Chapter 47: Bounceback

December 5, 1987, McKinley, Ohio

I elected not to go to confession after Vespers, but I did let Father Nicholas know what had happened with Angie. When I explained I was angry, he offered to hear my confession, but I truthfully told him I was in no frame of mind to repent, and that I’d discuss the situation with Father Roman on Monday.

After I spoke to Father Nicholas, Serafima stopped me as I was leaving the nave.

“Mike, the girls want to help you,” she said.

“How so?”

“On Saturdays, they’d come to your house to clean, watch Rachel, and prepare a meal for you.”

“Why do I have the distinct impression you’re setting up a battle with the grandmothers?” I asked.

Serafima laughed, “You’re our responsibility, not theirs! Elizaveta was our friend, so we want to help. This was something Alyssa and I discussed, and the other girls volunteered to pitch in when we suggested it.”

“And if I refuse?”

“I’d say ‘good luck to you’ because you know the grandmothers will all insist. We’re giving you a way out!”

“By doing the same thing!” I chuckled.

“Yes, but we’re your friends, and we were Elizaveta’s friends, as I said. And I’m Rachel’s godmother. That’s different.”

“I suppose it is, and it would help on Saturday mornings for when I have band practice.”

“What time does that start?”

“8:00am. I need less than ten minutes to walk from the house to campus.”

“Then I’ll be there next Saturday at 7:45am. I assume it’s OK for Elias to hang out.”

“Of course, though you could put him to work!”

“He probably cleans like you do!”

I chuckled, “You only have Elizaveta’s word, and she never saw me clean because she refused to allow it! Ask Maryam! I did a competent job yesterday!”

“Boys and girls have very different definitions of ‘clean’!”

“I’m going to be a doctor, for Pete’s sake!” I protested. “I know what clean is! Now you sound like Elizaveta!”

“She was my best friend, so does that really surprise you?”

“No,” I replied with a smile. “And I very much appreciate what you’re offering.”

“Alyssa and Subdeacon will take the second Saturday. After that, Oksana, Britney, Johanna, Irina, Katrina, Sara, Debby, and Viktoriya will take turns, though I don’t know for sure what order just yet. That will take us to the end of February.”

I wondered what the fallout would be when the grandmothers discovered what was going on, but that was between the women, young and old, and they could fight it out, however, they saw fit.

“My schedule might change,” I said.

“We can work around that, and Lara will be at the house with Rachel if you’re at the hospital, right?”

“Yes.”

“Then no problem! We’ll just figure out meals if that happens.”

“I know better than to argue with determined Russian women!”

“Good! Elizaveta trained you well!”

“And every other Russian woman with whom I’ve ever interacted, starting with my mom!”

Serafima laughed, “We’ll have to work on Alyssa and make her more Russian!”

“Poor Subdeacon Mark,” I chuckled.

“You don’t believe that for one minute!”

“Perhaps not! Anyway, I need to get Rachel to Lara so I can get to the hospital. Thanks a lot, Serafima. Elizaveta was right in choosing you and Elias to be Rachel’s godparents.”

“Thanks!”

I found Lara, we walked out to my car, got Rachel’s car seat, got her settled into Lara’s Corvette, and then she headed to the house while I headed to the hospital. The overnight staff was different from that on Wednesday night, except for Doctor Olson. The nurses were Faith and Tracy, the student nurse was Brenda, and the Fourth Year was Cathy. The on-call Attending overnight was Doctor Rosenbaum, but I most likely wouldn’t interact with him.

The first thing I did was check on the patients — there were eleven, though the three I’d closely interacted with on Wednesday had all been released. The patients ranged from a five-year-old to a sixteen-year-old, with a range of complaints, including a concussion from a Friday night football game.

I went to find Doctor Olson, who was sitting in the Attending’s office doing chart reviews.

“Mike, There are just three of us tonight,” he said. “Same procedure as Wednesday night — if there’s a consult, you and I will go down and Cathy will stay on the ward. Rounds at 10:00pm.”

“Anything that needs to be done right away?”

“No. Feel free to check in on the kids; Doctor Sumner likes your style.”

“Anyone who needs attention?”

“Chuck, the football player, could probably use some companionship.”

“It’s too bad the cheerleader was discharged!”

Doctor Olson laughed, “A good idea, but that would probably get me in more trouble than it’s worth!”

“And the young Zappa and Carlin fan who wanted a date with Joy?”

