Chapter 57: And Get in Plenty of Trouble!

October 16, 1989, McKinley, Ohio

"I hate those cases," Sophia said with a note of despair in her voice.

Our pyrexia case had just been admitted to oncology on a preliminary diagnosis of lymphoma and would have a lymph node biopsy. We hadn't detected the swollen lymph node in our primary exam because it was in the young man's armpit, and our usual tests were in the neck. There were blood markers, and the second exam had turned up the swollen gland.

"On the plus side, the recovery rate is very good," I said. "And all four of our chemical inhalation patients will most likely be discharged this afternoon after observation."

"That doesn't make cancer suck any less," she protested.

"No, it doesn't," I agreed. "But we also caught that lymphoma early, so the kid has a fighting chance. Get another chart, please, and Marv can do the workup."

"Right away!" Sophia replied.

The afternoon was routine, and I had dinner with Patrick Shore from Cardiology and Matt Keller from endocrinology. After dinner, things were eerily quiet, and I only saw one patient before I headed home at 9:00pm. When I arrived, I found a message from Jocelyn. I returned the call, and she excitedly informed me that she'd passed the Bar.

October 18, 1989, Circleville, Ohio

"I'm going to perform the test today," Kris said when we got out of bed on Wednesday morning. "I want you here, and I don't want to have to get out of bed at 4:00am tomorrow! Six days should be OK, right?"

"Yes, though there's a slightly higher risk of a false negative."

"Let me do the test," Kris said.

She went into the bathroom, opened the box, read the instructions, tore open the package, then urinated on the test stick.

"It says to wait five minutes for the results," Kris said.

"That's right," I replied.

"Could there be a false positive?"

"It's possible but highly improbable. If it's positive, then you should call Candace Forsberg and make an appointment. She'll draw blood to confirm the results."

Five minutes later, Kris smiled and showed me the twin pink lines of a positive pregnancy test. We hugged and exchanged a soft kiss.

"How long can we safely have sex?" Kris asked.

"Candace will give you advice as your pregnancy progresses, but the usual guidance is into the seventh month, so long as you're comfortable. It will mean you on top after the third or fourth month."

"What do you like to say?" Kris asked, with a twinkle in her eye. "'Oh darn'?"

"I have no complaints!"

"I'm positive, especially because now «la pipe» won't interfere with me getting pregnant!" ("fellatio")

"Yeah, yeah," I chuckled. "I am very, very happy."

"Me, too! And the timing is close to perfect. I'll deliver in late June, I think."

"Roughly June 20th," I replied after doing some quick math in my head.

"Besides the «vitamines», is there anything I should do right away?"

"We need to modify our fasting rule, and both Father Roman and Father Luke already approved, simply avoiding red meat."

"You could be stricter, if you like," Kris offered.

"No, we should keep the same rule as a family," I replied.

"OK. I'll call Doctor Forsberg later this morning. We should get Rachel, have breakfast, and say our morning prayers so you can get to the Free Clinic."

"Sounds like a good plan to me!"

We did as Kris suggested, and after morning prayers, I showered and dressed, then headed to the Free Clinic.

October 20, 1989, McKinley, Ohio

In order not to have to rush more than necessary, Kris picked me up at the hospital on Friday afternoon, just after 5:00pm. Our plan was to drive through Wendy's for chicken sandwiches, which we'd eat on the way to Newtown for Code Blue's gig.

"We're leaving immediately after you play, right?" Kris asked as we got into my Mustang.

"Yes. We won't get home until close to midnight as it is, and I have to be up around 4:00am. Fortunately, tomorrow's shift is only twelve hours. How was your visit with Candace?"

"Short! She checked my vitals, did a quick exam, and had the nurse draw blood. She said your advice for folic acid and iron supplements was exactly right."

"I might have paid a small amount of attention to things other than emergency medicine the past four years," I chuckled.

"It would seem so, given you successfully delivered a baby!"

