Chapter 80: We Have Our Work Cut Out for Us

February 21, 1989, McKinley, Ohio

On Tuesday, after lunch, I left Rachel with Anna and went to see Doctor Peter Schwenkmeyer, the dentist recommended by Doctor Smith. His office was in the same medical building as Doctor Smith's practice, but on the third floor, rather than the first.

"Michael Loucks," I said to the receptionist. "I have an appointment."

"Good afternoon, Michael. I have some paperwork for you to fill out as a new patient. Do you have your insurance information?"

"Yes," I said, handing her the insurance card from the medical school.

I accepted the proffered clipboard and sat down to fill out the two pages of demographic and health information. I had just finished when a door opened and a hygienist called my name. I handed the clipboard to the receptionist and followed the cute blonde hygienist to an exam room.

"I'm Bobbie and I'm going to clean and polish your teeth. Once I'm finished, Doctor Schwenkmeyer will do an exam and decide if X-rays are necessary."

"OK," I said, sitting down in the exam chair.

The entire appointment was routine and ended with a complete set of X-rays. Fortunately, I had no cavities, and as Doctor Smith had noted, no problems with my gums. When I returned to the reception area, I made my co-pay and scheduled an appointment for October. When I left the dentist's office, I headed to meet Peter for coffee. He and I hadn't had many opportunities to speak since the wedding, and at the end of May, he'd likely be moving to Georgia. We met at the diner near Taft, which was not far from his apartment.

"What's your feeling?" I asked.

"I feel really good about Emory," he said. "But as we've said, you can never be absolutely sure. I ended up listing eight separate programs, and as we discussed. I'll take a preliminary Residency if necessary. I assume there are no problems with Moore."

"None of which I'm aware," I replied. "Clarissa and I are both confident, and she told me that Fran and Nadine are both confident as well. Fran is hoping to Match in Columbus because Jason has a research job there."

"And Nadine told me she decided at the last minute to list UCLA first and Stanford second."

"I had that impression," I said. "She was much more up about the UCLA visit than she was about Stanford. Maryam is confident about Edward Hospital outside Chicago, and she's listing that first with Northwestern second."

"We'll know in a month!" Peter declared.

I was positive we'd all end up with our first or second choices, but my real curiosity was whether or not Melissa Bush would Match. I'd heard through the grapevine, which almost always meant from Fran, that she'd had a dozen interviews across the South, focusing on regional hospitals and was open to any specialty.

"I just need to survive another five weeks of boredom in the ICU!" I declared.

"You've been an 'action' guy from day one, which makes you perfectly suited to emergency medicine."

"And you've always been extremely methodical, which makes you perfectly suited to surgery.

"How are things otherwise?" Peter asked.

"They're good. Rachel is growing like a weed, and Kris and I are working through her adopting Rachel and also on naturalization."

"I thought that took seven years."

"Normally, it does, but by marrying, it can be as short as eighteen months. The immigration attorney will file the petition in early July, and then the cogs of government will grind for however long it takes. It doesn't really change anything for us, except that she'll have a US passport and be able to vote. Her Green Card gives her permanent residency, and marriage solidifies that."

"What is it with you and whirlwind romances?" Peter asked.

"It's not romance," I replied. "Not in either case. With Elizaveta, it was all about being ordained a deacon and opportunity presenting itself for both of us. With Kris, it's similar, in that we both wanted a partnership."

"Not to be an ass, but I've heard of immigration scams."

I nodded, "And so has the attorney who has handled things for the Korolyovs. But, as I said, Kris has a Green Card, and there really is no advantage immigration-wise except accelerating naturalization. She could live in the US for the rest of her life without changing her status, and any kids she has here would be citizens, no matter who she might have married. Literally, what I said just before is true — the only real changes are her passport and the right to vote."

"Sorry."

"I didn't take offense. As I said, her family's immigration attorney raised that as something about which the government would be concerned."

"Does anything bother you?"

"Bigots."

"And besides that?"

"The deaths of my wife and our friends."

"Yeah. I don't know how you do it."

