Chapter 76: Domestic Disturbance

February 12, 1990, McKinley, Ohio

When Julie and I entered Trauma 2, I saw Alana performing CPR while Jake bagged. I said a silent 'Lord, have mercy' and moved close to the treatment table.

"Mike, let's get him on the vent," Alana said.

"Intubation tray!" I said to Kellie, who was already moving to get one.

I looked at the monitor, and it showed no electrical activity, so a shock would not help, and the chances of him coming back were near zero. Flogging him for thirty minutes made zero sense to me, as much as it pained me to think that.

"Should we?" I asked. "Asystole? No electrical activity?"

"Kellie, amp of epi, IV push," Alana ordered. "I'm not giving up yet, Mike."

We were both Residents, and she couldn't tell me what to do, AND this was my patient.

"If the epi gets any response, I'll intubate," I said. "Jake, keep bagging."

Kellie injected the epinephrine and, as I had feared and expected, not even a blip on the monitor.

"He's gone, Alana," I said quietly. "No point in flogging him."

"No defibrillator?" Max asked.

"Ineffective for asystole," I replied.

Alana continued to do compressions, and Jake continued to bag for another thirty seconds with no change, and I decided it was over.

"I'm calling it," I said, looking up at the clock. "Time of death: 07:28. Jake, you can stop."

Alana performed five more compressions before finally giving up.

"He knew," I said gently. "He asked for his priest. You know as well as I do from the inverted T-waves that McKnight is going to find severe coronary disease, which is no surprise after sixty years of pack-a-day smoking."

She took a deep breath and let it out.

"Chart, please," she said to Kellie.

Alana filled out her portion of the chart, I wrote in the time of death, and we both signed it.

"I'll speak to my former father-in-law," I said. "Kellie, get the death kit. Max, help her; Julie, with me, please."

I left the trauma room, and I was positive Viktor knew the outcome from the look on my face, but I had to follow protocol. I gently took his arm and guided him to the consultation room.

"I'm sorry," I said. "He died because his heart stopped, and Alana Pace and I could not revive him."

Viktor nodded grimly.

"Mike?" Ellie said quietly from the door to the consultation room. "The priest is here."

"Ask Father Nicholas to come in, please."

She acknowledged me, left, and returned fifteen seconds later with Father Nicholas.

"Nikolay Vladimirovich reposed about three minutes ago," I said. "His heart stopped, and we couldn't revive him."

"Lord, have mercy!" Father Nicholas exclaimed.

"You can anoint him right away," I said. "Viktor, I assume you'll want to see your father."

"Yes," Viktor said.

"Should we wait for Yulia or the kids?"

"It's not necessary."

I nodded, and the four of us went to Trauma 2, where Viktor took his father's hand, then kissed him on each cheek.

"OK, Father," Viktor said to Father Nicholas.

"Mike, would you assisting me create any problems with the hospital or His Grace?"

"None I can think of," I said.

Father Nicholas took his stole from his bag, kissed it, put it around his neck, then removed the kit he carried that contained chrism and the other things he'd need to anoint Nikolay Vladimirovich. I filled an emesis basin with water, then prepared the portable censer while Kellie, Julie, and Max moved away from the table. Father Nicholas said the prayers for the newly departed, and I gave the appropriate responses,

We had just finished when Ellie let us know that Yulia, Geno, Anna, and Nikolay Vladimirovich's wife had arrived. I considered protocol, which usually limited the number of people to two, and instantly rejected it.

"Viktor, if you want to bring them in, it's OK."

He nodded and left the room, returning a minute later with a grim-looking Geno and three women with tears streaming down their faces. Normally, I'd have left my medical student with them, but in this case, Nikolay Vladimirovich was family, so I stayed. After about ten minutes, we all left the trauma room, and Kellie and Max began the death kit procedures.

"Viktor," I said quietly. "Do you want an autopsy?"

"What do you think, Mike? As his grandson-in-law?"

"I think all they'll find is evidence of a pack-a-day smoking habit. If it were me, I'd decline."

"OK. I'll call and make the arrangements for him," he said. "Thank you, Mike."

"I'm sorry, Viktor," I replied. "I wish there had been something more we could have done."

