Chapter 44: You've Always Were A Group Project

September 17, 1985, McKinley, Ohio

"Doctor Gibbs, I know this patient," I said when I recovered from the shock. "Can we step outside for a moment, please?"

"Ellie, please check her vitals and draw blood."

"Yes, Doctor," Nurse Ellie replied.

Doctor Gibbs and I stepped into the hallway.

"What's the problem?" she asked.

"It's complicated," I replied. "She's in my Sunday School class, and I have a major problem now, assuming what your nurse suspects is true."

"You can't reveal anything you learn about someone here to anyone at church."

"Which creates a serious dilemma for me. I have religious obligations which might conflict with medical ethics."

"Mike, if you violate medical ethics, you could be dismissed from the medical school."

"And if I learn something, well, I may already have, and it comes out later I knew it, there will be, if you'll pardon the lame joke, hell to pay."

"Why?"

"Because the details will matter. She's underage, which means if her boyfriend is eighteen or older, it's a felony offense, and I am duty-bound to report that to my priest and bishop. Failing to report it would have me laicized — defrocked."

"Well, hospital policy on that is that if a young woman fourteen or older comes in alone, we make sure her vitals are OK, perform a basic exam, do a pregnancy test, and then refer her to the clinic. We don't ask questions unless there are signs of abuse or she complains about being raped. If a parent brings her in, we do the same. If she comes in with a male close in age, we also don't ask questions unless there are signs of abuse. If there's a big age difference, we let Family Services handle it, and a social worker decides what to do."

"I'm basically screwed if she's pregnant," I sighed.

"Your bishop doesn't understand medical ethics?"

"Oh, he does, but I'm also bound by what you would call a vow of obedience."

"The only way I can see out of this is for her to agree you could tell; otherwise, you simply can't talk to anyone — your priest, your bishop, or even your wife. Check with your advisor at the medical school, but I'm positive I'm right."

I wondered if I could talk to ANYONE.

"What about a fellow medical student? Or a licensed clinical psychologist? I mean to get advice?"

"You could probably do that, but you would need to be very careful to limit anything that could identify her."

"And my priest in confession, where he can't reveal anything?"

Doctor Gibbs shook her head, "It's not about you; it's about her. I don't think it would be out of line for you to talk to him, again without giving too many details, if you didn't know her. Knowing her is what matters, and so is her privacy."

"So now what?"

"Well, the cat's out of the bag, either way — I heard her gasp when we walked into the room."

"Yes, of course," I agreed. "The problem I see is that if she asks if I'll tell anyone, I can't promise."

Doctor Gibbs gave me a hard look directly in my eyes.

"I only have one question for you, Mike, and it's the only one that matters — do you want to be a doctor more than anything else in the world? If the answer is 'yes', then you'll have to risk the wrath of your bishop. If the answer is 'no', then you may as well go home now and withdraw from medical school tomorrow. And I am not kidding about that."

"«Говно» (gavno)," I said sotto voce. ("shit")

"I'm sorry?" Doctor Gibbs said.

"A Russian curse word," I replied.

"Which isn't an answer."

There really was only one answer — my entire life since fourth grade had been about becoming a doctor. I'd often said it took precedence over everything, and now, during my third four-hour stint in the ER, less than a month into the program at McKinley Medical School and less than two months after my ordination, I had to effectively choose between the two.

Worse, in a sense, was WHO the girl was — Vickie Trent, Debby's little sister. Ordination aside, THAT created a potential for a parish-wrecking disaster, given how her parents would likely react to the idea that I had hidden something from them and the scandal that might cause. In the end, I came back to something I've said several times — I had to put my patients first, or I had no business being a doctor.

"I want to be a doctor," I declared firmly, "more than anything."

"Then you have exactly one option."

"I know," I sighed with resignation.

"Doctor Gibbs?" Nurse Ellie said, coming out of the room.

"Yes?"

"Her vitals are fine, and I'll get the blood to the lab 'stat'. I'd say given her reaction to Mike, she's not only pregnant, but she knows it. She's more than a bit upset right now."

"About me?" I asked.

"Yes. She's clearly afraid you'll tell her parents or your pastor."