I smiled, "I know it's trite, but I can do all things through Christ who strengthens me."

Peter nodded, "That really does work for you."

"I have a good role model," I replied. "Fortunately, we no longer put people to death for being a pain in the ass to the leadership."

"Socrates?"

"Jesus, too," I replied. "And countless others who were exiled, censored, or imprisoned."

"Martin Luther King Jr.?"

"Among others. Speaking truth to power is a dangerous profession."

"You've managed."

"By being careful in how I go about it, and listening to the advice and reprimands, and learning from them where the uncrossable lines are. They tend to be invisible until you cross them, sort of like land mines. The problem is, progress only comes when concerned people speak out."

"Just don't stick your neck out so far that your head can be chopped off."

"Something about which I've been warned several times, mostly to do with Angie."

"Clarissa and Fran have told me about your relationship with her, and all I can say is that you've shown tremendous restraint. If that happened to someone I loved..."

"And if I were in a field other than medicine, the gloves would have come completely off. Now, I have to bide my time lest, having run the race this far, I fail to take the prize. I can wait because, unfortunately, the damage is done, and is permanent. The best possible outcome is she returns to a state where she can function in society."

"That sucks."

"There are many things wrong with the universe, and I can't fix them all, but I sure as heck can work on my little corner of the world."

"And that's why you're staying here — you feel you can make a real difference."

"All I can do is try," I replied.

February 25, 1989, McKinley, Ohio

On Saturday, after band practice and grocery shopping, Kris and I took Rachel for her eighteen-month checkup with Doctor O'Neill. A nurse weighed and measured a highly suspicious Rachel, though her suspicions were unwarranted, as she wasn't receiving an injection at this visit. Doctor O'Neill came in about two minutes later and greeted us.

"No med student today?"

"Out sick. Hanging around these little germ factories will do that to you! How is Miss Rachel today?"

"Mom and Dad have no complaints," I replied. "But I'm positive Rachel would have a long list, which included insufficient French fries, chocolate, and cake."

"Fry!" Rachel giggled. "Yes!"

Doctor O'Neill laughed. "Limited, right?"

"Much to her chagrin. We're careful with those things. She eats a balanced diet, so I'm OK with her having occasional treats."

"Is she still taking her bottle?"

"She's far less interested in it," I replied. "I think she's really more interested in being cradled than the bottle itself."

"Any concerns, Mom?" Doctor O'Neill asked Kris.

"No. She and I get along just fine, though she's really taken to my little sister."

"Because your little sister never tells Rachel 'no'!" I chuckled.

"How are Rachel's language skills?"

"Well, she hasn't adopted a French accent, so I'd say pretty good!"

"Hey!" Kris protested. "You told me you liked it!"

"On YOU!" I replied. "Anyway, Doc, ask Rachel about her toes or her tummy."

Doctor O'Neill smiled, "Rachel, where are your toes?"

Rachel reached down and grabbed her toes, something I'd taught her in the past few weeks.

"How many words are in her vocabulary?"

"Around fifty that anyone can understand and around seventy that I understand. When she and her friend Abigail are together, they have long conversations, but they're like eighty percent unintelligible to anyone except Abigail. She does the same with one girl at daycare, according to Jackie and Marcie."

"That's not uncommon for toddlers. How old are the other girls?"

"Abigail is almost three, and Jennifer is three-and-a-half."

"That fits the pattern. How is her walking?"

"Pretty good. She still trips over her feet when she's wearing shoes, but barefoot she does fine."

"She doesn't wear shoes in the house, right?"

"Correct; none of us do. Her socks have grippy soles because we have hardwood floors."

"She'll get the hang of shoes soon enough. What about feeding herself?"

"With her hands, she's fine. The spoon is a real challenge, but she's determined to eat her applesauce, tapioca, and pudding, even if she makes a mess."

"Choc!" Rachel exclaimed.

"Her maternal grandmother's doing," I said. "Chocolate pudding for dessert."

"Nana!" Rachel declared.

"Well, there's a new one," I remarked. "I hadn't heard her use that word."

"How many people is she able to identify?"

