Chapter 77: Back in the Saddle Again

January 10, 1989, McKinley, Ohio

"Morning, Mike!" Felicity called out when I walked into the Cardiology lounge on Tuesday morning. "How did it go?"

"Really well. I'm positive they'll list me, so I have my backup in place."

"Not that you'll need it. There is no way Moore is going to let you go, no matter what happens."

"And yet, having a backup is critical because there is always a risk, even if it's infinitesimal. What do we have today?"

"Nine in the ward, with three discharges today and four procedures. Pre-op labs are complete, and all the results are back. No contraindications for any of the four procedures. Doctor Javadi is on days this week, and she's being allowed to assist with procedures. Doctor Abbot is on until noon and will cover consults, then Doctor Pace comes on. I have the chart summaries for you."

"Good job. Let's review them."

We sat down, and she took me through each of the nine cases. The most interesting was a seventeen-year-old girl with mitral valve prolapse who would have valve replacement surgery. I very much would have liked to see that procedure, but my role was caring for patients on the ward, including pre-op and post-op, which mostly precluded being in the cath lab or the OR. I would get a few chances before the end of the month, but as I wasn't going for a cardiology Residency, that wasn't the priority for this Sub-I. Maryam, on hers, had been able to observe procedures on around half her shifts.

"Good job on these," I said. "You're very much improved from a month ago."

"Thanks. We should prep Sarah for her valve replacement procedures."

"How is her attitude?" I asked as we got up to go to her room.

"About as well as can be expected for a teenager who's been on bed rest for three weeks."

"How active was she before her regurge became severe?"

"She was part of the High School drum and rifle corps. She was performing at a football game when she had severe shortness of breath, and they called the paramedics. She came in, was checked, then sent home while a new valve was procured, and wanted to wait until after the holidays."

"I'm not sure I'd have done that," I replied, "but her condition seems stable enough."

"You know how much everyone hates being in the hospital over the holidays," Felicity said.

"True. And we do our best to follow the patient's wishes."

We went to Sarah's room, and Felicity gently woke her and helped her sit up.

"Sarah, this is Mike, a fellow medical student," Felicity said.

"Hi, Sarah," I said. "We're going to get you ready for your procedure. How do you feel?"

"Tired and hungry; they wouldn't let me eat, and I have trouble catching my breath."

She was on oxygen, which helped, but couldn't solve the problem with her heart's reduced ejection fraction.

"You'll be able to eat once you're out of recovery if you feel up to it. Do I have permission to listen to your heart?"

"Every other freaking person in the hospital has, so why not let the cute medical student put his hand inside my gown?"

"The cute married medical student," I replied with a smile.

"You aren't wearing a wedding ring!" she protested.

I held up my right hand, "Russian Orthodox Christians traditionally wear the ring on their right hand. Still OK to listen?"

"Yes, of course."

I put my stethoscope in my ears, warmed the bell with my hands, then slipped it under her gown. I heard the telltale sounds of a murmur, a clear sign of her heart problem. I then checked her lungs, which were clear. Next, I checked her pulse and BP manually, despite her being on a monitor, then wrote her vitals on the chart.

"Everything looks good," I said. "We need to insert an IV. I'd like Felicity to do it, if you're OK with that."

"Sure," Sarah agreed.

I nodded to Felicity, who set up a saline IV and then inserted the needle and catheter. Doctor Javadi came in just as Felicity finished.

"Hi, Sarah," Doctor Javadi said. "It looks like you're all set."

"I just want to get this over with!"

"Mike?"

"Vitals are good; pre-op labs show no contraindications; lungs clear, detectable murmur on auscultation. Saline IV inserted. We're ready for the anesthesiology Resident."

"Good. Sarah, I need to check your heart and lungs, please."

"Mike just did that," she said.

"I trust him completely, but because he's a student, I'm required to check his exam."

Sarah sighed, which I totally understood, and Doctor Javadi completed her auscultation.

"Confirmed, Mike."

Just then, Doctor DeMille walked in.

"Hi, Sarah," he said. "I'm Doctor DeMille, from Anesthesiology. Any concerns, Doctor Javadi?"

"No, she's ready."

