Chapter 43: Fives Across the Board

September 23, 1988, McKinley, Ohio

"How did your dinner with the Sokolovs go last night?" Clarissa asked when we met in the ED on Friday morning.

"Fine. It was, in many ways, similar to the dinner Elizaveta and I had with them. The main difference is that Kris is far more worldly than Elizaveta was, and in fact, in many ways, more than I am."

"That's a fairly low bar!" Clarissa declared mirthfully.

"Love you, too, Lissa! I'm not nearly so provincial as I was when you met me."

"I grant you that much!"

"What did I do to deserve the abuse today?"

Clarissa laughed, "It's no different from any other day! And if I'm not giving you a hard time, then something is fundamentally wrong with the universe!"

"That would definitely concern me! How was overnight?"

"Strangely, a steady stream of patients, but not a single surgical consult. I volunteered to do scut the same as you, so I had stuff to do."

"Sitting around waiting is, in one sense, part and parcel of the ED; but these 'on-call' situations are really a waste of time if you're just sitting doing nothing except waiting for a surgical case. At least the Residents and Attendings can use the time to do chart reviews."

"You study, right?"

"Yes, but even that has diminishing returns at this point, as we've memorized everything we need to fulfill our roles and to pass the exams. At least in the ED, I can't do any more than I'm already doing. Heck, even next year I won't be able to do a chest tube because I won't have had surgical training. That's one thing I think can change, and something I'll push for once I've completed my first year of surgery — any Attending in the ED should be permitted to perform a thoracostomy, so long as they've been trained."

"They can, with supervision, right?"

"Yes, but that defeats the point, especially given the surgical Residents want to do the procedures, not watch somebody else do them. I'll be assigned full time in the ED, so I'll be able to supervise, but that's still a few years away."

"What other procedures would you allow?"

"The key ones are trach tubes, chest tubes, central lines, and pericardiocentesis. Having to wait on surgery or cardiology to do those puts patients at risk, and there's no reason an ED doc can't do those things. Yes, there's risk, but the reward is worth the risk, in my estimation. But it's not up to me, and won't be for decades. I can, on the other hand, push for those changes."

"Mike Loucks, Lobbyist!" Clarissa teased.

"Now you're being nasty, Lissa!" I protested.

Clarissa laughed, we hugged, she left, and I went into the lounge to see what the day would bring.

"Morning, Mike," Debbie said. "Want to get coffee?"

"Sure," I agreed.

We left the lounge and headed towards the cafeteria.

"I'm still thinking about that rape kit on Monday," she said.

"I struggled with it both the first time and this time, too, but it'll lead to a conviction because they found 'foreign' pubic hair and semen, and as she told the police officer, she'd never had vaginal intercourse with anyone."

"Yes, but pictures? I mean close-ups that are worse than anything you see in Playboy or Penthouse!"

"I'll remind you that in our anatomy books there are similar close-up photographs. And the Polaroids the deputy took won't be shown to anyone except the prosecutor, and, if necessary, the judge and jury. I'm not a lawyer, but I don't think they'll need them, though the ones of the abrasions are evidence that intercourse was involuntary."

"Why phrase it that way?"

"Because you can bet your bottom dollar, the captain of the football team is going to claim it was consensual."

"Do you know if they arrested him?"

"Normally I don't follow up on cases, but according to the McKinley Times, he was arrested and is out on bond. He was suspended from Hayes County High, and the paper speculated he'll lose any chance at a football scholarship, but I think that's the least of his worries at the moment, given the potential for a lengthy prison sentence."

"You don't follow up on cases?"

"No. When you practice emergency medicine, you treat traumatic injuries and hand the patients off to another team or release them. It took me some time to get used to the idea of not knowing what became of most patients. It bugged me at first, but now I'm basically used to it."

"I'm not sure I could deal with that."

"Then, as was made clear to me in no uncertain terms by several doctors, emergency medicine isn't for you. And unless you become a GP, you won't know the outcome for most patients beyond their discharge. Cardiology and OB are two where you also tend to have a longer-term relationship with your patients. If that's important to you, then you need to consider specialties which are focused on the longer-term."

"You decided on emergency medicine in fourth grade, right?"

"Yes, and I hadn't considered 'treat and street', because the concept I had of doctors was my pediatrician. I had never set foot in a hospital until I was an undergraduate."

"You were born at home?" Debbie asked.

I laughed, then said, "No. But I also certainly didn't know where I was or why I was there! And I certainly didn't walk out on my own!"

"You know what that phrase means!"

"Of course! But I also think you chose to understand it in an extremely literal way, when I meant volitionally, as in 'I would never set foot in' and then fill in some place I would never voluntarily go."

"Such as?"

"Good question! When I was a deacon, I could have said 'a mosque', though I don't know of any which are nearby."

"But you would now?"

"As a learning experience? Sure. I was prohibited from doing so as Orthodox clergy for historical reasons. As a layman, such restrictions no longer apply."

"Do you know much about Islam?"

