Chapter 22: Pocket Your Victories And Move On

May 20, 1986, McKinley, Ohio

"Doctor Newsome? I'm Michael Loucks."

"Come in, please, and have a seat."

I entered his office and sat down.

"What can I do for you?"

"You're attending the case of one of my friends and fellow medical student, Sandy Pierce."

He nodded, "The young woman who took an overdose of acetaminophen and diazepam. I'm sorry that there isn't much we can do for her at this point."

"Medically, no, but spiritually, yes, both for her and her friends. She's going to die, and barring a miracle, nothing will change that. But she doesn't have to die alone. I certainly wouldn't want to. Would there be any way she could be moved to a room where her friends, boyfriend, and parents could spend time with her?"

"We really can't do that, given her condition."

"Not to be flip, Doctor, but I don't see how the outcome changes either way, except in terms of spiritual and emotional health."

"It's more complicated than that, Mike, but there are liability concerns, even in cases which appear to be hopeless. We have to follow the standard of care, even in situations like this, and the standard of care for someone with liver failure is the ICU."

"Pardon me, but that sounds like ... sorry, never mind."

"Ass-covering?" Doctor Newsome asked.

I nodded, "Yes, though I realized halfway through the sentence that accusing you of that was not a good career move, as it were."

"What did they teach you about voicing your opinion?"

"That we should be forceful advocates for our patients. That we should speak up when we see something wrong, or believe something was missed, but also understand that we're not fully trained."

"So, care to revise your comment?"

"Only to say it seems as if the hospital is covering its butt."

"Because it is," Doctor Newsome replied. "The bottom line is if we do not follow the normal standard of care, the hospital can open itself to lawsuits, and doctors can be charged with malpractice. Did anyone use the phrase 'defensive medicine' in your Practice of Medicine courses?"

"No."

"It's a phrase that's coming into vogue and means, in effect, running extra tests to ensure that nobody can claim we didn't do 'everything possible'. Now, that sounds great until you realize that it subjects patients to unnecessary testing and can significantly increase the cost of care.

"And to answer the question forming on your lips — because judges and juries love to second-guess doctors, and the person bringing the suit can always find a doctor who says 'well, if it had been me, I would have run test A and B, because, in my experience, they show this problem'. But you see, they already KNOW the problem, so, of course, they can say they would have run the test that finds it. The thing is, we don't actually have the resources to run every possible test for every possible condition. You know how we do diagnoses, right?"

"Yes. The basis of 'differential diagnosis' is to, as quickly and as efficiently as possible, find the cause of the ailment which is presented, starting with the most common and most obvious diagnoses until they are proven not to be the case. We favor a diagnosis which is more easily treatable than one which is complex, so long as we have not ruled out the diagnosis based on testing or observation. This ensures we spend our limited resources in an appropriate manner."

"And it fails from time to time, which is where we end up with malpractice suits. So, in some situations, doctors order shotgun testing to avoid being second-guessed. For the vast majority of patients, that's overkill and costs them a small fortune. Is it perfect? By no means. The thing is, we do have limited resources, and we have to allocate them properly. It also helps prevent using expensive treatments when a more cost-effective treatment is appropriate."

"And the bottom line is, to protect the hospital, you won't agree to have Sandy moved from the ICU."

"My hands are, in effect, tied."

"And the ICU rules limit visits to direct family members, and for five minutes at a time. I understand why that is from my coursework, but I also know that it is, in effect, arbitrary, and it's meant to ensure efficient, effective care in the ICU. Is there anything we can do?"

He was quiet for a minute, obviously considering his options.

"She was part of your study group, wasn't she?"

"Yes."

"I think we can look the other way for you and the others in the group to spend some time with her. It would have to be one at a time and no more than twenty minutes at a time, with time between the visits."

"What about her boyfriend and parents?" I asked.

"Pocket your victories and move on, Mike," Doctor Newsome counseled.

"I apologize for overstepping. Thank you very much, Doctor."

"Just advice for the future — if you ask for something, and the person who can grant it meets you part way, take it. If you push, you might lose even that accommodation."

"Understood, Doctor."

"Which Preceptorship are you doing?"

"Surgery. The team I'm assigned to is covering the ER."

"When do you do your internal medicine Preceptorship?"

"It's next and begins on July 1st."

"I'll see you then, if not before. I'll write the order allowing you and your study group into the ICU. Would you write out the names, please?"

He handed me a pad and pen and I wrote out five names, then handed the pad back to him.

"Thank you again, Doctor Newsome."

"You're welcome. These orders will be in place within the hour."

We shook hands, and I headed down to the ER. As I walked down the steps, I briefly considered having Pete wear Peter's coat and ID, but rejected it as far too risky for all concerned. Getting a message to Fran was easy, as she was in the hospital, so I'd start with her. Once I arrived in the ER, I checked in with Doctor Lindsay in the lounge, then excused myself so I could use the phone. I dialed the pathology lab and asked for Fran.

