Chapter 70: Four Dimes

December 25, 1989, Feast of the Nativity, Circleville, Ohio

"How was your day?" Kris asked when I arrived home on Christmas Day evening.

"It wasn't busy, but unfortunately, three of the four MIs I had didn't make it."

"Heart attacks?"

"Yes, sorry. I try not to use medical shorthand with you."

"What happened?"

"One we stabilized and sent to the cardiac catheterization lab for insertion of a stent, which I've explained. He developed arrhythmia before they could begin the procedure and died. The second one died about a minute after the paramedics brought him in. The third one is resting comfortably in Cardiology. The fourth coded while the Cardiologist was examining him, we brought him back, but then he coded again about five minutes later. Oh, and there was one panic attack brought on by indigestion because the patient thought he was having a heart attack."

"It must be terrible to have a loved one die on Nativity."

"As I said at the hospital, Mr. Worf's opinion notwithstanding, today is not a good day to die. How was your day?"

"Good! We went to church with my family this morning, then Rachel and I spent the rest of the day there. We came home about forty minutes ago so we could be here when you arrived home."

"Shall we read to Rachel, say our prayers, put Rachel to bed, then take a nice, warm bubble bath?"

"That sounds wonderful!"

Rachel chose The Bears' Picnic, one of her favorites, and once I'd read it to her, the three of us gathered before our icons and said our evening prayers. Once we'd completed them, Kris and I put Rachel to bed, then went to the master bathroom for our bath.

"Do you still plan to visit the prison on Sunday after church?"

"Yes. It's really the only time I can go. Protodeacon Ivan is driving so he can take the Eucharist to Nick Papadakis, and he'll have me back here in time for Rachel, you, and I to leave for my dad's house."

"You should just leave from church. I can drive your car home."

"That sounds good."

"I'm curious what we'll do about a car when we have three kids, with two of them in car seats?"

"Well, that's three years from now, so it's not an immediate need, but I don't see any option other than trading the Tempo for a minivan. We've been saving towards a new car in addition to what we're saving for the house, so we'll be in good shape. I think about fifteen months from now is the right time to start building a house. I figure five bedrooms, so that we have two spare rooms. Assuming things go the way we've discussed, I'd want the child Clarissa will conceive artificially to have a room."

"You expect him or her to live with us part-time?"

"I'd like to leave things open so that he or she feels completely welcome. Are you still comfortable with the idea?"

"Yes, though I do wonder what you'll say to His Grace."

"The truth. I will take whatever paperwork is generated to show him to remove any speculation that I might have violated my vows. Of course, there will be gossip, but I want Vladyka to know so there is no doubt of any kind in his mind."

"She's a lesbian!"

"Yes, of course, but she still has the appropriate parts, as do I, and orientation doesn't preclude biological function! And that's what will cause the gossip. You know the truth."

"Will there be a problem baptizing that child?"

"No. First of all, the church baptizes children born out of wedlock because the circumstances of one's birth are irrelevant. And Clarissa and Tessa have both agreed to do it. They come to church at least one Sunday a month."

"I noticed that Lara and Nathan are in church more often than not."

"They pretty much have to, given they're marrying on January 28th at the Cathedral."

"What are we giving them?"

"Clarissa and I discussed it, but neither of us has any ideas. I mean, what do you get a girl who's a millionaire at twenty-two?"

"Higher taxes!" Kris declared mirthfully.

"That's a gift I don't think would be appreciated!" I chuckled. "But I have time to think about it."

"Are they taking a honeymoon?"

"During the Summer, when school's out, they're going to Europe for a month. I'm looking forward to the day in the future when we can go to Europe as a family."

"This time, though, not just the tourist parts!"

"Well, that's in the future. Right now, there's another place I'd rather visit!"

"Bed?"

"Yes!"

December 26, 1989, McKinley, Ohio

Tuesday morning was back to normal at the hospital, though a number of Attendings, Residents, and nurses were on vacation, so shifts were jumbled, and there were a number of outside physicians working in the hospital to earn extra money, as well as keep their privileges. That also meant that on Wednesday, I'd work at the hospital rather than at the Free Clinic.

"Morning, Mike!" Doctor Gibbs said when I walked into the ED. "How was your Christmas?"

"I was here!" I replied. "And it was Heart Attack City! I had four MIs myself, and there were three others; five didn't make it."

"That's out of the ordinary."

"The number or the number who died?"

"Both! Do your handover then come see me."

I spoke with Paul Lincoln, who had two patients on the board — one with food poisoning who was being admitted to Medicine, and one with a broken ankle who needed surgery. Paul left, and I went to see Doctor Gibbs.

"What's up?"

"What are you doing in May?"

"Working!" I said with a smirk. "What do you think I'll be doing?"

"I meant in your personal life?"

"Kris isn't due until mid-June, so no specific plans. Why?"

"There's a regional trauma conference in Indianapolis the weekend of May 19th. When is your Easter?"

"April 21st," I replied.

"We'd like you and Ghost to go to Indy for the conference."

"I appreciate the recognition."

"I'd send you to the International Conference on Emergency Medicine in Toronto, but it runs from June 20th to June 24th, and someone might bring out the guillotine for me if I did that!"