“Which one was that?”

“Jim, the Crohn’s patient. He also hit on my friend Clarissa and when she said her girlfriend would object, Jim said he’d take them both!”

“When I was fourteen, I was trying to cop a feel!” Doctor Olson grinned, shaking his head. “He’s already thinking about threesomes!”

“I was like you,” I said. “High School was a mostly fruitless frustrating exercise. College was different.”

“Same here. The brainiacs didn’t get much attention in High School, more in college. Of course, med school and Residency really turned on the spigots!”

“No plans to settle down?”

“And give up my playboy lifestyle? Not anytime soon!”

“I’ll leave you to your chart reviews,” I said.

He nodded, and I left the office and headed to Chuck’s room.

“Hi,” I said. “I’m Mike, a Third Year medical student. What position do you play?”

“Quarterback. I just won the starting job this week and got creamed when a lineman and my fullback both missed their blocks on a blitzing safety who steamrolled me from my blind side.”

“How’s your head?”

“I have a hell of a headache.”

“Double vision or blurry vision?”

“At first, yeah. I had my bell rung, big time. But by the time they got me to the ER, my eyes were OK, but my head hurt like hell, as does my neck.”

“No other injuries?”

“No, thank God. You play? You’re built like a free safety or a wideout.”

“I am athletically challenged,” I grinned. “Martial arts and running are pretty much where it maxes out. I tried to play baseball when I was in grade school, but I couldn’t hit. I can manage slow-pitch softball, but even then, I’m pretty lame.”

“Well, the world needs doctors, too!” he chuckled.

“Nice! Anything I can get for you?”

“A beer?” he asked hopefully.

“Alcohol probably isn’t the best choice right about now.”

I picked up the chart from the rack at the end of the bed and flipped through it.

“It says you’ll be out on Monday morning if you don’t show any other symptoms.”

“Why not tomorrow?”

“Usually when you have blurred vision or lose consciousness, they keep you for forty-eight to seventy-two hours of observation.”

“Looking for what?”

“Seizures, mainly, or onset of paralysis or tingling in your limbs, or a change in vision or hearing.”

“What?” he asked.

“Not falling for that one,” I replied with a grin.

“Are you going into pediatrics?”

“Trauma surgery,” I replied. “It’s a relatively new discipline where I’ll train in the Emergency Department — what you call the ER — and as a surgeon, and be assigned to the Emergency Department full-time. During medical school we do twelve clinical rotations to broaden our education as well as help us decide what specialty we want to choose.”

“Can I ask why I’m here with the little kids, not the adults?”

“Pediatrics takes patients sixteen and under,” I replied. “With your height and weight, you could be in either Internal Medicine or Pediatrics, but the docs here are specifically trained to treat adolescents and younger kids. One thing they impressed on me was that pediatric patients aren’t just ‘small adults’ — there are a host of considerations for kids who are still growing, even if they’re six-foot-tall quarterbacks!”

“You know you’re the first person to spend more than five minutes in my room.”

“It’s a slack time right now,” I replied. “And there are eleven patients on the ward; plus I suspect there were some discharges this morning. The nurses check on you every hour or so, right?”

“Yeah, but they seem busy.”

“They are. And overnight there’s only one doctor on the ward, plus two medical students.”

“One doctor for all the patients?”

“And two nurses, plus a nursing student. That’s a pretty typical ratio for overnight in a non-critical-care ward like Pediatrics. If there were more patients, there’d be another nurse or two to keep the ratio at about five-to-one. That’s actually more important overnight than a doctor, because they’ll administer your medications, change IV bags, and so on. Obviously, they’d call the doctor if there were some kind of problem.”

“What are you allowed to do?”

“Suture, insert IVs, blood draws and injections, take medical histories, check vitals, and hook up monitoring equipment. Soon I’ll learn to intubate and do other emergency procedures.”

“When are you officially a doctor?”

“When I pass the second part of the Medical Licensing Exam and graduate. A license comes later, but I’m officially a doctor at graduation. Then I have about eight years of training in emergency medicine and surgery before I’m licensed to practice unsupervised.”

“That’s a long time!”

“Cardiac surgeons and neurosurgeons train for nine or ten years,” I replied. “Those are the most complex specialties.”

“Yeah, I could see that. If you goof on somebody’s heart or brain, it’s over.”