"What's up?" Fran asked.

"I saw Sandy briefly and asked if she could be moved so that she could have visitors. To be blunt, I don't want her to die alone. Doctor Newsome said they can't move her because of standard of care rules."

"Figures. Fucking rule book!"

"I know. But then I asked for an accommodation, and he gave special permission for our study group to spend time with her in twenty-minute stretches, but not continuously."

"What about Pete?"

"I tried, but Doctor Newsome basically cut me off and told me to be happy with what he'd allowed, rather than lose it by pushing my luck. Her parents will still only have their two five-minute visits each during the day."

"When are you going to sit with her?"

"When my surgical shift is over. Elizaveta holds off on making dinner on Tuesdays until I call to let her know when I'll be home."

"I'll come back tonight for a stint. Are you going to call the others?"

"Would you make the calls when you finish today? You're off at 5:00pm, and I have no idea when I'd be able to make the calls."

"Sure. Thanks, Mike."

"I just wish I could have done more, both before and after."

"I think we all do," Fran replied with a heavy sigh.

May 21, 1986, McKinley, Ohio

"How are you this evening, Deacon?" Father Nicholas asked when I arrived at the church on Wednesday evening.

"OK, I guess. I sat with Sandy twice today — once early this morning and then once again after class."

"And her prognosis is the same as when you called yesterday?"

"As I said last night, barring what would be called a medical miracle, yes. It's possible she could recover, but it's highly unlikely; as in 'struck by lightning and winning the Ohio Lottery on the same day' unlikely."

"Yesterday, you said you felt responsible. I think we should talk about that after Vespers."

I nodded, "I was sure you would want to do that, so we already planned for Elizaveta to ride home with her parents."

"Then let's speak after I hear confessions."

Ninety minutes later, after the service and after Father Nicholas had heard five confessions, I joined him before the icon of Christ. He said the confession prayers, then we sat down next to each other on one of the benches along the north wall of the temple.

"You said you thought you could have done more," Father Nicholas said. "Which, if I may gently remind you, is how you first felt about Angie."

"And how I still feel about Angie," I replied. "That said, I realize that with Angie, there wasn't much else I could have done because I didn't understand her illness. With Sandy, we saw all the signs."

"And you did what you could to help her, right? Reducing study hours, talking with her boyfriend, and encouraging her to get counseling, which she did."

I took a deep breath and let it out.

"Father, I'm going to violate one of the guidelines for confession and tell you that during my Sophomore year, Sandy and I were involved."

"'Involved' involved?"

"Yes."

"And how is that relevant now?"

"Because I kept her at arms' length, as I do pretty much everyone except Clarissa, Robby, Peter, and the members of our Dinner Club."

"You know why that has to be, and given you were intimate with Sandy, that goes double, so to speak."

"And yet, I believe that contributed to the situation. I failed her, Father. And there really is no way around that."

"Do you remember me telling you about a parishioner who committed suicide? And what I said?"

"Yes."

"When that happened, I felt the same way you do now. What the bishop said to me then applies to you right now — there are limits to what any of us can do in the face of someone who is determined to end their own life. And I don't believe you ever indicated that Sandy had said or done anything which might have telegraphed her intent. Did she?"

"No," I admitted. "But her stress levels were off the charts."

"As were yours, Deacon, when you first arrived here. You mentioned last night, when we spoke on the phone, that her stress levels appeared to be down. Do you know what might have caused that?"

"I had thought it was reducing our study sessions to give her more time to relax, but you obviously have a different thought."

Father Nicholas nodded, "It's possible that she had already decided on a course of action and believed the end of her stress was in sight."

"You think she might have been stressing about being stressed?"

"You certainly did at one point. Were you suicidal?"

"No, though there was that incident when Jocelyn and I had our 'time of troubles'."

"But you didn't have what they call 'suicidal ideas', did you?"

"Not consciously, though Milena and Clarissa both think I would have allowed myself to freeze to death because I was clinically depressed."

"And those signs were obvious at the time. As you did with Angie, you're insisting that you ought to have 20/20 hindsight, and you know it doesn't work that way."

"But we knew Sandy was struggling!" I protested.

"Yes, but did you know she was having thoughts of harming herself or ending her own life? Be honest, please."

"No," I sighed. "But perhaps we should have."

"You encouraged her to go to counseling, and she did? Right?"

"Yes."

"You're not omniscient, Mike. And despite doctors viewing themselves as gods, they aren't, and neither are you. But you are aware of everything I've said — now you need to internalize it. If you don't, you'll have significant trouble as a physician when a patient has an adverse outcome you might have been able to resolve had you known about it in advance. And, finally, you know the theological answer; we're even still in the Paschal season."

I nodded, "Christ is risen from the dead, trampling down death by death, and upon those in the tombs bestowing life."

"Oh Hades, where is thy victory? Oh Death, where is thy sting?"