"I can't do that," I said firmly. "Doctor Gibbs made that clear."

Ellie smiled, and her eyes twinkled, "Anything that happens here stays here! Our rules are tougher than the Mafia!"

I caught the dual implication and decided my best approach was to ignore her flirting.

"I don't think the State Medical Licensing Board will put a hit on me," I said with a wry smile.

"No, but being forbidden for life from practicing medicine would be a fate worse than death for most doctors and nurses."

I nodded, "I can see that, and I think I agree. What do I do now, Doctor Gibbs?"

"Come in with me," Doctor Gibbs said. "Ellie will be right back once she calls the lab to send an orderly to get the blood."

"Why?"

"We always see patients in pairs if possible, and that's especially true of minors."

"Ah, OK. And I might have to leave."

"Yes. Ready?"

"Does it matter?" I asked.

"A great deal, actually. If that coat means anything, it means you're ready each and every time you step into a treatment or exam room. In private practice, you might be able to ask your patient to wait five minutes while you collect yourself. When five seconds can mean life or death, you don't have five minutes. Get your poop in one group right now, Mister."

I laughed hard, "Seriously?"

"They frown on swearing or using profanity when talking to medical students."

"But not flirting with them?" I asked.

Doctor Gibbs laughed, "It's a profession run by men! Flirting is a sacrament!"

I laughed hard once again, "Wow! But I'm ready."

"Then follow my lead, and don't say anything unless I nod to you."

"Got it."

We went into the treatment room, and Vickie's eyes went wide again, then she stared at the floor.

"Hi, Vickie! I'm Doctor Gibbs!"

"Hi," Vickie said sullenly.

"Vickie, I understand you know Mike from church. He's a medical student and is assigned to me for his very first training in emergency medicine. He's bound by medical ethics to keep anything he learns here private, with no exceptions. That means he can't tell anyone, not your priest, not your bishop, not your parents. That said, if you aren't comfortable with him being here, I'll ask him to wait outside. I'm not going to do any exams which would be embarrassing to you."

"Is that true, Deacon?" she asked quietly, without looking up.

Doctor Gibbs nodded to me.

"Yes. I could be expelled from the medical school if I were to reveal anything I learn here to anyone."

She sighed deeply, "I guess it doesn't matter at this point."

"Are you sure, Vickie?" Doctor Gibbs asked.

"Yes," she said quietly as Nurse Ellie came back into the room.

"OK," Doctor Gibbs said with a friendly smile, "There is one important thing for you to do, too."

"What's that?"

"Not tell anyone about Mike seeing you here. That would put him in a very difficult and awkward position because he wouldn't be able to answer any questions or even admit he'd seen you."

"OK," she replied.

"Good. Now, why did you come to the hospital?"

"I've been feeling sick in the morning, and on the way home from school, I got carsick."

"Who brought you in?"

She furtively looked at me before answering, "My, uhm, boyfriend."

"Is it possible you're pregnant? Have you had intercourse?"

A blush and another furtive glance told me the answer to THAT question before Vickie spoke it aloud.

"Yes."

"When was your last period?"

"Uhm, about seven weeks ago."

"We'll do an exam so I can make sure you're healthy, and then we'll talk about what to do next."

"My parents will kill me!" she exclaimed, a tear running down her cheek.

"Let's worry about that when we see the results of the blood test. Has your period been regular?"

"Mostly, though sometimes I'm a couple of days early or late."

"When did your periods start?"

"A few days after my thirteenth birthday."

"Have you ever missed one before?"

"No."

"What about your diet? Do you eat breakfast, lunch, and dinner every day?"

"Yes."

"Do you participate in athletics?"

"I play on the school softball team."

"Have you been sick recently? I mean, other than in the morning or car sick?"

"No."

"No fever, rash, or coughing?"

"No."

"Any pain, especially in your lower back?"

"No."

"Alright. I need to listen to your breathing and your heart. Your blouse is loose enough, so you don't have to take it off. Just unbutton the top three buttons and untuck it, please."

