Chapter 22: Blood Chemistry

October 18, 1987, McKinley, Ohio

I wasn’t surprised when Viktor came to the cottage shortly after I’d arrived home from my dinner with Sheila. I invited him in, poured him some vodka, poured some grapefruit juice for myself, and we sat down in the living room.

“I’m going to assume you spoke with His Grace at some point this week,” Viktor said after sipping his vodka.

“I had dinner with him and Father Nicholas on Monday evening.”

“How much are you permitted to share?”

“Nothing, unfortunately. That was a direct command from Vladyka.”

He nodded, sipped his vodka again, and asked what I knew he’d ask.

“Was this morning about Yulia?”

I shook my head, “No. All of us understand she was distraught. What I can say is that individuals approached the bishop, Father Nicholas, and my grandfather with ‘concerns’, which are really nothing but unfounded gossip. Beyond that, I’m not permitted to say anything.”

“Are you considering asking for laicization?” Viktor asked.

“I’m not permitted to answer that question,” I replied.

“Is there anything I can do to help?”

“Take care of Yulia because Rachel will need her grandmother.”

“My daughter never thought so,” Viktor said, sipping more of his vodka.

“Neither of us knew what was coming,” I replied. “I think you’d agree circumstances have changed radically.”

“They have,” he said, downing the last of his vodka.

“Another?” I asked.

He shook his head, “No. May I ask a question unrelated to the bishop’s stern words?”

“Of course.”

“The young woman with the baby — I’ve seen her twice now, once at Rachel’s baptism and then again this morning.”

“Sheila. I was part of the team caring for her while she was in labor. I had the opportunity to discuss Orthodoxy with her and did what I usually do.”

Viktor nodded, “You are an accomplished evangelist.”

“Mostly by simply living the Gospel as best I’m able, with the help of God’s grace.”

“Yes, but you know how to convey the message of God’s love without coming across as preaching.”

“I know some who would disagree!” I countered.

“Yes, but that doesn’t make it untrue. Her husband doesn’t come with her?”

“Single mom,” I replied. “The baby’s father is in prison, and he and Sheila were never married. And, to allay what might concern you, she is a friend. All the single parents I know, at least to this point, are women. I looked into one support group and it was literally all women. I haven’t found a ‘single dad’ support group anywhere in Hayes or Harding Counties.”

“You have help from Rachel’s godparents and her grandparents, plus Lara Federov.”

“The support groups are for parents. There aren’t many people with experience in raising a child alone in our parish.”

“Thank God for that,” Viktor said. “Those things do happen, but fortunately the few recent cases have led to marriage, except for Vickie. How are things at the hospital?”

“I know it sounds crass, but I wouldn’t mind having more opportunities to do procedures.”

“Which would require more patients.”

“Yes. But I have had opportunities to suture, which was the next big step. Unfortunately, my training requires patients who are sick enough or injured badly enough to need the ER.”

“Which isn’t quite as unfortunate as for the young woman in your anatomy lab.”

“True,” I agreed. “I suppose what it comes down to is me champing at the bit to be a Resident, but also know I need more training.”

“Are you looking forward to those thirty-six-hour shifts?”

“No!” I chuckled. “But that comes with the territory, just as this period of my training does. I know I could do more, but I’m not permitted. It’s just something I have to deal with.”

“I won’t keep you any longer, but please let me know if there’s anything I can do, and please come talk to me when His Grace releases you from your ‘cone of silence’.”

“I loved watching Get Smart reruns on the UHF station!”

Viktor got up, we shook hands, and he returned to the main house. I went to the kitchen and dialed Clarissa’s number, as I’d promised to call her.

“You’re going to have to explain the Bishop’s homily,” Clarissa said after we greeted each other.

“You’ll have to use your feminine powers of deduction because I’m under strict orders to not speak to anyone about it.”

“You know I’m not going to say anything that would ever harm you, Petrovich.”

“And you know that I have to be obedient to my bishop unless he’s doing something so far beyond the pale that I’m willing to risk discipline or defrocking for speaking up. I did that before; this is NOT one of those situations.”

“When will you be able to talk about it?”

“Ask me again in a few weeks. Just so you know, I’m serving at Holy Transfiguration next Sunday, and the Cathedral the following Sunday.”

