Chapter 68: Confrontation

December 14, 1989, McKinley, Ohio

"I hear you're being released today," I said to Nancy when I visited her on Thursday morning.

"Finally!" she exclaimed. "Four freaking weeks in the hospital!"

"Mind if I look at your chart?"

"Why not?" she said with a smirk. "You've seen everything else!"

I chuckled and picked up the chart. I'd looked at it each time I'd visited, but I wanted to see the final discharge notes from the physical therapist. Nancy was making excellent progress, though it would be a few months before she'd have the cast removed from her leg. She'd had her final surgery on her arm, removing some of the hardware that had been installed when they'd reconstructed it.

"Looks good," I said. "How does your arm feel?"

"It throbs, but Tylenol solves that. The cast is crazy uncomfortable, and I itch."

"I'm glad the double-vision cleared," I said. "Concussions can be lifelong problems."

"Me, too! That was driving me completely nuts, even more than you did!"

"Ouch," I chuckled.

"I'm teasing, Mike! We had our ups and downs, and despite the problems, it was good. We just weren't meant for each other. Mom was disappointed, but she likes Matt, and she spoils Matty to death!"

"I believe that's the job of grandmothers and, apparently, little sisters!"

"Yours? Or your wife's?"

"My wife's, of course. I don't even want to think about what my little sister might teach my daughter! Being taught French is bad enough!"

"That's right, you told me your wife is a recent immigrant from France. And I would have figured you were teaching her Russian."

I shook my head, "No, we're American through and through. The French is only to annoy me, though, ultimately, her being able to speak French is probably far more useful than Russian. That said, with what's going on in Eastern Europe, you never know. Russia might become an ally once again, but this time without a communist government. It's really only since the end of World War II that Russia hasn't been a US ally."

"I take it you plan more children?" Nancy asked.

I nodded, "We do. Can you keep a secret? I mean, from everyone?"

"Your wife is pregnant?"

"Due in late June. We plan to announce it at Christmas dinner."

"If I recall correctly, you have to work holidays."

"I do. We'll have our dinner on the 24th after Vespers. I already received permission from the bishop for «ekonomia» for both families to have our celebration that night because I have a shift from 0500 to 2100 on Christmas day."

"Er, I don't do military time."

"Sorry. That's 5:00am to 9:00pm. The trick is that if it's before 1200, it's AM, and if it's after 1200, it's PM, and you subtract twelve. We use it because it reduces confusion as to when your shift starts or ends, especially when it's a thirty-six-hour shift!"

"Ugh! How do you do that?!"

"Fortunately, I don't. The Emergency Department switched to eighty-hour weeks, with no more than twenty-four hours per shift and at least eight between shifts. There was a situation in New York attributable to overworked and overly tired Residents at the end of a thirty-six-hour shift with little sleep, and that's caused some hospitals to change their scheduling practices."

"What happened?"

I explained the basics of the Libby Zion case to Nancy, who just shook her head.

"Sorry to cut this short," I said at the end of the story, "but I need to get back to the ED. I just wanted to come say 'hi' before you're released."

"Thanks! Mom wants to have you and your wife to dinner. Is it OK for her to call you?"

"Absolutely. Let me write down the number."

I wrote my name and number on the scratch pad next to the bed, then said 'goodbye' to Nancy and headed back to the ED.

December 17, 1989, McKinley, Ohio

On Sunday, after Matins and the Divine Liturgy, Kris, Rachel, and I had lunch with the congregation, and then I met with Bishop JOHN.

"I'm sorry I didn't have time to speak last week when you asked about Nativity," he said after we sat down in his office.

"It's OK, Vladyka," I replied. "I totally understand, and I cannot monopolize your time!"

"I enjoy speaking with you, Michael! How are things at the hospital?"

"There's been a bit of drama surrounding a medical student and a doctor having an affair and an allegation that her grade was improved because of that affair."

"I find it hard to believe it's not against the rules for what amounts to a teacher being intimate with a student."

"It is now," I replied. "As a direct result of that situation. I've been pushing for that rule for two years, and things finally were serious enough that the medical school and hospital both instituted rules limiting that."

"Limiting?"

"There is a bit of leeway for students and doctors who are not on the same service, but it has to be disclosed."

