Chapter 69: Last Day

December 30, 1988, McKinley, Ohio

"This is the last shift I'll have with you," John said. "Well, I will have one hour each day after your honeymoon."

"Clarissa can provide you the same guidance and support, and teach you the same things. And she'll give you a slightly different perspective."

"She's awesome! It's too bad she has a girlfriend."

"Something I've lamented for the past seven years!" I declared.

"I did kind of get that vibe about you two."

"As she's said, no matter how close we are, the fact that she likes pussy as much as I do is an impediment."

John laughed, "She actually said that?"

"She did. I was the first person she came out to, and I stood next to her and held her hand when she came out to her parents. That did not go well."

"I can imagine, given what so many people think about that."

"Of course, her parents' initial thoughts didn't help — that she was pregnant, or that we were getting married."

"They had no idea?"

"None. She was a nerdy, bookish girl in High School so they weren't surprised she didn't date, though she hung out with a group of other nerdy kids. I was the same way, though I dated."

"You played the guitar, right?"

"I didn't learn until I was at Taft. I had trouble getting dates in High School before my Senior year, when I finally had my first girlfriend."

"I was a second-string DB, so I had that going for me. I wasn't good enough to make a college team, so I focused on studying, decided on pre-med, and here I am!"

"I'd say that was a good choice. You still seeing the nursing student?"

"Olivia? When we have time! It's like a conspiracy to put us on opposite schedules!"

"Clarissa and I have complained about that because pretty much the only time I see her is the handovers here. I think we should get some sleep."

There were only two patients in the ward. Doctor Abbot was sleeping and Doctor Bielski was at home, though he lived only five minutes away.

"Sounds like a plan," he said.

We went to the on-call room and got into separate bunks. We'd barely laid down when my pager went off. I hopped out of bed, grabbed my medical coat and stethoscope, and hurried into the hall, heading for the stairs to Internal Medicine. I arrived in the room to see a Fourth year performing CPR while a nursing student bagged the patient, and a nurse was setting up the defibrillator. Doctor Vega and Doctor Abbott arrived a few seconds later.

"Mike, run the code," Doctor Abbott ordered.

I moved over to the side of the patient where the 'crash cart' was. There was no EKG, so I had no idea if the patient had a shockable rhythm. The protocol in such a case was to administer shocks, as they generally couldn't make things worse.

"Condition?" I asked.

"Fifty-three-year-old, being treated for COPD," Doctor Vega said. "Jim?"

"Found non-responsive with no pulse about two minutes ago."

"Stop CPR, please."

He did, and I listened to the patient's chest, but heard only faint sounds, and still no pulse.

"Resume CPR, charge to 150!"

I had a strong sense it was hopeless, and that the patient had had a fatal fat embolism, but we had to run the code.

The machine whirred and beeped, and I picked up the paddles.

"Clear!" I ordered.

Jim and the nursing student, June, stepped back, I positioned the paddles, and pressed the button to trigger the shock. The patient convulsed, and as I had no EKG, I felt for a pulse, and found one.

"Thready pulse," I replied. "Let's get the EKG on him. Twelve-lead!"

I listened to the patient's chest again and heard irregular beats, but until we saw an EKG, we couldn't know for sure. Doctor Abbot and Nurse Kim quickly put the pads and leads on the patient and turned on the monitor.

"SVT," I announced. "Doctor Abbott, I believe it's multifocal atrial tachycardia."

She listened and nodded, "Confirmed. What do you want to do?"

"O₂ five liters and stat lytes to check magnesium and potassium," I replied, then pulled my notebook from my pocket and quickly looked at the notes for atrial tachycardia and COPD. "And diltiazem."

"Very good," Doctor Abbot declared. "Kim, Bolus 0.25 mg/kg, please, then 10 mg/hr via IV Ringer's. June, draw blood and carry the tube to the lab and wait for the results. Jim, oxygen. Anything else, Mike?"

