, or call a chaplain."

"We're Catholic," the young man said.

"I can call Father Clifton, if you like."

"He needs last rites," Mrs. Noonan said.

"OK. Stay here, please, and I'll make the call. Would you like to see your husband?"

"With our priest."

"OK."

I left the room and went to the Clerk's desk, found the number for the rectory on the list, and placed the call. A secretary answered and called Father Clifton to the phone.

"Father, it's Mike Loucks at Moore Memorial," I said. "I have two of your parishioners here who need you and a need for last rites."

"Who?"

"Jack Noonan," I replied.

"Lord have mercy! What happened?"

"All I can say now is that his heart stopped, and CPR, drugs, and procedures didn't solve the problem."

"I'll be there in fifteen minutes. Should I ask for you?"

"Yes."

We said 'goodbye', I hung up, then went to let the Noonans know Father Clifton was on his way. That accomplished, I went to the trauma room to let my students and Wendy know that I'd be bringing the family into the room in about twenty minutes, then went to see Becky. She wasn't in the room, and a check with Nate revealed that the orderly had arrived to take her for her X-rays.

"Are any of the walk-ins in immediate need?" I asked.

"No," Nate replied.

"OK. Then I'll be in the lounge. Let me know when Father Clifton arrives."

He acknowledged me, and I went to the lounge, filled my mug with coffee, and sat down on the couch to relax for a few minutes before the priest arrived. About a minute later, Matt Keller came in.

"I'm going to admit Mr. Harrington," he said. "My money is on an insulinoma, as nothing in his history or symptoms indicates any of the other typical causes of hypoglycemia."

"OK. I'll have him sent up once I'm done with the family of the MI we lost. His priest is on the way."

"I don't envy you guys down here in trauma. I rarely have to even tell people they're terminal. I don't know how you do it."

"And I don't know how pediatric oncology does it."

"People qualified for instant sainthood," Matt said, then left.

Just over ten minutes later, Nate ushered Father Clifton into the lounge.

"How are you, Deacon?" Father Clifton asked.

"We don't retain titles when we voluntarily leave our clerical office," I replied.

"Forgive me," he said. "I'd completely forgotten that you had asked to be laicized. What can you tell me about Jack Noonan?"

"Not much. He was brought into the ED in full arrest and never had a heartbeat. According to the paramedics, he was found on the sidewalk, and citizens were performing CPR. The paramedics and firemen continued that, gave him epinephrine, and brought him in. We put him on a ventilator, continued CPR, and tried more drugs. The monitor showed PEA — Pulseless Electrical Activity — which is not a shockable rhythm, and then asystole."

"Any idea what might have caused it?"

"No, and I can't speculate. Doctor McKnight will perform an autopsy and let the family know."

"OK. I've done these before. I assume the usual protocol with the breathing tube and other medical devices still in place and covered with a white sheet?"

"Yes. I'll take you to Mrs. Noonan and her son, though I don't know his name."

"John, same as his dad, though his dad usually went by Jack."

We left the lounge and walked to the consultation room where the Noonans were waiting. Father Clifton greeted them, and they spoke for a minute before he turned to say that they were ready. I explained what they'd see, then led them to the trauma room where Wendy and my students were waiting.

"Krista, Al, please step out; Mrs. Noonan, stay as long as you like. Nurse Wendy will stay with you."

"Thanks, Doctor," she said.

My students and I stepped out into the corridor.

"Al, Mr. Harrington is being admitted to Endocrinology. Call for an orderly with a wheelchair and escort Mr. Harrington, then come find us. Krista, grab the next walk-in chart, please."

She was about to do that when I saw an orderly pushing Becky Matthews into the ED following her X-rays. Krista and I followed them into the exam room, and I let Becky know that as soon as I heard from Radiology, I'd have someone from Ortho come down to examine her.

The rest of the morning was busy, I assisted Doctor Jackson from Ortho in reducing Becky's shoulder and handled a number of walk-in cases. At noon, I was able to get away to have lunch with Clarissa and Sophia.

"How's your Fourth Year?" Clarissa asked.

"Well, she read her cardiology textbook and passed my basic EKG quiz, so there is that, but Kylie spoke to her and ... Sophia, this is confidential."

She shook her head and rolled her eyes, "As if I didn't know that!"