"Knowing you, I have to ask — how involved were you?"

"Up to my eyeballs, of course! The student was a troubled one who was assigned to me when everything went down. She was dismissed for making false sworn statements, and the doctor in question is suspended pending completion of the investigation."

"What was your part?"

"The false accusation was leveled against me, but I'd taken steps beforehand to ensure a claim like that wouldn't stick."

"Now I have to ask — did you do anything at all questionable?"

"Not in the way you mean," I replied. "I did speak to Father Roman about my response to some of the tension that was created because of the internal battle over the rules change and the responses to the situation."

"May I ask what steps you took?"

"On the advice of one of my mentors, I began carrying a pocket tape recorder and recorded a meeting with the student. Her characterization of the meeting was directly at odds with the tape recording, which led to her dismissal."

"That could have gone very badly," Bishop JOHN observed.

"It was actually that meeting that caused her to make the false accusation because I confronted her with other lies she'd told. I was also careful to have a trusted nurse stand in a strategic spot so she could see the student and me."

"Perhaps you should start at the beginning and explain, as best you can, without violating any hospital rules."

I nodded and gave a complete rundown of the situation, beginning with Felicity Howard and running through the hearing the previous Monday. Bishop JOHN listened intently but didn't ask any questions until I finished the story.

"You discussed this with Father Roman?"

"Most of it, yes. I'm seeing him face-to-face the first Sunday in January."

"Good. How are things otherwise?"

"Very good. I'll tell you now, as I won't have a chance to do so before the usual gossip brings it to your attention — Kris is pregnant, and we're due towards the end of June."

"Wonderful news, Michael! When will you make it public?"

"We'll tell our families on the Eve of Nativity at the dinner for which you granted «ekonomia»."

"Of course, Michael! Your schedule is such that accommodation is totally warranted. I assume you've modified your fasting rule?"

"Yes. Father Luke, Kris, and I worked out a rule for any time she might be pregnant, and I believe she informed him in confession that she was pregnant. The one place besides your office, completely immune to gossip!"

"If there was one thing I could end with the wave of my staff, that would be it! How is Rachel taking it? Or does she know?"

"We'll tell her right before we tell our families; toddlers are not known for discretion, nor are they good at keeping secrets!"

"Nor many adults, sadly! I'm very happy for you, Michael."

"Thank you, Vladyka."

December 18, 1989, McKinley, Ohio

On Monday afternoon, just after 3:00pm, Shelly Lindsay appeared in the ED and asked to speak to me. The consultation room was free, so we went there.

"Mark King reached an agreement with the hospital," she said. "Exactly along the lines you and Strong predicted. He'll be permitted to finish his Residency on probation, but agreed to not even apply for an Attending role here."

"Plus a payoff?"

"Yes. He'll pay Krista some amount, but it's a private agreement between them in exchange for her dismissing her case with prejudice. Also, as you two predicted, she was allowed to withdraw from the medical school on condition she not apply to or attend a medical school for two years."

"I think, all-in-all, that works out best," I observed. "I know you and the other female staff aren't happy, but it's also the case that as scummy as Mark King might be, he didn't break the rules in force at the time. Thankfully, those rules have changed. I can't imagine Krista would be able to get into medical school again."

"You never know," Shelly said. "Stranger things have happened."

"If she gets in touch, which I expect her to do, I'll encourage her to use the money from her settlements to enroll in a PhD program and become a researcher. She's intelligent enough; her problem was always clinical skills."

"You really do try to find the good in everyone," Shelly observed.

"I believe the world would be a better place by finding the good in each and every person, insofar as that's possible. Orthodox Christianity doesn't believe in unforgivable sin in the sense that some individual act or series of acts puts you on what AC/DC called a Highway to Hell with no exits. But I'll spare you the rest of the theology lesson."

Shelly laughed, "I do appreciate you doing that, though I am always curious about what makes you tick. I need to get back upstairs for afternoon rounds; dinner?"

"You're welcome to join Clarissa and me."

"See you for dinner, then. Just call when you get your break."

"Will do."

We left the consultation room, Shelly headed back to the surgical ward, and I went to the lounge to get water from the cooler.