"The Ringer's should resolve any hypokalemia; I'd be concerned about giving magnesium sulfate before we see the lab results. That said, something like ten percent of the public has hypomagnesemia, so the risk would be minimal, so long as his kidneys are functioning."

"No renal trouble," Doctor Vega said.

"Then," I said, "I'd administer two grams of magnesium sulfate IV drip; if he does have hypomagnesemia, then up that to five grams."

"Very good. Kim, please add two grams of magnesium sulfate to the IV bag."

Kim did so, and a few minutes later, the EKG showed multifocal atrial rhythm, which was an improvement, as the patient's heart was beating slower, and a few minutes after that, converted to normal sinus rhythm, but with tachycardia and mild hypotension. I updated the chart with everything we'd done and handed it to Doctor Abbott to review and sign.

"I think we can leave you with this, Maria," Doctor Abbott said to Doctor Vega. "Call me when you see the test results or if there are any arrhythmias."

"We have it. Thanks."

We left the room and walked towards the elevators.

"Any critiques of how I ran the code?" I asked.

"Well, if I wanted to bust your chops, I'd call you out for looking up the drug in your notes, but you're a Fourth Year, so that's not out of line, and it didn't take too long to concern me. I'd have said something if it had taken another fifteen seconds. That said, kudos for actually having that in your notes."

"It's something I saw when I had my Medicine Clerkship," I replied. "Do you think he had PEA?"

"That would be my guess, given no pulse and no audible heart sounds on auscultation, but we'll never know because they didn't have him on a monitor."

"We need more monitored beds."

"That we do, but you know why we don't."

"The same thing it always comes down to — resources."

"There will be more monitored beds when the expansion is complete."

"Oh, I know, but that's small comfort to someone who might benefit from one now but doesn't have one because they aren't one of the sickest."

"I don't disagree with you, Mike, but we have to work with the resources we have."

"I completely understand," I replied. "That doesn't mean I have to like it."

"Don't go jousting at that windmill," Doctor Abbot said. "You can't predict the outcome. What happens if you win and they reallocate money from some other service or improvement? What if they decided to cut a Residency slot? Or an Attending? And how many monitored beds would that cover? The only choice the Hospital Board has is to rob Peter to pay Paul, because the County Board is in no mood to raise property taxes, especially after putting the hospital bonds on the ballot."

"No windmill tilting," I said. "But that doesn't mean I won't state the obvious!"

"We'd all be shocked if you didn't!"

When we returned to Cardiology, I went to the on-call room and got into my bunk. John was woken once, and I managed to fall back asleep almost right away, and we both got up at 4:45am so he could to the handover to Felicity. The handover was quick, as we only had two patients on the ward, and no scheduled procedures.

"Did you arrange your rotation so that you were in Cardiology over the holidays?" Felicity asked when we went to the cafeteria for breakfast a few hours later.

"No. The only thing I asked for was that my trauma Sub-Is were first and last. The rest were scheduled by Doctor Mertens. If I had to do it over again, I'd have asked for assignment to the ICU during this period, but that might have caused problems with taking the extra time off. So, in the end, this seems to have worked out for the best."

"I did speak to Clarissa about her flashcards, and she'll lend me hers from Internal Medicine, which will flesh out your complete set."

"Good."

After breakfast, we completed rounds with Doctor Javadi, but with only two patients in the ward, that only took a short amount of time. I would have loved to go to the ED and help out, but given I was on the code team, I really couldn't get involved in anything because I could be paged at any time. That meant for a long, boring day, and there wasn't really anything I could do except read, study, or sleep.

The only interesting thing that happened for any of us was an admission after lunch for an MI, but the patient went straight to the ICU and would remain there until they were stable enough to come to the ward. I had dinner with Doctor Javadi, then read and studied until the end of my shift.