He nodded, then turned to Sarah, "I'm going to give you some medicine to relax you, then in the OR I'll be there the entire way to put you to sleep and monitor you."

He administered a low dose of propofol, then left to go to the OR. I supervised Felicity inserting a Foley catheter, which she did expertly. A moment later, Doctor Bielski arrived to check on Sarah, and once he was satisfied, instructed us to call for an orderly to bring her to the OR. We did that, and ten minutes later, she was on the operating table, and Felicity and I left to prep a seventy-nine-year-old man for angioplasty, which Doctor Getty would do.

After the second patient was in the cath lab, Felicity and I did rounds with Doctor Abbot. There were two consults during the morning, with one admission for a mild MI. After lunch, we prepped the other two patients, and I spent time in recovery with Sarah, eventually bringing her back to her room just before John relieved Felicity.

"Welcome back," he said.

"Thanks. How have the nights been?"

"Mostly quiet. We have three admissions for procedures tomorrow, according to Felicity."

"Correct," I confirmed. "Two for the cath lab; one for coronary bypass. They should arrive sometime in the next two hours."

One of them did arrive before Clarissa relieved me at 6:00pm, and after doing a handover to her, I headed to daycare to get Rachel. Twenty minutes later, she and I walked into the house and were greeted by Kris.

"Dinner in about thirty minutes," she said. "How was your first day back at the hospital?"

"I kept busy, but it's mostly work in the ward, so not much exciting happens unless there's a code, and there wasn't one today. Not that I want those to happen, obviously."

"No, but if nobody ever was sick or dying, you'd have to find a different job!"

"Very true. I might have ended up a monk-priest if it hadn't been for medicine."

"Well, after evening prayers and putting Rachel to bed, we'll do some very un-monk-like activities!"

"No objections! Your period starts soon, right?"

"Probably tomorrow."

"That won't deter me if it doesn't deter you!"

"It'll be messy!"

"So?" I asked with a grin.

"Go change!" Kris said with a soft laugh. "You can leave the Tsarina with me."

I handed Rachel to Kris, then went upstairs to change.

January 13, 1989, Cincinnati, Ohio

"Skyline for dinner?" Clarissa asked when we met outside UC Medical Center following our interviews.

"Sure. I didn't give my mom a specific time for picking up Rachel."

We began walking towards my car.

"How did it go?" I asked.

"Same as OSU, basically. How about you?"

"Pretty much the same. They're certainly interested, and I gave the same basic answer I did at OSU, so I suspect they'll list me in their top two or three. One thing makes this one more interesting than even Moore."

"Wait!" Clarissa protested. "What?!"

"UC established the very first Residency program in the world in emergency medicine in 1972."

"I didn't know that!"

"I didn't, either, until it was pointed out in the interview. It does add a slight positive for UC, but not enough to change my order, given everything else."

"Interesting. I have a good feeling about Internal Medicine here, but not enough to change, obviously. But more pressing — we have to stop at Graeter's for ice cream after we have our Five-way!"

"The most I've ever had was a three-way," I chuckled. "But it's nice to know my wife approves of me having a Five-way with you!"

Clarissa laughed, "Cute. Who would you invite?"

"Not even going to go there," I chuckled. "I know you well enough that I'm not giving you any additional ammunition with which to tease me!"

"You're just no fun, Petrovich!" Clarissa teased.

"You know better than that!" I replied. "And it's not as if you need any help in finding things to tease me about!"

"Are you enjoying your 'quality time' with Kris?" Clarissa asked with a smirk.

"I very much enjoy French kisses!"

"Every kiss is a French kiss!" Clarissa declared.

"Exactly what I said to Kris!"

"Everything seems to be going well."

"It is," I replied. "You and I just need to get through the next nineteen weeks, and then we're doctors!"

"A crazy thought if there ever was one!"

"I just have to not be bored out of my mind babysitting for February and March."

"The ICU?"

"Hours of boredom surrounding moments of pandemonium, and patients who mostly can't converse, or if they're conscious and not on a ventilator, are too weak to have much interaction."

"Do you think it was a mistake choosing that Sub-I?"

