Chapter 40: Waving the White Flag

August 23, 1989, Columbus, Ohio

Tom Kirkland smiled, then turned, "Sure, Arthur."

They walked away and went into a room.

"White flag," Lara said. "They're going to offer some kind of agreement equivalent to a plea bargain."

"You think?" I asked.

"There's no other reason for Greenberg's counsel to speak to mine. Just wait."

About five minutes later, they emerged from the room, and Mr. Kirkland asked Lara and Angie's parents to join him, which they did.

"Not you?" Clarissa asked.

"I'm not party to the suit, even if I'm pulling the strings, so to speak. We did that on purpose."

About two minutes later, Lara came out and walked over.

"Greenberg will accept a ninety-day non-prejudicial suspension. Tom Kirkland thinks he's looking at a year if we go to the end of the hearing, but, as he warns, we can never be sure how the board will vote. They could let him off the hook completely or with a reprimand."

"What do the Stephens think?" I asked.

"Same as me — it's up to you."

"What does 'non-prejudicial' mean?"

"He gets his license back automatically. If the board imposes a suspension, it can be either prejudicial, which means he has to apply for reinstatement, or non-prejudicial, which means he only has to refrain from seeing patients for ninety days, then can resume. Tom doesn't think they'd give him a prejudicial suspension based on a single incident with this fact pattern."

"Take it," I said. "We thought he might not even receive a reprimand when we started."

"OK. I'll be right back."

She walked away, leaving me alone with Clarissa.

"That was wise," Clarissa observed.

"I achieved my goal," I said. "He paid a settlement to the Stephens for Angie's future care in the malpractice suit, and he's admitting an error before the State Medical Board."

"Lara didn't say he was admitting error," Clarissa objected.

"No, but by accepting the suspension, he has to admit the allegations were true. I'm sure he'll be permitted to make some kind of statement, and he'll admit that, in hindsight, he made an error in judgment. That will satisfy everyone. Heck, that admission without a suspension would be enough for me."

"That was what you insisted Doctor Mercer do."

I nodded, "Admit your error, learn from it, and move on. Call it medical «metanoia». Which, by the way, is the point of our M & M conferences. Identify the error, learn from it, and move on. Nothing developed or said in those conferences can be used in any way, shape, or form against the treating physician. They're almost as sacrosanct as the confessional, and hence, the parallel I drew by using «metanoia»."

"An interesting parallel," Clarissa declared. "I hadn't considered, but then again, I haven't been immersed in Orthodox Christianity from my first breath."

Lara and the Stephens returned, and Mr. Braun went into the room where Tom Kirkland had remained. They emerged two minutes later and went back into the hearing room. We followed them and took our seats. About five minutes later, the Chairman reconvened the meeting.

"Mr. Chairman," Arthur Braun said. "My client will accept, and the complainant will not object to, a ninety-day non-prejudicial suspension."

"Will Doctor Greenberg be sworn and admit to the complaint?"

"Again, with agreement from the complainant, he will admit to an error in judgment based on a negative outcome."

The Chairman turned off the mics and conferred with his colleagues, and by their nods and facial expressions, I knew the answer before he announced it.

"The Board will accept your offer. Doctor Greenberg, come forward, please."

He did and was sworn in.

"Members of the Committee," Doctor Greenberg said, "after carefully considering my actions and the negative outcome in this case, I admit that I made an error in judgment in my choice of treatment methods for Angela Stephens. I did not assign sufficient weight to her observed behavior, which led me to follow the usual standard of care, which turned out, in this case, to not be appropriate. I apologize to Angie, her parents, her friends, and this Board, and I will accept a ninety-day suspension. Thank you."

"Thank you, Doctor Greenberg," Doctor Brewer said. "Your license is suspended as of this moment and will automatically be reinstated on the ninety-first calendar day from today. You are prohibited from practicing medicine in any form and from having any contact with your patients. You're instructed to turn over their care temporarily to another licensed physician. You may, of course, discuss the cases with this physician, but treatment decisions are up to them. Any violation will result in an immediate, indeterminate, prejudicial suspension, and you will be referred to the local prosecutor for practicing medicine without a license. Do you understand?"

"I do," Doctor Greenberg said.

"You'll receive a letter outlining what I've just said. Do you have any questions?"