“Pretty much. Not too many do overs in those kinds of surgeries. One of my friends is planning to be a cardiologist, and another two plan to be surgeons, so they’ll train about as long as I do. Two other friends are going in internal medicine and obstetrics/gynecology and they train for three years after graduation.”

“What about a regular doctor?”

“In Ohio, two years, split between internal medicine, pediatrics, and emergency medicine. Some states, like Illinois, only require one year. Most of what a GP does we learn in medical school. Think about all the stuff I said I can already do — that’s pretty much what a GP does, along with a few other procedures. For anything more, they’d refer you to a specialist.”

“Mike?” Doctor Olson said from the door to the room. “We have a consult.”

“Duty calls,” I said to Chuck. “I’ll see you later on rounds.”

“Thanks for coming to talk to me,” he said.

I left the room and followed Doctor Olson to the elevator.

“Two-year-old who swallowed several coins,” Doctor Olson said.

“Endoscopy?” I asked.

“Think of them similar to any foreign object that is swallowed, except batteries. We do an AP series, along with a chest and neck series, to locate the coins. Forgive the pun, but if they’ve passed the ‘choke’ points, we admit and repeat the X-rays in twelve hours. If the coins are moving through the system, we’ll release him to his parents with instructions to watch his stools, and if they don’t see the coins in a week, bring him back. With multiple coins, quite often some are lodged in the esophagus, and those would be removed via endoscopy, if they didn’t progress to the stomach.”

“And in this case?”

“That’s what we’ll see.”

We stepped into the elevator and went down to the ground floor, walked to the ED, and entered Exam 3.

“Olson, Pediatrics,” Doctor Olson said, for the benefit of the child’s parents.

“Hi, Matt,” Doctor Taylor said. “Hi, Mike.”

Also in the room were Nurse Teri and a Fourth Year I recognized, Leslie Dunston.

“What do we have?” Doctor Olson asked.

“Jared Kwiatkowski; twenty-six-month-old male, otherwise healthy, with good vitals, ingested several coins. He presented about just under three hours ago, and the coins were swallowed sometime between 5:30pm and 6:00pm. Films are on the viewer.”

We walked over to the viewer, and Doctor Olson studied the films.

“What do you see, Mike?” he asked a minute later.

“Six coins of various sizes, and judging from the images, two dimes, three pennies, and a quarter. The smaller coins appear to have entered the stomach, while the larger coin appears hung up in the middle esophagus. I see no edema.”

“You can be sure about the coins?” Mr. Kwiatkowski asked.

“Reasonably,” I said. “I’m basing it on relative sizes, as well as Jared’s anatomy.”

“What’s next?” Doctor Olson asked me.

“Physical exam, specifically looking for any breathing abnormalities.”

“Proposed management or treatment?”

“If no breathing or heart abnormalities exist, admit for observation and repeat X-ray in about eight hours to see if the coins are making progress. If they are, and the quarter has passed into the stomach, then release and monitoring for the coins to pass.”

“Good. Do the physical, please.”

I did a complete ER intake physical and reported the findings.

“Good bilateral breath sounds; pulse is strong in all four extremities; Jared does not appear to be in any distress.”

Which was more than I could say for the parents.

“Mrs. Kwiatkowski, when was the last time Jared ate?” Doctor Olson asked.

“Around noon,” she replied. “He’s had water and juice since then. Oh, wait, his afternoon snack was a banana, about 3:00pm.”

“OK,” Doctor Olson said. “Josh, Mike? Can we step out?”

I nodded and Doctor Taylor responded, “Yes” so we went out into the corridor.

“The literature on this is scant and all over the map,” Doctor Taylor said.

“Agreed,” Doctor Olson confirmed.

“Mike? Risk factors?”

“Impaction or failure to pass due to some underlying medical condition. An endoscopy always risks vomiting and aspiration, and he’s eaten recently enough that we wouldn’t want to put him under general anesthesia if we can help it. I’d manage it medically for another eight to ten hours, then repeat the films.”

“What about giving him something to eat, like peanut butter crackers and Sprite?” Doctor Olson asked.

“That would increase the aspiration risk tremendously,” I replied. “I wouldn’t do it.”

“What if it causes the quarter to pass from the esophagus into the stomach?”

“That would be better than an endoscopy and general anesthesia, assuming it works,” I replied. “I think there’s a strong chance it won’t.

“I agree with Mike,” Doctor Taylor said.

