Chapter 64: Cravings

August 6, 1987, Greater Cincinnati, Ohio

"How big a problem did I create?" I asked Doctor Cooper on Thursday morning.

"In one sense, you acted like most PGY1s who want more procedures than they are given, which is something I pointed out to Doctor Lane. The problem, or perhaps challenge, is that none of the medical schools here have adopted what McKinley, Indiana University, and the University of Chicago have with Preceptorships. The Doctor who started that in Indianapolis is a true pioneer, and that often makes waves in the medical community."

"Doctor Barton struck me as a man who didn't care if he made waves."

Doctor Cooper smiled and nodded, "The mavericks and innovators usually don't care. That's what has Doctor Lane concerned, by the way. She thinks you're a maverick and a cowboy, and are in over your head."

"If I hadn't had any Preceptorships, I'd probably agree with her. But I've been in the hospital one afternoon a week for two years. Well, minus some time in medical offices or clinics, but I've seen a wide range of procedures."

"Yes, which is not something we're used to here. Please don't take this the wrong way, but doing this rotation at one of those three hospitals would have been better for you, though I understand why you're here."

"What's the bottom line?"

"Doctor Kelly is your Resident, and she decides which procedures and exams you do, but she has to verify them, the same as she would for any medical student who was doing their first rotation in OB/GYN. The fallout is on Doctor Kelly, not you."

"I feel responsible."

"Because you ARE responsible! But that doesn't make you wrong, Mike. I see the value of the way things are done at McKinley and Moore Memorial Hospital, but I also know that change takes time, and has to be properly managed. You are, well, a bull in a china shop."

"I can point you to a few people who would never believe that!"

"I'm sure you can, because as most medical students eventually do, you had an epiphany, and changed your behavior, in fact, changed your personality to match what's necessary to actually BE a doctor. Pretty much anyone of above-average intelligence with good study habits and good test-taking skills could get through the first two years of medical school and pass the MLE, but that's when the rubber hits the road, so to speak. Normally, that epiphany comes during Fourth Year, or sometimes during PGY1. Yours was accelerated by your early clinical rotations. Most Third Years do not have the experience you and Maryam and the rest of the students at McKinley Medical School have. And that makes all the difference in the world."

"What's on tap for today?"

"The usual mix of annual exams and prenatal checkups. A typical patient load is twelve, though sometimes we squeeze someone in if they're concerned about something. You may find a bit of resistance today, as I have a couple of teenage patients."

I thought back to Erin and how she'd behaved and how the twins had acted, and decided against mentioning those to Doctor Cooper.

"I totally understand," I replied. "If they're uncomfortable, I'll step out."

And that was how it turned out, with both girls, one sixteen and one seventeen, electing to not have a male in the room during their exams. Fortunately, another Doctor in the practice, Doctor Karl Farmer, had patients who didn't object to me being in the room, most likely because they already had a male doctor.

Around 4:00pm, after Doctor Cooper had updated charts and returned phone calls, we headed home. I showered, and then Elizaveta and I headed to Mr. Andreyev's house for dinner. We were joined by his son, his son's wife, and their two teenage boys. We had a nice meal, but didn't stay late, given how easily Elizaveta tired and because I wanted to be at the hospital at 5:30am to pre-round with Nicole.

August 9, 1987, McKinley, Ohio

On Sunday, after Liturgy at Saint George, Elizaveta and I drove home to McKinley, where we had our usual Sunday evening meal with Mark, Alyssa, Elias, Serafima, and Tasha. As had been the case for the previous three weeks, Tasha, Serafima, and Alyssa did the cooking with Elizaveta supervising.

"You're going back alone, right?" Elias asked.

"Yes. I appreciate you and Mark being OK with your wives spending time with Elizaveta while I'm away."

"I'm sure Elizaveta will repay the favor in the not-too-distant future," Elias said.

"You guys are pregnant?" Mark asked.

"No, but we see no reason to wait."

"We need to graduate and get jobs before we even think about it," Mark said. "But I absolutely want to have kids. It's just a matter of timing."

"We messed that up a bit," I said. "But only because of the way the visiting student program worked out."

"Will you be home next Sunday?"

"I hope so," I replied. "But that depends on the babies, not me. If anyone is in labor, I have to stay in Cincinnati. If not, I can come home on Sunday. We have our last prenatal checkup tomorrow, and then it's just a matter of waiting."

