Chapter 50: Rare Cases and Trick Questions

October 31, 1988, McKinley, Ohio

"Halfway done with this rotation," Clarissa said when we met for lunch on Monday. "Do you think you made the right decision?"

"Absolutely! I could tell the first few times how rusty I was with the scalpel, but now it's better, and I'm developing muscle memory. The only downside is that from now until my third year of Residency, I won't get to do much work with the scalpel. Unfortunately, none of the ER Attendings is a qualified surgeon, so I'll have to rely on the surgical Residents giving me a chance to do procedures. What do you think the chances of that are?"

"ZERO! No surgical Resident is going to voluntarily give up a procedure to a trauma Resident."

"Technically, I'll be a surgical Resident."

"That and $1.00 will get you a cup of coffee at Frisch's."

"Fortunately, the ED has good coffee, and the contribution works out to about 35¢ a day. Anyway, I've also been able to hone my diagnostic skills. I read the charts, predict what we'll find, and then compare what we find to what the doctors had diagnosed. I've seen a few real doozies where they missed."

"And some horrible stuff, too."

I nodded, "We'll see them in the ED, too," I replied. "Saying that it's something I have to get used to seems wrong, but honestly, that is what it comes down to in the end."

"What did you have this morning?"

"One of the rarest things you'll ever see. It'll be the M & M a week from Friday."

"Spill, Petrovich!"

"Asymptomatic papillary fibroelastoma. Death was from embolization of the tumor in the left main coronary artery."

"Damn. How old?"

"Twenty-nine. He was working construction and literally dropped dead on the job site. Two guys on site had CPR cards and performed CPR until the paramedics arrived. The paramedics did the same and brought him in. He never had a shockable rhythm."

"And nothing at all in his history to indicate that?"

"Nothing. He'd have needed a cardiac ultrasound, and why would anyone have ordered a test like that on an ostensibly healthy twenty-nine-year-old?"

"Could it have been excised?" Clarissa asked.

"According to Doctor McKnight, yes, had it been found. It was benign, too."

"Nothing at all in his medical record?"

"No. Not even a report of chest pain. Any interesting cases in Endocrinology?"

"We just diagnosed a case of nephrogenic diabetes insipidus. We're still looking for the cause, though Doctor Gilquist strongly suspects autosomal polycystic kidney syndrome. There's a family history of renal problems."

"That was one of the 'trick' questions on the MLE Step 1," I replied. "Med students often confuse diabetes insipidus with diabetes mellitus. And the minute you say 'diabetes' to a layman, they think 'insulin'. But, as you know, in both cases, it refers to generating excess urine."

"I'm sure you know the Greek or Latin origin!" Clarissa declared.

"Latin borrowed from Greek, but the word is basically the same — « διαβήτης» (diabētēs), meaning 'siphon' or 'to pass through'. And I'm sure you remember what 'insipidus' means!"

"Yes," Clarissa replied. "It means 'tasteless' as opposed to 'mellitus', which means 'sweet'."

"And which was mentioned in ancient Egyptian and Indian texts. I'm very happy we don't use the 'taste test' method of diagnosis!"

"Gross, Petrovich!"

"Science and medical advance demand sacrifices!" I replied with a grin.

"That's going too far! But that was the clue to the trick question, because the patient said they had 'diabetes' and then in the list of lab results was what amounted to diluted urine."

"Precisely," I said.

"Changing topics, did everything go well on Friday night?"

"Yes. My duet with Kris was well received, though I have to say singing with Milena was more emotional."

"If it weren't for Joel, I could see the two of you together."

I shook my head, "Our spirituality doesn't line up, and she couldn't compromise even as much as you could. And you agreed with Lara about my core beliefs and practices. That would have been a concern with you, too, though there were larger concerns."

"True."

"Rachel has a new word," I said. "'Poo'. But I have to work with her on that one."

"Why?"

"Because she said 'DADA! POO!', not 'MAMA! POO!'"

