Chapter 58: Hormones

July 11, 1987, McKinley, Ohio

"Everything looks good," Doctor Forsberg said when she finished examining Elizaveta on Saturday morning. "Your blood pressure is fine, you have good distal pulses, and no edema — that's swelling due to accumulation of fluids — in your hands or feet. This is basically a textbook pregnancy so far. Given you're in your eighth month, we'll do an ultrasound to check for amniotic fluid."

Doctor Forsberg prepared the machine, then spread gel on Elizaveta's stomach. She moved the transducer to get a good picture, then pressed a button to freeze the image.

"OK. I see several good pockets of amniotic fluid and Rachel Michelle appears properly developed for this stage of pregnancy. You can see ten fingers and ten toes, though she's sucking her thumb right now."

I gazed in awe at the image of my daughter, who was growing inside my wife's womb. It boggled my mind that I, no, WE, had created that life, and in about six weeks, we'd be able to hold her in our arms.

"Amazing," I breathed.

"It is," Elizaveta agreed.

"You can clean up," Doctor Forsberg said to Elizaveta, handing her a damp paper towel. "Mike, how is your on-call week going?"

"Other than being tired, it's good," I replied. "Mostly I'm doing scut, but that's because I'm on the surgical service, not the ER service, so I'm just an extra pair of hands. I've assisted with a few traumas, but the one case we were sure would be surgical never even made it to the ER."

"What happened?"

"Gunshot wound and he coded in the ambulance. The paramedics couldn't bring him back."

"Not much you can do when that happens. How is your proposal coming along?"

"I'll be ready to have Doctor Gibbs review it by the end of next week, then I'll make any suggested changes before I turn it in to Doctor Roth to review."

"Well, I won't keep you, as I'm sure you want to get home and get to bed."

"Thanks."

"Elizaveta, because everything appears perfect, I'll see you in four weeks, which is right before your projected due date. Obviously, if Rachel decides to make her appearance before then, I'll see you at the hospital!"

"When should I call you?"

"Once you begin having contractions. We'll decide then how soon you should go to the hospital. If your water breaks, then you want to go right to the hospital and have them call me. Mike, you're going to be about ninety minutes away, right?"

"About that," I replied.

"That will be more than enough time if Elizaveta calls you as soon as she has her first contraction. I've never seen a first baby come in less than four hours. My suggestion would be to drive straight to Moore Memorial Hospital in case Rachel has a burr under her little saddle. You can call home from maternity if Elizaveta isn't there."

"Sounds good," I said. "Are you still OK with Elizaveta coming to Cincinnati with me the first week in August?"

"If she's up to it, yes. And I mean that, young lady. Not because you want to, but because you actually feel good enough to do it. I want you to call me the day you're going to leave."

"I will," Elizaveta said, but I could tell she was not happy being given orders.

"Then I'll see you in four weeks," Doctor Forsberg said.

We left the exam room and went to the reception desk where we made our next appointment for August 10th, which was a Monday, and a day I would hopefully have off. If I couldn't make it for some reason, then Alyssa or Serafima would come with Elizaveta. We left the office and got into my car.

"If you're too tired, we can go home first," Elizaveta offered. "I can do the grocery shopping."

"I'm fine," I said. "I'll still get six hours of sleep."

"That's not enough, Mike!"

"I did that often when I was doing my classroom work," I countered. "I'll be fine. I only have two more nights."

"Yes, and then on Monday you go right from the ER to the surgical service! We're going home! And I will NOT accept any arguments! I can call one of the girls to help me."

"Yes, Kitten," I replied flatly.

"Don't you 'Yes, Kitten' me, husband!" she said threateningly.

"You just don't like Doctor Forsberg giving you orders, so you're taking it out on me!" I protested.

"You agreed with her! I saw it in your eyes! And if I have to follow orders, so do you! Drive home!"

I had no real choice but to do as Elizaveta demanded. I knew she was trying to look out for me, but I was going to have far worse shifts as a Resident, and could potentially have some very long ones on the OB service. I drove home, and under the watchful eye of my wife with her hands on her hips, I got ready for bed. When I got into bed, she turned off the light and closed the door. I was tired, so it didn't take long at all for me to fall asleep.