"Not by choice! My plan was to never have to do that in my entire career once I completed my OB/GYN Clerkship! And if OB had done their jobs, it would have never happened. An OB nurse has far more qualifications to deliver a baby than any doctor outside OB. They see dozens a week; I've seen one since Third Year, and it was that delivery!"

Kris laughed, "Listen to the big, brave man scared of a little baby!"

"You're wrong," I replied with a grin. "It's women in labor who scare me!"

"You weren't with Elizaveta, were you?"

"No," I replied. "I would have been had Doctor Forsberg not determined that an unplanned C-section was indicated. And really, it was only out of an abundance of caution, which, in a sense, turned out to be warranted, even if the results were tragic."

"You're OK to talk about it?"

"Yes. The medical side of what happened is completely understandable and fits with everything I've learned. If it were anyone except my wife or a close friend, I'd chalk it up to 'one of those things' and move on. Being able to do that is an important trait for doctors, especially in emergency medicine. I pray for every patient and for the souls of those who don't make it, but I can't allow that to affect my focus because there is always another patient."

"I'm not sure I could be so ... detached, I think, is the right word."

"Yes, and if you can't be, then you practice some other type of medicine or find a different career."

"I've never asked, but how often do people die in your presence?"

"Because I'm mostly handling walk-ins, it's fewer than one per week. For a typical doctor in the ED, it's one or two per week, depending on how you count."

"What do you mean?"

"Unless it's obvious someone is dead, that is, decapitation, visible brain matter with no pulse, exsanguination, or a cold, pulseless body, the paramedics bring them in. I've had patients legally die in front of me who are actually already dead, but because dying in the presence of a physician means far less paperwork, the paramedics bring them in. And lest I sound as if I'm discouraging that, I'm not because a small percentage of those can be saved."

"Without the technical medical speak, please?"

"Our 'loss rate' is around ten per week out of thousands of patients. Most of the ones we lose are either what you would call a 'massive heart attack', usually a STEMI — ST-elevation myocardial infarction — or massive trauma, usually from a motor vehicle accident."

Our conversation was interrupted as we drove through Wendy's and resumed once we were back on Route 50, heading towards Cincinnati.

"If you think about it, far more people would die without the Emergency Dispatch Center, the paramedics, and the Emergency Department. Taking that into account provides a somewhat different perspective."

"Yes, I can see that. Do you talk to anyone about the patients who die?"

"I have mentioned them when speaking to my confessors, whoever they were, at various times, but after the first two or three, I became detached, as you've observed. But I think you've heard from Clarissa and Lara that wasn't the case with Sandy, Lee, and especially Elizaveta."

"Yes, of course. You don't talk very much about what happens except for the political subjects."

"I suppose the best thing to say is that as a trauma surgeon, I don't bring my work home with me. When I walk out the doors of the hospital, I can clear my mind and focus on everything else that's important — our family, our friends, church, and music."

October 21, 1989, McKinley, Ohio

"You look tired," Clarissa said when we met in the ED early on Saturday morning.

"I am tired!" I declared. "I only managed about three hours of sleep last night because we arrived home later than expected due to an accident on Route 50 just west of Owensville."

"No more gigs for the rest of the year, right?"

"The end of the semester concert at Taft in December, but that's an easy one, and it's over by 10:00pm at the latest."

"You have the same schedule in November, don't you?"

"Yes, and likely until the grant that covers the PGY1s rotating through the Free Clinic runs out."

"End of August next year, if I remember correctly?"

"Yes. Nobody knows if it'll be renewed, and if it is, it'll be the new class of PGY1s who are assigned there."

"Morning Mike!" Paul Lincoln said, coming up to me. "Three waiting on admits. Ready?"

"I'll catch you later, Petrovich!" Clarissa said, then walked away.

"Go ahead, Paul," I said.