"Nice, Petrovich. Did you tell Kris that?"

"I'm not as dumb as I look!"

Clarissa narrowed her eyes, studying my face. "Hmmmmm."

"Love you, too, Lissa!" I said with a silly smile.

We both laughed, then finished our lunches and headed back to work. At the end of the day, I collected Rachel and headed home. I fed her, ate a dinner provided by Mrs. Greenwald, and handed out candy to Trick-or-Treaters. I called Kris just before saying evening prayers with Rachel, and after our prayers, I put her in her crib. I read for about an hour, then went to bed.

November 3, 1988, McKinley, Ohio

On Thursday, I had my usual weekly lunch with Antonne, Paul, Julius, Jordan, Conchita, and Danika. All of them were doing well, and they had all been invited to join the honors program. I wasn't surprised to hear that Antonne and Danika had been invited to the Biology Department lunches. The only negative was Conchita complaining about not seeing Rachel, so we all agreed we'd have dinner the following Thursday evening at my house.

When we finished lunch, I headed to the medical school to meet with Doctor Mertens to discuss my interviews and the Match. I'd received letters from UCLA and Cook County in Chicago inviting me to apply, as well as one from Doctor Barton encouraging me to reconsider his offer. I'd also scheduled an interview in Pittsburgh. I explained all of that to her, and gave her a list of my interviews, though she had been notified by each hospital, so she already had the list.

"I'm sure I know the answer to this," Doctor Mertens said, "but have you given any thought about doing your final trauma rotation in a larger urban hospital?"

"It's just not practical," I replied. "But I'm sure that's why you said you knew the answer."

"It is. That said, and I won't belabor the point, I still think it would be valuable for you. Looking over your interview schedule, and knowing your intent, I don't think there's much guidance or assistance you need from me, but I have to meet with all of my students. Is there anything I can do for you?"

"Not that I can think of," I replied. "Everything appears to be on rails at the moment."

"It's been that way with regard to your medical training since I've met you."

"And the rest of my life has been a complete and utter mess. There are times when I wonder if somehow Loki has taken control of the universe."

"Loki?" Doctor Mertens asked.

"The Norse god, known as the trickster, and the creator of change or chaos."

"Forgive me if I'm out of line, but how does that statement line up with your faith?"

"I did say 'wonder'! I think Loki, like most popular portrayals of Satan, is the personification of natural occurrences, similar to the Greek Fates or, in popular American culture, Mother Nature. Satan, as described in the Bible, is more like a prosecuting attorney or the 'Grand Inquisitor' found in The Brothers Karamazov. Popular conceptions of Satan do not match the Bible."

"I'll take your word for it!"

"If I may say just one more thing..."

"Yes," Doctor Mertens agreed.

"Satan is not identified with the serpent in the Garden of Eden until much later. That is not part of the origin myth. Identifying the serpent as Satan, and identifying Lucifer, a fallen angel, as Satan are later developments, and the Christian myth and the Hebrew myth tell different stories."

"Myth? I thought you believed!"

"I'm using that term in a technical way, to make it distinct from the word 'story' or 'parable', and to differentiate myself from those who claim that the Scriptures are 'word for word inerrant and true'. To give a short version, I don't think the earth is only six thousand years old and I don't think there necessarily was a literal garden. As a scientist, I'd be hard-pressed to adhere to any faith that posited things like the Garden of Eden, a literal world-wide flood, and so on."

"I'm probably going to regret this question, but Jesus rising from the dead?"

"A true miracle, contra science, though if I wanted to be snarky, I'd point out that I personally have been involved in raising the dead!"

Doctor Mertens laughed, "Someone who is, for all intents and purposes, dead without defibrillation or CPR?"

"Yes, though obviously I draw a distinction between those and the Resurrection."

"Obviously!" Doctor Mertens said with a smile. "Anyway, I won't keep you longer unless there is something else you need to discuss."

There wasn't, so I thanked her and headed back to the hospital to work on an autopsy report.