"Not at all. I'll be caring for patients in what laymen call 'critical' condition, very similar to some patients who come into the ED. Seeing how the next stage of care works is important, and I'll certainly be exposed to all manner of conditions. But it is, in the end, babysitting as a med student."

"All our rotations are mostly like that, except emergency medicine; well, and pathology for you. You're really champing at the bit."

"Aren't we all? I hear the same from Peter."

"You need to 'do something' more than any of the rest of us. It's your personality, and it's not a bad thing. It's exactly the attitude of an emergency medicine specialist whose job is to 'do something' basically every time. 'Watch and wait' is not you, and you're ready to work in the ED."

"You're not wrong," I replied.

"You've made it through seven-and-a-half years, you can make it through two-and-a-half months before you're back in the ED."

"Oh, I know! This is just my usual complaint about how medical training works."

"Nobody we know is a natural the way you are, but they don't allow you to skip two years the way they allowed Lara to skip two grades."

"I wish!" I exclaimed. "Well, no, actually, if I set aside my personal feelings and look at the overall reality, I don't. It's just that the end is finally in sight. In three weeks we'll fill out our Match forms, and in eight weeks, we'll have our Match. I remember when that was still eight years into the future!"

"And then the MLE in early May," Clarissa said as we got into my car. "Did Fran talk to you about the study plan?"

"No. I haven't seen her since the wedding," I said, starting the car and pulling out of the parking spot.

"She was hoping we could meet at your house, 8:00am to 5:00pm each day."

"That will work. Kris will be in school, so she'll only be there after about 3:00pm. I'll just have to figure out what to do about Rachel, as she'll be very much underfoot, given how much she likes attention! I wonder if Milena would be OK with her babysitter taking Rachel, given Rachel and Abigail like each other so much."

"That might lead to a very interesting future!" Clarissa teased.

"Some teenage boy's wet dream?" I chuckled.

"Or a teenage girl's!" Clarissa smirked. "But I was thinking more along your lines. Anyway, about the study sessions?"

"It's conveniently between Pascha and Pentecost, so no fasting. We can order sandwiches from the deli in Circleville, but we'll have to pick them up."

"I'll pick up bagels and doughnuts on my way to your house each morning if you can have coffee and tea available."

"Of course."

"Big plans for the weekend?"

"I'm covering Kylie's Medicine shift tomorrow from 0700 to 1900."

"No band practice?"

"The rest of the band is practicing. I'll start again next Saturday. I didn't feel I could turn Kylie down."

"No, you have a perfect situation with her being able to trade shifts. That's the last thing you want to mess up."

When we arrived at Skyline, we ordered our Five-way chili, and when the counterman gave us our tray, we went to sit by a window to eat. The chili was awesome, as always, and when we finished, we walked down the street to Graeter's.

"Wow! Splurging!" Clarissa teased after I ordered. "A double scoop of chocolate!"

"Get off my case, Lissa!" I growled.

She laughed, "Your eyes give away that you aren't upset!"

"Obviously."

"But you're such a creature of habit that it was mildly surprising."

"When something is really good, you want more of it!" I declared.

"That explains a LOT about you, Petrovich!"

"Right, because you don't enjoy doing that, too!"

"Maybe..." Clarissa replied impishly.

We ate our ice cream, then headed to my mom's house to get Rachel before heading for McKinley.

January 14, 1989, McKinley, Ohio

"Hi, Mike," Doctor Subramani said when I walked into the Internal Medicine locker room early on Saturday morning.

"Morning, Doctor Subramani," I replied.

We both changed into scrubs, put on our medical coats, slung our stethoscopes around our necks, clipped on our badges, and put our clothes and bags into lockers.

"Congratulations on your wedding," she said as we left the locker room.

"Thanks. Are you married?"

"Engaged. My fiancé is a cardiology Resident at Cleveland Clinic."

"That has to be tough."

"It's not ideal, but we're making it work."

"When will you marry, if it's not prying to ask?"

"Once I finish my Residency at the end of June. I've interviewed for an Attending role at Cleveland Clinic and a pair of other hospitals in Cleveland."

"Is that public knowledge?"

"Yes. They've known from the time we both Matched. He has another five years plus a Fellowship."

