Chapter 53: A Forceful Advocate

November 21, 1988, McKinley, Ohio

On Monday morning, it really didn't surprise me that my dad hadn't called by the time I needed to leave for the hospital, given it was 4:35am in Chicago. It was entirely possible that my dad and Holly had been delayed in leaving or along the way, or that they were at the hospital, but had not yet spoken to the cardiology Resident. I was positive my dad would call me as soon as he'd spoken to a doctor.

I arrived at the hospital a bit earlier than usual, which meant I couldn't take Rachel directly to daycare, but I wanted to see Clarissa first thing, so it couldn't be helped. I went to Internal Medicine, where the Endocrinology team had their offices, and asked for Clarissa. The duty nurse directed me to the lounge, where I found Clarissa preparing chart summaries.

"CLA!" Rachel exclaimed, announcing our presence.

"Petrovich?! What are you doing here?"

I handed my squirming toddler to her favorite 'aunt'.

"Two things," I said. "And I'm not actually sure which is more important."

"How much trouble are you in now?" Clarissa asked with a smile.

"I suppose that depends on your perspective. The one that doesn't have me in trouble for sure is that my paternal grandfather had another heart attack. According to my dad, it was bad, and he and Holly drove up to Chicago late last night. I asked him to call as soon as he spoke to a cardiologist so I could speak with them, but I haven't heard from him yet."

"Bad as in..." Clarissa asked.

"I'd say so from my dad's suggestion that if I can only take a day or two off, I should wait."

"Well, shit," Clarissa sighed. "That sucks."

"It does."

"What's the other thing?"

"I had no choice but to reveal two very important secrets to Kris."

"Uh-oh. Me?"

"Yes, and the bishop's plan."

"OK, that second one is irrelevant because you're going to turn him down, but the other ... how did that come up?"

"It turns out my betrothed has a serious problem with secrets, and I found out about it because of something which should have been totally innocuous."

"What?"

"Her mom invited me to dinner for Kris' birthday last night, without telling Kris, and asking me not to say anything. I told Kris on the way home from the monastery because we needed to get Rachel from my mom, and Kris gave me a real piece of her mind on the topic. After that, I felt I had to tell her about the bishop's intentions and about our plans."

"And?"

"We didn't get that far. We had a fairly deep conversation about secrets and philosophy, and it kind of ranged all over the map. All I can say is that she didn't say 'no' out of hand."

"I'd say that's a positive sign."

"I agree, but it's not approval."

"So no trouble?"

"I think I managed to not talk my way out of it."

"You've lost me!"

"I simply admitted I'd made an error, apologized, and promised not to do it again. No justification, no explanation, just admission and repentance."

"Which is the norm for you."

"Yes, and Kris commented that it made it difficult for her to stay upset with me."

"How did she like the birthday gift?"

"She loved it. I think her little sister is jealous!"

"Fairly typical for little sisters, I think."

"Sorry to cut this short," I said, "but I need to get to daycare."

"Let me know what's up with your grandfather, please."

"Will do."

I left the lounge and headed to daycare, where I turned Rachel over to Marcie, and then I headed to the basement where Pathology was located. I changed into scrubs, then verified we had the lab reports and charts for the autopsies we had scheduled. There was one set of labs missing, so I went upstairs to the lab, obtained them from the lab tech, then returned to Pathology. I filled out the initial information on the autopsy forms, then clipped each to a metal clipboard and attached the lab results. Next, I wrote out chart summaries and clipped those on top of the lab reports.

"Mike?" Jamie, a new clerk, said from the door of the small office I was using. "You have a call on line 3."

"Thanks."

I pressed the correct button on the multi-line phone and lifted the handset.

"Mike Loucks," I said.

"Mike, it's Dad."

"How is Grandpa?"

"Not good," Dad said grimly. "I have Doctor Casey Jordan, who agreed to speak with you."

"OK. How are you doing?"

"Hanging in there. One moment."

I heard him hand the phone to the doctor.

"Doctor Jordan," he said.

"Mike Loucks," I said. "I'm a Fourth Year at McKinley Medical School in McKinley, Ohio. I was hoping you'd tell me my grandfather's condition in medical terms."

