Chapter 14: You're a pretty girl!

June 15, 1988, McKinley, Ohio

On Wednesday afternoon, Kylie stopped me in the corridor to ask if I wanted to get together.

"I'm free on Friday evening," I replied. "Rachel will be with her aunt and grandmother."

"Crap. I have something going on Friday evening. Are you free any other time?"

"Not this week," I replied. "And Friday evenings are pretty much my only totally free time."

"Bummer. A week from Friday?"

"Sounds good," I replied.

She left, and I continued to Exam 1 to evaluate a four-year-old boy. I picked up the chart from the rack, then went into the room.

"Good afternoon, Mrs. Kingston," I said. "I'm Mike and I'm going to examine Kevin."

"Hi, Doctor," she replied.

"I'm a Sub-Intern," I replied. "That's the final training before I become a Resident. My job is to do a basic exam and take a medical history before a doctor examines Kevin. What seems to be the problem?"

"He's irritable, has a fever, and complains his ears hurt."

I made a bet with myself that he had otitis media, though there were other possibilities.

"How long has he complained about ear pain?" I asked.

"Since Sunday, but this morning he complained they hurt bad. He's had a fever since yesterday."

"Has he had an ear infection in the past?"

"No."

"Any recent injuries or illnesses?"

"He had a case of the sniffles a few weeks ago, but both his dad and I have hay fever, so he probably has that."

"How is his appetite? Any changes in the past few days?"

"No changes, and I'd say he eats a normal amount for an active four-year-old boy."

"Has he seen a dentist?"

"No. His pediatrician says his teeth are OK."

"You should probably take him to the dentist," I suggested. "That's recommended around age two, and certainly by age five. May I examine Kevin?"

"Yes."

I turned to the little boy sitting on the exam table

"Hi, Kevin. I'm Mike and I'd like to listen to your heart and breathing, count your heartbeats, look in your eyes, ears, nose, and mouth, and take your temperature. Is that OK?"

"Mom said so," he replied. "So I have to."

I washed my hands, put on gloves, and began my exam by listening to Kevin's heart and lungs, explaining each thing I was doing. I used an otoscope to check his ears and nose, changing the speculum between each ear and each nasal cavity. I used my penlight to check his pupils, and, combined with a tongue depressor, his tonsils.

Kevin's right tympanic membrane was red and bulging, a strong indication of otitis media. I checked his tympanic temperature in his non-infected ear, and determined he had a low-grade fever of 37.7°C, or just under 100°F. His pulse was slightly elevated, at 80 beats per minute, but he had no other symptoms.

"I'd say he has an ear infection," I said to Mrs. Kingston. "Let me report to Doctor Casper and he'll come speak to you."

"Thank you," she replied.

I left the room and found Doctor Casper in Exam 2 with Lauren and Nurse Mary.

"Ready to report?" Doctor Casper inquired.

"Yes. Four-year-old male complaining of ear pain; mother reports irritability; pulse 80; temp 37.7°C; heart and lungs show no negative signs on auscultation; right tympanic membrane is red and bulging; eyes, nose, and throat clear; no previous ear infections or recent illnesses. I believe he has otitis media."

"Recommendation?"

"Ibuprofen or acetaminophen for pain and follow up with his pediatrician."

"Let's step out for a moment," Doctor Casper said. "Lauren, please wait with Mr. Cutler for ortho."

"Yes, Doctor," Lauren replied.

Doctor Casper and I stepped into the corridor.

"No antibiotics?" he asked.

"Most cases resolve in about a week without medical intervention. In addition, it could be viral, which would mean antibiotics are not indicated. If it is bacterial, then the literature is mixed on the effectiveness of antibiotics for otitis media except for infants. Doctors often prescribe them due to parental pressure or because they began their practice before overuse of antibiotics became a concern."

"Parental pressure can be very difficult for a GP to overcome," Doctor Casper said. "But you are correct. Let's go see your patient."

We went back to Exam 1, and I introduced Doctor Casper, who checked Kevin's ears and listened to his heart and lungs.

"Go ahead, Mike," he said.

"Mrs. Kingston, Kevin has a mild ear infection. Generally, they resolve without treatment beyond Advil or Tylenol to help with the pain. You should give him over-the-counter children's pain killers and follow up with his pediatrician on Monday if he's still complaining about pain."

"My sister's son was given amoxicillin when he had an ear infection two years ago."

"I can't really say anything about the physician's decision in that case, because I don't have enough information. Doctor Casper and I discussed Kevin's situation, and we believe the infection will clear on its own."

"I want a second opinion," Mrs. Kingston declared.

I looked to Doctor Casper, who nodded.

"I'll speak to our supervisor," I said. "She'll assign another doctor or check Kevin herself. It will take a few minutes."

She nodded, and Doctor Casper and I stepped out.

"Did I do or say anything wrong?" I asked.

"No. You were wise not to try to use statistics to convince her, because that almost never works and has a tendency to make the parent think you're ignoring their concerns. As for her requesting a second opinion, don't let that make you less confident in your diagnosis or your treatment decision. Let's go see Doctor Gibbs."