"Exam 3, Male, sixty-two, A-fib, stable, waiting on Cardiology; Trauma 1, Female, nineteen, agitated, five of Haldol, waiting on Psych; Exam 1, male, forty-one, on a banana bag after a drunk and disorderly arrest, positive for Hep-C; waiting on Medicine."

"I have it. Have a good Saturday."

He left, I found my Saturday students, Karl and Andy, and we checked on the patients.

"Andy," I said after we'd seen all three, "call each of the services and find out when they'll be taking the patients because we need the beds. The board is nearly full. If they give you any grief, let me know, and I'll speak to Doctor Mastriano. Karl, the only open room is a trauma room, so go grab your breakfast."

They acknowledged my orders, and I went to see Isabella.

"No exam rooms," I said. "I have Andy chasing Cardiology, Medicine, and Psych."

"The new ED can't open soon enough," she replied.

"Eighteen months. We're going to have real problems if other services slow-walk admits overnight."

"Everyone has the same problem — patient loads are up and are increasing faster than our budget."

"What we need is a clinic across the street that would take non-emergent cases, but EMTALA wouldn't let us redirect anyone there or even put up a sign that said waiting times are shorter."

"The road to Hell is paved with good intentions," Isabella said. "I'm going to call Loretta and let her know we're basically stuck until we can move six patients upstairs. If we get a multiple trauma before..."

"Don't say it!" I interrupted.

"You're the last person I'd think would be superstitious!"

"Just allowing my confirmation bias to turn correlation into causation where no causation actually exists. I'll leave you to call the Chief."

I went to the Clerk's desk and checked the charts. Fortunately, there wasn't anyone who needed immediate attention, which would have meant using the sole available trauma room. Unfortunately, that meant longer waits. I went to the lounge, poured myself a cup of coffee, and sat down with the McKinley Times to catch up on the news. As I read, my mind turned over the problem we were having and how we might suggest to people to go to the Free Clinic or the new 'Urgent Care' facility that had opened just south of town.

It struck me that posting the estimated waiting time without any encouragement to go elsewhere was within the letter of the law, at least as it had been explained. I wondered if keeping in touch with the Free Clinic and the Urgent Care facility and posting their wait times was a possible loophole which we could use to help patients.

Of course, given how litigious our society was, I was sure some court somewhere would find that simply posting comparative waiting times was 'encouraging' people to leave without treatment. That was technically true, but it was for their benefit and would lead to faster assessment of their complaint. I pushed that out of my mind and returned to reading the paper.

"Medicine took the drunk with Hep-C," Andy said, coming into the lounge about five minutes later. "Psych says 8:15am; Cardiology said 'soon'."

"Is the exam room still open, or did someone grab it?"

"It's open, but there are six patients in the waiting area."

"Grab a chart, and I'll meet you in Exam 1. You'll do the H&P, and I'll observe."

He left, and a minute later, I got up and went to Exam 1.

"Doctor Mike, this is Kevin Dougherty; Kevin, Doctor Mike. Kevin presents with a complaint of pain in his left foot."

"Proceed with your exam, please."

Andy did a good job, and after verifying his findings, we stepped into the corridor, joined by Karl, who was returning from breakfast.

"Every indication is a fracture," Andy said. "I suggest X-rays."

I nodded, "That's my assessment as well. Most likely a hairline metatarsal fracture."

We went into the room, I introduced Karl, and after Andy gave his proposed treatment and the patient agreed, I signed the chart ordering the X-rays. I asked Karl to make the arrangements so that Andy could have his breakfast and then went to check on the other two patients. The young woman who was sedated with Haldol had unchanged vitals; the sixty-two-year-old man with A-fib complained of flutters in his chest, and I reassured him his condition was not life-threatening and promised to call Cardiology. I left the room and went to the Clerk's desk and dialed Cardiology.

"Hi," I said to the nurse, who answered the phone. "This is Doctor Mike in the ED. I have a patient with a-fib who's been waiting for nearly four hours for admission. Could you provide a timeframe, please?"