About seven hours later, the alarm rang, I got out of bed, dressed, then went out to the kitchen. Serafima was with Elizaveta, which didn't surprise me at all.

"Hi, Deacon," Serafima said.

"Hi," I replied.

I went over to Elizaveta and kissed her.

"Did you sleep OK?" she asked.

"I'd say 'like a baby' but that would mean waking up every two hours to eat and have my diaper changed!"

"Dinner is in about five minutes," Elizaveta said.

"I was just leaving," Serafima said.

She and Elizaveta hugged, and then I walked her to the door. Once she'd left, I went back to the kitchen to help get dinner on the table, and then we sat down to eat.

"Are you in a better mood?" I asked carefully.

"Oh, please!" Elizaveta protested. "You know I was right!"

"And you know Doctor Forsberg was right! You get your back up when she sets any limits!"

"She's a worrywart!" Elizaveta declared.

"She's advising you based on her experience, and it matches what I've been taught," I countered. "Your most important job right now is taking care of yourself and Rachel."

"And you!"

"I love you, Kitten, and I know you want to take care of me, but our baby takes priority and I know and accept that; in fact, I WANT that."

"I'm fine, Mike. I really am. Doctor Forsberg said all my vital signs are good and you've seen the blood work from the previous test. Obviously, we haven't seen the results from this morning's blood tests, but she said everything is perfect!"

"And she knows how to ensure things stay that way," I replied gently. "All the advice she is giving you is based on the experiences of the millions of pregnancies since modern medicine really began after World War II. That's why you take folic acid and prenatal vitamins. That's why you were given advice not to lift anything heavier than a baby, or about ten pounds. That's why you shouldn't travel the last two weeks before you're due. And so on. Most airlines won't let a woman who is nine months pregnant on an airplane."

"What?!" asked in outrage.

"Think about what happens if she goes into labor on a long-distance flight. Do you want the stewardess or co-pilot to deliver the baby? Or have an emergency landing to get medical care? That can take upwards of an hour, even over the US. We learned about all of this in our coursework. And it's in the brochure Doctor Forsberg gave you."

"It just seems too much, Mike! I mean, women were having babies before 'modern medicine'! And I've heard you complain about OBs!"

What I wanted to say, but knew better, was that pregnancy often caused wild swings in emotion, and my wife's way of dealing with that was to become feisty. Normally, her being feisty was a good thing, but when it got her 'Russian up', as I referred to it, she could become even more stubborn than usual. I didn't think she was at any real risk, and all her vitals were good, but that didn't mean she should ignore what was very good advice from Doctor Forsberg.

"And mortality rates for infants and mothers were extremely high!" I countered. "My complaint is that most OBs are men, and that midwifery is illegal in some states and frowned upon by the medical community. We don't want to go back to the old ways, but we can change the current system to make it better. Mortality rates are still too high, both for mothers and infants. I know you're frustrated, but please listen to Doctor Forsberg. For Rachel. For you. For me. You have your Russian up, Kitten, and you need to let it down, please. And that's your husband, Mike, speaking, not Mike the medical student."

Elizaveta screwed up her face the way she did when she knew I was right, but didn't like it.

"I love you, Kitten," I added.

"I know," she replied, "it's just annoying. I'm pregnant, not sick!"

"And the goal is to ensure you and the baby are healthy and stay that way."

"I know," she sighed. "But you know I don't like anyone telling me what to do."

"No kidding," I chuckled.

"Hey!" she protested.

"I was just agreeing with you, Kitten."

"Uh-huh."

We finished our dinner, and I helped clean up, then kissed Elizaveta goodbye and headed to the hospital for my second-to-last overnight shift.

July 12, 1987, McKinley, Ohio

"You're not going to get enough sleep, Mike," Elizaveta observed when I arrived home from the hospital on Sunday morning."

"I'm not skipping Liturgy," I stated firmly. "I managed an hour-long nap last night, and we'll come home immediately after the service ends."

"You need to eat, Mike."

