Chapter 24: New Opportunities

July 26, 1988, McKinley, Ohio

"Why are you laughing?" Lauren asked, sounding offended as we walked from the cafeteria on Tuesday afternoon.

"I'm sorry. I wasn't laughing at you, but at me, because I am dense. But it's also the case that given the shenanigans that have gone on since I started medical school, I've developed a personal rule that I won't get involved with anyone I supervise, anyone who supervises me, or anyone who is on the same team."

"Which makes me off limits?"

"Before I answer that, I think it's important to point out that I'm hoping to re-marry, and relatively soon."

"Not to be insensitive, but it's been less than a year."

I nodded, "I know, but I believe it's in both Rachel's best interests, and mine, to re-marry."

"That changes the situation pretty significantly."

"It does, and unless you were only interested in a short-term relationship, you have to consider the fact that our long-term goals diverge — you want to go back to Harlan County or someplace in eastern Kentucky, and I want to stay here. And those things need to be considered before we even discuss the risk associated with a relationship between someone you've requested as your supervisor for next year."

"I guess I hadn't thought that far forward because I wasn't considering anything other than being interested."

"So what would you do if we did start a relationship, and it was moving along successfully?"

"I suppose at that point I'd have to consider where to Match and where I'd eventually apply for an Attending role."

"How would that affect you? I guess I mean, how important is it for you to go home?"

"I suppose it would depend on how I felt about the guy, but as I said, I haven't really considered it because I wasn't dating anyone here."

We reached the Emergency Department and were immediately called to Trauma 1 to help with a rule-out MI. The patient had been received by ambulance just before we'd gone to lunch, and needed to be monitored and have additional blood drawn to check enzyme levels. Lauren handled the blood draw while I checked the monitor, which showed normal sinus rhythm and pulse, BP, and PO₂ in normal ranges, despite the patient complaining about chest and upper-arm pain.

An hour later, the patient had shown no signs of a heart attack, either on the monitor or through his blood work. I reported that to Doctor Gibbs, who signed a discharge form, and then advised the patient to follow up with his personal physician. Once the patient had left, we were assigned to suture a forearm lac, which I did.

"How come you did that one?" Lauren asked.

"Because it required fifteen sutures, and, frankly, I need the practice. I've let you do every single one to this point, but I need to do some occasionally, or I'll get rusty. That's one of the balancing acts that needs to be done as a Resident and an Attending. The more experienced you are, the more complex cases you manage, and the simpler cases you assign, but even Doctor Gibbs will suture on occasion to keep up her skills."

"I've never seen Doctor Northrup do much of anything," Lauren observed.

"Some Chief Attendings are administrators, some are physicians; he's an administrator."

"That almost sounds like an insult."

"Because it almost is!" I declared. "The entire point of a medical degree is to practice medicine, not be an administrator. Granted, if he were in hospital administration, that's one thing, but he's an Attending in emergency medicine and ought to be practicing his skills at least part time. The fact that he isn't, tells me he's angling for Medical Director, though that usually goes to a surgeon who has decreased dexterity, rather than a practicing physician from one of the other services. Add in that surgeons believe that only a surgeon can supervise surgeons, and that feeds into the Medical Director usually being a surgeon."

"Kind of like the captain of an aircraft carrier being a former pilot?" Lauren asked.

"Is that a requirement?"

"According to my uncle, who served aboard the USS Enterprise in air operations."

"I suppose it makes sense," I replied, "and there is a requirement that all surgery be supervised by the Chief Surgeon, which is why I'll technically be on the surgical service even if I'm assigned full time to the ED."

"Even for the part that is purely emergency medicine?"

"Yes. The Residency is surgical, because that's the only way it can work given the rules. At some point, with a qualified surgeon in the ED full-time, other Residents and Attendings who aren't surgeons will be allowed to perform some of the things which currently require calling a surgeon, including chest tubes. Fundamentally, at Moore Memorial, if you pick up a scalpel, you either have to be supervised by a surgeon or a pathologist, and pathologists do not treat living patients."

"Can we go back to the discussion from before?" Lauren asked.

"Sure," I agreed.

"Let's say, for the sake of argument, I was interested enough to consider marrying soon. Is there any room in your ethical system for that to work?"

"From my perspective, it would be ethically untenable if you choose emergency medicine as your specialty, because I'd always be senior to you. If you chose another specialty, it could possibly work, though your emergency medicine Sub-I would have to be handled very carefully because other Fourth Years might think I was playing favorites, and Residents and Attendings would question my evaluations."

"Emergency medicine is interesting," Lauren said, "but I'm truly undecided. Wouldn't surgery create the same problem?"

"Possibly, in reverse, because you'd be senior to me as a surgeon, but it's easier to manage by assigning us to separate teams. That can't really happen in the ED."

"So you wouldn't date a nurse you had to work with?"

"No, I wouldn't," I said firmly. "Nor a medical student whom I might have to supervise."

"Which means it's a 'no', no matter what? Because I'm planning an emergency medicine Sub-I?"