"He had a major cardiac event," Doctor Jordan said. "It was a STEMI, and he's suffering from bilateral congestive heart failure, and is in critical condition in the cardiac ICU."

"What's his ejection fraction?" I asked.

"37% at the last measurement."

That was a sign that he probably wasn't going to make it, as normal EF was between 50% and 70%.

"PO₂?" I asked.

"86% on ventilation."

Another very bad sign.

"I take it the prognosis is poor?"

"Yes."

"Thanks, Doctor. May I speak with my dad, please?"

"You're welcome. One moment."

He handed the phone back to my dad.

"Hi," Dad said. "What's your take?"

"I'm still a medical student, but what Doctor Jordan told me is about as bad as it gets. Grandpa's heart is not pumping enough blood, his oxygen saturation is very low considering he's on a ventilator, and bilateral congestive heart failure usually does not resolve following an ST-Elevation Myocardial Infarction, or STEMI. That's the medical term for a massive heart attack."

"That's the impression I got from the doctor as well, though he didn't use any medical terms."

"We're taught not to because they can confuse the patient or their family."

"How long?" Dad asked.

"Nobody can say," I replied. "There are many possible problems which can develop at this point."

"Can you guess?"

"No, and, to be honest, neither can the cardiologists or the doctors in the ICU. I'll pray for Grandpa, Grandma, and you."

"Thanks, Mike."

"Call me with any updates, please."

"I will."

We said 'goodbye', I hung up, and decided I needed to call my mom and Kris, and chose to call Kris first. She was surprised to hear from me, of course, and expressed her sympathies, then asked if I was going to Chicago.

"I can only take two days of bereavement leave, so, as terrible as it sounds, I'll wait until the funeral."

"You're positive he's going to die?"

"Recovery is very unlikely. The most likely outcome is another heart attack, which would probably be fatal. There are other complications as well, all of which lead to the same negative outcome."

"Do you plan to drive up?"

"Flying wouldn't be much faster by the time I drove to the airport, waited for a flight, and got from the airport to my grandfather's church, so yes. It'll be tough, but I'll manage."

"I'll go with you, if you like. I can miss two days of school without any trouble and get any missed assignments from my friends."

"I'd like that," I replied. "For now, all we can do is wait. I'll call you tonight with any new information."

"OK. Take care, Mike."

"You, too."

We said 'goodbye', I flashed the switchhook, and dialed my mom's number. Stefan answered and called her to the phone.

"Mike? What's wrong?" Mom asked.

"Grandpa Loucks had a serious heart attack. Dad and Holly are in Chicago. I spoke to the cardiologist there, and the prognosis is not good."

"Lord have mercy!" Mom exclaimed. "Are you going to Chicago?"

"He's unconscious and in the ICU, and Dad has Holly with him. I can only take a couple of days for bereavement, so Dad and I agreed I'd wait to see what happens."

"You'll go for the funeral?"

"That's my plan, yes. I'll probably drive up. Do you think you'd go?"

"I'm not sure your dad would want me there," Mom said. "So probably not."

"Then would you watch Rachel while I'm gone? Kris will most likely accompany me."

"Yes, of course! How are things with the Kozlovs?"

"Fine. Rachel doesn't fuss when we're there on Saturdays, though obviously we missed this past Saturday because of our trip to the monastery."

"How did that go?"

"We weren't just monk-y-ing around," I chuckled.

Mom groaned, "That's a horrible pun!"

"Things are fine. Father Roman will be my confessor and spiritual father as soon as he speaks with Vladyka JOHN to confirm, which will happen today."

"I think that'll be good for you. I'll call Liz and let her know, as well as my parents."

"Thanks, Mom."

We said 'goodbye' and I replaced the handset in the cradle, finished my paperwork, then went to find Doctor McKnight. I let him know about my grandfather, and he offered to sign off on an extra day if I needed it due to timing and travel. I thanked him, and we went to Autopsy A for the day's first autopsy, a patient who had arrested on the table during an otherwise routine laparoscopic adrenalectomy for a benign tumor.

