Chapter 73: Preliminary Diagnosis

January 20, 1990, McKinley, Ohio

"Finally, a full day of practicing medicine!" I exclaimed when I saw Isabella Mastriano on Saturday morning.

"How is this year's crop of candidates?"

"I don't have previous years to compare it to, but we've only knocked out a total of four from surgery and emergency medicine."

"You're on both teams?"

"Yes. That was Cutter's idea."

"Protecting the patients?" Isabella asked with a smirk.

"Hardy-har-har," I deadpanned.

"Mike?" Nurse Jenny called out. "EMS three minutes out with a rollover MVA."

"What a way to start the day," I said. "Where are Andy and Karl?"

"Lounge. I'll let them know."

"Thanks. Isabella, care to join me? Rollovers usually require two docs."

"I suppose my crossword puzzle could wait," she replied with a theatrical sigh.

Isabella and I headed to the ambulance bay, putting on gowns, gloves, and goggles on the way. Andy and Karl joined us, along with Nurse Mindy.

EMS Squad 4 pulled up in front of us about two minutes later, and Roy jumped from the cab.

"Jessica Melbourne, twenty-seven; restrained, high-speed rollover MVA; pulse 120; BP 100/60; PO₂ 93% on 5 litres; resps labored; crush injuries to the chest; broken left arm and leg; multiple lacerations and contusions, including the head; GCS 6; IV saline TKO; backboard and cervical collar; vehicle was t-boned."

"Trauma 1!" I ordered. "Andy, Foley; Karl monitor, but hold the EKG until we assess the chest; Mindy, hang a unit of plasma, then stat ABG, type and cross-match; then CBC, Chem-20, RPT; Isabella, assess the head injuries!"

Somewhere in the back of my mind, an idea that I knew this patient floated ephemerally, but I pushed it aside and focused on the immediate problem. We moved to the trauma room, and six of us carefully transferred the patient to the trauma table. Everyone sprang into action, and Andy and I cut away most of Jessica's clothing.

"Pneumothorax; probable collapsed lung," I announced. "Andy, chest tube tray as soon as you have the Foley in."

"In!" he announced about thirty seconds later. "Urine in the bag; pink tint."

"OK. Dip it once you get me the tray!"

"Pupils sluggish; no cranial fluid in the ears or nose," Isabella announced.

"Karl, call upstairs," I said. "We're going to need a surgical team. I don't know the extent yet. Just tell them multiple abdominal injuries."

I inserted the chest tube, and that brought Jessica's PO₂ up to 98%, so intubation wasn't necessary, at least for the moment.

"Positive urine dip!" Andy announced.

"Abdomen is rigid," I said. "Certainly internal bleeding. Andy, EKG, please."

"Surgery says fifteen minutes," Karl announced.

"V-tach!" Andy announced. "Run of five!"

I looked up at the monitor and confirmed, but it wasn't severe, so the best course of action was to not administer drugs, leaving those choices to the surgeon and anesthesiologist. I continued my exam, and given the time we had, I asked for the ultrasound, which would save time upstairs. I confirmed free fluid in her abdomen, and the urine dip confirmed the presence of blood.

"What do you think, Isabella?" I asked.

"Neuro consult can wait until after they repair her internal injuries. I'd say severe concussion, but no skull fracture."

"Then let's take her upstairs. Karl, get a gurney! Andy, portable monitor and EKG."

He did, and we carefully transferred Jessica to the gurney.

"Karl, Andy, Mindy, with me; Karl, grab the portable paddles."

He grabbed the portable defibrillator and put it at the foot of the gurney along with the monitor, and we rushed Jessica from the room and down the corridor.

"HOLD AND CLEAR THAT ELEVATOR!" Karl called out in his booming voice.

Fifteen seconds later, we were in the elevator on the way to the second floor, and that idea that had been floating in the back of my head suddenly focused.

"Mindy, check the right bicep and tell me if you see a jagged scar."

"Why?"

"I think I know this patient."

Mindy checked the arm and looked up, "Five-centimetre scar about three centimetres above the elbow."

"Unreal," I said, shaking my head.

"What?"

"This young woman is why I became a doctor."