"I'm sure you did everything possible."

"Viktor," Father Nicholas said. "Let's go to your house."

Viktor nodded, and they left.

"You speak Russian?" Julie asked quietly.

"After a fashion," I replied. "I could when I was younger, but I don't use it very much."

"I'm not sure about the question I'm about to ask, but who is Elizaveta?"

"The patient's granddaughter. She and I were married, and she died of an intraparenchymal bleed due to a congenital arteriovenous malformation shortly after giving birth to our daughter about two-and-a-half years ago. Have you studied enough neuro, or do I need to explain?"

"I honestly do not know what that is," Julie admitted. "But first, I am SO sorry."

"Thanks. It's a vascular anomaly where an artery and vein are directly connected rather than via capillaries. Without the capillaries, there is no dampening of the pressure of blood moving from the artery to the vein. That deprives the area around it of the usual function of capillaries, which can lead to a buildup of carbon dioxide and a lack of nutrients for cells.

"Over time, it grows into a nidus, which has no capillaries and is extremely fragile. When Elizaveta's blood pressure went up during labor, it caused the AVM to expand and bleed due to the abnormally direct connections between high-pressure arteries and low-pressure veins. When that happens within the medulla oblongata, it's routinely fatal due to damage caused to the vagus nerve, which is crucial to circulation and pulmonary function."

"I'm amazed how calmly you can say that," Julie observed.

"If you can't, even when it's personal," I said, "don't try to Match for emergency medicine."

"You have to be totally emotionless?"

"No, you have to be able to work under intense pressure and approach your work dispassionately — be rational, logical, impartial, and unemotional. It's the hallmark of emergency medicine, and, to a similar extent, surgery, though there most of the time you have an opportunity to plan and study your procedure and confer with others using a more considered approach."

"OK to ask another question?"

"A large part of your evaluation is the questions you ask," I replied. "You do not need permission to ask me or anyone else. Ask. And insist on answers when appropriate. What's your question?"

"Why give up so easily on your, well, I'm not sure what you'd call him."

"Rachel's great-grandfather," I replied. "And did I give up easily? You've had two cardiology rotations — a Preceptorship and a Clerkship. You tell me."

"I don't know enough to answer for sure, but I do know you can't shock asystole. Well, I mean, you can, but as you said, it's ineffective."

"Speculate. There are enough clues."

She considered for a moment.

"His age and his smoking habit. I have to surmise there was extensive heart damage."

"An inverted T-wave indicates ischemia, though it can't tell us the severity. But you're on the right track."

"With his medical history, no electrical activity, and with no response to CPR or epinephrine, the chances of recovery were small. If he had extensive cardiac damage, his health would generally mean he wouldn't qualify for a transplant. That would mean he'd very likely be confined to a hospital bed until he had a fatal MI. And that's why you objected to intubation — he'd have most likely been on a vent for the rest of his life, such as it was."

"Yes. Now think a bit more — would I do that for every patient?"

She considered again and shook her head.

"You knew him, so you felt confident that you were respecting his wishes, especially after what you said about him asking for his priest. With someone else, you might have kept going. But would you have intubated?"

"It's a judgment call. Most people want you to attempt to save their loved ones, even if it means they'll only live for a few hours or days in the ICU. I have to consider that when making the decision if I can't ask. Think further about intubation."

Julie was quiet for a moment, then nodded.

"He didn't have an occluded airway, so bagging was as effective as the vent. If Doctor Pace had managed to get his heart beating, he would very likely have been breathing on his own."

"Exactly right," I replied. "You're on track, Julie. Keep it up."

"Thanks."

"Get the chart, and we'll have Doctor Gibbs countersign it."

"I thought Attendings had to pronounce."

"That's the general rule, but I have sign-off to pronounce. I don't do it very often, but this was an easy call from a medical point of view."

"You made it seem easy all around."

"And that is the point I was trying to make before — dispassion. Staying calm under fire, as it were. Think airline pilots dealing with emergencies or the Apollo 13 astronauts, or perhaps more relevant for you, the NASA CAPCOM in Houston on January 28, 1986."

"Challenger?"