“I think giving him food now is OK, as we have to wait for a second set of X-rays before surgery would take him,” Doctor Olson said. “That allows enough time to pass, and if it works, we’re heroes. If it doesn’t, well, no harm, no foul.”

“A snack, then NPO?” Doctor Taylor asked.

“Yes,” Doctor Olson confirmed. “If Jared won’t eat, that’s a sign of distress that isn’t appreciable with our exams.”

“I’d like you to confirm the proposed treatment plan with your Attending,” Doctor Taylor requested.

“I planned to do that,” Doctor Olson replied. “I’ll take Jared on my service, and if he needs the endoscopy, I’ll get the surgical consult. I’d like to avoid a general if I can.”

“Agreed,” Doctor Taylor replied.

“Mike, wait here and bring him up as soon as Doctor Taylor completes the paperwork. You can sign the transfer on my behalf. I’ll note my verbal approval in the chart when you come up. Josh, I’ll call Doctor Rosenbaum to confirm about the food.”

“What about his parents?” I asked.

“One can stay,” Doctor Olson said. “The guest chairs fully recline, and we have blankets and pillows.”

He left, and Doctor Taylor and I went back into the exam room.

“Mr. and Mrs. Kwiatkowski,” Doctor Taylor said. “We’re going to admit Jared for observation. If things progress, then he’ll be released to you and you’ll just need to watch his stools for the coins to pass. If they don’t progress, then Doctor Olson will discuss the options with you.”

“What about staying with him?” Mrs. Kwiatkowski asked.

“One of you can stay per the hospital rules for patients under five years of age. There is a recliner in the room where he’ll be, and the nurses will provide blankets and pillows. You don’t have to decide right now, though. You can both go up, but you’ll need to decide in the next hour who is staying.”

I checked with Doctor Taylor, then placed a call for an orderly. Doctor Taylor wrote up the transfer order, I signed it, and once the orderly arrived, we transferred Jared to a wheelchair. Leslie and I escorted him and his parents to pediatrics. Faith, the charge nurse, directed us to room 4, which was a shared room, but the other bed was empty. Leslie and I got Jared settled and after I updated the chart, I took it to Doctor Olson to sign.

“Rosenbaum agreed with my plan,” he said, writing on the chart. “Ask the nurses to give the little guy a package of cheese crackers and some Sprite.”

I verified that he’d written the orders on the chart, then went to find Brenda to tell her about the orders, and she brought Jared his snack. I observed as he ate and noted on the chart that he had no difficulty swallowing. After reporting to Doctor Olson, I went to the lounge to read, as I didn’t want to disturb any patients who might be trying to sleep.

Just before rounds were to begin, Cathy and I pre-rounded, ensured that all labs were back and medications were given, and took vitals, which, of course, disturbed two sleeping patients. I hated doing that, especially with kids, but we had no choice. At 10:00pm, Doctor Olson joined us for evening rounds. Everything was in order, and there were no concerns about any of the patients overnight, though the nurses would monitor Jared closely for any distress. Doctor Olson wrote out orders for X-rays for 8:00am, and assigned me to take Jared to radiology for the film series.

Once rounds were completed, Cathy and I both sacked out in separate bunks in the on-call room.

December 6, 1987, McKinley, Ohio

I managed four hours of sleep before Faith woke me to let me know there was a consult. I put on my medical coat and slung my stethoscope around my neck, then joined Doctor Olson at the elevators. We headed down to the ER to find Doctor Casper who was at the nurses’ station.

“What do you have, Ghost?” Doctor Olson asked.

“Female; five; febrile at 39.3°C; vitals normal after adjustment; constipation; good appetite; eyes, nose, ears, and throat all clear; no signs of injury.”

“Mike, what’s the adjustment?” Doctor Olson asked.

“Each degree of fever over 38°C results in resps increasing by five and heart rate by ten.”

“Good. Ghost, any abdominal pain or tenderness?”

“No. That’s why I called you, not the surgical Resident.”

“How long has she had the fever?” I asked.

“Two days. It was 38°C yesterday, and after she vomited earlier this evening, her parents brought her in on the recommendation of their pediatrician.”

“What do you think, Mike?” Doctor Olson asked.

“With no signs of other gastric distress, I’d go with a virus or some kind of infection.”

“In an adult, I’d agree,” Doctor Olson said. “Remember what I said about pediatrics? That our patients aren’t just ‘small adults’?”