"Any thoughts before we begin?" Doctor McKnight asked.

"Besides the obvious fact that healthy thirty-seven-year-old men are not supposed to die on the table during routine surgery?"

"Yes, besides that!"

"My first thoughts would be a negative reaction to the anesthesia or an undiagnosed heart ailment. Nothing on the chart suggested any conditions which might lead to cardiac arrest, and nothing in the surgical report indicates excessive bleeding or any complications prior to cardiac arrest."

"What do the labs show?"

"Nothing at all out of the ordinary," I replied. "The routine tox screen was negative, and everything else was within the norms for a healthy young man."

"Then let's begin."

Four hours later, we had no more understanding of why the patient had died than we'd had when we'd started, though a large number of things could be ruled out.

"All we can do now is wait for the complete tox screen and see if it shows anything," Doctor McKnight said.

The tox screen run by Pathology screened for more things than the surgical screen, but I didn't think it would turn up anything, as we found absolutely no signs of drug abuse and the patient had not been on any prescriptions, using only Advil for pain.

"I'll take the samples to the lab," I replied.

I collected the samples, made sure the proper labels were attached, and filled out the appropriate forms. As the subject was deceased, I didn't need Doctor McKnight's signature, as the tests were not 'diagnostic' as normally meant by that term. That completed, I took them to the lab, turned them in, then returned to Pathology to create the draft report for Doctor McKnight.

I had lunch with Clarissa, Maryam, Peter, and Fran, and then returned to Pathology for two additional autopsies, both of which confirmed the cause of death reported by the doctors in the ICU. By the end of the day, I hadn't heard anything from my dad, so I retrieved Rachel from daycare and headed home for dinner with Kari and Lara, which Lara had prepared, letting herself into the house with her key after school let out.

"I'm probably going to Chicago for a couple of days soon," I said after greeting them.

"Why?" Lara asked.

"My paternal grandfather had a severe heart attack, his second. He's in the ICU on a ventilator, and his prognosis is poor."

"I'm sorry, Mike," Kari said.

"Thanks."

"I take it your dad went up to Chicago?" Lara asked.

"Yes. He and Holly went up late last night. I thought about going up, but given I only get two days for bereavement, and I have my Match interview at the hospital tomorrow, I'll wait until the inevitable, then go up for a couple of days for the funeral."

"You seem sure," Kari observed.

"I spoke to a cardiology Resident and asked some key questions. Basically, my grandfather's heart is severely damaged, it's not pumping enough blood, and his blood oxygen saturation is low, despite being on a ventilator. If I were speaking to a patient's family, I'd be preparing them for the patient's death."

"You seem awfully calm about it," Kari said.

"He's in 'Doctor Mode'," Lara interjected. "You may not have seen it, but when he's discussing anything to do with medicine, he is coldly clinical. Doctors who specialize in the ER or in surgery have to be unflappable, and Mike is well suited. He could give the Stoics lessons!"

"Usually," I replied.

"OK, but if that hadn't caused you to express emotions, then I'd have said there was something seriously wrong with you."

"And you wouldn't say that, anyway?" I asked with a grin.

"True! Dinner is in about ten minutes."

"Let me get Rachel's dinner ready," I said.

"I'll take her," Kari offered. "I can handle ten minutes!"

"Not ready for a baby just yet?" Lara asked.

"Oh, hell no!" Kari exclaimed. "Rachel is totally cute, but I can't see myself caring for a baby full-time. I don't know how Mike does it!"

"Mike doesn't know how Mike does it!" I chuckled.

I finished making Rachel's bottle and her solid food just as Lara was putting food on the table. Kari put Rachel in her high chair, then we all sat down. I said the blessing, and then we began eating, with me feeding Rachel between bites of my own dinner. When we finished eating, Kari and Lara cleaned up while I read to Rachel and made a quick call to Kris to let her know I didn't have an update.

Both Lara and Kari stayed for evening prayers, and left when I put Rachel down to sleep. Just as I was climbing into bed, the phone rang, and I was positive I knew what the call was.

"Loucks Residence, Mike Speaking," I said when I answered the phone.

"Mike, it's Dad."