"Yes. CAPCOM said in an even, dispassionate voice: 'Flight controllers here are looking very carefully at the situation. Obviously, a major malfunction. We have no downlink.' And then, a few seconds later, equally dispassionately: 'We have a report from the Flight Dynamics Officer that the vehicle has exploded.' Do you think he had no feelings and no emotion about seven of his friends dying?"

"I'm sure he did, but he didn't show it."

"Exactly. Get the chart, please."

She retrieved the chart from Trauma 2, then walked with me to the Attending's office.

"I pronounced a patient," I said, handing her the chart. "Alana Pace was there."

Doctor Gibbs scanned the chart.

"Only a single dose of epi? And only three minutes of CPR?"

I nodded, "Asystole on the monitor with no electrical signals and no spontaneous breath. I made a judgment call on behalf of Elizaveta's dad; it was his father."

"Rachel's great-grandfather?"

"Yes. A pack-a-day smoker with inverted T-waves. He was alert enough upon arrival to ask me in Russian to call our priest, which I did. Alana evaluated him and was preparing to take him up to the cath lab for an emergency cardiac ultrasound when he coded."

"It is a judgment call, but you know a personal relationship cuts both ways, right?"

"Yes, I do. I knew Viktor's thinking on the matter, and I felt my patient knew he was dying. I took into account his age, his smoking habit, and the chances he'd recover, and felt that with no response to CPR and epi, flogging him made no medical sense. Viktor declined an autopsy based on what he knew about his dad's smoking habit."

"OK. If you are comfortable and the family is comfortable, I don't see any concerns."

She scribbled notes on the chart, signed it, and handed it back.

"How is your former father-in-law?"

"Our priest arrived, said the prayers for the newly departed, then he escorted Viktor and the others home. I did my part; now the priest has to do his."

"You're learning."

"I always knew, Lor. I just didn't like it. I still don't. The difference is now I accept it and don't fight it."

"That'll be the day!" Doctor Gibbs declared.

"Yeah, yeah," I chuckled.

"Go heal the sick!"

Julie and I left the Attending's office, and I handed the chart to Nate, then instructed Julie to take the next walk-in chart and call me when she was ready. She did so, and I went to the lounge and dialed the number for the Chancery in Columbus. The secretary answered, and I was fortunate she could put me right through to Vladyka JOHN.

"Master, bless!" I said when he came on the line.

"The Lord bless you, Michael. How are you?"

"I'm fine, Vladyka, but I'm calling with some sad news. Nikolay Vladimirovich Kozlov reposed about thirty minutes ago following a heart attack."

"Lord, have mercy on his soul! I assume Viktor knows?"

"Yes, he was here, along with other family members. Nikolay Vladimirovich was lucent enough when he arrived to ask for Father Nicholas, who arrived just after Nikolay Vladimirovich's heart stopped. He and I said the prayers for the recently departed, and Father Nicholas escorted the family back to their house."

"Thank you for letting me know, Michael. I'll speak to Father Nicholas and Viktor Nikolayevich."

"You're welcome, Vladyka. I will see you on Sunday."

"Before you go, how is Angela, from your perspective?"

"About the same," I replied. "Kris, Rachel, and I will have dinner with her family on March 3rd."

"Good. I'll let you go and see you Sunday."

We said 'goodbye', and I hung up. I got some coffee, and about ten minutes later, Julie came into the lounge and said she was ready to present.

The rest of the day was far less eventful, and before I left for home, I called Father Nicholas to learn the arrangements for Nikolay Vladimirovich. The funeral would be on Thursday morning, with a vigil the night before, and the burial would be in the parish churchyard, not far from where Elizaveta lay.

February 14, 1990, McKinley, Ohio

Kris and I had agreed we wouldn't celebrate Western Valentine's Day, so nothing special was said on Wednesday morning when I left the house to drive to the Free Clinic. I was very happy to be back there but not nearly as happy as Gale Turner, who greeted me warmly.

"I'd feel terrible stealing you permanently from the hospital, but patients rave about how great you are, and Trina sings your praises constantly, as do the nurses."

"Thanks. I promise, when my schedule allows, I'll give you a few hours a week of volunteer time, but my surgical training starts in earnest in June, and the exchange program is for PGY1s only."

