Chapter 16: I Know the Answer Already

June 22, 1988, McKinley, Ohio

"I think she overplayed her hand," Kari said after I explained during dinner on Wednesday what had happened with Danijela. "And I think Clarissa's analysis is accurate. Sure, there's a risk that Danijela tells you to go away if you call her in October, or whenever, but I doubt it. OK to ask a question you might not want to answer?"

"I'm fully capable of not answering if it's not appropriate," I replied.

"Have you and Danijela knocked boots? I'm asking because that might explain her reaction to your upcoming family gathering."

"No, we haven't. And I agree that would have made a significant difference, given her take on the matter."

"We spoke about your friend Annette's views on that, and now that I have some experience in that regard, I have to say I think she's right. I get why that wasn't possible with your wife, given she wasn't sixteen until a month before your marriage and you were already engaged, but now? Why take that risk?"

"I totally understand your point," I said, "but I don't think it's the complete answer. A girl who has decided she wants to wait for marriage isn't going to respond well to a request for what Annette called a 'test drive'. And how tacky would it be to have sex with someone and then say that it wasn't good enough for you to marry?"

I had thought that way about Oksana, but had come to the realization that I had been mistaken, both in terms of my thinking and in terms of her ability to change her thinking.

"That would be tacky," Kari observed, "but isn't compatibility very important?"

"I think that can be resolved by a combination of talking beforehand and teaching when appropriate. That strategy worked quite well with Elizaveta, who was completely inexperienced when she approached me about marriage."

"You are pretty good," Kari said with a sly smile.

"Just 'pretty good'?" I asked.

Kari laughed, "Male egos are so fragile! But seriously, I have nothing to compare it to, so maybe there is someone better!"

"Maybe there is," I replied. "But, in the end, it's a question of being satisfied with that part of the relationship. From my conversations with Danijela, I don't think that would be a concern with her, or Danika for that matter."

"And Nadiya?"

"I can't make any assumptions, but she did say she hadn't dated seriously in High School because, in effect, High School boys are immature."

"That was my reason as well. I'm sure I made the right decision, both in not getting serious in High School and in getting serious with you. And that's regardless of how things turn out between us."

"I was certainly immature in High School, and it took repeated beatings from Clarissa to whip me into some semblance of maturity. Elizaveta did some heavy lifting as well, and Rachel completed the process."

"Completed?" Kari asked with a silly smile.

"As much as possible for someone with the 'hold my beer and watch this' gene!"

"That's poor judgment, not lack of maturity!" Kari countered.

"The two often go hand-in-hand, but all kidding aside, having a daughter to raise on my own has caused me to consider everything I do more carefully than I did before."

"Oh, right, because you didn't think about the possible wrath of your Russian wife?" Kari asked.

"Anicka, er, Doctor Blahnik, said something about that?"

"You can say her first name and I'll know who you mean. She just said that your wife was feisty and kept you in line!"

"That she did, though I still managed to get into trouble, mostly to do with church."

"Doctor Blahnik doesn't know much about that, or if she does, she's not sharing."

"Most of it was stuff I couldn't speak to anyone about, and in a few cases, could only give Elizaveta the barest of details."

"It'll be like that with the hospital, too, right?"

"Not as bad, actually. So long as I don't reveal names or make it easy for you to identify the patient, I can discuss specific cases."

"You don't say much about it."

"Mostly, it's routine. Well, routine for me."

"Do you have patients die on you?"

"Yes. On Monday, a sixty-year-old man came in having a heart attack. Specifically, a STEMI — ST Elevation Myocardial Infarction — which are fatal more often than not. He went into V-fib — Ventricular fibrillation — which is basically your heart fluttering so it can't pump blood. We tried to defibrillate him, but he didn't convert to sinus rhythm, which is what we call a 'normal' heartbeat. Then he went into asystole, which means the heart is not beating. At that point, we used CPR and epinephrine to try to revive him, but it failed."

"You don't try to shock him again? Why?"

"Because it doesn't work. You need what's called a 'shockable rhythm' — V-fib, A-fib, or V-tach. It doesn't work for asystole or PEA. V-fib I explained, A-fib is similar, but it's atrial rather than ventricular. V-tach is ventricular tachycardia, which is an extremely rapid heartbeat. PEA is Pulseless Electrical Activity, which means we see activity on the EKG but the heart isn't beating. In those cases, we use epinephrine and CPR to try to get the heart started again. With the type of heart attack he had, it doesn't work very often."

"What's an ST elevation?" Kari asked.

"On a standard EKG there are various electrical impulses measured, referred to as P, Q, R, S, T, and U. The P wave represents atrial depolarization, the QRS complex represents ventricular depolarization, the T wave represents ventricular repolarization, and the U wave represents papillary muscle repolarization, but it doesn't always show on an EKG strip.