December 31, 1988, New Year's Eve, Centerville, Ohio

Kris and Rachel arrived at the house early on Saturday morning so we could prepare breakfast for Dale, Pam, Jocelyn, and Gene, who arrived about twenty minutes later. Dale and I shook hands, he introduced Pam, and I introduced Kris. Jocelyn and I hugged and Gene and I shook hands, and we brought everyone to the dining room where I put Rachel in her high chair. Kris and I went to the kitchen, and each made two trips, bringing the food and drinks to the table. After I gave the blessing, we all began eating.

"What do you do, Pam?" I asked.

"I'm a relocation consultant. Kris, what's your plan for your career?"

"I plan to get a Bachelor's in political science, with a minor in finance, then a Master's degree in public administration."

"I'll be the only one of our trio without an advanced degree," Dale said.

"Nah," Gene said with a grin. "Mike will have a vocational certificate in medicine, not an actual doctorate!"

I laughed, "Doctors did appropriate that term from PhDs, though I'd say four years of medical school with clinical rotations is a bit more than a 'vocational certificate'."

"Oh?" he smirked. "Elias' progression as an electrician is apprentice, journeyman, master. Yours is student, Resident, Attending. And you both have classroom work followed by practical training, supervised by more experienced practitioners!"

"And your wife?" I asked.

"Three year vocational certificate in law," he grinned. "A JD isn't really a doctoral degree!"

"What do you think, Jos?" I asked.

"That my husband is every bit as much a pain in the butt as you and Dale ever were!"

"Good!" Dale and I declared simultaneously, causing everyone to laugh.

"Rachel is mostly eating on her own?" Dale asked.

"She's getting there," I replied. "So she still gets a bottle before each meal, though she's less interested in them than she was. Obviously she can't cut her own food or use a spoon or a fork, but she has tried to use a spoon with hilarious results, at least to me."

"She wears her applesauce?"

"Pretty much. She's just at that stage where she's beginning to want to do things for herself, but she obviously doesn't have the dexterity or coordination to do it."

"That never stopped you!" Jocelyn teased.

"Love you, too, Jos!" I replied flatly.

"You two haven't changed one bit!" Dale declared. "You're still as bad as any brother and sister!"

"Mama? Waf!" Rachel requested.

"Mike, her first piece had maple syrup," Kris said. "What do you think about the second piece? Butter or maple syrup?"

"She's eaten her eggs and sausage, and she had her bottle when she got up, right?"

"Yes."

"Then she can have maple syrup on her waffle."

Kris took a quarter of a waffle, spread maple syrup lightly on it, and gave it to Rachel, who happily accepted it and stuffed it in her mouth.

"She already calls Kris 'mama'?" Dale asked.

"She does," I replied. "And it makes sense, given she never knew Elizaveta."

"Sorry, I didn't mean it that way, just that she was saying it before you were married."

"Terminating a betrothal in the Orthodox Church requires an ecclesiastical divorce. That's why most people have the betrothal and crowning ceremonies back-to-back and use a traditional Western engagement to agree to marry."

"And Mike is nothing if not traditional," Jocelyn observed. "Orthodox tradition, though, not Western."

We finished our breakfast and Jocelyn and Gene offered to clean up while Dale and I caught up. He was very much enjoying his job at Boeing, and Pam had been able to find a job with a company that had a contract with Boeing, Microsoft, and other large companies in Washington state. The plan was for her to stay home when they had kids, which they planned to do in about three years.

"More kids for you, right, Mike?" Dale asked.

"Yes. It's a matter of timing for Kris. Jocelyn filled you in on their situation, right?"

"Yes. Once Jocelyn has her job, it's just a matter of waiting for an infant or toddler to become available."

"Is Gene working?" Pam asked.

"He's an indentured servant like me," I chuckled. "Though he at least gets a stipend as a PhD candidate. I'm sure he told you that he'll be hooded in May, and already has a job offer."

"He did," Pam confirmed. "They start paying you once you graduate, right?"

"Yes. Well, once you Match for a Residency and start working. For me, that'll be July 1st."

"Dale told me you were taking a month off and going on a delayed honeymoon to the Great Smoky Mountains. But the mountains out west laugh at those hills!"