Vickie blushed but pulled her blouse from her jeans and unbuttoned the top three buttons while Doctor Gibbs turned to the sink and washed her hands carefully. With her hands clean, Doctor Gibbs listened to Vickie's heart and lungs, used the ophthalmoscope for her eyes and the otoscope for her ears, nose, and mouth, then had Vickie lie down.

"Mike, I'm first going to perform an auscultation to check for bowel sounds, then use percussion and palpation to check for organ location, masses, and rigidity."

She did as she had said, then let Vickie know she could button her blouse and tuck it back in.

"We'll be right back," Doctor Gibbs said to Vickie, then motioned me to follow her out.

"Any questions?" she asked me once we were in the hallway.

"Well, we're all pretty sure she's pregnant, so what were you checking for?"

"Generally? Tenderness or rigidity, either of which would lead me to order further tests. I also ruled out appendicitis specifically, as vomiting is a common symptom, but she showed no lower right quadrant tenderness and isn't complaining of pain."

"Can you feel if she's pregnant?"

"At three to five weeks, probably not. Did any of your courses in college cover embryology?"

"Not in detail."

"OK, and I'm going from memory here, at about four weeks, we're talking about an embryo that might be 2 millimeters in size. I'm not an OB and not her OB/GYN, so I can't be sure if her uterus is enlarged. And even the OB/GYN might not be able to tell at this stage. That's why we do the test for hCG — human Chorionic Gonadotropin. That test works six to twelve days after a woman becomes pregnant; urine tests are best after about four weeks, and usually, you want a morning sample because the hormone levels are higher."

"What do you do if she's pregnant?"

"First, we suggest she tell her parents and see her OB/GYN. The other option is to send her to the McKinley Free Clinic for counseling. I take it your church is opposed to abortion like the Catholic church is?"

"Yes. And before you ask, I'm going to do my OB/GYN rotation at a Catholic hospital. I would never perform nor recommend an elective abortion. But I also would never refuse to refer a patient to the Free Clinic, if that's in the patient's best interest. And yes, I acknowledge, despite my feelings, the patient's best interest might be that option."

"You've obviously thought about it."

"For four years. And I discussed it with my bishop and a doctor at my church."

"Which?"

"Doctor Evgeni Petrov."

"I've met him, but I don't really know him. He's some kind of a legend in the OB ward."

"He delivered a LOT of babies as a GP in the 50s, 60s, and 70s. How long does the pregnancy test take?"

"If the lab isn't busy, fifteen to twenty minutes."

"Doctor Gibbs?" Nate called out. "Ambulance is three minutes out. Car versus bicycle. Based on the radio call, I paged ortho and neuro. Trauma 2 is free."

"Thanks, Nate. Mike, let's go to the ambulance bay. Our pregnant fifteen-year-old will have to wait."

We walked quickly to the ambulance bay, and a minute later, I heard the sirens, and soon after, the Fire Department ambulance screamed into the driveway which led to the ambulance bay. It skidded to a stop, and Doctor Gibbs hurried to the back as the driver hopped out. Doctor Gibbs pulled open the door, where we saw a fireman and a paramedic doing CPR.

"Hit and run car versus cyclist," the driver said, "male, mid-twenties; unresponsive at the scene; went into full arrest during transport; CPR for three minutes; PO₂ 89%; bleeding from ears, nose, and mouth; multiple extremity fractures; multiple lacerations; cervical collar and backboard.

There was a mad scramble to get the gurney from the ambulance, and the fireman climbed on to continue chest compressions while the paramedic 'bagged' the victim. Two orderlies helped push the gurney into the ER.

"Trauma 2!" Doctor Gibbs ordered.

I followed and took up a place in the corner while Doctor Gibbs and a nurse worked to put in a breathing tube to which the breathing bag was connected, and another medical student attached EKG pads and a pulse oximeter. Doctor Simons came in along with another nurse, and they began an exam.

"Halt compressions," Doctor Simons said, then listened to the victim's chest. "Start again!"

She checked his ears and eyes, then announced, "Blood and cerebral fluid in the ears, pupils fixed and dilated. How long has he been down?"

"About six minutes," the fireman said.

"No coughing reflex when I intubated," Doctor Gibbs said. "Asystole. Flatline on the monitor."

"Stop compressions and bagging."