"An elevated ST segment is abnormally high, usually by 1 small block on the EKG strip. A convex ST segment is highly indicative of a myocardial infarction, and it is obvious on the video monitor as it is on the paper strip. It's caused by lack of oxygen to heart muscle, usually caused by coronary artery occlusion. I can explain further, if you want."

"No, I think I got it. Basically, you can read the EKG and tell if someone is having a heart attack."

"Yes, and there are different kinds. The kind we just discussed make up something like thirty to forty percent of all MIs. Other kinds are indicated by inverted T waves, a wide QRS complex, and various other signs on an EKG accompanied by chest pain, shortness of breath, and diaphoresis."

"What's that last one?" Kari inquired.

"Sweating, which is a typical heart attack sign, along with the others I mentioned. Oh, and just to make you feel good about being female, heart attacks are much more difficult to detect in women, and false negatives are very common."

"Why?"

"Nobody knows. I asked the Chief of Cardiology and his opinion is male physiology lends itself better to current EKG technology. In his opinion, it comes down to tolerances because, for example, women typically only have 66% to 75% of the ST elevation rise a male would have. And the types of heart attacks can be quite different.

"Whereas men often have obstructive coronary artery disease where an artery becomes blocked, women typically have small artery disease or coronary microvascular disease, and those are difficult to detect via angiogram or cardiac catheterization. Add in the fact that nausea and dizziness are much more commonly reported by women for other conditions, and that causes doctors to look for other problems.

"Your risk for breast cancer is far higher than your risk of a heart attack until you're in your mid-fifties, at which point heart attacks cause more deaths than breast cancer. After that, the risk increases significantly for every five years, to the point where in your seventies the risk of dying from a heart attack is six times that of dying from breast cancer. And, as I said, it's often undetected."

"Is there a way to detect it?"

"A stress test with an EKG," I replied. "Basically, they put you on a treadmill and watch for EKG changes."

"Trying to induce a heart attack?"

"Looking for minor EKG changes that indicate a potential heart attack before it happens."

"And you just keep all the information in your head?" Kari asked.

"Yes. You've seen my flashcards and my notebooks. I review whenever I have spare moments. The most important skill for a doctor is the ability to recall information and synthesize it into a diagnosis and treatment plan. Except for surgery, most procedures are easy to learn. I could teach you to insert an IV, draw blood, or insert a Foley catheter in less than an hour. Some things, like suturing and intubation, take practice, but again, I could teach you those things. In fact, I'll be teaching those things starting next June."

"Right after you graduate?"

"Yes. My Attending will continue to train me while I train medical students in the things I know how to do well. The system actually works reasonably well and produces excellent physicians. I think it needs some tweaks, but it does work."

"Coming back from that rabbit trail, I think your response to Danijela has to be 'not now' unless you are absolutely sure she's the right one, and you are decidedly not sure. In fact, I'd wager that if I said I was ready to be a mom, you'd ask me before you'd ask her."

"I suspect you'd win that bet," I replied.

"If you could wait until I graduated ... but I know that's not going to happen."

"Just out of curiosity, how would things be different if we were married for those three years, rather than get engaged or be a couple or whatever you want to call it?"

"I don't think I can give you a satisfactory answer other than to say that I'm not ready to accept the responsibility that comes with being a mom."

"What about living together?" I asked.

Kari smiled, "As much as I like that idea, the only difference would be the paperwork. Honestly, it comes down to being afraid of the responsibility. I'm positive you know how I feel."

I nodded, "At least as much as anyone can understand another person's feelings. The responsibility frightened me, and still does, but I didn't, and don't, have a choice. I had to grow up completely that day. That was the end of my childhood and the beginning of my adulthood."

"Not the day you married?"

"My wife was prepared for motherhood from the moment I met her. I wasn't ready for fatherhood until I held Rachel in my arms after Elizaveta reposed. At that point, as I said, I had no choice. It was either grow up or abandon my daughter. It was an easy decision."

"PAPA!" Rachel exclaimed, interrupting our conversation.

She'd had her dinner before Kari and I had started eating, so I wasn't quite sure what she wanted, and felt it might simply be attention. I took her from her high chair and held her in my lap, which caused her to gurgle in delight.

"Daddy's girl, for sure!" Kari declared.

"We'll see," I replied with a grin. "Women have a way of ganging up on men!"

June 24, 1988, McKinley, Ohio

"Hi!" Sara exclaimed when she arrived at the house on Friday evening.

"Hi. Come in. I ordered Italian from Antonio's before I left the hospital. I'd like to see The Presidio, and then get ice cream."

Sara came into the house and as I was about to close the door, I saw the deliveryman from Antonio's with our food. I waited for him to come up to the porch, paid him, then took the food inside. Sara and I went to the table, I said the prayers of blessing, then we unpacked the food and began to eat.

"Can I ask you something about last Friday night?" Sara inquired.

"Sure."

"Why no 'good night' kiss?"

"Because we simply can't go back to the status quo ante and pick up as if nothing happened."