"Including active volcanos!" I replied. "How close is Mount Saint Helens to Seattle?"

"It's about a hundred miles south," Dale answered. "It's actually closer to Portland, at just over fifty miles. Mount Rainier is about that distance from Seattle, and had its last eruption in 1894. It's twice the size of Mount Saint Helens, and has more glaciers, and given its location, an eruption would be worse."

"I'll take my chances with tornadoes against volcanos, earthquakes, and tsunami!" I declared.

"The risks are pretty small, really," Dale countered. "Well, unless you think geologic timeframes. And if you're going to do that, Yellowstone is the biggest risk, because if that blows, kiss the Eastern part of the US goodbye. The last eruption was over 600,000 years ago, so that gives you an idea of the timeframe."

"Sure, but isn't California expecting the 'Big One'?" I countered. "And won't that affect you?"

"It would potentially affect Washington," Dale agreed. "But nobody can predict when it will happen, or where, though I've read the most likely location is somewhere between San Diego and Santa Barbara. But it's not something I really worry about too much. You don't really worry about tornadoes, do you?"

"No. The house has a basement if we need it, but I really don't think too much about needing it. We had one tornado alert that required us to take shelter while I was at Taft, and none since. Even in 1974, when there were around 150 tornadoes in the Midwest, none were really close to us. The closest ones were in Adams County, which is southwest of Harding County."

"Tornadoes are really rare in France," Kris interjected. "I think the last ones that were reported were 1982, though mostly they were in Belgium. You get them almost every year here."

"And mostly they tear up farms or woods," I replied. "Events like 1974 are rare, and fatalities are not common, either. Most tornadoes just do property damage."

The doorbell rang, surprising me, as we weren't expecting any visitors. I excused myself and went to answer it.

"Hi!" Clarissa and Lara exclaimed.

"Last Day, Logan 5!" Clarissa smirked, repeating an old joke between us.

"Not even close, Jessica 6!" I replied, completing the exchange.

"We're here to kidnap your bride-to-be and your daughter!" Lara declared.

"She's not a big fan of surprises," I said quietly.

"She'll live!" Clarissa exclaimed. "We're taking them to church for a wedding shower and lunch, but just the teens and twenty-somethings. Jocelyn and Pam are invited, of course."

"Come in and you can ask her," I replied.

"Then I should probably tell you that Subdeacon Mark, Elias, Peter, Robby, José, and Sticks will come by in about an hour. They're planning a pizza bachelor party for you."

"And if we'd had other plans?" I asked.

"We spoke with Jocelyn," Clarissa replied. "She confirmed they were spending the day here before tonight's New Year's party at Doctor Blahnik's house."

They followed me from the foyer to the great room.

"We're here to kidnap the bride in true Russian tradition!" Lara announced. "And her daughter, of course!"

"Pam, you're invited," Jocelyn said. "We're going to the church for a wedding shower and lunch. Just the teens and twenty-somethings."

"I did not know about this," I said to Kris.

"Lar! Clar!" Rachel exclaimed.

"Well," Dale chuckled, "that seems like one vote in favor."

"She does like her 'aunts'," I observed.

"You OK with me going?" Pam asked Dale.

"Of course. Have fun."

"Some of the guys are coming over in a bit for a bachelor pizza party," Lara said. "Kris, how long do you need to get ready?"

"I actually don't have any things here," Kris said. "But I don't need to go home."

"What about Chloé & Pierre?" I asked.

"Chloé is invited, of course," Lara said. "Kris, if you call her, we could pick her up, and then bring Pierre here. There's enough time."

"That would be OK," Kris agreed.

"If nobody objects, we'll all come back for takeout Chinese before the party," Clarissa said.

"If it's OK with Kris, it's OK with me," I replied.

"Who's taking Rachel tonight?" Lara asked.

"Kris' parents," I replied. "They'll bring her to church tomorrow, and then to the wedding and reception, then my mom will take her until next weekend. She'll get time with her cousins, Elaine's daughter, and Larisa Antonov."