"No."

"Then this hearing is adjourned."

He banged the gavel, and everyone left the hearing room.

"Mike?" Doctor Mercer called out.

I stopped and walked back to her.

"Should I call you 'Doctor Loucks'?"

"Mike is fine," I replied. "I go by Doctor Mike professionally, but colleagues call me Mike."

"And I'm a colleague?"

"I don't hold grudges," I replied.

"Now that this is behind us, I'd like to restore our relationship, if you think it's possible."

"Doctor Paulus really got on your case, didn't she?"

"Not just about this," Doctor Mercer admitted.

"Kitten?"

"Yes. I'm not surprised you knew that."

"Elizaveta being sixteen was a hobby horse you wanted to ride into the sunset," I said.

"I think you're mixing your metaphors!" Doctor Mercer countered.

"Could be, but it fits," I replied with a smile.

"Call me in the next few weeks; I'd like to get together and catch up."

"I will. And thank you."

"You're welcome."

"Dinner?" Lara asked after Doctor Mercer had walked away.

"I don't think I should. I need to rescue my daughter from her crazy French aunt, then meet Kris at home so we can have dinner and go to Vespers at the Cathedral. We'll see you and Nathan on Sunday for Rachel's birthday party."

"Crazy French aunt?"

"My fifteen-year-old sister-in-law, who is teaching my daughter French and otherwise being a serious troublemaker!"

Both Clarissa and Lara laughed, we hugged, and after speaking briefly to the Stephens, I went over to Mr. Kirkland and thanked him. After shaking his hand, I hurried to my car for the drive to the Korolyovs' house.

August 24, 1989, McKinley, Ohio

"How did it go yesterday?" Doctor Gibbs asked when I arrived in the ED on Thursday morning.

"Ninety-day non-prejudicial suspension with an admission of an error in judgment."

"Wow! What happened?"

"Doctor Greenberg and his counsel felt the risk of a longer suspension was too great after the Chairman ruled in our favor on some key issues. Lawson and Forth were there, but in the end, they couldn't testify."

"What could they have testified to?"

"That in the course of my psych rotations, I had admitted that no doctor should be punished for a judgment call on treatment. But, the Board refused to allow that testimony because they didn't want to set a precedent that might deter med students from asking questions or giving their opinions. They limited all testimony by me or about me to my relationship with Angie and her observed behavior."

"So the rumors that Lawson was gunning for you were true."

"They weren't rumors," I replied. "He actually threatened me, but in a way that had plausible deniability. Ultimately, though, he was boxed in by information I had about him failing to Match for surgery despite applying to eight programs and having to Scramble for psych and that his hospital in Detroit wouldn't hire him as an Attending.

"Add in the fact that he actually called you for me to make a consult as a med student, and allowed me to do intakes as a Third Year, and he had nothing. The Board did hear about 'Mr. Alien Encounter' and the Chairman said I hadn't violated any principles of emergency medicine, so even that was defanged. In the end, rather than take the risk and have Lawson publicly exposed as being driven by personal animosity, they chose the least risky course of action."

"I think I'd avoid Lawson and Forth for a while."

"I certainly won't go out of my way to see them, and consults are always Fourth Years or Residents. And it's not like there's any love lost between Psych and the ED. And I had support from the surgical team."

"I'm not surprised. How is Krista doing?"

"Average work," I replied. "I'd rate her a three at this point, up from a two. She has a Medicine Sub-I next, so they'll make or break her, as that's her choice for the Match. If she survives that, she'll have her surgical Sub-I, and you know how that works for Fourth Years. It's sink or swim."

"Which will she do?"

"Scrape by unless she picks up the pace. There's no way she'll Match here because Shelly Lindsay and Owen Roth will see the same things I have in her procedure book and her attitude. She was smart enough to stop being bitchy around me, but Libby reported that she has a bad attitude at the triage desk."

"Every med student does!"

"Not every."

"OK, not the one who might actually be the alien that 'Mr. Alien Encounter' was concerned about!"

"Which would explain my approach to treating him, now wouldn't it?" I asked with a grin.

Doctor Gibbs laughed, "Hiding in plain sight!"

There was a knock at the door, and Ellie opened it and stuck her head in.

"Multi-victim MVA," she said. "At least three victims. First one three minutes out."