"If we decided to go out, it would have to be after the end of this month, and then when you did your Sub-I in the ED, we'd have to talk to Doctor Northrup in advance and ask him. But all of that is highly speculative because I don't get the feeling you're interested in exploring a permanent relationship right now, while I am."

"I'd say you're correct, and the more I think about it, the more I think I'd be better off with you as a teacher than a boyfriend. Wait! That didn't come out right!"

I chuckled, "It came out exactly right! I prefer honesty, and if that's your honest feeling, then I'm cool with it."

"Mike?" Bob called out. "Five-year-old with skinned knees and elbows in Exam 2."

"Got it," I said, then turned to Lauren, "Let's go."

July 28, 1988, McKinley, Ohio

On Thursday, Lauren and Maryam's prediction proved accurate, and Marcie joined us for lunch. I watched for signs and concluded that what Maryam and Lauren had said about her liking me was absolutely true. The question was whether or not I wanted to do anything about it.

The answer wasn't clear, because the situation with Nadiya wasn't clear. The moment that thought crossed my mind, I realized that I had, in effect, put Danika in the same exact position as I'd put Danijela. That said, Danika actually accepted it, and had expressed it by saying that if I chose a different girl, she'd like me to continue to mentor her and to be her friend.

I had no idea what Nadiya was going to decide. At some points, I was positive she'd decide she wanted to marry; at other points, I was positive she'd decide not to. Her confusion was understandable, and I wasn't going to push her, but Danika would be back in McKinley in less than a month. She hadn't given a deadline, nor did I think she would, but every day I waited past the 18th would risk her family finding an alternative suitor, or ruling me out as indecisive.

My ruminations would amount to nothing unless either Marcie or I took the next step. She'd taken the initial one, which, I thought, meant the next one was up to me. I decided I'd say something to her when I saw her in daycare. Lauren and Maryam clearly had other ideas, as they excused themselves immediately after finishing their lunches, leaving Marcie and me alone at the table.

"Did you arrange that?" Marcie asked once they'd walked away.

"No," I replied with a smile. "Did you?"

"No. You obviously don't recognize me."

"Recognize you?"

"I had short hair, wore glasses, and had braces when you saw me three years ago."

She had long hair, perfectly straight teeth, and contact lenses.

I shook my head, "I'm sorry, I can't place you."

"I'm from Rutherford, and graduated from High School in May last year."

Which made her younger than I had thought, as she was at most twenty, and might possibly be nineteen.

"I'm still drawing a blank. When did we meet?"

"We didn't, actually. We both testified at Sasha Antonov's annulment hearing."

I instantly knew who she was, though I didn't really remember her, other than the fact that she had basically corroborated Sasha's story. That instantly gave me pause, because the last thing I wanted was to have anything to do with Sasha and Timmy.

"Sasha's friend who testified," I said.

"Yes, but she and I haven't spoken since not long after that."

"May I ask why?"

"We had a falling out because I discovered she had lied to me about a bunch of stuff."

"You knew who I was when I brought Rachel to you that first day?"

"I recognized you, but I didn't know anything more about you than what you said in court that day. To be honest, you didn't make much of an impression because you were wearing clerical robes and were married, not to mention I was only sixteen and you had already graduated college. I had no idea you were a medical student, and I hadn't seen you here at the hospital before June.

"I obviously knew what happened to your wife, but I didn't put two and two together until you brought Rachel to daycare and I recognized you. Honestly, Sasha never mentioned you by name, and the only thing she said was that a guy Tasha had dated had suggested she go to the clinic. I never knew she asked you to marry her, or anything else."

"Small world," I said noncommittally.

If what she said about Sasha was honest, that would allay my concerns, but I needed to be careful about anything I said or did until I was sure, if I could be.

"Your entire demeanor changed when I told you who I was," Marcie said.

"To be honest, my first thought was that I wanted nothing to do with Sasha and Timmy."

"Join the club!"

"I'm curious about something," I said. "You were Sasha's friend, but you don't know anything at all about Orthodox Christianity."

"She never once talked about it except that she was a member of a church in Rutherford and her dad was a deacon, which, for your church, is a member of the clergy. That's not the case in our church where deacons head ministries. I understand deacons in your church help lead services. That is literally all I knew, except that her dad was really strict and controlling."

"According to her," I replied. "It sounds as if you never spent time at their house."

"Never. I don't think she ever invited any of her friends to her dad's house."

"So the only thing you knew about him was from what she told you, right?"

"Yes. I met him maybe three times. Why?"

"It explains why you gave testimony that contradicted mine and didn't match what I knew to be true. I'd suspected that was the case, and you just confirmed it."

"Are you upset?"

"No. You didn't lie, you simply repeated what Sasha had told you. The problem is, it allowed the judge to grant the annulment, and that basically ruined Sasha's dad's ministry."

"How so?!"

"It's a long story, but the short version is that because the judge ruled that he had forced her to marry, it led to him being what you would call 'defrocked' and it also exacerbated his health problems."

"NO!" Marcie gasped. "I had no idea!"