"A basic outline, but I can't actually read their holy book, the Qur'an, because it's in Arabic, and translations don't count in their minds."

"But you've read it?"

"Yes. And what I learned in a world religious course and while I was studying to be a catechist, has helped me understand Doctor Rafiq's views, although I disagree strongly with him."

"He's a male chauvinist pig," Debbie declared, though she kept her voice low.

"He certainly has no respect for women," I replied, "but that's not uncommon amongst the surgeons who are in their forties and older. Doctor Roth obviously is not that way."

"Your church has only male leadership, right?" Debbie asked as I filled a cup with decaf.

"If you mean only male deacons, priests, and bishops, yes, that's true, but the majority of parish councils in our diocese are led by women. When we elected our current bishop, half the lay representatives were women. And our church isn't hierarchical the way the Roman Catholic Church is, where everything is 'top down'. In our church, it's close to 'bottom up'."

We paid for our coffee and headed back to the Emergency Department. It was a mostly quiet day, with only one surgical consult, though Debbie and I were asked to help with some minor cases. The entire experience of being on call in the ED convinced me that the new way, with a surgeon assigned to the ED, made much more sense than having an entire surgical team on standby. It would take a decade before the new system could be fully implemented, but every year would bring some amount of improvement.

At the end of the day of the penultimate week of my surgical rotation, I collected Rachel from daycare and took her to her grandparents' house before heading home to shower and change. Kris arrived, we hugged, then headed to the Chinese restaurant for dinner with our friends. After dinner, we went to a jazz concert at Taft, and then Kris headed to Oksana's house for the night.

September 25, 1988, McKinley, Ohio

On Saturday, after breakfast, band practice, and shopping, Kris, Rachel, and I had headed to Rutherford to spend the afternoon with my grandparents, my sister and her husband, and my mom and stepdad. We'd had an enjoyable time, and my grandmother had not shown any signs of disapproval, which I considered a good thing.

Kris, as was her usual practice, stayed with Oksana, and Rachel and I picked her up for church on Sunday morning. We'd agreed that we'd attend at Saint Michael twice a month and the cathedral twice a month, until we married, and then we'd be at Saint Michael full time. So far, nobody had said anything negative, and it appeared that the gossip and backbiting were firmly in the past.

Following the service, Father Nicholas asked if we could speak after lunch. I agreed, and after I ate, I left Rachel in the custody of Kris, and accompanied Father Nicholas to his office.

"I know you don't prefer embroidery," Father Nicholas said with a slight smile, "so I'll simply ask you where you and Kris plan to be members beginning in January."

"Here," I replied. "I feel things have changed sufficiently for it to work."

"I'm happy to hear that," Father Nicholas replied. "Is Father Stephen still your confessor?"

"Yes, until I make contact with Father Roman, which I plan to do in the coming weeks. Well, assuming he'll accept me for spiritual direction."

"Is Kris OK with that?"

I smiled, "She's ROCOR, and you know how fanatical they are!"

Father Nicholas laughed, "Says the historically most zealous member of this congregation!"

"I think you have me confused with Nik Antipov!" I replied with a smile.

"I did say 'zealous' not 'fanatical'!" Father Nicholas countered. "But in all seriousness, are you and Kris on the same page with regard to prayer and fasting? I ask because I understand that you both basically rejected pre-marital counseling."

"We did, and we are. We're also on the same page for attending services, though you know my shift schedule will interfere with that. And we will attend at the Cathedral from time to time."

"Are you able to teach Sunday School?"

"Assuming my schedule allows it, I could teach some of the time, but I wouldn't want to be the main teacher because I can't make the necessary commitment."

"I think that would be good for the teens," Father Nicholas said. "You connect with them better than any of the other qualified teachers. What's your schedule like for October and November?"

"I'm on a pathology rotation, and have regular hours — 6:00am to 6:00pm, Monday through Friday, with no on-call."

"What do you do in pathology?"

"Assist with autopsies, mainly, but also checking in specimens, following up with the lab, and anything else I'm asked to do. It's not a typical rotation for anyone who isn't interested in being a pathologist, but I'll spend two months being able to use a scalpel, and as a medical student, that's the only opportunity to do so. It's against the rules for a med student to perform any kind of invasive procedure, even minimally invasive ones, except for exams, intubation, IVs, catheters, and giving injections."

"Exams?"

"OB/GYN," I replied.

"Ah, OK, I don't think we need to discuss the details!"

"Fortunately, something I will rarely be called upon to do. Very few women in labor come through the Emergency Department. Even when the paramedics bring them in, they usually go straight to OB. It would only be the case where they had some kind of traumatic injury or life-threatening condition that we'd treat them. In the case of someone not in labor, we'd call for an OB/GYN consult, and one of the doctors from that service would do the exam. Though, with EMTALA, that might change to doing a quick exam in the Emergency Department."

"EMTALA?"