"What's free?" Doctor Gibbs asked.

"Trauma 1, 2 and 4," Ellie replied.

"Let's go, Mike. Ellie, ask Doctor Varma to join us and we'll need nurses."

"Already assigned. You have Wendy and Jamie, Mike has Kellie, and Naveen has Angela."

"If there's a fourth victim, give them to Ghost; Ron will have to handle walk-ins."

"Got it!"

I went to the lounge to get my students, and we gowned, gloved, and met the team in the ambulance bay to await the paramedics.

"I'll take the first, Mike the second, Naveen the third," Doctor Gibbs directed.

Two EMS squads turned into the driveway and, a few seconds later, pulled up in front of us. I focused on the second patient, who was being bagged by a firefighter.

"Female, late twenties; unbelted passenger; crush injuries to the chest; fractured arm; forehead lac and contusion; tachy at 120; BP 70/30; PO₂ 92%; difficult to bag; LOC on site, IV saline TKO; cervical collar and backboard."

That PO₂ was sufficient that I felt I could give Krista her shot at intubation, but only one shot.

"Trauma 2!" I ordered. "Al, monitor then Foley; Krista, bag and I'll walk you through an intubation; Kellie, hang a unit of plasma, type and cross match, CBC, and rapid pregnancy test!"

"EKG?" Al asked.

"Let's see what we have first!"

We quickly moved the gurney, and I called out to Ellie for another nurse, and she came into the room herself. With concerted effort, we moved the patient to the trauma table.

"Ellie, 24 French and intubation tray to Krista!" I ordered.

I saw the questioning look in her eyes, and I didn't disagree, but I had to give Krista the chance. I began my primary exam by auscultation and immediately found decreased breath sounds from the left lung.

"Tension pneumo! Ellie, I'll need a chest tube tray. Krista, hold off on intubation until I get the tube in, but keep bagging."

"PO₂ 90%, pulse 130, BP 60/20!" Al announced as he moved to insert the Foley catheter.

"She's bleeding internally," I said. "But we need to get the lung re-inflated first."

I slung my stethoscope around my neck and began the thoracostomy necessary for the chest tube. As soon as I cut through the subcutaneous tissue and muscle, a gush of blood ran out, and the patient's BP bottomed out.

"Ellie, two units on the rapid infuser!" I ordered.

I got the chest tube in and sewed it in place, but I didn't worry about taping it.

"Easier to bag?" I asked Krista.

"Yes."

"Where's that blood?" I asked.

"Large bore in," Ellie announced. "Units running in now!"

The patient's BP came up a bit, so I could move on.

"Al, five-lead," I ordered as I cleared the patient's C-spine so I could remove the cervical collar.

"Krista," I said as I moved to examine the patient's abdomen, "stop bagging and put the patient in the 'sniffing position'."

"What?" she asked.

That meant she hadn't read the textbook, and it was my fault for not checking first.

"I'll need to do it," I said. "Get me a portable ultrasound, please. We'll discuss after."

She moved, and I quickly inserted the tube, had Ellie bag, and listened. Once I heard good breath sounds, I instructed Ellie to hook up the ventilator.

"Need help?" Ghost asked, coming in.

"I won't turn it down," I said. "Chest tube and vent, about to check the belly. Neuro survey, please."

"Got it."

"Al," I said. "Call upstairs; I'm positive she's surgical. Tell them sinus tach; needs an ex-lap; flail chest; blood in her urine; lost 400ccs during thoracostomy; three units in."

"Sinus tach; ex-lap; flail chest; blood in the urine; lost 400ccs during thoracostomy; three units in," he repeated.

Krista, who was obviously unhappy, pushed the ultrasound in, and two minutes later, I confirmed what I had already known.

"Fluid in Morison's; likely splenic lac; possible liver lac. Let's move! Ellie, portable vent; Kellie, disconnect the EKG and monitor. Al, get a gurney!"

Everyone did as instructed and we transferred the young woman to the gurney and quickly made our way towards the elevator, following right behind Doctor Gibbs and her patient. That meant that at least one scheduled surgery was going to be pushed, if not both, and I was going to get to scrub in.

"Al, stay with the patient; Krista, with me up the stairs so they can share the elevator."