"Doctor Mike?" John said, coming to the door. "Labs are back on the abdominal pain in Exam 2."

"Interpretation?"

"Everything is within nominal ranges."

"So, tell me what's wrong with him."

"I don't know."

"What do we know?"

"Sharp, localized abdominal pain that increases, peaks, and subsides; vomiting; no fever; no signs of appendicitis."

"So, where do you go from there?"

"EKG, and if it shows no signs, then the most common differentials are gallstones, kidney stones, or small bowel obstruction."

"We have plenty of time, so set up a twelve lead and come get me."

"Right away!"

He was back about five minutes later and let me know the EKG was established. I followed him to Exam 2, where Kelly was waiting with the patient, Mr. Wolff. The EKG appeared normal, and auscultation and palpation did not provide any evidence. I asked John and Kelly to step out of the room.

"Clear EKG," I said. "What next, John?"

"Ultrasound."

"OK. Let's do it. You can handle the transducer, and we'll review the screen together."

"I haven't done that before."

"There's a first time for everything," I said. "Do you know the theory?"

"Yes."

"And you've observed ultrasounds?"

"Yes."

"Watch one. Do one. Teach one. Learn it. Know it. Live it."

"Wait!" Kelly exclaimed. "Did you just quote Fast Times at Ridgemont High?"

"I did indeed!"

"Phoebe Cates or Jennifer Jason Leigh?" Kelly asked.

"A girlfriend asked me that right after we saw the movie, and I replied it was Jennifer Jason Leigh, hands down, no question, not even close!"

"Most guys prefer Phoebe Cates!" Kelly declared.

"One thing of which you can be sure is that I'm not 'most guys', nor am I 'normal'! Get the ultrasound cart, please."

We performed the ultrasound, and I appreciated small masses both in the gall bladder and in a bile duct. I directed John's attention to them, then asked for a diagnosis.

"Choledocholithiasis," he replied.

"What does that mean?" Mr. Wolff asked.

"Gallstones," I replied. "Two of them have migrated into the bile duct."

"What's the treatment?" Mr. Wolff asked.

"A laparoscopic cholecystectomy," I replied. "It's a routine procedure where we make small incisions, insert special surgical tools, and remove your gall bladder. You don't need it to live a normal, healthy life, and most people have no lasting side effects from its removal. Let me call upstairs and see when they can take you."

I went to the phone and dialed the number for the scheduling nurse.

"Jackie, this is Mike Loucks in the ED," I said. "I have a patient who presented with symptomatic cholelithiasis. Ultrasound revealed stones in the gall bladder and bile duct for a diagnosis of choledocholithiasis. We need a team for a laparoscopic cholecystectomy, and I'd like to scrub in, if the Attending will permit it."

"OR 2, with Doctor Burke and Doctor Lindsay; we'll be ready in twenty minutes."

"Thank you."

I hung up and let Mr. Wolff know we'd be taking him upstairs. I had Kelly call for transport, then updated the chart. I reviewed the consent form with Mr. Wolff, and after he signed it, I excused myself to present to Doctor Gibbs. I let her know I was taking Mr. Wolff up and had asked to scrub in.

"Who'll do consults if you're upstairs?"

"Whatever poor PGY1 is on the ward," I replied. " I think it's Penny Nichols."

"OK," Loretta replied. "We're not busy, so go learn how to be a sawbones."

"Did you hear about Mark King?"

"No."

"Shelly let me know they cut a deal with him. He'll finish his Residency on probation with an agreement that he won't interview or apply for an Attending position here."

"The Board agreed to that?"

"I don't know the exact details, but I'd speculate that Doctor Rhodes simply lifted the suspension, then put King on probation. That would bypass the Board."

"I take it Shelly isn't happy."

"She's not, but in the end, there was insufficient proof to sustain dismissing King from the program. He has to pay Krista some undisclosed sum to go along with whatever the hospital and medical school paid her, and she will be shown as having withdrawn from the program."

"So she can try again?"

"Not for at least two years. I hope she goes to graduate school and becomes a researcher. She'll be very good at that."

"You're an odd duck, Doctor Loucks. Go play with your surgeon friends!"

She signed the chart, and I returned to the exam room just as the orderlies arrived to transport him to surgery.