"I'll eat a banana when we come home. That'll be sufficient because I'll be sleeping."

"But only for four hours!"

"I know, Kitten, but this is part and parcel of my training, which we discussed."

"I need YOU healthy, Mike."

"And I'm going to get more total sleep this weekend than I will on my thirty-six-hour ER shifts during my PGY1."

"It just seems like a double standard! You insist I do what the doctor says and you don't want to do what I say!"

"I'm not serving this morning, and you know going to church is my way of staying healthy mentally and spiritually, and that the services re-energize me. And you know there is literally nothing you or anyone else can do about the schedule that is required for medical training."

"You know how dumb that is, right?" Elizaveta asked.

"I understand your objections, and I have similar ones, but part of it is ensuring that doctors can function in true crisis situations. If you can't, then you can't work in the ER. Can you imagine a situation where there is what they call a 'mass casualty' event and doctors clock out and go home and just leave the patients to fend for themselves?"

"Well, no."

"Exactly. Maybe it's not the best training method, but it's the one I have to pass to be a doctor in the ER. Let me get a quick shower and then we'll go to Matins."

It was a bit strange standing in the nave with Elizaveta, rather than serving in the altar, but that was necessitated by the pager I was wearing. I hadn't been paged during my on-call times, but there hadn't been any events that would have necessitated it. Immediately after Liturgy, Elizaveta and I headed home, where I ate a banana and got into bed to get four hours of sleep.

Our friends joined us for dinner, as usual, but I left for the hospital immediately after we finished eating.

"How was the day?" I asked Nadine when I met her in the lounge.

"Mostly quiet. There was an MVA this morning, but after that, only one MI and the usual collection of weekend walk-ins we get because GPs generally don't work weekends."

"I saw there is literally nothing on the board."

"The MI went to cardiology, the MVAs were treated and released."

"Then I'm going to take the opportunity to nap," I said. "I have to go straight from the ER to the surgical service tomorrow morning. Wake me in ninety minutes if someone hasn't come to get me for something else."

"Will do," Nadine replied.

I went to one of the curtained-off cots, took off my medical coat and stethoscope, and lay down. I managed the entire ninety minutes before Nadine woke me. I put on my medical coat, grabbed my stethoscope, and went out to the ER to see a still-empty board. I went to find Doctor Taylor, but he was chatting up one of the nurses, so I went back to the lounge to read The Stand. Doctor Taylor came in about ten minutes later.

"Have a good nap?" he asked.

"I did. Get anywhere with the nurse?"

Doctor Taylor laughed, "Young, good-looking physician versus cute nurse is no contest!"

"Something which is likely true but completely irrelevant for me! Anything at all happen in the ninety minutes I was napping?"

"One walk-in for a hand lac. Nadine put in three stitches, and that was it. Seems like McKinley is quiet on hot Summer nights."

"Everyone is inside in air conditioning!" I chuckled. "And our public housing is low-rise, scattered-site."

"That is a complete mess in Chicago — it's all high-rise and concentrated. One reason I listed Cook County fourth on my list!"

"I hear all kinds of horror stories about that ER, but they sure chose the right place for the first 'shock-trauma' center."

"I'll say the same thing about Los Angeles County and the paramedic program," Doctor Taylor said. "President Reagan, when he was Governor of California, signed the Wedworth-Townsend Paramedic Act of 1970, despite opposition from doctors, nurses, and attorneys. The thing that convinced him to support it was that a detailed study showed that soldiers who had been seriously wounded on the battlefield during the Viet Nam War had better survival rates than individuals who had been seriously injured in motor vehicle accidents on California freeways."

"The 'Golden Hour'," I replied.

"Exactly. Helicopters in Korea and Viet Nam made all the difference, just as paramedics do in ambulances."

"We learned that the first actual trained Emergency Medical Technicians were in Pittsburgh, as part of the Freedom House Ambulance Service, started by Peter Safar, the father of CPR, using unemployed black men."

"I think we're supposed to say 'African-American' now," Doctor Taylor suggested.

"Not to be obtuse, but am I a Russian-American? Are you a Norman-American?"