The elevator doors opened, and we rushed her to the operating room where Doctor Roth and Doctor Lindsay were waiting, having been called in. I very much wanted to scrub in, but we were shorthanded in the ED because the schedules had been scrambled to allow for interviews.

"Doctor Mike, what did you mean?" Karl asked.

"In fourth grade, she cut her arm badly on some jagged metal on the playground equipment, and blood pumped out. I took off my shirt and used it to apply pressure the way I'd seen on Emergency!. I did that until the ambulance arrived. I was written up in the local paper for saving her life. That's when I decided I wanted to be a doctor and specialize in emergency medicine. Her family later took me to a Reds game as a 'thank you'. I hadn't seen her since sixth grade when they moved, but something triggered the memory. That's why I asked about the scar."

"That's quite the coïncidence!" Mindy declared.

"Just another one of those 'Only Mike' moments, as Doctor Clarissa Saunders would say."

When we reached the ED, Deputy McCallum was waiting for us.

"Any updates?" he asked.

"She's undergoing an exploratory laparotomy. Did anyone get in touch with her family?"

"They're in Cincinnati. Her husband and parents are on their way here. I directed them to come to the ER."

"I'll take care of it," I said. "Why only one transport?"

"The driver who t-boned her wasn't belted and went through the windshield."

"That'll do it every time," I said, shaking my head. "Alcohol?"

"No idea. Witness says he ran a red light on 23 just south of here. Any idea when we'll be able to speak with her to close out the investigation?"

"Days, at best. Once they repair her internal injuries, she'll need a neurological assessment. She took a pretty good whack to the left side of her head. I'd bet at least forty-eight hours in the ICU."

"OK. Whose working on her?"

"Owen Roth and Shelly Lindsay."

"Thanks, Doc."

He left, and I went to the triage desk and asked them to let me know when Jessica's husband and parents arrived. I spent the next ninety minutes treating four walk-in patients before Nurse Amelia called me to the triage desk. I immediately recognized Jessica's parents despite the fifteen years that had passed. I made the assumption that the man with them was Jessica's husband.

"Mr. Melbourne?" I called out, with Karl beside me, as he'd provide the escort.

"Yes," he said, coming over to me.

"I'm Doctor Mike," I said. "Your wife is in surgery."

"How is she?"

"We stabilized her and sent her up for emergency surgery to control internal bleeding. Someone upstairs will provide more details, and a surgeon will speak with you as soon as the surgery has been completed."

"What injuries?"

"I can't say the extent of her internal injuries, but a broken arm and leg as well as head injuries. Most importantly, she was breathing on her own, and her heartbeat was strong. We gave her blood and performed emergency life-saving procedures, then rushed her to surgery with the two best surgeons in the hospital. My student, Karl, will take you up to the surgical waiting room."

"Thank you, Doctor."

"Mr. and Mrs. Glazer?" I said with a smile.

"Do we know you?" Mr. Glazer asked. "Nobody said our name."

I nodded, "Indeed you do. We met about seventeen years ago."

A look of recognition spread across Mrs. Glazer's face.

"Mike? Jessica's Mike? From fourth grade?"

"Yes, Ma'am. I was a bit shorter and didn't have facial hair!"

Both she and her husband laughed.

"Gary," she said to Jessica's husband. "This is the Mike. The one who saved her life when she was ten."

"And it was that incident that led directly here," I said. "That day was when I decided I wanted to be a doctor and work in the Emergency Department."

"I suppose we owe you another Reds' game!" Mr. Glazer said.

"Are you married, Mike?" Mrs. Glazer asked.

"Yes. I have a two-year-old daughter, and my wife is pregnant and due in June."

"Mom, Dad, I want to go upstairs," Mr. Melbourne said.

"Yes, of course," Mr. Glazer said.

"Karl," I said, turning to my student, "please escort them up to the surgical waiting room. Mr. Glazer, I'm on until 5:00pm today, then I'm back on Monday at 5:00am."

We shook hands, and Karl led them towards the elevators that would take them to the surgical floor. The rest of the morning was busy but unremarkable, and at noon, I met Antonne and his study group in the cafeteria.