November 4, 1988, McKinley, Ohio

"CLA!" Rachel exclaimed when Clarissa and I went to daycare on Friday afternoon.

"Come to Aunt Clarissa!"

She held out her arms and Rachel happily went to her.

"How was she today?" I asked Jackie.

"Just fine. She's consistent in asking for her bottle and telling us when she needs her diaper changed. She's much steadier when she's walking and standing than she was last week."

"The advances come fast and furious at this point," I replied. "We'll see you next Monday."

Clarissa and I left daycare with Clarissa, carrying Rachel.

"You're taking her to her grandparents tomorrow afternoon, right?"

"Yes. Kris, Rachel, and I will spend a few hours there. Yulia isn't happy, but Viktor is OK with my plan."

"Any idea what bothers her?"

"I'm going to guess it's her cousin who is one hundred percent boy. He's loud, obnoxious, and rambunctious, or in other words, a typical male toddler. Rachel almost exclusively plays with the girls in daycare, at least insofar as a fifteen-month-old plays with others. That's a skill that comes during the 'terrible twos', which I think her cousin has entered a bit early."

"Geno and Anna have their own house, right?"

"Yes, but Anna spends her days at Viktor's house to be with Yulia. Yulia is still seriously suffering from losing her daughter. I can relate, but you know why I had to basically set it aside."

"I do. And you know I'm concerned about that."

"Me, too. I grieved, but I wonder if I grieved enough."

"You had to get on with your life," Clarissa declared. "I don't think you're disrespecting Elizaveta."

"I don't think so, either, but that's not the same as properly grieving. The problem is, nobody knows what that means, and nobody can actually know if they've grieved properly except by time passing and them functioning properly in the world. The question I have to ask myself is if I'm masking or internalizing it, and if so, how that will affect my relationship with Kris, my training, and, most importantly, Rachel."

"You put Rachel before medicine? That's new!"

"In the end, if push comes to shove, she has to be first," I replied. "It's a balancing act, but do you think I'd sacrifice her health or wellbeing for a medical license?"

"No."

We reached the car, and I took Rachel from Clarissa, put Rachel into her car seat, and told her we were going home to see Mama. That caused her to gurgle happily and smile. I hoped she would tolerate visiting her grandparents on Saturday, but there was no predicting how she'd react to any given situation, something which I suspected was going to be true for quite a few years. Once Rachel was settled, Clarissa and I hugged and I got into the car to drive home to meet Kris.

Kris arrived about fifteen minutes after I had carried Rachel into the house, and after Kris and I hugged, she picked up Rachel, who had toddled over to her.

"Mama!" Rachel gurgled.

"Hi, Rachel! Mike, are you ready to go to dinner?"

"Yes. And tonight we'll see if Rachel will eat some rice which hasn't been mashed and puréed. I don't know that she'd be able to eat anything else, given she doesn't have all her teeth yet."

We left the house and drove to the Chinese restaurant to meet our friends. We had a good time and Rachel very much appreciated all the attention she received. After dinner, when the rest of the gang went to the movies, Kris, Rachel, and I went for ice cream.

"OK to give her a taste of my sundae?" Kris asked.

"Yes, though she might not like how cold it is."

"I bet sugar overrides that!" Kris said with a smile.

It turned out we were both right, in that Rachel reacted to the cold ice cream, but also liked it. Of course, I couldn't imagine anyone not liking vanilla ice cream with fudge topping, even if I preferred my plain chocolate ice cream. When we finished our ice cream, we headed home for evening prayers, and then put Rachel down to sleep.

"I'm almost afraid to ask," I said, "but how are the wedding plans coming along?"

"You haven't asked your mom?"

"No. I prefer to completely avoid that subject! I figure if they have questions for me, they'll ask. Responses to the invitations aren't due until the day before Thanksgiving, so I'm not concerned about that yet, either. Did your grandparents make their flight reservations?"

"Yes. And I was surprised, but my best friend from school in France, Chloé, is going to attend, along with her boyfriend, Pierre."