"It had to be said," Clarissa interjected. "Go on, Mike."

"Kylie said Krista felt I was sidelining her and agreed that Krista isn't as smart as she thinks she is. Kylie doesn't think Krista is salvageable."

"Which, of course, you took as a challenge."

"I have to try. I honestly don't care if she likes me or not or thinks I'm treating her badly. What matters is if she's willing to learn. She showed me one thing, and that's a start."

"Even with Leila's negative comments?"

"Even with those, though, I will heed her advice to not leave Krista alone with a patient. I'll use nurses and Al or be with her myself. I think her next test is intubation. But I have to find the right opportunity."

"Someone who needs it but is not so critical that two failed attempts won't kill them."

"Exactly."

"What do I need to do to get that procedure, Mike?" Sophia asked, smiling and batting her eyes.

"Ask my WIFE that question in that way!" I chuckled. "If you survive, you can do it!"

Clarissa and Sophia both laughed.

"In all seriousness," I continued. "I'd have trusted you to do it as a Third Year."

"The difference between us and Mike," Clarissa said, "is he gets off on those adrenaline dumps!"

"I wouldn't go THAT far," I chuckled. "But I do thrive on them. Pretty much a requirement for an emergency medicine doc. And the long-term exposure will help with surgery because I won't have adrenaline dumps when the inevitable happens, and the bovine excrement hits the air circulation device."

"Any interesting cases this morning?" Clarissa asked.

"Not really. We were busy with Intern scut — walk-ins, but we also had an MI who was brought in receiving CPR."

"Not one of the five percent who make it out of the ED?"

"Correct. PEA then asystole. Nothing we did changed a damned thing. That said, I have to commend his fellow citizens who were performing CPR when the paramedics arrived, even if it was ultimately fruitless. Young guy, though, with a fourteen-year-old kid. I turned the patient's wife and son over to Father Clifton."

"Any updates on the hearing next week?"

"No. The only thing that would change at this point is if he accepted a suspension without contesting it, which I can't imagine he would because his license is really at risk. A reprimand is most likely, and a one-year suspension would be extreme, based on historical precedent. Maybe we'll get lucky, but I'm not holding my breath. That said, at least we do have a shot at the suspension, even if the odds are long.

"On a completely different topic, I heard that Deputy Turner challenged Emmy to a shooting competition. They're going to an outdoor range in Zanesville, but the date isn't set. They're waiting on approval from the two Sheriffs, which I suspect will involve significant wagering!"

"Bet it all on Emmy to win, right?" Clarissa asked.

"I wouldn't bet against her, that's for sure. Her dad, «мудак» (mudak) that he is, taught her to shoot when she was five, and she's been a crack shot since age twelve." ("asshole")

"Back to using Russian again, Mike?" Sophia asked.

"Mike won't call someone an 'asshole' in English," Clarissa smirked. "Even if they are."

"And Len Nelson is certainly the poster child for that word," I said.

"Speaking of assholes, how is Rosenbaum's 'other woman'?"

"Several whacks on the nose with a rolled-up chart appear to have done the trick with Doctor Mastriano," I replied. "She's not giving me any grief, and we've worked together on several patients."

We finished our lunches, and each headed back to our services. I was looking forward to being able to teach Sophia, but that was still about three weeks away. During the afternoon, I handled walk-ins with Al as Krista was at the triage desk. I was also looking forward to September 1st, when nurses would take over intake completely.

At 6:00pm, Krista and Al went off shift and Serenity and Walt came on. A few minutes after they arrived, I went to the cafeteria to have dinner with Doctor Javadi and Doctor Vega. Clarissa couldn't join me as she was busy with a patient who was, in Medicine terms, 'circling the drain', and they weren't quite sure why.

We handled walk-ins and two paramedic runs for MVAs, but things quieted down just before midnight when I went to the on-call room to sack out, along with Doctor Varma.

August 11, 1989, Circleville, Ohio

"How was your shift?" Kris asked when I arrived home on Friday evening.

We were immediately interrupted by our toddler demanding to be picked up.

"Hi, Rachel!" I said.

She hugged me and gave me a slobbery kiss on the cheek, then I answered my wife's question.

"I actually managed to sleep for two hours around midnight, then about ninety minutes starting at 4:00am. My students and I only lost one patient, but he was basically dead when he got to us. How about your day?"