“Who’ll watch Rachel while you’re in Columbus?”

“I hadn’t thought that far ahead. I think it might be best to ask my mom, so there are no uncomfortable questions.”

“I suppose that makes sense. Can I ask about you and Sheila? She’s obviously interested and the fact she wants her baby baptized speaks volumes.”

“She’s a friend, Lissa. I haven’t detected a single thing that says otherwise. And she’s aware of my clerical obligations. She wasn’t aware that she’d have to convert before we’d baptize her baby.”

“Who is named for you!”

“True. But it was her friend who was non-stop aggressively flirting with me, not her.”

“And, of course, girls don’t use different strategies!”

“I don’t get that feeling,” I replied.

“You’re used to aggressive girls, except for Angie.”

“I suppose so,” I replied. “Speaking of her, I should probably call and see how she’s doing.”

“She was going to call when she decided what to do about her driving license, right?”

“Yes. I had suggested she speak to Father Stephen, but I’m not sure if she has.”

“Well, because you can’t tell me anything, I guess I’ll see you tomorrow in the Emergency Department.”

“You know I love you, Lissa, but I have to follow Vladyka JOHN’s instructions.”

“I know.”

We said ‘goodbye’ and I hung up. I was about to dial Angie when Rachel fussed, so I went to check on her and could tell immediately she needed a clean diaper. I dealt with that, and realized it wasn’t time for her to eat if I wanted her to stick to her schedule, so I gave her some apple juice while I rocked in the rocking chair. I felt it was better to keep her with me than return her to her crib, as the longer she stayed awake, the more likely she was to stay on her schedule.

When she finished her bottle, I got up so I could call Angie, and I cradled the phone with my shoulder while I cradled Rachel in my arms. Mrs. Stephens answered and called Angie to the phone.

“Are you able to speak freely?” I asked.

“Yes. Mom is watching TV, so she won’t hear me so long as I don’t raise my voice.”

“How are you?”

“OK. I’m having a bit of trouble sleeping, but otherwise, I’m fine. How are you doing?”

I suppressed a sigh, because one of the first signs of a ‘down’ period was difficulty sleeping. That meant the prescription she was taking wasn’t sufficient. It was possible it was just one of those things, but I suspected it wasn’t. And that meant, more than likely, Angie would be back on her medication sometime in the next few months.

“I’m doing OK,” I replied. “Rachel and the hospital are keeping me busy. I’m back at the dojo and the band has a gig in Goshen for Halloween.”

“When? I’ll ask Mom to speak to Mrs. Kane and see if I can be there.”

“On the 30th,” I replied. “Fortunately it’s at 8:00pm, or I wouldn’t be able to make it on time. I just have to hope nothing delays me at the hospital.”

“Who’s going to watch Rachel?”

“My mom,” I replied. “She’s living in Goshen now, if you remember.”

“That’s right, she married a lawyer from Cincinnati.”

“Yes. Have you spoken to Father Stephen?”

“Yes, and he was supportive, but felt I should be completely off my medication.”

Something dawned on me — it was common for patients with schizophrenia to not comply with taking their prescribed medication, and that could be why Angie was having difficulty sleeping.

“Ang, are you taking your medication?” I asked gently.

“I don’t need it,” she said quietly.

“You just told me you were having trouble sleeping,” I replied. “And I want you to remember what we discussed with regard to you taking your medication.”

“But I’m fine, Mike!” Angie protested.

“We agreed you would take your medication and only change if your doctors approved. Please start taking it again and speak to Doctor Mercer about stopping. Maybe they can reduce it or change it.”

“If I tell her I stopped, she’ll tell my mom and I’ll lose my privileges.”

I had a real dilemma, and the question of how to respond makes me think of the canons, and whether I should apply ‘lenity’ or ‘strictness’. I felt it was in Angie’s best short-term interest to not say anything to Doctor Mercer if she became compliant, and that she could omit that information, at least at this point. If Angie continued with non-compliance, then I’d have to tell Doctor Mercer.

“Start taking it again, then speak to Doctor Mercer. Just don’t mention anything about not taking it. Tell her you want to reduce the dosage or try going without and see what she says.”

“You won’t tell?”

“Not if you take your medication, starting right now, and you continue to take it.”