"Sorry about the weekend scheduling," I said. "But this is really the only time that worked for me until late next month."

"We'll let you slide," Antonne declared.

"No, we won't!" Conchita protested. "Rachel isn't in daycare today!"

"Sorry," I chuckled.

"You could have one of your own!" Jordan teased.

"No chance!" Conchita declared. "I can't think of a better way to mess up my education than having a baby!"

"We'll have you all out to the house once it's nice enough to grill," I said. "Conchita can get her fill of Rachel! How are things going otherwise?"

They were all doing well and were having no trouble in school, which was to be expected. Five out of the six were set on attending McKinley Medical School, with the lone holdout being Danika, which didn't surprise me. I couldn't imagine that she'd go against her dad's wishes and attend anywhere but Stanford. Ultimately, that had been what had taken her out of the running.

When we finished lunch, they left, and I returned to the ED. I was busy during the afternoon, but it wasn't overwhelming. Just before 5:00pm, I called up to surgery to check on Jessica. They'd repaired a liver laceration and a kidney laceration, as well as removed her spleen, then sent her to the ICU, where she'd had a neuro consult. After my call to surgery, I called the ICU, and they reported she was stable and that the neuro exam suggested only a severe concussion.

My shift ended, and I hurried home for dinner, then Vespers at the Cathedral.

January 21, 1990, McKinley, Ohio

"How was your visit with the prisoners today?" Kris asked when I returned from Southern Ohio Correctional Facility in Lucasville.

"About the same as always. I played chess with Frank Bush, but he's still deflecting any discussion of faith. The other men are doing well, and I had good talks with them."

"I meant to ask earlier — how often does Protodeacon Ivan visit the Greek prisoner?"

"Every two to three weeks. Vladyka is considering having the Protodeacon serve a Typika once a month. I believe all five of the men besides Frank Bush would attend."

"Would you participate?"

"Maybe. I have to keep my schedule flexible, so sometimes there are more than four weeks between visits. Once June rolls around, and I have my regular weekday schedule, I'll have Saturday and Sunday off, though I have to be on call one weekend a month, so we'll see."

"How long will that last? The entire year?"

"Probably. A lot depends on how quickly things progress with the surgical training. This is all new, and they're kind of making it up as they go along."

"How does being on-call work?"

"I'm required to carry a pager at all times and cannot be more than fifteen minutes from the hospital. On those weekends, we'll need to attend services at Saint Michael the Archangel because the Cathedral is more than fifteen minutes from the hospital."

"How do you feel about attending there?"

"I'm OK with it," I replied. "I seriously doubt Father Nicholas would give me grief about anything at this point. When we had lunch, we buried the hatchet and not in each other's backs. And Ghost will be chrismated on Holy Saturday, so in the end, Father Nicholas' goal was achieved, just not the way he wanted."

"What did you decide to do about counseling?"

"I'm going to call Doctor Mercer, though, with my schedule, it'll be difficult to meet with her face-to-face."

"Papa!" Rachel called out.

"I guess she's done napping," I observed.

I got up from the couch and went up the stairs. I unlatched the gate which prevented Rachel from coming down the stairs by herself, then carefully helped her navigate them. As a 'Big Girl', she was insistent on doing things herself, something which came naturally via Elizaveta and by nurture from Kris.

"What should we do?" I asked my daughter.

"Papa should play guitar and sing!" she declared.

I hadn't been to band practice in months, and our next gigs were our usual two Proms — Goshen and Hayes County High. Kim had arranged a pair of gigs for the Summer, and my new schedule made that easier. We'd play on the Fourth, and we had a gig at Shaken Not Stirred. Once I'd been given my new schedule, Kim had begun looking for other gigs.

"I'm going to have to find some time for band practice," I said.

"You'll have Saturdays off starting in June," Kris said.

"Yes, and that covers four practices before the Fourth. I think I need more. It's going to have to be Sunday afternoons after Pascha. That would give us eight or nine practices before our first Summer gig."

"I think Rachel would love to hear you practice."

"I suspect so. Of course, we also have the random event sometime in mid-June, though you could be as late as the first week in July, which could throw a wrench into the works."