"No breathing reflex," Doctor Gibbs said. "Still flat line."

"No heart sounds," Doctor Simons confirmed after listening. "What's your assessment, Doctor Gibbs?"

"Check corneal response and call it."

"Go ahead."

Doctor Gibbs got a piece of gauze and touched it to both the victim's eyeballs.

"Nothing."

"Call it."

She looked up, "Time of death: 16:23. Cynthia, tell Nate to cancel ortho and neuro."

"Yes, Doctor," Nurse Cynthia replied.

"Lord have mercy," I said quietly, having just watched someone die before my eyes.

All of us left the room except a nurse.

"You OK, Mike? You look pale."

"I think I'll be OK. I'm just stunned at having seen someone die before my eyes."

"If it's any consolation, he died in the ambulance, and most likely, had we been at the scene with a full trauma team, we wouldn't have been able to save him. The autopsy is going to find a severe skull fracture, among other things. A helmet might have saved his life, but a lot depends on how fast the car was going."

A pair of police officers came up to us.

"Did he make it?" one of them asked.

Doctor Gibbs shook her head, "No. His injuries were too severe. I take it you're going to call the crime lab?"

"It was a hit-and-run, so yes. One of us will stay with the body."

"Trauma 2."

The police officers moved off, and Doctor Gibbs waved me to the lounge.

"Sit," she said.

I sagged into a chair.

"The first one is the hardest," she said. "If you don't have an emotional response, you're not human. If after ten, you still have an emotional response, this is not your specialty. But you will need to talk to someone. Don't go home and get drunk."

"I won't," I replied. "I'll talk to my priest and probably Doctor Evgeni. I have a question."

"Go ahead."

"Why no defibrillator?"

"Despite what you see on TV, it's basically useless unless the patient has a shockable rhythm — V-fib, A-fib, or V-tach. It doesn't work for asystole or PEA."

"OK. I know what the first three are because of TV, and asystole is obviously a flat line. What's PEA?"

"Pulseless Electrical Activity. It's a cardiac rhythm which shows on the monitor but, as the name says, doesn't generate a pulse."

The door opened, and a nurse called out, "Doctor Gibbs, we have the labs on your patient in Exam 1."

Doctor Gibbs got up and took the sheet of paper from the nurse, then handed it to me.

"It shows hCG levels at 620," I replied. "I'm not sure what that means."

"Normal levels are less than 10. 620 is consistent with the fourth or fifth week of pregnancy, which fits missing a period three weeks ago."

"What are the chances of a false positive?"

"Slim. She needs a full gynecological exam and pregnancy counseling. Either her OB or the clinic will do a second test, but a missed period, a positive pregnancy test, and morning sickness are basically conclusive. Let's go tell her what I think she already knows."

"So why would she come to the ER?" I asked.

"All kinds of reasons, but most likely to hide things as long as possible. She may not have even told her boyfriend about the missed period. He might just think she's sick."

"Which is what her parents said on Sunday about why she wasn't at church."

"Going to her OB might have given it away, depending on her situation. I'm curious, and you don't have to answer, but what will happen at church?"

"Pretty much the reaction will be, in effect, that these things happen. A friend of mine's sister, who's in a different parish, found herself in the same condition and after a brief freak-out by her dad, everything turned out OK. Well, as OK as it can be for a pregnant teenager. I'm sure there will be a suggestion that Vickie gets married, but I'm not sure when her sixteenth birthday is."

"There's a dumb idea if I ever heard one! No sixteen-year-old is ready to marry."

"Are you SURE about that, Doctor Gibbs?" I asked.

"Positive," she declared firmly.

I nodded and decided that I'd invite Elizaveta to the ER the following Tuesday and let her face off with Doctor Gibbs. It might actually be entertaining!

"So, how do you tell Vickie?"

"Directly. Follow me, and you can see first-hand."

We went to the exam room, where Vickie was waiting.

"Vickie, your test results came back, and they confirm that you're pregnant."

"I am SO dead," Vickie sighed, having clearly anticipated that result.

"Let's talk about what you should do next. First of all, does your boyfriend know you came here because you were afraid you were pregnant?"