"Not to reveal just how clueless I am," Elias said, "but will the exam be able to tell you when the baby will be born?"

"Not really," I replied. "All Doctor Forsberg can do is look for various signs that Rachel Michelle is ready. Most of those have happened. At this point, it's up to my daughter as to when she announces her presence. Sometime in the next ten days, most likely, though it could be as late as the 27th, which would put her a week past term, which is not uncommon for first babies."

"Will you participate in the delivery?" Elias asked.

"I'll be there with Elizaveta, if that's what you mean, but it's a violation of ethical rules to treat a relative except in an absolute emergency when there are no other alternatives. The rule makes sense, because you likely won't be thinking clearly. Except for psychiatrists and psychologists, treating friends is a judgment call between the doctor and the patient, but the doctor has to be very careful not to bend rules or cut corners, and that goes double for writing prescriptions."

"I suppose you could hook us up with amphetamines, or whatever."

"Eventually, yes, though some Schedule drugs are tightly controlled for exactly that reason. And that's why doctors are prohibited from writing their own prescriptions."

"That actually makes a lot of sense, now that I think about it," Mark said.

"Mark," I asked, "would it bother you if Rachel was baptized on the same day you're ordained? That would save His Grace a trip. It's likely not going to be exactly forty days, but it'll be awfully close, and I'm not a stickler for the whole 'forty-day' thing, anyway."

"And there is no chance I'm staying away from church for that long!" Elizaveta declared, coming into the room. "We'll church Rachel on the Sunday closest to the eighth day, and I'll be there. Anyway, dinner is ready."

August 10, 1987, McKinley, Ohio

"Everything looks good," Doctor Forsberg said to Elizaveta upon completing the exam. "Your blood pressure is good, your pulse is good, and so is Rachel's. You do need to take it easy from now on. Limit your riding in cars, don't go more than fifteen minutes from Moore Memorial Hospital, and make sure you eat enough."

"I just feel full all the time," Elizaveta replied.

"That's common. Break your meals up into five or six smaller ones throughout the day. Make sure you eat healthy, too."

"I'll hide the peanut butter cups," I chuckled.

"Mike!" Elizaveta half-whined.

"Her severe craving," I replied. "It originally included pickles and Rocky Road ice cream, but now it's Reese's Peanut Butter Cups!"

"Michael Peter Loucks!" Elizaveta groused.

Doctor Forsberg laughed softly, "So long as that's not the only thing you're eating! Your weight is exactly where I would like to see it, plus or minus a pound, and your blood tests have all shown normal glucose. Just don't OD on the candy. Make sure you drink plenty of fluids, and I suggest one bottle of Gatorade a day. That'll help make up for the sodium and potassium you lose with frequent urination."

"Somebody needs to tell Rachel to GET OFF MY BLADDER!" Elizaveta declared feistily.

"Good luck with that," Doctor Forsberg replied. "Your first lesson in parenting — if your children can do something to annoy you, they will!"

"You're a new mom!" Elizaveta protested. "How do you know?"

"Because I, like your husband, was a teenager not all that long ago!"

Elizaveta rolled her eyes, "And, of course, that means what I think it means."

Doctor Forsberg smiled, "Let's just say I gave my father fits."

"Sounds like my mom and my sister," I chuckled. "Elizaveta, on the other hand, was a saint, or so she would have us believe!"

"Careful, husband!" Elizaveta warned.

"Your brothers tell a slightly different story," I teased.

"And if you believe a word that Joe says, you're dumber than the average man!"

"Kitty has claws," I chuckled.

"You're a brave man, Mike," Doctor Forsberg said.

"I can outrun her," I replied with a smirk. "She waddles."

"It's YOUR fault, Mike!" Elizaveta declared.

"If I recall, you were there at the time and, in fact, demanded that I get you pregnant!"

"I think I'm going to get out of the blast radius!" Doctor Forsberg declared mirthfully. "Elizaveta, call my service when you have your first contraction. If your water breaks, go straight to the hospital and have them call me."

"Yes, Doctor," Elizaveta replied.

"See you soon!" Doctor Forsberg exclaimed, making a hasty exit.

"Why are you teasing me?" Elizaveta asked.

"Because I love you, Kitten!" I replied.

"Don't think I'll forget about it just because you say that! A good flogging is in order!"