"Going to class, doing homework, and, of course, rescuing Rachel from her Fridays with my sister!"

I laughed, "That's what I said to Lyudmila on Wednesday!"

"I know! She told me! I also hear that her friend Cheryl thinks you're a 'hunk'!"

"And your little sister made sure Cheryl knew I was taken, though, of course, she had to add that it wasn't by the 'better sister'. Speaking of that, did you know Lyudmila is teaching Rachel to speak French?"

"My sister is a subversive!" Kris declared. "At least to YOU!"

"I might have noticed!" I chuckled. "She's treating me in ways similar to how Liz treated me, though with a French flair."

"«J'ai faim, papa!»" Rachel declared.

"She's hungry," Kris translated.

"Your sister and I are going to have words!"

Kris laughed, "You do realize she's doing that to tease you, right?"

"Yes, of course," I replied. "If I didn't know better, I'd say she has a crush."

"She does, but it's innocent. Her friend Cheryl, on the other hand, has one that is NOT."

"I have all the women I need in my life already! You, Rachel, Clarissa, and Loretta!"

"So we'll have a baby boy?" Kris asked.

"NO BROTHERS!" Rachel said firmly.

"You've made that point before, young lady, but it's not up to you!"

My daughter pouted, then gave me the usual look she had when she didn't appreciate being corrected.

"Dinner is ready, Mike. Shall we eat?"

"Sounds good."

"I take it from what you said we'll go to bed at a normal time?"

"Yes."

"And make love?"

"«Absolutement!»" I replied, causing her to groan and then laugh at my terrible pronunciation.

August 13, 1989, Loveland, Ohio

Saturday had been typical, with band practice, grocery shopping, and a stop at the record store before I'd had my Saturday shift at Moore Memorial. Now, on Sunday morning, we were at Saint George in Loveland.

"How are you, Michael?" I asked my godson, who I'd helped deliver nearly two years previous.

"Happy!" he said. "Zoo today after church!"

"That sounds like fun. What animal is your favorite?"

"Giraffe!" he exclaimed.

"Great! Sheila, how are you?"

"Pretty good. Do you know Jeremy?"

"I do not," I said, then extended my hand to the man next to Sheila. "Mike Loucks."

"Jeremy Mains," he replied. "Catechumen. You're a doctor, right?"

"Yes. This is my wife, Kris, and our daughter, Rachel."

"Papa? Angie?" my daughter asked, spotting Angie walk into the church.

"Go ahead," I said.

I watched as Rachel hurried over to Angie as fast as her little legs would carry her. Rachel reached up and Angie picked her up, then she and her mom made her way over to us.

"Hi, Mike," Angie said.

"Hi, Ang. How are you?"

"I'm OK," she replied, a beat slow, as usual. "I'm happy to see you."

"And I'm happy to see you, too. How is Aikidō?"

"I go three times a week. Are you going to your dōjō?"

"No. I have thirty-six-hour shifts, so there simply isn't time."

"That's unconscionable!" Mrs. Stephens protested.

"I don't disagree, and in fact, we'll have slightly reduced hours starting next month because of an incident in New York. I can tell you more at lunch because the bells are ringing, so it's time for Matins."

We all went into the nave, lit our usual candles, and then I put Michael down on the floor and Angie did the same with Rachel. The two of them went over to where two other toddlers were sitting and plopped down with them while we adults stood in a small cluster. At Eucharist, as was traditional, I took Michael forward, fulfilling one duty of a godparent. I'd been somewhat lax so far, though I had sent him a card and gift for his name day.

When the services ended, about three-and-a-half hours after they'd begun, we joined the rest of the congregation in the parish hall for lunch.

"Michael and Rachel get along really well," Sheila observed. "You never know..."

"Actually, that's canonically prohibited," I said. "Because Michael is my godson, Rachel is his spiritual sister, so marriage is prohibited by the canons."

"You're joking!" Jeremy exclaimed.

"No, he's right," Kris interjected. "It has to do with the obligations and duties of the godparent. He is, spiritually, a father to Michael, even if not biologically. In a way, not all that different from my relationship with Rachel from a legal point of view."

"So much for THAT idea," Sheila groused.

"Is it OK to ask how you came to be his godfather?" Mrs. Stephens asked.