"I'm glad to hear that. I did hear from Dale, my friend in Seattle, that he plans to attend. It works out well for him because he had planned to visit his parents during Christmas break."

"That's good. The caterers are booked, as is the string quartet."

"Perfect," I replied.

"The DJ is booked as well, and I went over the playlist with Father Luke, so there shouldn't be any problems. Are you OK with me selecting the song for our dance?"

"Given we don't have a song, whatever you choose will be our song."

"That's not an answer!"

I laughed, "What song did you have in mind?"

"Just the Way You Are by Billy Joel."

"I like that song, so that's fine with me."

"And for the last song before we leave, I prefer You Light Up My Life."

"OK," I replied, though that was not one of my favorite songs.

"Is there anything specific you want played?"

"Not really, no," I replied. "But there is one song that really cannot be played, and that's Up Where We Belong."

Kris nodded, "Your mom mentioned that to my mom, and why. I agree, obviously."

"I also don't plan to play my balalaika," I said. "It just feels wrong."

"I understand. Mom wanted to know if we wanted to stay in a hotel that night. They'll book a suite for us, if you want, and of course, your mom will take Rachel for a few days."

"You know, that sounds like a good idea. Two or three nights in a suite in a hotel in Columbus. That way, we don't have to worry about driving any real distance or the weather or anything."

"They'll book a limo for us, if we want, so we can leave your car at home."

"I like that idea."

"Will you drink toasts? And wine with dinner?"

"Yes. It's a special occasion, and I have a week off from the hospital, so that won't be a concern."

"Great! Did you make arrangements for June?"

"You mean reservations? Yes. The travel agent booked ten nights for us at a resort in Gatlinburg, Tennessee. They can provide a trundle bed for Rachel, assuming you're still OK with bringing our daughter on our honeymoon."

Kris laughed softly, "Chloé said that was decidedly strange, but she also thinks getting married at eighteen is strange!"

"Is she Orthodox?"

"No. Her family is Roman Catholic, but they don't practice. Father Jacques wants to attend, and he's seeking permission from the bishop to do so. But because we're OCA and they're ROCOR, I don't think he could concelebrate."

"That's more of a problem for ROCOR than the OCA."

"Oh, I know! I was just commenting. I don't think there's anything else, so we could listen to music before I go to Oksana's house."

"That sounds good," I agreed.

November 5, 1988, McKinley, Ohio

On Saturday morning, Kris arrived for breakfast, and then she and I walked to Taft, pushing Rachel in her stroller, as Rachel could only walk short distances. After band practice, we did our shopping, then went home for lunch. Once we'd eaten, we left to spend the afternoon with the Kozlovs. Rachel was fine until we pulled into the driveway when she started fussing.

"Uh oh," Kris said quietly.

"Yeah," I agreed. "But we have to make this visit. And watch for signs of what it might be that has her so upset about coming here."

I parked and Kris and I got out, and I unbuckled Rachel from her car seat and picked her up.

"NO!" Rachel exclaimed. "NO!"

"Yes," I countered.

I pushed the door of the car closed with my hip and then carried Rachel to the door. Kris knocked, and Geno let us in a moment later.

"I may know the source of the problem," he said quietly. "Well, one of them."

"What's that?" I asked, keeping my voice low.

"My son has been stealing her toys and generally being a boy, and Rachel doesn't appreciate it."

I smiled, "That was what I'd surmised. According to the woman at the hospital daycare, Rachel prefers to be with the other little girls and avoid the boys. She's mellow while they tend to be very active. I suspect Anna says 'no' to little Viktor quite a bit?"

"Yes. How did you know?"

"Rachel learned the word and uses it emphatically! That was one of the clues."

"My son appears to take after his Uncle Joe with regard to his behavior."

"Nah," I chuckled. "He's just an active male toddler, whereas my daughter is a mellow female toddler."

"The word 'mellow' does not apply to ANY of the women in this family!" Geno declared.