"Promise?" I asked hopefully.

"You!" she exclaimed, and couldn't hold back her laughter.

"Russian men are used to being flogged, though mostly verbally," I replied.

"Did you have to tell Doctor Forsberg about the Reese's?"

"Is that a serious question?"

"You promised not to act like a doctor!"

"Only during labor and delivery! And besides, I'm being a caring, loving husband and making sure your doctor has all the important information. You will note she didn't say not to eat them!"

"We should stop at the store on the way home," Elizaveta said. "I need a case of Gatorade, I guess."

"And more Reese's?" I asked with an arched eyebrow.

"Perhaps," she allowed with a soft smile. "I do love you, Mike."

"I know, Kitten."

August 12, 1987, Greater Cincinnati, Ohio

"How is your wife doing?" Doctor Kelly asked when she came into the lounge at the hospital on Wednesday morning.

"I believe she's had just about enough of being pregnant," I replied.

"Late in the ninth month? That's par for the course. At that point, most women are very much of the 'will you just decide to be born already' attitude."

"That pretty much sums it up! I did pre-rounds with Nicole. Anything new?"

"Not yet, anyway. I suspect you know about Mrs. Griffin. She's in labor and will be here within the hour."

"No, I didn't know because I grabbed breakfast and left without seeing Doctor Cooper. I'm not surprised, though, because Doctor Cooper warned me yesterday it was likely to be very soon as Mrs. Griffin is at term and this is her fourth."

"One will be more than enough for me!" Doctor Kelly declared.

"I hear that a lot from female doctors, and that's basically what my friends Fran and Nadine are planning."

"I want two," Maryam said. "But the timing will be difficult."

"Cardiology, right?"

"Yes."

"Finish your first year of Residency, at least," Doctor Kelly advised.

"I'd need to be married first," Maryam replied.

She'd gone out a couple of times with college students from Saint Michael, but none of them had measured up. She had hinted that there was a guy at Saint John Chrysostom in Fort Wayne who she felt might, but the distance and her schedule made that difficult for the two of them.

"Maryam, would you come with me?" Nicole asked.

"Sure!" Maryam said brightly and followed Nicole out of the lounge.

"Who's the Attending today?" I asked.

"Doctor Phillips," Doctor Kelly replied. "And a pair of residents besides me. And of course, Doctor Cooper is meeting Mrs. Griffin here. We had three births yesterday, and all three of them will be discharged today."

Doctor Kelly's pager beeped, and after she looked at it, she went to the phone and dialed. I listened and shook my head, knowing we'd be heading down to the ER.

"How bad?" I asked after she hung up.

"Her boyfriend hit her five times, hard, in the stomach. It appears she's miscarried six weeks LMP."

"I hope they arrested him," I said.

"One of those things we'll never know unless either she or the cops tell us, and often they don't."

We left the lounge to head to the elevators.

"Assuming it's a miscarriage, what do you do?"

"That depends on whether or not it's complete. If it's complete, just management of any bleeding. If it's incomplete, a D&C is usually indicated, but I'll need permission from the Medical Director to do one."

"I'm sorry, but why? It's a standard medical procedure following a miscarriage."

"Yes, it is, but the hospital wants to make sure we're not doing surreptitious abortions. Not every doctor or nurse who works here is Roman Catholic, and even some of us who are, have no objection to elective abortions."

"Have you ever had a procedure refused?"

"Me, personally? No. I heard about one, but I don't trust hospital gossip."

"How did the policy come about?" I asked.

"My understanding is it pre-dates Roe and had to do with ensuring no violations of Catholic Canon law occurred, as well as complying with various Ohio laws restricting abortion, and ensuring compliance with the therapeutic exceptions in the law."

"Will you do the procedure?"

"Most likely, yes. I'll speak to Doctor Phillips to confirm, but I've done a dozen of these over the past three years."

"One of the things that surprised me most in my reproductive physiology class was the high number of spontaneous miscarriages."

"Thirty to forty percent of all conceptions," Doctor Kelly replied. "But most of those are never known by the woman because they occur too early."

The elevator reached the ground floor, and we walked to the ER, where after checking the board, we went to Trauma 2 where we found an obviously battered woman being treated by two doctors and a nurse.

"OB consult," Doctor Kelly announced.

