Chapter 60: A Terrible Diagnosis

July 23, 1987, McKinley, Ohio

"OK to talk shop?" Doctor Gibbs asked when Elizaveta and I joined her and Bobby at their apartment.

"Elizaveta expects it," I chuckled.

"It's all medicine, all the time!" Elizaveta declared. "But I think it has to be while he's a student."

"Pretty much," Doctor Gibbs agreed. "I read your proposal, Mike, and it's very good, though I think you're going to get serious pushback from the Emergency Medicine Chief."

"Did you miss the part where he gets an additional staff member who is on the surgical service budget? And the Residency slot comes from the surgical service?"

"All well and good, but it's about fiefdoms."

"The Chief of Emergency Medicine will scuttle this if he doesn't have control?"

"He won't want to cede even that small amount of control to the surgical service."

"Pure lunacy," I said. "This is better for patient outcomes, which should be the only thing anyone cares about. Period. End of discussion. And yes, I know money matters, but in this case, it's money already budgeted for the surgical service. From their perspective, it reduces on call because I, and the other two Residents who would eventually be added as the hospital grows, would cover the ER. That's a win for everyone, especially patients. And Doctor Northrup will kill it because he isn't in complete control? Give me a break!"

"I'm just telling you the lay of the land. I have a few minor changes that I wrote in purple ink on the proposal. I don't think you'll reject any of them because they're slight changes for how things are done here versus the hospital in Chicago."

"Thanks."

"To get this through, you'll have to convince the Medical Director and the Hospital Administrator. Most of the Chiefs will line up against you, so it'll be on the Chief, Doctor Cutter, and Doctor Roth to win them over."

"Wait!" Elizaveta giggled. "The Chief Surgeon is Doctor Cutter?"

"Yes," I chuckled. "I thought I'd told you that."

"No! That's hilarious!"

"Well," I said to Doctor Gibbs, "all I can do now is make the changes you suggested and give it to Doctor Roth to review."

"Why don't you ask my dad?" Elizaveta inquired. "He's on the Board of Directors for the hospital."

"That would be a really bad idea," I replied. "If I used that connection to force the issue, Doctor Northrup could make my life a living hell, and scuttle the plan by making it fail."

"But why would he do that?" Elizaveta protested. "It makes no sense!"

"Because doctors are human," Doctor Gibbs said. "With all the normal human faults — they're territorial, political animals who jealously guard their turf."

"Doctors opposed paramedic services in California," I said. "And they oppose midwifery, nurse-practitioners, and any other thing which they feel encroaches on their 'rightful territory'.

"Doctor Gibbs isn't like that!"

"I just became an Attending," Doctor Gibbs smirked. "Give me time!"

"Except you won't, Lor," Bobby said, "because you always put your patients first, no matter what. And you don't give a damn about territory. In fact, if they offered you the Chief's spot, you'd turn it down because you hate administration as much as I do! One nice thing about being a paramedic is that nobody will EVER consider me for captain. That's the LAST thing I want to do — manage."

"Here's my question for you, Doctor Gibbs," I said. "Will you endorse the proposal?"

"She will," Bobby interjected. "Because, in the end, she agrees with me — our first duty is to patient care, not to the hospital or Fire Department."

"You do know I can speak for myself, right, Bobby?" Doctor Gibbs asked.

"And you were going to give some wishy-washy, wait-and-see answer. Basically the opposite of everything else you've done since I met you. Well, you're an Attending now, and you should act like one! Nobody can fire you for an opinion! And you told me that Mike's proposal, copying the program in Chicago, is exactly what emergency medicine needs!"

"Remind me why I decided to marry you?"

"Because you can't get enough of this hunk of burning love! Oh, and because you know I'm right."

"You're a pain in the ass, Bobby Murphy!" Doctor Gibbs declared just before the doorbell rang, signifying the pizza had arrived.

Bobby went to get the pizza and pay for it and I helped Doctor Gibbs get plates, napkins, and drinks.

"So you'll endorse the proposal?"

"Yes," she said. "And I'll catch hell for it from Doctor Northrup for 'selling out' AND for letting surgery steal you away!"

"Except I'll be assigned to the ER!"

"Yes, but what will you do if the proposal is turned down?"