"Around twenty," I said. "Usually with just the first syllable of their name, or like you just heard."

"Good. Let me do the exam. She's not due for any injections today, and unless you've seen any signs that would indicate a need for blood tests, we won't draw any blood."

"Nothing I've observed," I replied.

The exam took about ten minutes, with Rachel carefully eyeing Doctor O'Neill.

"Your daughter is healthy, and in the 85% percentile for height and weight, and she's well within the guidelines for being proportional. Her heart and lungs are fine, her eyes are clear, and her distal pulses are strong. What's your thinking about pediatric dentistry?"

"I don't have an opinion," I replied. "Though I just saw a dentist for the first time in about eight years."

Doctor O'Neill frowned, "You should know better than that."

"Doctor Smith gently reminded me during my annual physical earlier in the month. The same with eye exams, though, every two years."

"On dentistry, I'd say you should take her for a quick checkup. I don't see anything, but you know the value of preventative care. The same goes for eye exams. She obviously can't read an eye chart, and I don't see anything at all concerning, so just keep an eye on her hand-eye and foot-eye coördination, as well as whether she runs into things."

"She does that all the time!" I chuckled. "Mostly due to momentum."

"That does take some time to work out, but I was more concerned with bumping door jambs, tables, or that kind of thing at slower speeds. Have you started trying to have her identify animals?"

"No."

"Get one of the numerous picture books available and start showing her animals and teaching her names. You'll know pretty quickly if she has vision issues."

"OK. Anything else?"

"Do you have pets?"

"No. We never had them growing up, so it's not really a thing for me. Kris?"

"My parents had a cat, but she had to stay in France. They don't have one now, and I'm actually not sure why."

"Are either of you allergic?"

Kris and I both shook our heads and said 'no'.

"Has Rachel been around animals?"

"Her friend Abigail's family has a cat," I replied. "And I haven't seen any sniffles or anything that would indicate an allergy."

"Good. She's in daycare?"

"It's a mix now because of my shifts in the ICU. In the Fall, we'll mix and match between the hospital daycare, the church daycare, and visiting her friend Abigail, who lives close and has a full-time babysitter. And, of course, Rachel's grandparents and godparents."

"I think we're done. I'll see her in six months, then we'll go to annual appointments. Obviously, if you have any questions, call the office or come see me at the hospital."

"Will do. Thanks, Doc."

"You're welcome! Does Rachel have a plan for siblings?"

I laughed, "Cute. And I strongly suspect Rachel is very happy to be an only child who can monopolize Papa's time. That said, it's not up to her, and probably about sixteen months from now, if we can get the timing right."

"Kris, who is your OB/GYN?" Doctor O'Neill asked.

"I'm going to start seeing Doctor Forsberg on Mike's recommendation."

"Candace is awesome," Doctor O'Neill said. "I'll see the three of you in six months."

She left the exam room, and after I dressed Rachel, we went to the receptionist, paid our co-pay, and made an appointment for August 19th.

"Why was she asking about a baby?" Kris asked as we got into the car.

"Trying to drum up business," I chuckled. "But she'd never ask a question like that of a typical parent. She was, in her own way, giving me a hard time. You'll find most doctors do that with me."

"With good reason!" Kris declared mirthfully. "Someone besides me has to yank you off that pedestal, which everyone seems to have you on!"

"In all seriousness, is there a problem?"

"No," Kris replied. "It's just things seem to come so easy for you, and everyone treats you like a ... demigod."

"Well, crap," I growled. "I've clearly failed."

"No false humility, Mike, remember?"

I laughed hard.

"I meant 'failed' in the sense that they only think I'm a demigod, not a god!"

"Of course you did!" Kris replied, rolling her eyes.

"And besides, I have you, and soon enough, Rachel, to knock me down a peg or two."

"And we have our work cut out for us!"

February 27, 1989, McKinley, Ohio

"How has your first month been?" Doctor Grady, the ICU Chief, asked on Monday afternoon.