She was just coming out of Trauma 2, so we walked over to her so I could present the case.

"I'd bet money her son's pediatrician is over forty," Doctor Gibbs said. "Doctors who finished their Residencies before 1980 tend to always prescribe antibiotics. Do you want a pediatric consult or just a second opinion?"

"Do I want to annoy the Pedes Resident or you?" I asked rhetorically. "Hmm..."

Both Doctor Gibbs and Doctor Casper laughed.

"I think you should do it," I continued. "Why call for a consult when it's completely unnecessary? Being 'the boy who cried wolf' won't win me any friends. If I was unsure, then I'd ask for a consult, but I'm confident in my diagnosis, and Doctor Casper confirmed."

"Then let me go see him. Wait here, please."

She was back about five minutes later.

"Confirmed," Doctor Gibbs said. "Let's go see her as a group."

The three of us went back to Exam 1, and Doctor Gibbs spoke to Mrs. Kingston.

"Kevin has a relatively mild ear infection," Doctor Gibbs said. "Antibiotics are not indicated. You should give Kevin over-the-counter analgesics such as Children's Tylenol or Children's Advil and follow up with your pediatrician on Monday. Of course, you can see him sooner if you feel strongly that our diagnosis is incorrect."

"I spend two hours here and the answer is basically 'take two aspirin and call me in the morning'?" Mrs. Kingston asked crossly.

"I'm sorry you're unhappy, Mrs. Kingston," Doctor Gibbs said. "But that is the best medical advice for mild ear infections."

"If you think I'm paying for this, you're out of your mind!" she declared.

"Doctors have nothing to do with billing," Doctor Gibbs said. "You can take that up with Patient Services."

Doctor Gibbs signed the discharge form and handed a copy of it and a diagnosis and treatment form to Mrs. Kingston.

"Patient Services is across the corridor, next to the exit to the waiting room."

We left the exam room and went to the Attending office.

"How often does that happen?" I asked.

"Often enough," Doctor Gibbs replied, "and almost always with some kind of mild complaint. If you think about it, that makes sense because if we do offer treatment, patients aren't likely to complain. Refusal to prescribe antibiotics is often the source of complaints because people simply don't understand that they are ineffective for viral infections. Pain medication is another common source of disagreement, and I recall you were involved in a case like that."

"During my Preceptorship," I replied. "I'm curious, but what happens if she refuses to pay?"

"Eventually, the County will either write off the charges or send her account to a debt collector, depending on an assessment of her ability to pay. Of course, if she has insurance, it would only be the co-pay. But that's not our concern. We treat and let the administrative staff handle billing."

"Sorry, I was just curious about what might happen."

"Understood. Did you see the schedule for July?"

I had, and it was the same as June, which would make things easier on me.

"Yes," I replied. "Thank you for the consistent schedule in July."

"As we discussed, you'll pay for that in your second rotation. It's your last one, if I recall correctly."

"April and May next year, right before graduation."

"You'll get some time off to study for the MLE, per the medical school rules."

"You know, I never looked into that. How much time?"

"A week. But that's in a year. In the here and now, I'm sure there are patients on the board who can use your attention, so hop to it!"

"Yes, Doctor!"

I was relatively busy for the rest of the afternoon, and at 6:00pm I went to daycare to collect Rachel, who was doing better, but was still a bit cranky because she was teething. We headed home for our usual Wednesday evening with Kari.

June 17, 1988, McKinley, Ohio

Thursday and Friday were routine at the hospital, with no particularly interesting cases, and I was looking forward to the following week when I'd be on ambulance duty again. I had my usual lunch with Antonne, and he filled me in on his family's move to McKinley. Everything was going according to plan, and we agreed that I'd have dinner with them once they were settled.

At the end of the day, I took Rachel to my in-laws' house, then headed home to change clothes so that I could join the usual Friday night group, something I hadn't done for quite some time. Or at least that was my plan until I pulled into the driveway and saw Sara sitting on the steps to the front porch. I parked the car in the car port, then walked around to the front door rather than going in the side door through the laundry room.

"Hi," Sara said, when I stepped around the corner.

"Hi."

"I was hoping we could talk," she said. "But I'll understand if you have a date or whatever."

"I actually don't," I replied.

I decided not to mention my plans to join the gang, because I hadn't actually told them I was going to show up, so they weren't expecting me. That meant I didn't need to call anyone, and I didn't want to discourage Sara from talking to me. I unlocked the door and invited her in.

"What did you want to do for dinner?" I asked.

"I hadn't really thought about it because I wasn't sure you'd be available. Where's Rachel?"

"With her aunt and grandmother. That's her usual Friday night. I'll pick her up after band practice tomorrow. Why don't we go to Frisch's?"

"OK."

I took my bag to my study, hung my medical coat on a hanger in the foyer closet, then Sara and I left the house to head to Frisch's. She was quiet during the six-minute drive, and I decided to let her set the pace of the conversation, so I listened to the radio while I navigated the streets of McKinley. She finally spoke after the waitress had taken our orders.

"I didn't plan for anything to happen at the party," she said quietly. "And I didn't know they were going to play those games when I accepted the invitation."