"Match for emergency medicine."

"So you see why he's going to be upset?"

"I can see that some serious changes need to be made," I replied. "Nobody should put their turf before improving patient outcomes. Ever."

"I'll be interested in hearing your opinion when you're Chief of Emergency Medicine someday."

I chuckled, "That's a long time from now, and so much will change, nobody can predict what medicine will be like."

"Not nearly as long as you think," Doctor Gibbs said.

July 24, 1987, McKinley, Ohio

"How was Japan?" I asked Lara when she arrived at the Chinese restaurant on Friday evening while Elizaveta was making one of her frequent trips to the ladies' room.

"Awesome! That's a trip you should absolutely make if you ever have the chance."

"What are you doing the rest of the Summer?" Jocelyn asked.

"Being a bum!" Lara declared. "Doctor Blahnik is allowing me to use their guest room when I want, so I'll split time between here and home. Mike, does Elizaveta need any help?"

"You'll have to ask her. I know she's worked out a plan with Serafima and Alyssa, and Anicka Blahnik offered her help, but I've pretty much kept out of the planning."

"Is Elizaveta still planning to stay with you in Cincinnati the first week you're there?" Jocelyn asked.

"That is the plan," I replied. "Obviously, it all depends on how she feels, but Doctor Forsberg is happy with Elizaveta's blood work, weight, and blood pressure, and with how Rachel is developing."

"Who'll be with her when you're working?" Jocelyn asked.

"Annette, the daughter of the doctor I'm assigned to, and Tasha changed her work schedule so that she can spend mornings with Elizaveta, both in Cincinnati and in McKinley. It's only a forty-five-minute drive for Tasha in either direction, and she's almost as excited about our baby as we are!"

"I think we all are!" Lara declared.

Elizaveta returned, and we all sat down. There were no deviations from our usual meal, so the waitress put in our 'standard' order of dishes to share with the entire table.

"Mike, are you and Elizaveta up for a movie?" Robby asked.

"That's up to her, because she's been unable to convince Rachel to stop sitting on her bladder!"

"It's fine," Elizaveta said. "I'll manage. What were you planning to see?"

"There are so many good movies at the theatre — RoboCop, Full Metal Jacket, Dragnet, Spaceballs, and Roxanne. Sophia voted for Roxanne but I want to see RoboCop."

"Spaceballs! Gene declared. "And Jocelyn agrees."

I laughed, "Pull the other one! I couldn't DRAG her to see science fiction when we were growing up."

"She said Mel Brooks trumps her distaste for science fiction!"

"Seriously, Jos?" I asked.

"Seriously! It's a comedy!"

"I think we're going to have to take a vote," Clarissa said. "Tessa and I want to see Roxanne."

"Smart!" Sophia declared.

"Kitten?"

"Roxanne," she replied.

"That's actually two more votes for Roxanne," Fran smirked, "because there is no chance Mike is going to disagree with his VERY pregnant wife!"

Everyone laughed and I nodded my agreement.

"I think that makes the decision pretty clear," Sophia declared.

There was consensus, and after our wonderful meal, the gang headed to the theatre. We all loved the movie, and when it finished, we went for ice cream before Elizaveta and I headed home to get to bed. We could sleep in on Saturday, as Kim and Sticks were both on vacation, so there was no band practice.

July 27, 1987, McKinley, Ohio

On Monday morning, I went to Doctor Roth's office to turn in the proposal. We were on call, and I had permission from Doctor Taylor to go upstairs.

"Doctor Gibbs agreed to endorse the proposal," I said, "but she's very concerned about how Doctor Northrup will respond."

"That's a fight between the Chiefs," Doctor Roth replied. "And we Indians have to let it play out. I have Doctor Getty ready to endorse it, though we don't know what his Chief will do. Doctor McKnight is totally on board, and he's master of his domain. And we have eighteen months to get this done. I'm going to guess you're still leaning towards emergency medicine if this doesn't go through."

"You guess correctly, but I have over a year before I schedule interviews."

"And you're going to take Doctor Barton in Chicago up on his offer of an interview."

A statement, not a question.

"It's highly unlikely I'd move there, but he did make a valid point — he has a program like the one we're proposing up and running."