"My response would be that if you want me to go, you have to ask Kris, and I'd say your estimate of her reaction is accurate! Who'll go?"

"Me and a Resident. I have to decide which. Any suggestions?"

"Kylie Baxter," I replied without hesitation. "Is it up to you?"

"That's the other piece of information — Northrup handed in his resignation on Christmas Eve. He's going to Swedish Covenant in Chicago as Medical Director."

"That's a fairly small hospital, if I remember correctly," I said.

"It's a stepping stone for him. Once he has the position, he can parlay it into a similar job at a larger, more prestigious hospital. But he does have one thing going for him!"

"What's that?"

"Harrison Ford was born at Swedish Covenant Hospital in July 1942!"

"Interesting! What's the scoop on the Chief's job?"

"That'll be up to Cutter, but given he's brand new in the position in January, I'd put my money on a nationwide search."

"You're going to apply, right?"

"Of course!"

"You have my vote," I replied. "Though I'm not sure what that's worth."

"I certainly wouldn't mind a good word being put in with Cutter when the time is right. You surgeons are thick as thieves!"

"Guilty as charged," I chuckled. "I do have to extract a promise from you — no turf wars about who the trauma surgeons report to."

"As if I'd want to manage you? Seriously?"

I chuckled, "I can be difficult."

"You fit right in with the rest of the red shirts!"

"Ouch! But in TNG red shirts are command or 'line' officers; gold is engineering or security; and blue is science. The 'red shirts' don't die in this series!"

"Oh, shut up!" Doctor Gibbs growled. "Stop being so pedantic and ruining a good joke!"

I was SO tempted to stick my tongue out at her, but I controlled the urge.

"Whatever!" I said instead.

"Go heal the sick! I'll get you the details for the conference in January. Just block out that weekend, please."

"Will do!"

I left her office and went to check on the two patients Paul had handed over. While I was in with the food poisoning patient, Clarissa arrived to admit her to Medicine, and about five minutes later, Val Jackson from Orthopedics came into the ED to admit the broken ankle.

"May I present?" Jenny asked when I went to Exam 5 to see a new patient.

"Go ahead."

"Female, twenty; jogging this morning at the Y and twisted her left ankle. Pulse 70; BP 110/60; PO₂ 99%. No appreciated injuries other than the left ankle. Moderate ecchymosis; no pain in the malleolar zone; no bone tenderness. I believe it's a Grade 2 sprain, but recommend an X-ray to rule out a fracture."

"Why?"

"It's the standard protocol," she replied.

"How sure are you of your diagnosis?"

"There is no indication of a break."

"So you'll subject the patient to a possibly needless X-ray?" I challenged.

"Er, uhm..." Jenny stammered.

"Speak your mind, please. Remember, your job is to be a forceful advocate for your patient."

"We have protocols for a reason, and unless the patient has had excessive X-rays, there's no reason to reject the protocol."

"Has the patient had X-rays recently?" I asked.

"Oops!" Jenny exclaimed with a smile. "I get it. I'll be right back!"

She went back to the treatment room and returned a minute later.

"Dental X-rays last year. That's insufficient to warrant caution. May I ask a question?"

"You may."

"I've observed you order X-rays without checking."

"Yes, I have. Tell me why?"

She thought for a moment.

"Because in the case of an ankle injury, something on the order of 90% are sprains, not breaks, which means nine out of ten X-rays are probably unnecessary. You've ordered them in cases when there wasn't really an option."

"Correct. Let's go examine your patient, get the X-rays, then if they confirm your diagnosis, you can wrap the ankle."

I confirmed Jenny's diagnosis and ordered the X-rays. Forty minutes later, I observed as Jenny wrapped the ankle with an ace bandage. I wrote out the discharge orders, had Kelly retrieve a pair of crutches, and then take the patient to the door of the hospital in a wheelchair.

The morning was relatively calm, and we saw five walk-in patients, none of whom needed admission, and one EMS run for a moderate MVA, with the patient discharged with a cervical collar on account of 'whiplash'. I had lunch with Clarissa, then had a busy afternoon with a string of walk-ins. I had dinner with Shelly Lindsay and had my first challenging case just before 7:00pm.

"What do you have, John?" I asked when he came into the lounge.

"Tommy Fields; toddler with gastrointestinal distress. No fever; tympanic membranes not bulging; no mucous; no vomiting; pulse 78; BP 120/80; PO₂ 98%. No recent injuries. No other family members are ill. No reports of any medical condition; no evidence he ingested any hazardous liquids or medicines."

"What do you want to do?"

"Have you teach me to do an abdominal exam."

I nodded, "Then let's do that. You know the procedure, right?"

"Yes. Checking for rebounding, guarding, distension, tenderness, and pain with pressure. I haven't done one, though."

"Do you know what those things feel like upon palpation?"

"No."

"Then I'll perform the exam, and if I detect something, I'll have you feel it with the parent's permission. How old is your toddler?"

"Sorry. He's three. His mom is with him. I should have said that."

"Let's go see him.

