Chapter 55: Don't Count Your Chickens Before They Hatch

October 23, 1990, McKinley, Ohio

After a routine week in surgery, where the only time I'd had a chance to touch a patient was that one opportunity to close following the bowel resection — and a Cincinnati Reds sweep of the Oakland A's in the World Series — I was back in the ED.

On Tuesday, I had lunch with Antonne and the rest of the study group. They were Juniors at Taft now, and were all doing well. All of them had either a boyfriend or girlfriend, except Danika, which didn't surprise me, given the discussions we'd had. There was no doubt in my mind we'd made the right decision, as she absolutely belonged at Stanford, and I was positive I'd have been singularly unhappy leaving southern Ohio.

Once lunch was finished, I returned to the ED just in time to not have to be paged for a multi-victim MVA. There was only one surgical case, but it was orthopedic — a compound tib-fib fracture — so we called for a consult from an orthopedic surgeon. Immediately following that, I helped Letitia with an MI who was admitted by cardiology, and then consulted on a rule-out appy for Mai.

After that flurry of activity, the ED was quiet until Mary relieved me at 5:00pm. I made my way upstairs and quickly showered and dressed in my street clothes. Twenty minutes later, I walked into the house and was greeted by my wife and daughters. We had a nice family dinner together, then I played my guitar for Rachel. We said our evening prayers, I read to Rachel, then we put the girls to bed.

Once they were in bed, Kris and I watched an episode of Star Trek: The Next Generation I'd recorded. The episode, 'Suddenly Human', was more family drama than science fiction, but it did touch on important ethical and moral issues. I felt the episode was, at best, average, though it wasn't bad. When it finished, Kris and I went up to our bedroom and made love, then snuggled together and fell asleep.

October 24, 1990, McKinley, Ohio

"Thanks for coming to see me, Mike," Doctor Cutter said when I arrived in his office late on Wednesday morning.

"This is about Loretta, right?"

"That is the primary reason, but I also want to hear your feedback on the trauma surgery training program and your lectures at the medical school. Have a seat."

I sat down in a comfortable chair across his desk from him.

"I'll ask directly — is Loretta able to function as an emergency medicine specialist?"

"I'll answer directly — no. She needs two arm crutches, not just for moving, but for stability when she's standing. That makes it impossible for her to participate in treating traumatic, life-threatening injuries. As much as I wish there were a role for her in the ED, we cannot tie up an Attending slot for triage management. Residents and nurses should do that.

"Loretta can absolutely practice medicine, and the role we discussed — Chief Physician at the new urgent care clinic — is appropriate. Except in the rarest of instances, she'd be able to use a stool while examining or treating a patient. She'll be an excellent teacher for Residents and medical students assigned there, and can provide a valuable service to the community. I hate it, and it sucks, but that is where we are."

"That is the consensus, though there are opinions that we should conduct a full search and interview multiple candidates."

"As I said to Dutch, Loretta literally took a bullet for the hospital. I don't see how, in good conscience, we cannot offer her that position. I'd argue that the recently passed Americans with Disabilities Act basically forces our hand by requiring reasonable accommodation. Now, I'm no lawyer, and I'd never want to be one, but I believe we have to offer her some position, so offer her that one, and make it a transfer to accommodate an injury sustained while she was working in the ED. If my understanding is correct, we'd have to find her a role even if she were in a wheelchair."

"I have to ask — did you speak to Leland about this?"

I shook my head, "No. I did discuss it with my wife, who has very strong opinions on the matter."

Doctor Cutter laughed, "You do seem to gravitate to strong-willed women! I gather your mom was the strong one?"

"Yes."

"I'll have to discuss that with Leland and with Human Resources, but that might well be the way around both the policy and the objections to waiving it."

"It also happens to be the right thing to do."

"Thank you for your input. Unless you have more to say, we can move on to the training program."

"I believe it's working well. As I've said to Owen, I'd like more procedures, but I believe every single Resident in the history of Residency has made that same request. If we could somehow speak to Doctor Osler, I'm certain he would confirm that belief. That said, I've been provided with an appropriate number of procedures to achieve the goals of the program. My intent, which I discussed with Mary Anderson, is to obtain my medical license during PGY3, and then seek Board certification in emergency medicine once I've completed PGY3. Obviously, surgical Boards are about six years in the future. Mary intends to follow the same plan, and we both believe that should be the norm for anyone entering the trauma surgery program."

"I'll discuss that with Dutch and Owen, but on its face, that strikes me as the correct approach. How are things working in the ED?"

"Very well, and if they weren't, you could be sure either Dutch or I would have been in here to complain, depending on which way things had gone badly."

Doctor Cutter laughed, "Of that I can be absolutely sure! Neither of you is afraid to express your opinions. What's your opinion of Dutch wanting trauma surgeons to be in the Emergency Department rather than on the Surgical Service?"

"That can't happen until there is an Attending trauma surgeon, unless the hospital changes the rules about only surgeons supervising surgeons, which is why you're sitting where you are, and Doctor Northrup is at Swedish Covenant in Chicago."

"I'd still like your opinion."

"Trauma surgeons are always going to be caught in the middle, so to speak. The training program, of necessity, involves both services, as does scheduling. The only thing that will work, as I see it, is some form of matrix management. I don't see how you escape it, so, in the end, trauma surgeons will be part of both departments. That said, I wouldn't be me if I didn't say 'No one can serve two masters; for either he will hate the one and love the other, or else he will be loyal to the one and despise the other'."

"If I recall correctly from Sunday School when I was in grade school, that's about serving God or serving money, right?"

"Yes, though throughout the history of the Church the application has always been wider."

"Where do you come down?"

"I think the jury is still out," I replied. "The program started sixteen months ago, and there are only two of us."

"What if I insisted you answer provisionally?"

"Then I'd give a provisional answer."

Doctor Cutter laughed, "Now there is a Loucksian answer if there ever was one!"

"I do not want to go on record, even provisionally, with an answer because I do not have enough information with which to give an informed opinion. May I request you ask me a year from now, after we have our third trauma surgeon and the new ED has been running for six months?"

"You may," Doctor Cutter said with a sly smile.

"Please ask me a year from now, after we have our third trauma surgeon, and the new ED has been running for six months," I said with a sly smile of my own.

Doctor Cutter laughed, "I knew, somehow, you would turn that around on me. Let's move on to your lectures."

"I think they're going well. You'd have to ask the MS1s their opinion. I suspect some are still grumbling a bit about the mandatory sessions, but engagement has improved. There is a lot of good discussion following the set-piece lectures."

"What topics have you covered?"

"The most recent one was on non-discrimination; before that, it was about taking responsibility for your own medical training. Mainly, the focus is on how to be a good, well-rounded physician practicing holistic medicine, something that is often ignored in our pharmaceutical-driven medical practice."

"You're extreme on that even for someone wearing red scrubs!"

"Other than the sedative someone injected into me when Elizaveta died, I've never taken anything stronger than aspirin or ibuprofen. Not even a course of antibiotics. I did, of course, take the full range of vaccines because neither my parents nor I are idiots, at least in that regard."

"I can't speak to your parents, but you're a man of science, despite your intense faith, and the science is clear."

"On that we absolutely agree. My biggest objection is the 'lifestyle' drugs we're seeing — don't worry about diet and exercise, just get your doctor to give you a drug! It smacks of patent medicines, though fortunately, the Pure Food and Drug Act put those to bed. The big difference is there is no direct-to-consumer advertising as there was for patent medicines."