"As I said to your student, the on-call Resident is aware and said 'soon' when I asked her about it."

"That was, I believe, about thirty minutes ago," I replied. "We're out of beds, so anything you could do to speed up the process would be greatly appreciated."

"Let me see what I can do," she said.

"Thanks."

I hung up and thought about calling Psych but decided I'd leave that to Isabella or Doctor Gibbs. About two minutes later, Pat Shore from Cardiology arrived with a Third Year.

"Hi, Pat," I said. "Thanks for coming down."

"Sorry about the delay," he said. "I just came on. Doctor Lyon and Doctor Pace are out sick, along with two nurses, so we're shorthanded. What do you have?"

"Lee Schmidt; male, sixty-two; presented four hours ago with complaints of flutters in his chest. EKG confirmed A-fib; given ASA."

"OK. Let's go in."

We went into the room, I introduced Doctor Shore and waited while he examined the patient and reviewed the EKG. As I expected, he prescribed warfarin and referred Mr. Schmidt to a cardiologist. Once the chart was updated, we stepped out, and I went to present to Isabella, who approved the discharge and signed the chart.

My students and I saw three more patients, and finally, just before 9:00am, Psych called to say they were ready to accept the young woman who had been sedated in the ED since she'd arrived at 11:15pm the previous night. I felt that was unconscionable, but given my past interactions with Psych, the only thing I could do was note it on the chart and flag it to Isabella.

Other than the overnight patient load, it was a routine day, and I saw a total of nineteen walk-ins, assisted in one trauma, and provided surgical consults for two others. By the time 5:00pm came around, I was beat and ready to go home and sleep, but before I could do that, we'd have dinner and attend Vespers at the Cathedral.

October 23, 1989, Circleville, Ohio

On Monday, I could actually sleep in until the alarm Kris had set went off at 6:45am. I didn't have to be at the Pickaway County Courthouse until 8:15am so I could relax and have a leisurely breakfast before taking Rachel to Milena's house so she could play with Abi.

I arrived at the courthouse about ten minutes early and was directed by a Sheriff's Deputy to the jury assembly room, where by 8:15am, over a hundred people had gathered, ranging in age from around eighteen to what I estimated to be mid-seventies, about equally mixed between men and women, and with very few minorities, which reflected the ethnic makeup of the county.

I wondered if I'd actually be chosen or if I'd have to spend each morning and possibly afternoon reading medical journals. According to the booklet I'd received after returning my questionnaire, there were morning and afternoon trials; some could be very short, such as someone challenging a parking ticket, and some could be long, such as a complex murder case.

I had no way of knowing what kinds of cases were on the docket, as that would have required manually reviewing the docket for each judge and trying to guess if a trial would actually be held. I was actually fascinated by the process, even if I'd have preferred to be in the ED rather than sitting in court.

One thing I was certain of, after speaking to Stefan, was that I wouldn't be seated on a jury where the death penalty was an option, as I was morally opposed to it in all circumstances, and that fact would lead me to be excluded from a jury. That struck me as wrong because it, in effect, stacked the deck in favor of the government, but Stefan assured me it had been litigated and the government had presented arguments which passed Constitutional muster, which didn't surprise me, given the Eighth Amendment clearly authorized the death penalty, my moral objections to the contrary notwithstanding.

Promptly at 8:15am, a jury coördinator gave a brief set of instructions, which I interpreted as 'shut up and read a book' until we were called for voir dire, the legal term for the process of selecting or excluding individuals for a given jury trial. Each juror would be asked a series of questions by the attorneys, supervised by the judge, to help them decide whether to challenge a person for cause or peremptorily, that is, 'on general principles'.

A random selection was made, and I was among the first dozen people brought into a courtroom. As soon as I understood the nature of the case, I knew I'd be challenged for cause.

"This is a medical malpractice case," an attorney said. "I challenge juror candidate nine for cause, as he's a practicing physician."