"Which actually will sway the Medical Director and the Administrator — to have a top student turn them down because they didn't have a program they COULD have had will hurt."

"But will they override objections?"

Doctor Roth shrugged, "Who knows? We need to get the proposal in front of the Medical Director and see what happens. That's when the politics begin in earnest. Anyway, plan to meet me here on Friday at 1:30pm so we can go over your evaluation. I'm sure you'll be pleased with it."

"And you'll be pleased with the one I turn in for this rotation," I replied.

"I sure as hell hope so! You've done more than any Third Year in history at this hospital. Doctor Gabriel let me know you performed a perfect Foley catheterization right before you came up to the OR. I don't recall a Third Year even being asked to do that before."

"It was an 'all hands' response," I replied.

"Yes, but they trust you, which is the key to everything. You'll find that trust information is shared, and other Residents and Attendings will default to trusting you, which will give you more procedures. Don't squander that and don't feel it's 'unfair' in any way. Sharing procedures is NOT to your advantage. Take everything you can get and run with it. What are you doing after OB?"

"Emergency medicine," I replied. "Then pediatrics."

"When's your next surgical rotation?"

"August of next year; it's my second elective after my second stint in the ER."

"I'll do my best to get you assigned to my team again."

"Thanks, Doctor Roth. I appreciate everything."

"The actual thanks comes from you becoming a doctor serving this hospital. That's the entire point of this exercise! Shall we join the team for lunch?"

We left his office and headed to the cafeteria to join Doctor Lindsay, Doctor Taylor, and Hope, who was unlikely to be happy with her evaluation if I had correctly picked up the signals from Doctor Lindsay. Hope had made a serious blunder in trying to play the 'sexism' card to a female PGY3 who was doing procedures usually reserved for Residents a year or two beyond her experience.

There was no question I was receiving favorable treatment, but I'd earned it with my grades, test scores, and evaluations to date. Ultimately, the goal of medicine was to operate as a meritocracy. Those who showed the aptitude were expected to do more, and when they did, they were rewarded with even more. My concern, though, was that every 'extra' procedure I was permitted to do was taken from someone else. Followed to its logical conclusion, that would leave huge numbers of improperly trained physicians. But that was a problem for when I was the teacher, not the student.

I had two years to figure it out before I was a Resident and was teaching medical students, a thought that truly frightened me. Would I really have all the necessary tools and skills to teach medicine in less than two years? I'd heard, repeatedly, the phrase 'watch one, do one, teach one' and I understood the philosophy, but that didn't allay my concerns about going from student on the last day of Fourth Year to teacher on the first day of Residency.

That drove home just how important it was to learn everything I could during my clinical rotations, to keep notes, and to decide what worked and what didn't when it came to imparting knowledge. I did it in Sunday School and catechism, but that was a VERY different thing. It was one thing to teach theology and Orthodox praxis; it was a very different thing to teach medicine.

"What's got you deep in thought?" Doctor Taylor asked.

"Just thinking that in less than two years I won't just be a student, I'll also be a teacher. That's weighing heavily on me."

"That's a good thing," Doctor Roth said. "Medicine is the most demanding of fields, and you either sink or swim based on your ability to follow the training program, both as a student and as a teacher. When I was a Resident, we had a Resident dismissed because he simply couldn't or wouldn't teach. You might get away with that in Internal Medicine for a year if your plan is to be a GP, but not for anything else.

"The thing to remember, though, is that you have a responsibility as a student to seek out every opportunity to learn. Residents are busy, and if you take a laissez-faire attitude towards learning, they'll worry about their own work and learning and you'll be on your own. That means asking to be taught to read an EKG or an X-ray, learning how to interpret labs, and a host of other things."

All of which I'd done, but I didn't feel it was necessary to acknowledge Doctor Roth because it was obvious to me that he was speaking to Hope. Our lunch was interrupted by Doctor Taylor being paged to the ER, which meant Hope and I had to go with him. I shoved the last bit of my sandwich in my mouth, drained my Coke, and followed Doctor Taylor out of the cafeteria.

"What do we have?" he asked Doctor Gibbs when we went into Trauma 2.

"Nineteen-year-old male; archery victim; BP 130/80; pulse 80; resps strong; good distal pulse in the leg with the arrow."