We went to Exam 3, where Tommy, his mom, and Kelly were waiting.

"Mrs. Fields, this is Doctor Mike, my supervisor," John said. "Doctor Mike, Tommy and Mrs. Fields."

"Hi, Tommy," I said. "Hi, Mrs. Fields. Is there anything more you can tell me other than what you told John and Kelly?"

"Not really. He was fine until about two hours ago when he complained that his 'tummy hurt' really badly. He didn't have a fever and didn't throw up, but he started crying. I gave him Children's Tylenol, which seemed to help, but then he complained an hour later that it hurt worse, so I brought him here."

"John says that you're sure he didn't ingest any cleaning fluids or medication."

"Positive. Everything is in locked cabinets, out of reach. We moved everything as soon as he started crawling."

"OK. Tommy, I need to listen to your heart and your breathing, look in your eyes, ears, nose, and mouth, then feel your neck and tummy. Is that OK?"

"Yes," he replied.

I performed the exam and detected no indicia of any viral or bacterial infection, no rigidity, guarding, or tenderness, and no swollen glands.

"Tommy," I said. "Did you eat anything other than the food an adult gave you?"

"No."

Given the time of year, there was another possibility, but I had to be careful about asking.

"Tommy, does your family celebrate Christmas?"

"Yes! I got lots of presents!"

"What kind of presents?" I asked.

"A train set," he said.

I turned to his mom, "What scale?"

"HO," she replied. "But we made sure there were no small parts on any of the trains."

"OK. Tommy, what else?"

"Simon!"

"What else?"

"Clothes and books."

"Do you have a dog or cat or fish?"

"No."

"Mrs. Fields, do you have a real or artificial tree?"

"Artificial."

"Miniature bulbs?" I asked.

"Yes. We have the big ones outside, and the tree has the small ones."

"Tommy, did you put anything in your mouth at all besides your food?"

"No," he said.

"Mrs. Fields, has he been using the bathroom regularly?"

"Yes. He had a BM earlier today."

"OK. I'm going to do an ultrasound because I strongly suspect Tommy ingested something. If this were a virus or food poisoning, he'd have a fever, swollen glands, or be vomiting. There's an outside chance it's appendicitis, but I don't believe that's the case. That said, children do not have the same classic signs adults have. The ultrasound will help us determine what's wrong."

"What else could it be?"

"There is a range of possibilities, most of them extremely rare, so let's wait to see what we find with the ultrasound, OK?"

"Yes."

"Kelly, John, let's step out a moment. Mrs. Fields, we'll be right back with the ultrasound machine."

We left the treatment room and stopped just outside the door.

"Any thoughts?" I asked.

"What do you think he swallowed?" Kelly asked.

"No clue, and I'm not sure that's what it is, but with nothing to go on except stomach pain, it's a theory. The ultrasound will give us an idea. You handle the transducer."

"OK. Where do I scan?"

"Sternum to pubis. Do you know your anatomy well enough to evaluate the image?"

"I think so."

"Either you do or you don't."

He was quiet for a moment, then said, "I don't."

"It's never wrong to admit you don't know," I replied. "It's always wrong to say you do if you don't. I'll point out each important anatomical feature while you're moving the transducer. Kelly, get the ultrasound cart, please."

Kelly retrieved the cart, and the three of us returned to the exam room. John turned on the ultrasound and made the correct settings on the console. Once that was complete, he asked Mrs. Fields to remove Tommy's shirt, then explained to Tommy what he was going to do. Tommy was reasonably coöperative, and John began the scan.

As he slowly moved and tilted the transducer, I pointed out each organ in Tommy's internal anatomy with nothing anomalous being visible until the transducer was just above Tommy's navel.

"There," I said, pointing, then pressing the button to freeze the image.

"What are those?" John asked.

"Move the transducer to the right and tilt it away from us," I requested, then pressed the button to unfreeze the image, followed by the 'zoom' button.

John did as I asked, then said, "Coins?"

"I'd wager four dimes," I said, pressing the button to freeze the image. "From the size, but they could be pennies as well. Tommy, did you eat any money?"

"NO!" he protested.

"He ate coins?" Mrs. Fields asked.

"It certainly appears that way," I said as I pressed the button to print the image.

"What do we do?" she asked.

"Typically, if they aren't lodged in the esophagus, we wait for them to pass, which can take anywhere from two days to two weeks, depending."

"You can't remove them?"

"I'd strongly prefer not to perform what's called an endoscopy, which would require putting Tommy under general anesthesia, something we want to avoid whenever possible, then putting a tube down his throat. I'm going to call a pediatric specialist to come down and talk to you."

"OK."

I went to the phone and dialed Pediatrics. I explained to the charge nurse what I had discovered, and she promised that Matt Olson would be down within ten minutes. I thanked her, hung up, then let Mrs. Fields know he'd be down shortly. Strictly speaking, I didn't need a pediatric consult, but in cases where the answer was 'go home and wait', I'd found parents were more comfortable hearing that from a specialist than from a doctor in the ED.

"Tommy, another doctor is going to come see you," I said. "If you look at the screen, you can see there are four pieces of money in your stomach, which is why it hurts."