"Unless I'm in active labor, you should play. Lyudmila promised to watch Rachel."

"I bet she did!" I chuckled. "Abby and Rachel are forming their own little subversive cell, and your sister is egging them on!"

"You know it's all about you, right? She still has a crush on you; heaven knows why!"

I chuckled, "Which doesn't say much for YOUR judgment then, does it, «ma chérie»?! Let me get my guitar. We can continue this later!" ("sweetheart")

"In bed?" Kris asked with an inviting smile.

"It appears pregnancy hasn't reduced your libido at all!"

"Is that a complaint?!" Kris asked with an arched eyebrow.

"Never! I know on which side my bread is buttered!"

"You just like «la pipe»!" Kris teased.

"I'm not going to deny that!" I declared. "And I dare you to deny you like my tongue in your «minou»!" ("pussy")

"Is that an offer?"

"It is! Now, let me get my guitar before the Tsarina sends for the headsman!"

January 24, 1990, McKinley, Ohio

Monday and Tuesday had primarily been occupied with interviews, and I'd checked on Jessica Melbourne each day. Finally, on Wednesday morning, she had been moved from the ICU to the critical care ward, which was a step down from the ICU but had more intensive nursing than a regular ward. After I ate lunch, I went up to see her and found her husband with her.

"Good morning," I said from the foot of the bed in the six-bed ward.

"Hi," Jessica replied. "I couldn't believe it when my mom told me who the ER doctor was!"

"The universe is a strange and mysterious place. Mind if I check how you're feeling?"

"You mean an exam?"

"No, I want to look at your chart, but you aren't my patient, so I ask permission before I look."

"Of course."

I took the chart from the foot of the bed and paged through it, then returned it to the hook.

"What's it say?"

"That you were in a horrible accident, needed repairs on your liver and kidney, had your spleen removed, and likely have a headache from the severe concussion. How's your vision?"

"Better. I was mostly seeing double until last night. The ringing in my ears has mostly gone away. Mom says you're married and have a toddler and one on the way."

"That's right. You?"

"Two little boys who I think are in training to be terrorists!"

I chuckled, "That sounds like my nephew. He's four, and he's one hundred percent boy. My daughter and my niece both think he's too rambunctious."

"My boys are non-stop! They're five and three. How long have you been a doctor?"

"Since the end of May last year," I replied.

"And you work in the ER?"

"Yes. I'm a Resident in trauma surgery, but the initial training is in the Emergency Department. What do you do?"

"I'm a marketing specialist for P&G."

"Do you know Sheila Nixon?" I asked.

"I do! How do you know her?"

"I helped care for her during my OB/GYN rotation in medical school. I'm actually godfather to her son."

"Wow! Another 'small world' connection! Wait! Her son is named 'Michael'! After you?"

"Yes. I'm sorry I can't stay long. I just wanted to come to say 'hi', and I'll come to see you again. You'll be our guest for at least another ten days, I suspect."

"That is what Doctor Lindsay said this morning. Dad said we owe you another Reds game!"

I chuckled, "And I'll be happy to accept. Have him get in touch with me, though sometime after June 1st is probably best, based on my schedule."

"Thanks, Mike; I mean Doctor."

"It's OK to call me 'Mike'; all my friends do. I go by 'Doctor Mike' professionally."

I shook hands with her husband, said 'goodbye' to them, and returned to the conference room where we were conducting surgical interviews. Our first interview of the afternoon was with Felicity Howard, which surprised me, given she had stated her intent to Match for oncology. She was greeted and given a chance to say her piece. When she finished, Doctor Burke nodded to me.

"I'm curious, why surgery?" I asked.

"After my oncology Sub-I, it was clear that wasn't for me. On the other hand, I very much enjoyed my surgical Sub-I."

The questions were routine until Shelly asked a question I'd known was coming.

"You received sub-par scores during your first three Clerkships," Shelly said. "What happened?"

"I didn't have a proper focus and didn't understand how different clinical work was from coursework. I had excellent grades and test scores and thought that was enough. When I had my first sub-par evaluation, I developed a bad attitude, which led to two more sub-par evaluations."