"He's part of Doctor Thomas Kurian's team, right?"

"Yes! How did you know?"

"I'm friends with his daughter, Danika. I mentor her and the other members of her study group."

"Small world! Shall we speak to Doctor Vega and get the handover?"

"We should!"

There were an even dozen patients in the ward, with no scheduled discharges. More than likely I'd simply spend the entire day in the ward, though it was possible I'd get to tag along on a consult. The more I thought about the way the training was done, the less I liked it, but I also totally understood why it seemed as if Fourth Year students did less than Third Year students. We Fourth Year students were qualified to 'stand watch', as the military would call it, while Third Year students were not.

About an hour after the handover, we joined Doctor Collins, the Chief of Internal Medicine, on rounds with Doctors Gómez and Brown, two Residents, and Joe and Lee, Third Year medical students. There was the usual mix of patients, with the most interesting case being one of a sixty-six-year-old man who'd had a foot amputated due to myonecrosis, commonly known as 'gas gangrene'. It had been caused by uncontrolled Type 2 diabetes, which had resulted in vascular blockage in his ankle.

"How often do you see cases such as this one?" I asked Doctor Collins.

"That get this far? Rarely. He lives alone, and when he didn't show up for his bi-weekly breakfast with his friends, one of them went to check on him. What are the risks associated with untreated Type 2 diabetes?"

"Specifically, in this case, it was either peripheral vascular disease or diabetic neuropathy, or both. In the general case, others include ketoacidosis, coronary artery disease, retinopathy, encephalopathy, nephropathy, erectile dysfunction, stroke, and a number of pulmonary conditions. And all of those can occur even with treatment, but treatment, especially diet and exercise, reduces the overall risk."

"What signs do you look for?"

"The most obvious are blood glucose and glycated hemoglobin, beyond that, frequent urination, unusual thirst, peripheral neuropathy, and fatigue. There are other less common signs and symptoms, such as blurred vision, recurrent vaginal infections in females, and general itchiness."

"He'll pass the MLE," Doctor Gómez observed.

"Antonio," Doctor Collins said, "Meet Mike Loucks, Fourth Year, top of his class at the medical school. You didn't meet him because his rotation was before you started, and he decided to do an ICU Sub-I instead of one in Medicine."

"ICU?" Doctor Gómez asked. "Why?"

"Because I'll see many more patients in acute conditions who need continual treatment and constant monitoring than I would in Medicine. After discussing it with my advisor, Doctor Mertens, and Doctors Roth and Gibbs, they agreed."

"Odder still," Doctor Subramani said, "he did a pathology Sub-I."

"Why would you do that if you weren't going into pathology?" Doctor Brown asked.

"As Doctor Roth put it, I'd get to use a scalpel every day, something I wouldn't be allowed to do at all during my first two years of Residency. Not to mention it helped hone my diagnostic skills by showing me things no emergency medicine specialist would ever find on preliminary exam."

"But autopsies?" he protested. "Really?"

"Really," I confirmed. "I'd actually suggest it for anyone going into surgery or emergency medicine, and possibly even internal medicine."

"That really goes counter to the current thinking," he replied. "And I've read articles arguing that it's a complete waste of time for students except with regard to anatomy class."

"In my admitted limited experience, I have to disagree. It helped tremendously, and I gained significant knowledge. In fact, I would say I learned more there than I did during my Internal Medicine clerkship."

"Jesus!" Doctor Gómez said. "Nothing like sticking your neck out and waiting for it to be chopped off!"

"Why do you say that, Antonio?" Doctor Collins asked him.

"Because he's talking to a group of doctors who specialize in Medicine!"

"I'd say he has big «cojones», Antonio," Doctor Brown interjected. "I wish I'd been self-confident enough as a med student to tell the Residents and Attendings how I felt."

"Mike is outspoken," Doctor Collins confirmed. "But he also understands the difference between making an observation or giving an opinion, and actual practice. I'm willing to wager you were frustrated more than once during your time in medical school, not to mention during the past eight months."

"I'd say that's true about everyone," Doctor Gómez agreed.

"And nothing will change if we don't speak up," I observed.

"In my experience, the nail that sticks up gets hammered down!" he replied.