"Oh, I know! We'll miss you when your rotation ends in May."

"I enjoy the work here, though it's not nearly as exciting as the ED."

"Something for which I thank my lucky stars every single day!" Gale declared.

I left his office and went to the small break room, where I greeted Trina and the nurses, and two minutes later, I saw my first appointment of the day — a Taft student looking for birth control pills.

"Good morning, Grace," I said. "What brings you to us today?"

"I want to go on the Pill," she said.

"Are you currently sexually active?" I asked.

"Yes," she replied.

"Are you using some form of protection?"

"Er, no."

"Just one partner?" I asked.

"Does that matter?"

"I'm assessing your risk for sexually transmitted diseases, and we may need to do a pregnancy test as well."

"Pregnancy test?"

"Have you had a period since the last time you had unprotected sex?"

"No."

"When is your period due?"

"This weekend."

"I'd like to do a pregnancy test and test you for sexually transmitted diseases. I can't make you have the STD test, but because you've had unprotected sex since your last period, I need to do a pregnancy test before I prescribe birth control pills."

"Uhm, OK on the pregnancy test, I guess."

"Michelle," I said to my nurse, "Draw for RPT, please. Grace, while she does that, I'll ask you some health questions, and then I need to do a brief exam — listen to your heart and lungs and check your blood pressure. OK?"

"Yes."

Michelle prepared to draw the blood, and I began my abbreviated history and physical.

"You're nineteen, right?"

"Yes."

"Any history of high blood pressure, blood clots, or breathing trouble in your family?"

"My grandpa takes pills for his blood pressure," she said.

"Do you know for how long?"

"A couple of years," she replied.

Michelle couldn't leave me alone, so she called Mary to collect the blood sample and run the rapid pregnancy test.

"How old is he?"

"Sixty-eight."

"Anyone else?"

"No."

"Any family history of diabetes?"

"No."

"When was your last physical?" I asked.

"The one for school, and it was in July."

"Have you had a gynecological exam since you became sexually active?"

"No. I haven't seen a gynecologist since I was fifteen."

"You really should have an exam annually, and now that you're sexually active, have a Pap smear. I'm going to take your blood pressure and listen to your heart and lungs. Would you untuck your shirt and unbutton the top two buttons, please."

She did as I asked, and her blood pressure, lungs, and heart were all within normal ranges. As I finished, Mary came in and handed Michelle a printout, which she handed to me.

"Grace, there's a hormone in your blood that we measure called hCG — human Chorionic Gonadotropin. If you aren't pregnant, your level is around 5; yours is 60, which indicates you are probably pregnant."

"What?!" she gasped. "No!"

"If you miss your period, that's strong confirmation, but we'll want to do another test because there are a few other things that might cause elevated hCG. For now, though, with these results, I can't prescribe birth control pills."

"I, uhm, don't know what to do," she said, almost in tears.

"There are a number of options," I said.

She sobbed, "I can't have an abortion!"

"OK," I said. "We can provide you with referrals to social workers, adoption agencies, and an obstetrician."

"My dad will kill me," she sobbed.

Something told me her statement wasn't hyperbole, and Michelle and I exchanged a look.

"Let me get someone to talk to you," I said. "A Nurse-Practitioner who has a sympathetic ear and who can discuss things with you. Michelle will wait with you."

Grace nodded, and I left the room and went to find Trina, who was just finishing with her patient. Once the patient was shown to reception, I explained the situation. We returned to the treatment room, I introduced Trina, and then Michelle and I left.

Michelle went to reception to check if there were any patients, and I handled a routine refill of birth control pills for a Junior from Taft. I felt the entire process was ridiculous, as any pharmacist or pharmacy tech could check blood pressure and ask the required health questions. It was a foolish waste of time and money to require a checkup with a doctor for something as simple as oral contraception.

"It's bad," Trina said, coming into the break room. "She comes from a hyper-religious family, and at a party about a month ago, someone convinced her to take MDMA, and under the influence, lost her virginity and ultimately had sex with three guys, none of whom she can identify. She was afraid she might be pregnant but was afraid to ask about that, so she said she wanted birth control pills, thinking those would end the pregnancy."

"Lord have mercy," I said. "Now what?"