"And there was no way for you to know," I said. "I'm not laying what happened at your feet, because you answered the questions from the judge the only way you could. It was Sasha who lied to you, and the blame lies with her. Do you recall how the judge explained why she was granting the annulment?"

"No. It totally went over my head except for her saying that she was giving Sasha her annulment."

"Sasha could have had the annulment automatically, without making any claims against her dad, simply by asking for it from the court before she turned eighteen. Because she didn't do that, either out of ignorance or spite, it caused the result I mentioned, ruining her dad's reputation and his health."

"I feel guilty," Marcie said.

"Me, too, but for other reasons. So does Tasha. The one person who doesn't is Sasha."

"Even more reason to stay away from her."

"On that we agree," I said.

"Is it OK if I join you for lunch on Monday?"

"Sure," I replied.

That would actually be after I saw Nadiya, which I felt was a good thing. We got up, she went back to daycare, and I walked to the ED just as my thirty minutes for lunch expired. The rest of the afternoon was busy, but there were no interesting walk-in cases, and when my shift ended, I collected Rachel and we headed to Doctor Forsberg's house for dinner with her and Doctor Smith.

July 29, 1988, McKinley, Ohio

On Friday afternoon, my last day in the Emergency Department, I met with Doctor Gibbs, Doctor Casper, and Doctor Gabriel for my evaluation.

"Did you turn in your evaluation?" Doctor Gibbs asked.

"Yes. I took a few minutes at lunch to hand it in so that Doctor Mertens had it before I met with you. I didn't realize it was a team evaluation."

"All Fourth Year evaluations in the ED include at least one Attending and one Resident," Doctor Gibbs replied. "And you know we poll the nurses as well."

"Maybe I should have gone out with Ellie," I grinned.

All three of them laughed.

"I don't think we need an evaluation of THOSE skills and abilities!" Doctor Gibbs declared. "Our evaluation of your relevant skills is extremely positive, as I'm sure you expect. We're happy with your progress, including the demonstration of your ability to teach and properly balance allowing those you're teaching to perform procedures."

"I take it you spoke to Lauren," I interjected.

"Yes. That's typical. And if you're wondering why I didn't ask you about Doctors Casper and Gabriel, it's because I know you well enough that you would have addressed any concerns you had with them or brought them to me or Doctor Northrup. Unless you have something specific for us, I don't think we need to take any more time away from patients."

"Nothing on my part," I replied. "As you say, I've addressed my concerns, which were minor, with my Residents."

"I know you have one more emergency medicine Sub-I," Doctor Gibbs said, "but we want to encourage you to apply for a Residency position at Moore Memorial."

That was the only official statement she could make, and one which would be repeated by Doctor Roth. It was silly because I'd designed my own Residency program, but necessary due to the rules for the National Match. It was a violation of the rules to promise a Residency, but what Doctors Roth and Gibbs had done complied with the rules, even though it was obvious they intended the new Residency slot specifically for me.

"Where else do you plan to apply, Mike?" Doctor Gabriel asked.

"Hospitals in Cincinnati, Dayton, Columbus, and Pittsburgh. I intend to put the Moore Memorial trauma surgery Residency at the top of my list."

That was something I could say and was a way for a hospital to know they were not wasting a selection on someone who was not interested. I'd tell the application committees of the other hospitals that I was interested, but that they would not be my first choice.

"What about Chicago?" Doctor Casper asked. "The Chief there was trying to recruit you."

"I have no intention of moving to Chicago, so I'm going to decline to interview. I wouldn't put them on my list. Columbus will be my second choice, then Cincinnati or Dayton, then Pittsburgh. I hope to not need any of my backup choices."

"We hope so, too, but you know how it works."

"I do."

"Surgery next, right?" Doctor Gabriel asked.

"Yes. I'm on Surgical Team A with Doctor Roth. The Residents are Doctor Lindsay and Doctor Taylor."

"When are you back in the ED?" Doctor Casper asked.

"Not until April. It's my last Sub-I."

"Then if you're satisfied," Doctor Gibbs said, "we're done. Fives across the board. If you'll sign, I'll get a copy for you."

I picked up a pen, scanned the evaluation form, and signed the line indicating that I'd received my evaluation. I shook hands with all three doctors, then rejoined Lauren for the final hour of my shift.

"All good?" she asked.

"Yes. How was your evaluation?"

"I'm happy. I didn't get all fives, but Doctor Gibbs said I was 'above average'."

"Where did you fall down?" I asked.

"Communication, because at first I was too quiet and didn't ask enough questions. But once I began working with you, I saw how you did it and tried to change my style. I also need to work on my diagnostic skills."

"That will come with time, but the most important thing you can do is review everything from First and Second Year on a regular basis. When you have your surgery rotation, you absolutely want to check the upcoming procedures and study them. For your first day, make a point of checking the night before, so you come in prepared. You won't actually do anything other than pre-op and post-op care, but you will be quizzed. And those quizzes make up an important part of your grade. That's doubly true if you want surgery."