"It's not because you think I'm slutty or dirty?"

"No. It's about breaking your promise and then avoiding me, not about making out with another horny teenager. I hope you don't think I have a double standard in that regard. You know I slept with other girls while you and I were seeing each other. I do not subscribe to the idiotic notion that guys who have sex are studs and girls who have sex are sluts. But if this is going to work out, then we take it slowly."

"But you're going to decide soon," Sara protested dejectedly.

"Not as soon as you might think," I replied. "Someone asked me to stop seeing anyone else and I'm going to refuse because I'm not sure. You and I have discussed the challenges I'm going to face at the end of August, and I have no idea how I'll feel after that. It's true that I had thought I'd be betrothed by then, but I've reconsidered that because I realize I'm not emotionally ready to make a lifetime commitment, and I don't understand how August 26th will change me, because I'm sure it will."

"That had to be Danijela, right?"

"May I give you some advice?"

"Yes."

"If I don't name a name, it's intentional. You can make inferences or assumptions, but you shouldn't, really. Asking questions when I'm being circumspect risks playing 'Twenty Questions', something I can't do as a doctor, and certainly couldn't do as a deacon."

"Sorry," Sara said quietly.

"It's OK," I replied. "I'm not upset, but it is the case that there will be things where I have to be circumspect or vague, and you'll have to accept it. If you can't, that will create a significant point of conflict. That was something Elizaveta struggled with, though more about things at church than medicine."

"I feel like I keep messing up," Sara sighed.

"We often learn more from mistakes than from doing things correctly. That's the point of the Morbidity and Mortality conferences which review cases which had sub-optimal or bad outcomes. Unfortunately, I haven't had the opportunity to attend many of them due to my schedule in the Emergency Department, but I'll be able to do that when I'm on my cardiology, surgical, pathology, and ICU rotations. And once I'm a Resident, I'll attend regularly."

"What happens at those?"

"Cases are reviewed by every doctor who is interested and questions are asked and answered. It's non-confrontational, and nothing said there can be used in any forum outside the conference. It's meant to allow doctors to speak freely and work out where things can be improved. Someday I'll make a mistake, or perhaps a sub-optimal choice, and I'll be the one being examined."

"You think you'll make a mistake?"

"I'm positive I will at some point. And someone might even die because of that mistake, error in judgment, or oversight. And it'll suck. But it's also unavoidable, especially in trauma. The key is to not be negligent or intentionally do something that unnecessarily puts a patient at risk. It's also the case that you can do absolutely everything right and the patient might still have a poor outcome or die."

"You say that almost cavalierly."

"Because it's part of the job," I replied. "It's one of those things a doctor has to accept — some patients will die no matter what he or she does. That happened this week with a heart attack case. We did everything according to the book, and the patient died."

"Why?"

"We don't know for sure, and I don't even know if his wife authorized an autopsy to find out, but the type of heart attack the patient had is fatal in more than two thirds of all cases, either immediately or soon after. Basically, heart muscle is starved of oxygen and dies, and that's not something that can be repaired. If the damage isn't too severe, the patient can recover, but if it's severe, only a transplant could save them, and those generally can't happen quickly enough, even if the organ is available via UNOS."

"UNOS?"

"A database of people waiting for organ transplants that is used to match them with available organs on a regional basis. It's increased the number of available organs for transplant, but organs are still scarce. And you would need a match. There is research into mechanical augmentation, but the LVAD, or Left Ventricular Assist Device, is experimental, and the first long-term implantation was in March of this year. It's meant to keep a patient alive until a transplant can be found and is intended to only be used for eight to ten days."

"You couldn't use one of those?"

"Not in the Emergency Department, and the patient's heart stopped even before the cardiologist arrived in the trauma room. But him not being there didn't affect the outcome because we did everything correctly."

"How did you feel?"

I shrugged, "I didn't, really. Death is part of the job. What sucks is telling the loved ones that the patient died. We're taught to be coldly clinical and allow the social workers or chaplains to handle things, but I don't like it."

"What do you say?"

"There's a rehearsed line, which basically says we made our best effort, using all our skills and abilities, but we couldn't revive the patient and they died. We can't say too much beyond that because the cause of death isn't always obvious. For the heart attack patient, we said his heart stopped and we couldn't get it started. Then we turned the wife over to the chaplain."

"I don't think I could do that."

"It's one of the many things doctors simply have to be able to do. If you can't, then you don't become a doctor. Well, you could be a dermatologist or podiatrist or GP and possibly never have to deal with it, but if you're in the Emergency Department, Cardiology, Surgery, Internal Medicine, Oncology, or the ICU, it's part and parcel of the job."

"So, what did you do?"

"Went on to treat the next patient," I replied. "It's the only thing a doctor or nurse can do. We save more than we lose, and if we weren't there, far more people would die or have a lower quality of life. But that's probably enough about medicine. What did you do this week?"