Chapter 86: A Chronic Condition

April 28, 1989, Great and Holy Friday, McKinley, Ohio

As Kris, Rachel, and I entered the nave on Great and Holy Friday, I marveled at how time had flown since our wedding on New Year's Day. Kris and I had been married for nearly four months, and I was halfway through my final Sub-Internship. My contract with Moore Memorial had been signed, and I'd be starting my Residency in just over two months.

Before that happened, I'd take the next step of the MLE test sequence, graduate, and spend a week on 'ride-alongs' with Bobby's unit at the Hayes County Fire Department. In my private life, there were a pair of Prom gigs and, more importantly, a belated honeymoon trip on which Rachel would accompany Kris and me. And, of course, the usual day-to-day obligations and joys of being a husband and father.

Being in church on 'Orthodox Good Friday' was, without question, the highlight of the Lenten and Paschal season, as the hymns and prayers moved from sorrow to joy as the day progressed, culminating in the most beautiful service of the year — the Lamentations, a rare evening Matins service, celebrated in anticipation, and revealing the 'world turned upside down' nature of Holy Week.

I pushed the thoughts about everything outside of church from my mind and focused on the matter at hand — worshiping God together with my wife and daughter, surrounded by friends and the faithful of Saint Michael the Archangel Orthodox Church. The services lasted the entire day, with breaks between the seven discrete services — First Hour, Third Hour, Sixth Hour, Ninth Hour, Great Vespers, and Lamentations. Following that would be the All-Night Vigil around the tomb.

Halfway through the day, we had a shared meal, which consisted of bread, humus, and raw vegetables. I ate sparingly, keeping to my tradition of eating very little during Holy Week, though I ate more than usual, as I had to maintain my energy for working in an increasingly busy Emergency Department. When Kris, Rachel, and I finished lunch, we joined Father Nicholas, Elizaveta's family, and our friends at Elizaveta's gravesite for a brief memorial service.

When we finished, we returned to the church for quiet contemplation until the Ninth Hour service began at 3:00pm. Just over five hours later, the choir sang my favorite hymn of the entire liturgical year — the Third Stasis of Lamentations. It was a hymn which began mournfully...

... but ended with joyful expectation...

Father Nicholas sprinkled rose water on the congregation while the choir sang, and at the completion of the service, he led the congregation as we carried the tomb, which held the Epitaphion, around the outside of the church three times. Following the service, the teens gathered to begin the All-Night Vigil, with Subdeacon Mark and Alyssa supervising them.

Kris, Rachel, and I stayed through the reading of the first five Psalms, then left the church to head home, where we said abbreviated evening prayers, then put Rachel to bed.

"Would taking a bubble bath together to relax violate our 'no sex' rule for Holy Week?" Kris asked.

"No," I replied. "Provided you can restrain yourself!"

Kris laughed softly, "I will not apologize for enjoying that specific benefit of marriage! And you know I can."

"I do. I'd very much like that after standing in church nearly the entire day!"

We had a very relaxing bubble bath, showered, then went to bed, as we'd be up early in the morning for the Vesperal Divine Liturgy of Saint Basil the Great, which was celebrated on Holy Saturday morning.

April 29/30, 1989, Great and Holy Pascha, McKinley, Ohio

On Saturday morning, after the Divine Liturgy, the ladies of the church served a traditional pancake breakfast — a late-morning meal designed to tide us over until the Paschal celebration — which would begin sometime around 2:00am, following the Paschal service. When we finished eating, Kris, Rachel, and I left to do our final shopping for our Pascha basket, which we'd prepare later in the afternoon.

"Does Rachel get candy?" Kris asked, as I selected my usual treat of Reese's Peanut Butter Cups from the candy section at Kroger.

"It would have to be something she won't choke on, and we don't want to give her too much sugar."

"You are ascetic even in your feasting!" Kris teased.

"Not even close!" I chuckled. "I'm thinking like a doctor, not an Orthodox dad!"

"What about a piece of stick candy?" Kris asked. "She'd be able to hold it, and it wouldn't be dangerous."

"True," I agreed. "They don't have those here, but we can stop at the candy store on Main. What flavor do you think she'd like?"

"I think we're safe with cherry or strawberry. I wouldn't choose something tart like lemon or green apple."

"Those would be my choices! Though I really like cherry Jolly Ranchers, too."

Saying that, I chose a package of those, along with a Snickers bar, and put them in the cart.

"What do you want?" I asked my wife.

"Good Belgian chocolate!" Kris exclaimed. "They have a small selection at the candy store, but the best selection is at a confectioner in Columbus."

"We can make that trip if it's important to you."

"I would love a package of Godiva pralines, and they carry them, so yes, please!"

We also bought a Summer sausage, cheese, and crackers to add to the other things we'd already purchased. We stopped at the State Liquor Store and bought a nice bottle of wine, then headed for the candy store, where we bought a pair of candy sticks for Rachel — one cherry and one grape, two flavors we knew she liked. Our final stop in McKinley was the bakery, and after we stopped home to drop off our purchases, we headed to the confectioners in Columbus, where Kris bought two packages of Godiva pralines, saying she wanted to share with others.

Later, at home, we assembled our Pascha basket, though without some of the more traditional items, as Kris was not a baker. We also prepared our contribution for the general feast — a chopped salad — and once everything was ready, we put Rachel down for a nap, and then Kris and I took our own naps so we'd be fresh for the Paschal service, which would begin before midnight and end sometime around 2:00am on Sunday morning.

After our naps, we fed Rachel, though Kris and I both refrained from eating, as we would be receiving the Eucharist later in the evening, or, more properly, very early in the morning. After our meal, I read to Rachel, then we listened to classical music until it was time to head to church for the service. Rachel had fallen asleep, and would likely sleep through the service, though I would wake her for the Eucharist.