“Do I have to?” she asked, sounding like she was a toddler.

“Yes, Ang, you do.”

“It’s not fair, Mike!” she protested.

“No, it’s not,” I agreed. “Life is unfair and all we can do is find our way forward as best we can, helped by God’s grace.”

“I’m sorry,” Angie said, sounding chagrined. “You lost Elizaveta and I’m whining about my medication.”

“It’s OK,” I replied. “I understand. Well, as much as I can, anyway. Promise me you’ll take your prescription.”

“I will,” she sighed. “For you.”

“Thank you. Let me know when you’re going to see Doctor Mercer, please.”

“I have my regular appointment on Thursday afternoon.”

“OK. Call me afterwards and let me know what she says.”

“OK.”

“I’ll speak to you then.”

We said ‘goodbye’ and I hung up. I put Rachel into her carrier, I said our evening prayers, and then fed her. Once she’d eaten, I laid her in her crib, then completed my nighttime routine before crawling into bed and falling asleep.

October 19, 1987, McKinley, Ohio

“Doctor Gibbs needs you in Exam 2,” Nurse Ellie said as I finished changing into my scrubs on Monday morning.

“OK.”

I clipped on my badge, draped my stethoscope around my neck, locked my padlock, then headed to Exam 2.

“Good morning, Doctor Gibbs,” I said when I entered.

“Hi, Mike. This is Leslie. Leslie, my student, Mike.”

I greeted the young woman, who looked to be about twenty.

“Hi,” she replied.

“CBC and Chem-20,” Doctor Gibbs said. “She’s been feeling lethargic and has been running a low-grade fever for a few days.”

“I’ll draw the blood and get it to the lab. Any other complaints I should know about?”

“Swollen lymph nodes in her neck. I’m about to do a complete physical, but I’d like the blood drawn first.”

I knew, without asking, what she suspected. The signs were all there, and I strongly suspected the blood tests would show a high white count. The complete set of tests was because oncology would order them before beginning treatment for what I suspected Doctor Gibbs suspected — leukemia.

I went to the supply cabinet, selected the necessary equipment and test tubes, set them on the instrument tray, then washed my hands and put on gloves. I drew the necessary tubes of blood, filled out the test sheet, then handed it to Doctor Gibbs to sign. She signed, then ticked the box marked ‘stat’.

“I’ll take these right to the lab,” I said, not waiting for her to give the instructions.

“Thanks, Mike. Send Ellie back in, please.”

“Will do.”

I left and let Nurse Ellie know that Doctor Gibbs wanted her, then hurried down the corridor to the lab. I handed over the tray with the vials, along with the form.

“Doctor Gibbs would like these as quickly as possible,” I said.

“There’s nothing in the machine right now, so I’ll get right on it,” the lab tech replied.

“Thanks. Page me please, when you have the results. Mike Loucks. L-O-U-C-K-S. My pager is number 842.”

He checked a laminated list, then said, “Got it! I’ll page you as soon as I have results.”

I returned to Exam 2 where Doctor Gibbs was just completing the physical exam, checking distal pulses and reflexes.

“They’ll run the tests right away,” I said. “Nobody ahead of you.”

“Good,” Doctor Gibbs said, then turned back to the patient. “Leslie, just relax and we’ll be back as soon as the lab finishes the blood work. If you need anything, just ask the nurse, or press the call button.”

“OK,” Leslie agreed. “What do you think is wrong?”

“Let’s wait for the blood tests,” Doctor Gibbs replied. “There are many, many things that can cause your symptoms, including influenza.”

We left the room and went to the lounge.

“Swollen liver or spleen?” I asked.

“Spleen,” she replied. “Possibly liver, but I couldn’t really appreciate any enlargement. Do you have a diagnosis?”

“I’m not foolish enough to answer that question until we see the blood work, but you’re going to be looking for an elevated white count.”

“Indicative of?”

“Leukemia,” I replied. “She has the classic symptoms, though it could be an infection, a parasite, or one of the rarer strains of influenza.”

“You a betting man?”

I frowned, “I’d have to put my money on leukemia.”

“Me, too. Let’s hope for her sake her blood count says otherwise.”

“I remember something about it not always showing up as an elevated white count.”