"I know where the sting is," I replied. "Right here, and right now."

Father Nicholas nodded, "It's a paradox that can be explained only with the «νοῦς» (nous)."

"Which doesn't make it any easier."

"No, it doesn't. You've prayed for both her and the doctors?"

"Yes, of course," I replied. "And maybe she'll be the one in a million, but those are very long odds."

"Do you plan to visit her every day?"

"Yes, before and after school. Fran is visiting at lunch, and Clarissa in the evening. Peter and Maryam will visit at irregular times because we're not allowed to be with Sandy twenty-four hours a day."

"Just make sure you take care of yourselves."

"Yes, Father."

"Has the school said anything?"

"Doctors Warren, Worth, and Mertens spoke to our class today. They emphasized the resources available to students, though, as I mentioned, Sandy spoke to a counselor at the medical school."

"Are you still seeing your counselor in Milford?"

"I called this morning and made an appointment to see her on Saturday."

"Is there anything on your heart other than your guilt about Sandy?"

"No."

We moved from the bench to stand before the icon of Christ, and Father Nicholas completed the prayers of absolution. Once we finished, I said 'good night' and headed home.

"How are you doing, Mike?" Elizaveta asked when I arrived at the cottage.

"I'm OK," I replied. "I just need to get a good night's sleep."

"Then let's go to bed."

"I sleep better after sex," I said.

"Me too!" Elizaveta happily agreed.

May 23, 1986, McKinley, Ohio

I stepped out from behind the curtain on the stage at Taft just before our concert was to start. The cacophony of voices quickly turned into silence as I moved to the microphone.

"Good evening," I said. "Normally, Robby Jackson and Lee Pierce would be yucking it up to introduce Code Blue. Tragically, on February 22nd, Lee was killed, and Robby was critically injured, by a hit-and-run driver. That driver is in the custody of the Sheriff and is awaiting trial on July 22nd for aggravated murder and attempted aggravated murder, as well as other charges related to the incident.

"In addition, a good friend of mine, Sandy Pierce, is in the ICU at Moore Memorial Hospital, suffering from acute liver failure, and is unlikely to survive. Robby, Lee, and Sandy are, or were, Taft students, and many of you may have known them. Code Blue would like to dedicate our concert to our friends — Sandy, Lee, and Robby, who is here tonight."

Sophia pushed Robby's wheelchair from behind the curtain onto the stage, and the audience stood as one and gave him what amounted to a standing ovation. He motioned for me to bring him the mic, so I removed it from the stand and handed it to him. I held up my hand for quiet, and the assembled students and faculty slowly stopped applauding and took their seats.

"Thanks," Robby said. "I asked Mike if I could take this opportunity to express my gratitude to the administration and faculty for everything they've done to help. I wanted to thank all my friends, especially Sophia Vasilakis, José Ochoa, and Mike Loucks, for their close friendship and support. Now, without further ado — I present to you CODE BLUE!"

The audience roared with approval and began another standing ovation as I took my place and picked up my guitar. A stagehand took the mic from Robby, picked up the stand, and moved them from the stage, while Sophia pushed Robby backstage.

"Our first song is a new one for us," I said into the mic. "And is for our friends."

José and I played Bridge Over Troubled Water, and then the band played With A Little Help From My Friends before we began playing our standard set. As had become our tradition, after the first set, we took a short break, and then Elizaveta and I sang Up Where We Belong followed by Joel and Milena, who sang Endless Love.

We played our second set, then our encore, including Lara's Theme, which I played on my balalaika. When we finished the concert, we hung out with our 'adoring fans', with Dona hanging on José's arm and Elizaveta never leaving my side, both carefully staring off any would-be groupies. After we mingled, the band, along with Joel, Milena, Robby, and Sophia, went to Doctor Blahnik's house.

"Has there been any change in Sandy's condition?" Anicka asked as we relaxed in the great room.

"No," I replied. "Her kidneys are failing, and she's suffering from coagulopathy, which means her blood doesn't clot properly. She's also suffering from advanced hepatic encephalopathy. And her body chemistry is a mess. I could give you the specifics, but they don't matter, really, because this is the natural progression of acute liver failure due to acetaminophen toxicity. We haven't really studied those things yet, but I read ahead into next year's coursework to learn more about the pathology of liver failure."

"And there's nothing that can be done?" Anicka asked.

"Dialysis and acetylcysteine," I replied. "Or a liver transplant. But a transplant is unlikely, as it's still considered experimental, and nobody at Moore Memorial Hospital has seen one, let alone done one."

"What about sending her to Ohio State?" Milena asked. "Or one of the hospitals where they have been done."

"She likely wouldn't be accepted into any of the programs because her liver failure was self-inflicted, and there are a very limited number of organs available. And even if she were accepted, there is no guarantee a match would be found in time. And her condition is deteriorating in ways that make it increasingly unlikely she'd survive the surgery."