"I didn't think you had planned for it to happen," I replied.

"Some of the girls put a lot of pressure on me and two other girls who said they didn't want to play. I was weak and agreed to play 'Spin the Bottle' and once I'd kissed another guy, it felt like it no longer mattered."

"Peer pressure is tough," I observed.

"I didn't do more than kissing and touching, you know, making out."

"It's not what you did," I replied. "It's that you did it after promising not to."

"I know," Sara sighed. "I've been beating myself up for it since it happened."

"I've forgiven you," I said. "You need to forgive yourself. That is as important as receiving absolution for sin, and the point of the priest saying 'have no further care for the sins which you have committed'."

"But I ruined everything," Sara protested.

"Only when you refused to try to reconcile," I replied.

"Because there's no time," she sighed.

"May I point out that you wasted a month from the time we last spoke and nearly two months since the party?"

"I keep messing up," she said sadly.

"You've made mistakes, yes, but you did come to my house today to see me. Why?"

"A remote hope, I guess. What would I need to do?"

"Start over at the beginning," I replied. "Let's eat dinner, see a movie, and get ice cream. Make it our first date and we'll take it from there."

"Is it OK to ask who you're seeing?" Sara inquired.

"Danijela and the girl who was at Pascha," I replied.

"What movie did you want to see?"

"I'd like to see Bull Durham," I replied. "It's about a minor league baseball player and stars Kevin Costner."

"That sounds good."

"How is school going?"

"I should have all A's. You're back in the ER, right?"

"Until the end of July, then I'll be on a surgical rotation. My schedule is the same in July as it has been in June."

"How is Rachel doing?" Sara asked.

"She's starting to toddle, she's teething, has three words she uses regularly, and she's making more sounds."

"What are you doing in August when Lara starts her student teaching?"

"That hasn't really changed — a combination of the hospital daycare and my in-laws until I remarry, but I won't ask anyone until after August 26th."

"That doesn't give us much time," Sara observed.

"As of this moment, I have no intention of asking anyone on August 27th, and I can't tell you for sure when I'll be ready to ask, but I know I have to get through the anniversary of Elizaveta's repose before I do ask. I've worked with a counselor and that's helped quite a bit. Let me say this, because I see the look in your eyes — focus on the here and now, not the end of August."

The waitress brought our food, and we continued our conversation while we ate. I really did like Sara, but I struggled with how I would know that I could trust her to keep her word in the future. That caused me to think about my parents, and wonder what had gone through my dad's mind when he'd decided to cheat on my mom. Paul Reynolds was another one who had cheated on his wife, but was perhaps a better example, as I was confident he would never cheat on my sister.

When we finished our dinner, we went to the theatre to see Bull Durham, which we both enjoyed, then stopped for ice cream before heading back to my house. Sara had parked on the street, so before I went into the house, I walked her to her car where we exchanged a hug, but not a kiss, as I didn't want to move too fast. Once she'd driven away, I went into the house, said my evening prayers, performed my bedtime routine, then got into bed.

June 18, 1988, Rutherford, Ohio

In the end, my family had decided it made more sense to meet at my grandparents' house, which meant my grandparents didn't have to drive, and Liz, Paul, and Michael would only need to travel a short distance from their house. My mom and Stefan had a drive similar to mine, and I was happy to see that Elaine and April had come with them.

The two girls and Michael seemed content to be with each other, and three babies meant there was plenty of opportunity for my grandparents to interact with their grandchildren, though April wasn't technically a grandchild yet, as the adoption process for Elaine would likely take another year.

"How are things going?" my grandfather asked when we had some time alone in his study after a family lunch.

"I'm happy to be back in the Emergency Department," I replied. "And you can see Rachel is healthy and happy, minus being a bit fussy because she's teething."

"I believe you know the answer your grandmother would like to hear about how things are going," he said with a smile.

"Of course, and I'm sure she has heard from Andrijana Dimitrijevic that I'm seeing Danijela every Sunday. I know Grandma's concern, of course, and it's the family gathering to meet Danika Kurian on the 25th."

"I have to ask, for my own knowledge, not to be shared with your grandmother, but if you're seeing Danijela regularly, why bring another girl to meet all of us?"

"Because I'm waiting until September to make any decisions in that regard, and it would be foolish of me to ignore other young women who might be interested. Grandma knows I was seeing girls from Holy Transfiguration, but none of them proved to be suitable matches."

"You can imagine her reaction to the news about the girl."

"Grandma is entitled to her opinion, and I'll listen politely," I replied with a smile. "Then make my own decision. Did you have an opinion?"

He smiled, "You know the Russian proverb about chasing two hares?"

I nodded, "If you start chasing two hares, you will catch neither."

"Beyond that, I have no opinion. I do not feel compelled to offer opinions the way your grandmother does."

"I value your counsel, «Дедушка» (dedushka)." ("Grandpa")

"My opinion," my grandfather said with a smile, "is that you should marry the young woman you feel best meets your needs and the needs of my great-granddaughter. I will love your wife as a granddaughter no matter who she is. That was my promise to your mother about your father."