"Nineteen-year-old with positive EPT; vaginal bleeding; BP 100/60; pulse 80; resps 15 and labored due to probably fractured rib; Foley inserted with blood in the urine."

"Blood work?" Doctor Kelly asked.

"Waiting on a stat pregnancy test, otherwise no blood work ordered."

"Did you call for a surgical consult?"

"Yes."

"Mike, I need the portable ultrasound. Find it."

"Yes, Doctor."

She moved to the treatment table to begin her exam while I moved back to the hallway. I looked up and down and didn't see the cart, so rather than hunting for it, I went to the nurses' station and asked the duty nurse.

"It was last used in Exam 3 and I don't recall it being moved," she said.

I thanked her and went to Exam 3, which was empty, and found the cart. I unlocked the wheels and pushed it to Trauma 2.

"Got it," I said.

"Set it up on the other side of the table, please."

I moved to the side of the table opposite Doctor Kelly and plugged in the machine, powered it on, and set the controls. Once again, it was GE equipment, so it was similar to the ones I'd used before making those tasks easy. I turned on the warmer and put the gel bottle into it, then wiped the transducer with an alcohol-infused cloth.

"Ready, Doctor," I said as Doctor Kelly removed her gloves following the vaginal exam.

She put on fresh gloves, then took the transducer wand from me. I handed her the warmed bottle of gel, which she squirted onto the patient's abdomen. She handed the bottle back, and I returned it to the warmer. She moved the transducer around and obtained a good image of the uterus and, having seen quite a few images of Elizaveta and others, I could see a small embryo, but given the amount of blood from the patient's vagina, I couldn't imagine the fetus was viable.

"Surgical consult first," Doctor Kelly said. "The vaginal bleeding does not appear life-threatening, and I'd rather know what's going on with her kidneys or bladder before I proceed."

"Is my baby dead?" the patient asked.

"I believe so," Doctor Kelly said. "We're going to have the surgeons check on your internal bleeding first, and then we'll take another look."

Tears streamed down the young woman's cheeks, and I felt truly sorry for her, and hoped that the police had arrested her boyfriend. The surgical Resident arrived, so I cleaned up the ultrasound machine, shut it down, unplugged it, and pushed it out into the hallway.

"In that alcove next to the nurses' station," a nurse said, pointing.

I returned the machine to its storage location, then followed Doctor Kelly to the elevators.

"One reason for waiting is to see if she naturally expels the conception products," Doctor Kelly said. "If they change position, then we wait, though not too long because we don't want her to become septic."

"How long is too long?" I asked.

"A judgment call. For me, up to twenty-four hours. In other hospitals, you'll find either more or less aggressive intervention. I generally take a middle position on things like this."

"You're sure the fetus isn't viable?"

"Positive. The amount and color of the blood is such that it's intrauterine. I suspect the fetus became detached, which is consistent with a battered woman who was struck in the abdomen."

"Why not wait in the ER for the surgical consult to be completed?"

"Because my gut says she's going to need an ex-lap."

I chuckled, "Your gut?"

"Did you hear me make a potential diagnosis based on a 'gut feeling'?"

"No. Unresolved, non-specific internal bleeding usually results in an exploratory laparotomy, so you're simply speculating that she'll have one based on your experience. And I suspect you use that phrase to make a point."

"I did. What point?"

"That experience and statistics inform our decisions, and those aren't 'gut feelings' the way Doctor O'Rourke meant it when he said it.

"In emergency medicine, you are going to have to go with your 'gut' on occasion because you won't have time. Doing nothing will be worse than ANY of the choices you might make, so you do the one that you feel best fits the circumstances. Ask if there's time, but if there isn't, save the life. Your job isn't perfection, it's stabilization. There are plenty of other doctors who you'll hand your patients to who can worry about perfection. But perfection doesn't mean a thing if the patient dies while you're trying to be perfect."

"And when they die because I wasn't perfect?"

"If you'll excuse the earthy phrase I picked up in my ER Clerkship — shit happens, people die, and there's nothing you can do to prevent it in some cases. I'm sure you saw at least one of those during your Preceptorships."

"MVA with ejection; severe head trauma; indifferent Babinski; she didn't make it."

"Going through the windshield is routinely fatal. No matter what you did, heck, if a fully equipped trauma team had been at the side of the road, there was likely nothing that could have saved her life. You did basic resuscitative and supportive care until neuro pulled the plug, so to speak."