"When?" I asked.

"About fifteen minutes ago."

"How are you?"

"Numb, I guess," he replied. "But I have Holly here, and I need to be strong for my mom."

"When you know the day for the funeral, please let me know. I can take a few days off, and Kris and I will drive up."

"Dad's pastor is here and said because of Thanksgiving, they'll do the service on Monday next week. They'll have a visitation on Sunday evening."

"OK. Then Kris and I will drive up on Sunday and stay until Tuesday morning. That way, we can be back in McKinley on Tuesday evening. I let Mom know, and she promised to call her parents and Liz. Do you know what time on Sunday and Monday?"

"Sunday evening at 7:00pm at the funeral home. I'll need to get you the details. Monday at 1:00pm at Grace Church of DuPage."

"OK. I'll need to book a hotel. Can you recommend one?"

"Your grandmother offered to put you up, though you and Kris would have to sleep in separate rooms."

"Kris would insist on that, so that's not a concern. Tell Grandma 'thank you' for me, and I'll call her to let her know when we'll arrive."

"Some ladies from the church will be at the house, so one of them might answer the phone."

"OK. I'll see you on Sunday, then. I'll pray for Grandpa, Grandma, and you. Please call me if there's anything I can do."

"I will. Thanks, Mike. See you Sunday."

We said 'goodbye' and I hung up, checked my watch, and decided it wasn't too late to call Kris and let her know. We had a brief chat, agreed that I'd pick her up Sunday morning at 5:45am at Oksana's so we could get Rachel to my mom before church, and then said 'good night'. Once I finished that call, I called my mom and let her know, and made arrangements to deliver Rachel to her early on Sunday morning. Once I finished with my mom, I called Clarissa and Lara and let them know as well. Those two calls completed, I went to bed.

November 22, 1988, McKinley, Ohio

On Tuesday morning, I let Doctor McKnight know that I'd be heading to Chicago on Sunday, so I'd only miss two days — Monday and Tuesday. He had me fill out a bereavement request form, which he signed, and which I would turn in at the medical school after my interview, which would begin at 9:00am and last until 3:00pm, with lunch brought in. Because of the timing, I wouldn't be assisting with autopsies, but that wasn't a problem, as there were only two total scheduled between Doctor McKnight and his Resident, and they could do them together with help from the Third Years.

At 8:40am I went to the locker room, changed from my dark blue scrubs into my suit and tie, then headed to the Board Room where the six-hour-long interview would take place. I was greeted by Doctor Rhodes, the Medical Director. He offered me coffee and a bagel, which I accepted, and then we sat down for the first part of the interview process.

"My goal, in the thirty minutes I have, is to assess your fit and temperament, as well as explore your philosophy with regard to the practice of medicine. I've reviewed your record, and I'd like to start someplace different from where I usually begin with Residency candidates. What is it that possessed you, as a medical student, to attempt to design your own Residency program?"

"I learned about the program when I was interviewing for medical school," I replied. "I felt it was a valuable innovation, which represented the future of emergency medicine. It was something I was positive would be a benefit to the hospital and the community."

"That's the answer for the newspapers and the medical journals," Doctor Rhodes said with a smile. "I'd like to hear the real answer."

"That is the real answer," I replied. "Everything I do, and everything I plan to do, is for the benefit of patients, the community, and the hospital. Does it benefit me? Absolutely. But I'm also not going to gain the experience then sell myself to the highest bidder. I intend to practice in this area for my entire career. Right now, and for the foreseeable future, Dorothea Rhodes Lummis Moore Memorial Hospital will be the only Level I Trauma Center. Harding County Regional Hospital will only be a Level II, even after they build their new ED. Their plans do not include being a full teaching hospital, and I want to teach in addition to practicing medicine."

"So it's purely altruistic?"

"Doctor Rhodes, I've never wanted to be anything other than an emergency medicine specialist and to serve my community. I turned down chances to go to other medical schools, and I've turned down interviews at hospitals in Chicago, California, and other places, because I want to stay here and practice here."

"And the interviews you have scheduled at UC, Ohio State, Indiana, and Pittsburgh?"