"Well, how did this happen?" Doctor Taylor asked the young man.

"My little brother thought he was William Fucking Tell! I was gathering arrows, and he thought he could hit the target while I was standing there."

"Doctor Gibbs, did you order X-rays?" Doctor Taylor asked.

"Yes. They should be ready any time now."

"Straight tip or barbs?" Doctor Taylor asked the patient.

"Just regular steel-tipped target arrows."

"OK. We'll need to see the X-ray to know if any major blood vessels are impacted. If not, Doctor Gibbs will remove the arrow and clean and dress the wound. If one of the major blood vessels is compromised, we'll take you up to the OR so we can safely remove the arrow."

Just then Nadine came in with the X-ray and handed it to Doctor Gibbs, who looked at it and handed it to Doctor Taylor.

"Not surgical," Doctor Taylor said. "I don't see anything other than soft-tissue damage. He's all yours, Doctor Gibbs."

"I agree," Doctor Gibbs said.

Hope and I followed Doctor Taylor out of the room.

"I'd hate to be his little brother," Doctor Taylor said once we were down the hall a bit.

"What's the procedure for removing the arrow if it has barbs?" I asked.

"Surgery. It's too risky to cut the shaft and try to push it through the way we sometimes do with fishhooks; you obviously can't pull it out because of the barbs. In this case, the steel-tipped arrow is embedded in muscle and can be easily extracted with minimal bleeding. He'll need a tetanus shot, of course, if he hasn't had one in five years. And, as I said, I wouldn't want to be his little brother!"

"Do you have a younger brother?"

"Yes, and this is exactly the kind of stunt he would have pulled if my parents hadn't kept sharp objects out of reach!"

"What's he doing now?"

"He graduated from the Naval Academy last year. He's a nuclear propulsion officer assigned to the USS Enterprise. Do you have a brother?"

"A younger sister," I said. "Well, actually, I have a half-brother who is four months old."

"I'm guessing your dad remarried after a divorce?"

"Good guess. His wife is younger than I am."

"What IS it with the men in your family?" Hope demanded.

"I can't speak for my dad," I replied, "but in my case, Elizaveta pursued me and proposed to me. She had to convince me that it was the right thing to do. So whatever it is you're insinuating, I suggest you take it up with my wife. But warn me first, so I can be outside the blast radius."

"She's eight months pregnant, right?" Doctor Taylor asked.

"Yes. And in no mood for anyone giving her grief about her decisions."

"Barefoot and pregnant?" Hope asked snidely.

"Elizaveta was a straight-A student who could do anything she wanted to do. What she chose to do is to be a wife and mother. She's an expert seamstress, an excellent cook, and fulfills her role as «diakonissa». That's what she wants, just as you want to be an orthopedic surgeon. Whatever you think, I suspect you're wrong. I encouraged her to think about college, but that's not what she wants to do. And last I checked, she's free to make those choices and doesn't need your approval."

"Just another misogynist hiding behind claims of 'it was her choice'."

"That's enough, Miss Fletcher!" Doctor Taylor ordered. "Doctor Lindsay warned you about accusations such as that, and we're going to speak to her right now. Mike, cover the ER, please."

"Yes, Doctor," I replied, turning back towards the ER.

I walked back and went into the trauma room as Doctor Gibbs was about to remove the arrow.

"What's up, Mike?" she asked.

"Doctor Taylor sent me back here. Anything you need?"

"Blood work should be ready on the patient in Exam 1. Nadine is assisting me, so would you retrieve it and review the results and give me the highlights, please."

"Yes, Doctor."

I left the trauma room, checked the chart for the patient in Exam 1 to get the name, and then quickly walked to the lab.

"Results for Wysocki, J., for the ER," I said to the lab tech.

He handed me the printout, and I scanned it as I walked back. The patient had a low hematocrit, low MCV — Mean Corpuscular Volume, and high RDW — Red blood cell Distribution Width, which I'd learned were classic signs of iron deficiency anemia. The patient wasn't pregnant, which ruled out gestational hypervolemia or edema. She also had a low white count. I pulled out my pocket diagnostic book and found the differential diagnoses — pernicious anemia, folic acid deficiency, copper deficiency, and leukemia.