"The Emergency Medical Treatment and Active Labor Act which requires an exam, and also complete care for a woman in labor, so in order to ensure we check all the boxes, we might have to do a brief exam in the Emergency Department so there isn't any question about whether we've met the requirements of the law."

"What does the law require?"

"The short version is that anyone who presents at the Emergency Department and requests treatment, has to have an exam, and has to be provided with any necessary life-saving treatment, and any woman in active labor must be cared for until she has given birth. All of that, without respect to their ability to pay. In fact, charges for services can't even be mentioned to a patient until after they are treated.

"The law creates civil liabilities for the hospital and individual doctors and nurses, which means a patient who isn't treated can sue and collect. Because juries are notoriously generous with insurance company money or taxpayer money, the hospital will, out of self-defense, go far beyond the requirements of the law. We're already seeing the impact of that because some people have figured out that they can receive treatment without paying up front, which they can't do with their personal physician or a free-standing clinic."

"Why is that?"

"Because it only applies to hospitals which offer trauma services. Your doctor can demand payment before he sees you, as can a free-standing clinic. We can't even mention it. That's going to create significant additional costs for the county, which means they'll either have to raise fees for paying patients or raise taxes, and I expect them to do both."

"Doesn't Medicaid cover some of that?" Father Nicholas asked.

"If the person qualifies and has applied for coverage. I don't have any specific numbers, but in our Practice of Medicine courses, they said that nationwide, enrollment was only a fraction of the people who would actually be eligible. I don't pay too much attention to any of that, because in the Emergency Department, we don't have to worry about specifics, especially with EMTALA in place."

"Out of curiosity, what happens if someone needs an expensive test or procedure?"

"From my perspective, I would order any test I felt necessary to diagnose and treat a patient. Remember, the law says I can't ask about their ability to pay before treatment."

"Can you ask about insurance?"

"That's an open question, and right now, the hospital does not ask. We'll need to see what final rules are promulgated by Health and Human Services to know for sure. If you think about it, asking about insurance is a proxy for asking if they can pay, so I'm not sure the government will allow that."

"You just told me my taxes are going to go up."

"I think that's true no matter what! I mean, do you really believe George Bush's promise of 'Read my lips: no new taxes'?"

"Sadly, no," Father Nicholas replied. "Out of curiosity, and you obviously do not have to answer, but who are you voting for?"

"Holding my nose, George Bush," I said. "I just can't bring myself to vote for Dukakis. I liked Gary Hart, but you know what happened there."

Father Nicholas nodded, "I do, and Biden's campaign collapsed after he got caught plagiarizing speeches and his law school record was questioned. And with Mario Cuomo refusing to run, I think the only choice I can make is the same as yours — hold my nose and vote for Bush. Anyway, is there anything you need from me at this point?"

"Not that I can think of. When did you want me to teach?"

"How about twice in October and twice in November? I'd like you to cover the Ecumenical Councils, if you would."

"I can do that," I replied.

"Thanks."

I asked for and received his blessing, then left his office and went to find Kris, who was with Rachel in the nursery, playing with toys.

"Any problems?" Kris asked.

"No. Father Nicholas was simply curious about our plans, and also wanted to ask me if I'd teach Sunday school on two Sundays in October and two in November. I said 'yes'."

"What subject?"

"The Ecumenical Councils. I've done that before, so I have my notes and some handouts, though I'll change how I present it slightly to keep it interesting for those who've heard it before."

"Which group?"

"Young adults, which is fourteen to twenty-four in our parish."

"High School and college are separate at the Cathedral."

I nodded, "Part of that is numbers, but part of it is that the former priest at the Cathedral felt it was better to keep the college kids and High School kids separate."

"Why?"

"You can guess the concern."

Kris rolled her eyes, "You Americans are simply too hung up on sex!"

"You're an American!" I countered with a smile. "Or you soon will be. My view is that having those groups together in a controlled environment, such as Sunday School or a youth group, is far wiser than trying to keep them apart. I've found the surest way to have a teenager do something is to forbid them to do it, or conversely, encouraging them to do it will make them reluctant to do it. That said, trying reverse psychology doesn't work because teenagers are far more savvy than most adults give them credit for being."

"In our parish in Paris, the Deacon led the group for teens, which included twelve to twenty, as you could start so long as you turned thirteen during the year, and finish if you turned twenty. Nobody thought there was anything wrong with that!"

"I'm only aware of one complaint in that regard at Saint Michael, and that person is no longer attending here. We weren't rigorous enough for him."

"The opposite of why people would move from our Parish to a Patriarchal parish in Paris."

"ROCOR does have a reputation for rigorousness. The OCA isn't, generally, but it's also not as lax as the Greek and Arab jurisdictions here. But, in the end, it's up to the bishops, and it does vary by parish. Anyway, shall we take a walk with Rachel before you head home?"

"That sounds good."

September 26, 1988, McKinley, Ohio

On Monday evening, Lara joined me for dinner. I'd seen her on Friday evenings when Kris and I had been with the group, but hadn't really had a chance to speak with her.