Doctor Taylor laughed, "How do you know the origin of my surname?"

"In High School English we studied etymologies of names. Mine, for example, is Dutch and comes from 'Lodewijk' in Dutch or 'Ludwig' in English. Those are both forms of 'Louis'."

"You're Russian. How'd you end up with a Dutch last name? Immigrants?"

"My mom is a full-blooded Russian, and her parents came to the US from Russia during the Revolution. My dad's family has been in North America since before there was a United States. They emigrated from Utrecht to New Amsterdam and lived on Manhattan Island while it was still a Dutch colony. My distant ancestor was a close friend of Peter Stuyvesant, the last Director-General of New Amsterdam. That was in 1660 or so."

"So you adopted your mom's religion, then?"

"Yes. As did my dad, so my sister and I were born and raised Russian Orthodox."

"How is that different from, say, Greek Orthodox?"

"The exact same theology, but slight variations in practices. The same is true for the Arab Orthodox, who usually go by the moniker 'Antiochian' in the US. In most countries, there's a single national Orthodox church organization. In the US, there are multiple jurisdictions because of the Russian Revolution."

"How could the Russian Revolution cause that?"

"Before the Revolution, all Orthodox Christians in the US were under the jurisdiction of the Russian Patriarch because he had established churches in Alaska. Nobody really objected to that until the Russian Revolution. At that point, the Patriarch felt he could no longer care for the flock, and directed the churches in the US to elect their own bishops. Unfortunately, they divided along ethnic lines and so we have a complete mess here. I bet you didn't know that the first clergymen martyred during the Russian Revolution had served as a priest in Chicago — Father John Kochurov."

"You're right, I had no idea. I take it he's a saint?"

"Not yet," I replied. "But I know quite a few people who feel he should be, including me. There's no formal system, really, in Orthodoxy for that the way there is in the Roman Catholic Church. What happens, as with many things, is that the bishops acknowledge the devotion of the faithful. I know one person who commissioned an icon of him, which is how it usually starts."

Nurse Kelly, who Doctor Taylor had been chatting up, stuck her head in the door.

"Rollover MVA with three victims; paramedics are four minutes out; a bad one."

"Thanks," Doctor Taylor said.

We hopped up and went to put on gowns, then joined Doctor Anderson, Doctor Gabriel, and Nadine in the ambulance bay.

"Mike, call upstairs," Doctor Anderson ordered. "We'll need help for sure."

I went inside the doors, picked up the wall phone, and dialed the surgical ward. I let the nurse know we needed Doctor Roth and Doctor Lindsay, and she said they'd be right down. I went back to the ambulance bay and let Doctor Anderson know. The first ambulance pulled up, and the paramedic driver jumped from his vehicle.

"Two patients! Male approximately forty-five; near amputation of the left leg at the knee. Tourniquet applied; pulse thready and tachy; BP 70/30; resps 10 and shallow; LOC on site; possible crush injuries to the chest. Saline IV wide open for volume."

Doctor Anderson and Doctor Taylor took that patient.

"Second patient — Female, approximately forty years of age; ejected from the vehicle; severe head trauma; GCS 4; multiple lacerations and contusions; pulse 80; BP 110/70; resps 15. Saline IV TKO."

"Mike," Doctor Gabriel ordered, "page neuro and meet us in Trauma 2!"

"Yes, Doctor!"

The second ambulance pulled in just then, as Doctor Roth and Doctor Lindsay arrived. I placed the call to neuro, then went to Trauma 2.

"Mike, check Babinski," Doctor Gabriel ordered as he prepared to intubate the patient. "Nadine, I estimate 80 kilos, so 12 mg sux and 40 mg etomidate, IV push!"

"12 mg sux and 40 mg etomidate, IV push," Nadine repeated.

She went to the emergency drug cabinet and retrieved the vials and quickly injected the drugs while I put on gloves, then carefully removed the patient's shoes and socks. I took a reflex hammer from the instrument tray, and held it by the hammer end, as the end of the handle was shaped as a tool for measuring the 'plantar reflex', commonly called the Babinski sign. I dragged the tool from heel to toe on both feet, getting no response at all.