Two minutes later, we wheeled our patient into OR 3, where Doctor Burke was waiting with a Resident, three nurses, and a student. I called out the information as we moved the patient to the surgical table.

"Mike, scrub in," he said. "Your Fourth Year can observe."

I'd have strongly preferred keeping Al as he intended to Match for surgery, but there was no reasonable way to make that substitution once Doctor Burke had made his decision.

"Al, go back downstairs and see Ghost," I said. "Krista, with me!"

We went to the scrub room, completed the process with the help of Millie, the scrub nurse, then, with my usual black surgical cap in place, returned to the OR.

"Mike, you're the third surgeon. Stand next to Rob to assist."

I acknowledged and moved, holding retractors and suctioning as necessary but mostly watching them work, which was typical for any Resident before PGY3. It took the best part of two hours to repair the abdominal injuries as well as the bleeder in her chest that had resulted in the blood loss during the thoracostomy. When the surgeons had closed the incisions, Krista and I were excused, and the patient was taken to recovery. She would certainly go to the ICU and need attention from Ortho as well.

"Why didn't you let me intubate?" Krista asked as we entered the stairwell. "You said you'd talk me through it!"

"Let's wait until we're someplace more private," I said.

She was quiet, and I led her to the temporary Residents' office but kept the door open.

"You didn't know the 'sniffing position'," I said. "That indicates you don't know the textbook steps, which is a prerequisite. I should have asked beforehand, but as a Fourth Year, you should have taken the initiative to learn. And that's particularly true, given what happened with the EKGs. That alone should have clued you in."

"Oh, right! Like I'm supposed to magically know what I need to know and study?"

"The first thing I and my study group members did when we were starting a new rotation was find out what the standard procedures for that rotation were and read the relevant textbook material. It's all in there, and if you read the optional material, which you should have known to do after I asked about Doctor Osler, it's all in there."

"You're not being fair!" she protested.

I wanted to say that life wasn't fair and list Elizaveta, Lee, and Sandy as primary examples, not to mention the young patients who had died in my presence over the previous two years.

"Your lack of initiative, even when prompted, is the cause of your current complaint, not anything I've done."

"How can I learn, if you won't teach me?!"

"How can I teach you, if you won't learn?" I countered.

"What?! How can you say that?"

"Because your medical training is your responsibility. My job is to teach you, your job is to learn. But learning isn't limited to your shifts in the hospital. It means studying anatomy, studying your textbooks, and being proactive. I shouldn't have had to tell you to learn to read an EKG, you should have read your textbook before your cardiology rotation and then asked Doctor Javadi to teach you further."

"I didn't know."

"Let's assume that's the case. I gave you an assignment to learn, then quizzed you. From that, you should have learned a lesson. On your surgical Preceptorship and Clerkship, you had to read about the procedures before they were performed to be able to answer the quizzes during surgery. From that, you should have learned a lesson. Finally, you should have known that learning to intubate is a standard trauma procedure for Fourth Years. You didn't read the textbook, which I know because it expressly describes the 'sniffing position' and calls it that."

"Mike," Ellie called out from the door. "Walk-ins are seriously backed up."

"Two minutes," I replied.

Ellie left, and I turned back to Krista.

"You have five weeks left in this rotation. If you don't have an intubation in your procedure book, you're going to have a tough time Matching for anything except dermatology or psych, and even those will be tough with the paucity of procedures in your book. I suggest you take a break, find your emergency medicine textbook, and learn the procedure. I'll give you a shot if you can tell me the procedure from memory. If not, no chance."

"Take a break?"

"Your call, but we have limited time."

"I'll go home and get my book."

"OK."

She left, and I went to find Al, but he was helping Ghost, so I asked Ellie for assistance from Kellie.

"Can't stay away from me?" Kellie teased.

"I know a good nurse when I see one!"

"I'd say flattery would get you everywhere, but I know you're more than a little married!"

"Being a little married is like being a little pregnant!"

Kellie laughed, and I grabbed the first chart from the rack.

"L-O-L, seventy-eight, weak and dizzy all over," I chuckled.

"Want to play the lottery and try slot two?" Nate asked.

"No. I'll take this one."

"Where are your students?" Kellie asked.

"I sent Krista to learn the procedure for intubation, and Al is with Ghost because I was in surgery."