“Aleukemia. That would require a bone marrow biopsy to diagnose, and we’d only recommend that after we exhaust the other differentials.”

“How old is she?” I asked.

“Nineteen. She’s a Freshman at Taft and her roommate encouraged her to come in.”

Nurse Trudy opened the door to the lounge and said, “Doctor Gibbs, paramedics three minutes out with a possible MI. Trauma 1 is free.”

“OK. Ask Maryam to meet me in the ambulance bay. Mike, check on the patients on the board.”

“Yes, Doctor.”

I really wanted to help treat the possible heart attack, but I knew Doctor Gibbs was making sure I could get the test results immediately upon being paged, and also dividing the opportunities as equitably as she could. I left the lounge and checked the board, and started with Exam 1, a forty-nine-year-old with a broken ankle which needed surgery, and was waiting on orthopedics to take him to surgery.

“Hi, Mr. Lewis,” I said. “I’m Mike. I need to check your vitals.”

“Any idea when the orthopedic surgeon is going to get his thumb out and fix my ankle?”

“I don’t know your surgeon’s specific schedule, but most surgeons perform their scheduled surgeries first thing in the morning. I can check, if you like, once I take your vitals and update your chart.”

“Thanks.”

“How is the pain?”

“Whatever they gave me took the edge off, so it’s not too bad.”

I checked his breathing, his heart, his pulse, his blood pressure, and his distal pulses, then wrote everything on the chart.

“Other than your ankle, any complaints?”

“A long list, but they’re about my ex-wife, so I don’t think you want to hear them!”

“Would you like me to check on the orthopedic surgeon?”

“If you would.”

I went over to the phone, consulting the list next to it, and dialed orthopedics. I inquired as to the surgery schedule, and as I’d expected, there were two scheduled for the morning, and unfortunately, Mr. Lewis would have to wait until around 2:00pm, which was nearly eight hours. He wasn’t going to be happy, but there wasn’t much that could be done as it wasn’t an emergency which would cause a change in schedule.

“I hate to say this,” I said after hanging up, “but we’re looking at 2:00pm.”

“Ugh,” he groaned. “Any chance I could get a book or magazine?”

“Let me check with Patient Services,” I said. “A nurse or candy striper should be able to help you.”

“Oh, they could!” he grinned.

“We frown on patients who are preparing for surgery raising their heart rates,” I replied with a slight smile.

He laughed, “That could happen if they’re cute enough, like that one who I saw when I came in. A real knockout.”

That was likely Ellie, and he was welcome to her!

“Nurse Ellie, I suspect.”

“That’s a book I’d like to read at leisure!”

I nodded and left the room, walking to Patient Services and letting them know that Mr. Lewis was looking for reading material while he waited for ankle surgery. Once I’d done that, I went to Exam 2 to check on Leslie, though I didn’t need to take her vitals.

“How long do you think it will take?” she asked.

“Probably another ten to fifteen minutes, and then Doctor Gibbs will need to review the results.”

“Do you know how to read them?”

“Yes, but until I pass the last part of the MLE — the Medical Licensing Exam, I’m not allowed to make a diagnosis. I can discuss it with one of the Attendings or Residents, but the law says I can’t diagnose or make treatment recommendations. I can do certain procedures under supervision, but that’s it for another twenty months.”

“So they let you stick me with a needle, but not read test results?”

I nodded, “I’m also allowed to take vitals, suture, and do exams, all under supervision. Over the next twenty months I’ll do more and more until I’m ready to take the final exam to get my MD and then I’ll be able to do anything under supervision.”

“How long before you aren’t supervised?”

“That happens when you’re an Attending, and it depends on your specialty. For me, about seven years after I receive my MD because I’m planning a joint trauma/surgery Residency. I’ll be a qualified surgeon, but I’ll work in the ER.”

“Interesting,” she replied.

“I need to check on another patient,” I said. “I’ll be back with Doctor Gibbs as soon as the lab results are back.”

“Thanks.”

I left and went to Exam 3, which was a seventy-one-year-old woman with bronchitis who was being observed. I took her vitals, chatted briefly with her, and updated the chart. Just as I’d finished, my pager vibrated, and showed the extension for the lab. Rather than call, I simply walked down the corridor to get the results.