"Come along," I said to John and Kelly. "We'll see if we can get you into the OR to watch."

We walked along with the orderlies and Mr. Wolff and made our way to the surgical ward on the second floor.

"Done slumming in the ED?" Shelly asked.

"You know that's my natural habitat! Permission for my students to scrub in?"

"Granted. Are you expecting to assist?"

"No. I haven't seen enough of these to be ready for contingencies. Put in someone with more experience."

Shelly smiled, "For all your attitude, you do know when to pull back."

"And you know that I've never allowed my personality to negatively affect patient care. I save it for all the other BS. I think the best thing for me to do is observe closely and take notes."

"I agree. I just wish we had our surgical theatre and video system. It's coming, but not soon enough. Scrub in, please."

I asked John and Kelly to wait and went to the locker room to remove my baptismal cross, as I couldn't wear it during surgery. I stashed it, along with my wedding ring, which I normally carried in my pocket or wore on a chain around my neck because I couldn't wear it under my gloves, in my locker. I rejoined John and Kelly, and we went to the scrub room. I guided them through the process, assisted by Maddie, the scrub nurse, and we went into the operating room. I stood in the place for a student observer and directed my students to a spot further from the operating table but with a decent view of the video screen.

The procedure went well, and I took notes on paper that had been sterilized before being brought into the OR and made drawings of the proper placement of the trocars, and the steps for inserting and removing them. By the time the procedure was completed, I had two pages of notes in addition to the drawing. My students and I scrubbed out, I retrieved my baptismal cross and ring from my locker, and we headed back downstairs.

"Why did you say you shouldn't assist?" Kelly asked.

"Because I'm not ready," I replied. "I'm allowed to do procedures PGY1s are not normally permitted to do because I'm responsible enough to say when I'm out of my depth and ask for help. That includes admitting to Doctor Lindsay that I wasn't ready to assist because if something went wrong, I wouldn't know what to do, and that is a recipe for adverse outcomes. Doctor Lindsay will tell Doctor Roth what happened, and that will improve my standing with him. The lesson to learn here is that you are credited with acknowledging your limitations, so long as it isn't because you're tentative or skittish."

"That seems counterintuitive to your normal advice to students," John said. "You tell students to demand to be taught."

"Yes, I do. And what exactly did I do in that OR?"

"Took notes and drew diagrams," John replied, then smiled. "You were learning."

"Yes. That's how surgeons learn. There's a difference between me talking you through inserting a Foley, or even intubation, and a surgeon trying to talk me through a procedure I've never done and haven't seen more than once."

"That makes sense," John agreed.

"I try," I chuckled.

December 22, 1989, McKinley, Ohio

"Is there anything you want to cover before we present at the M & M?" Ghost asked.

"Not that I can think of," I said. "I know you don't mean 'get our story straight' because we both agreed on all the relevant facts, and we both agree the expected outcome without intervention was death due to hypovolemic shock caused by multiple penetrating trauma."

"Carl mentioned he warned you about the likelihood of someone challenging you given the adverse outcome and your initial objection."

"Yes. My money is on Rosenbaum from Pedes."

"No bet," Ghost said. "He's the one, though I'd give decent odds on Tim Baker."

"He'd be my second choice," I agreed.

"While it shouldn't come up today, you did exactly the right thing reporting yourself to Doctor Cutter, too. That deflects any claims of trying to hide it or cover it up."

"The goal is creating and maintaining trust," I replied. "This being a completely new program cuts both ways — what engenders trust from the surgeons and the emergency medicine specialists creates mistrust from other services."

"They always think we're a bunch of cowboys who don't believe there are any limits and often refuse to acknowledge that seconds count here, sometimes even more than in surgery. You're straddling both services, so you have a somewhat unique perspective. Shall we go?

I nodded, and the two of us walked to the auditorium where the M & M conferences were held, choosing to sit about a third of the way back rather than right in front. Clarissa sat down next to me, and Shelly, Carl, and Loretta joined us a few minutes later. Promptly at 3:00pm, Doctor Rhodes called the M & M conference to order.

"Our first case concerns a twenty-three-year-old female who presented with multiple stab wounds. Doctor Casper and Doctor Loucks, please present the case."