"It's been instructive," I replied. "Except in rare cases in Medicine and Pedes, my interaction with patients and their cases has been a day or two, sometimes three, whereas here, it's been as long as two weeks. I think the best way to put it is that I now understand what it takes to care for patients beyond basic critical care or pre-op/post-op."

"Those are good lessons to learn, even if your future interactions will often be counted in minutes, or sometimes hours, rather than weeks, or in long-term care facilities, for months or years. It's a very different kind of medicine."

"Yes, and the value has come in understanding better how the pieces fit together."

"It's OK to say you're bored," Doctor Grady said with a smile. "We don't want action or excitement here. Those are almost always harbingers of bad outcomes. Your chosen area of practice is exactly the opposite. Action and excitement are the «raison d'être» for the Emergency Department; not so much for any other service."

"I realized about a week ago that I had the wrong attitude towards this rotation, and put my mind to figuring out how I could benefit from it, instead of just wishing it would be over. That's when I realized it had to be about something that always concerns me in the ED — continuity of care.

"I always think about that with regard to patients who don't see a personal physician and come to the ED with some condition that would have been detected and treated before it became acute, but not about what happens after. I'm not sure why it didn't hit me in Medicine or Pediatrics, but it sure has here."

"Because, even on those services, the goal is to discharge the patient as quickly as possible and put them under the care of physicians outside the hospital. Here, it's about getting them stable enough to go to another service. As a regional hospital with limited beds, we haven't really been equipped for long-term care, and most of those patients end up in Columbus, Dayton, or Cincinnati. That's changing, of course, and when the new ED and surgical wings are built, we'll be a full Level I trauma center, and have enough beds for long-term care. Did you consider a rotation in a large, urban trauma center?"

"I did, but life got in the way."

Doctor Grady nodded, "Your circumstances wouldn't really have allowed it. You might discuss a visiting physician situation with Doctor Northrup. Do you know about those programs?"

"Usually they're for rural areas in Appalachia east of here, or in the South, or on Indian Reservations."

"Yes, but there are also exchanges with urban hospitals. After your PGY1, speak to Doctor Northrup. I know Chicago, LA, or Baltimore might be out, but I suspect you could manage Cincinnati, Columbus, or even Cleveland."

"I'll consider it," I replied. "My original thought, while I was an undergrad, was to do a stint with «Médecins Sans Frontières», but because of other things going on in my life, I couldn't do that."

"Don't discard that idea," Doctor Grady counseled. "Sadly, opportunities to serve with Doctors Without Borders will be available whenever your circumstances allow. Anyway, both Doctors Friedman and Knapp are happy with your attention to detail and your ability to follow instructions. Keep it up, please."

"Yes, Doctor."

It was time for my hourly checks on the patients, so I went to the small scrub room next to the ICU ward, put on clean booties and a cap, tied on a mask with a beard pocket, washed my hands, then went into the ward to begin my checks. The rules required fresh gloves before touching any patient, so with wound checks, I'd need to change gloves about six times, but if I didn't need to touch a patient, I didn't need to wear gloves.

Despite the calendar changing to March on Wednesday, I wouldn't start my new schedule until Tuesday, March 7th in order to prevent back-to-back twenty-four-hour shifts, which gave me an extra day off on Monday. One week later, Doctor Grady would hand me my initial Match notice, which would simply state that I had, or hadn't, Matched. If I had, I'd receive the results on Thursday, March 16th.

If by some bizarre set of circumstances I hadn't, then on Tuesday I'd be given access to the Scramble list and would have to try to find a Residency program. The chances that would happen were so vanishingly small that I couldn't see them occurring, but it was possible. The others in my study group were in the same situation — there was only the smallest of a remote possibility of not Matching.

I'd heard talk that the algorithm that the Match used might be changed to reduce the need to Scramble, but that was years off. The best proposal I'd heard was switching the system away from giving the most weight to hospital choices. Instead, the applicant's choices would be given the most weight, including for programs to which they had neither applied nor interviewed. Those choices would only be honored if the hospital's list of choices had been exhausted without all positions being filled. I didn't totally understand the math or computer science behind it, but Lara assured me that the 'stable marriage problem' was well known and the system would work.