Just over six hours later, the three of us returned home to sleep before attending Agape Vespers at 1:00pm. When I arrived home, I went back to bed, as my May schedule had me on Sunday through Thursday, from 1800 to 0600, the opposite of my April Schedule.

Just before 6:00pm that evening, Doctor Billings and I received the handover from Doctor Boyd. Once I had it, I sat down in the lounge with the charts.

"And here I am, spending the night with you!" Felicity smirked when she came into the lounge a few minutes later.

"You might want to rephrase that!" I chuckled.

"No, I meant to say it! You've been giving everyone a hard time, so I figured I'd simply return the favor! How was your Easter?"

"The same as it has been every year of my life, and for about sixteen hundred years before that!"

"The service hasn't changed since the fourth century?"

"Only in minor ways, and with some small adjustments to accommodate modern life. The homily is the same one that's been read since around AD400. Nobody knows for sure when it was first given, but Saint John Chrysostom reposed in AD407, and had been exiled in AD405, so it was given sometime before then. He was canonized almost immediately on his repose."

"Exiled? Why?"

"Well," I said with a smile, "when you speak truth to power, power reacts VERY badly. He lambasted the aristocracy for their opulent wealth, not to mention directly confronting Empress Eudoxia for her paganism. In addition, the Arian controversy was raging, and unless you want a short course in Orthodox Christology, I'll just say it was a serious theological dispute that led to Santa Claus slapping a heretic across the face."

"Wait! Santa Claus?! What the...?"

"The appellation 'Santa Claus' comes to us through the Dutch «Sinterklaas», and is based on Saint Nicholas of Myra. Legend has it that Saint Nicholas slapped a heretic named Arius at the First Council of Nicaea in AD325. He accused Arius of making stuff up and claiming it had always been taught. I've said before that I'm very happy to be part of a church cool enough to have Santa Claus punching heretics!"

"That's a true story?"

"Maybe," I replied. "It's one of the hagiographic stories about Saint Nicholas meant to teach a lesson, similar to the parable of the Good Samaritan. The important thing is not whether it's literally true or not, but what message it conveys. There are many hagiographic stories such as that, and the Old Testament is chock full of stories that do not need to be literally true to convey truth."

"I think I'll pass on the theology lesson, but thanks for explaining."

"You're welcome. Did you review the charts for the three patients on the board?"

"Yes. There's no Fourth Year on Sunday days, so who did you receive the handover from?"

"Doctor Boyd; Doctor Billings and I received it together."

"It sucks for the fifteen-year-old with the broken wrist, having to wait until morning for an Ortho consult."

"Something that will change once the new emergency medicine wing is built," I replied. "To be certified as a Level I trauma center, an orthopedic surgeon will need to be in the hospital at all times. That's true for every department that consults, and no more on call for the Attendings on duty."

"Where did the county find the money for the staffing?"

"Well, 80% of Residents' salaries are covered by Medicare, so that helps, and the hospital bond issue included some money to fund operations for the life of the bonds. That kept the general tax increase fairly low, and was probably the only way they'd get it past the voters. There will need to be a tax increase when the new ED opens because fee increases only help so much, especially with the unfunded costs caused by EMTALA, which, by the way, is why we'll need a tax increase."

"Just like the federal government!" Felicity declared. "Pass a law that is popular but push the funding of the law onto someone else to avoid raising federal taxes!"

"Reagan signed it," I replied. "It passed the House with a comfortable majority and with over ninety votes in the Senate."

"What are you trying to say?"

"That even 'small government Republicans' supported the rules. The actual problem is not that it was unfunded, but that people are, well, people. Nothing in EMTALA requires hospitals to spend a dime, as either Medicare, Medicaid, private insurance, or the patient are responsible for the cost of treatment. We're suffering from unintended consequences, which, in hindsight, are obvious because the theory of the 'tragedy of the commons' is well known."

"You don't think the technocrats in HHS should have known what would happen?"

"I suppose it depends on how cynical you are. If people didn't take advantage of the system to obtain healthcare at zero cost to themselves, there would be no problem at all."

"You studiously avoided using 'free'."

"Because it's NEVER free. As I've pointed out many times, the Canadian and British systems are designed as 'no cost at the point of service', and are funded from the Exchequer in the UK and «L'Agence du revenu du Canada» in Canada." ("The Canadian Revenue Agency")

Felicity laughed, "Of course you used the French name!"

"There might be some influence in my life responsible for that! But the point is, Medicare and Medicaid aren't 'free', they are 'no cost at the point of service'. In that sense, they aren't much different from roads, police protection, and so on. As for HHS, as I said, it's a question of cynicism. In their roles, I'd be the world's biggest cynic and skeptic, which is, of course, why nobody would put me in that role, because I'd point out the flaws. We leave that to GAO and OMB. They get to be the spoilsports while the agencies tout how great their programs are and Congresscritters slap each other on the back in congratulations!"

"Speaking of being cynical!"

"Just making observations."

"If I can ask, what are your thoughts on George Bush?"

"That he was a far better choice than Mike Dukakis, but that's such a low bar that the statement is effectively meaningless! I was hoping Mario Cuomo would run, and would have preferred Gary Hart not self-destruct, but here we are."

"I know you have a serious concern for civil rights — what do you think of Jesse Jackson?"

"Too far left for my taste, though my wife believes he's a reactionary!"

"Reactionary? What does that mean in this context?"

"Somewhere to the right of Attila the Hun," I chuckled. "Kris is a dyed-in-the-wool, red-flag-waving, literally card-carrying socialist. But in all seriousness, 'reactionary' is the progressive word for 'conservative' and is an epithet in the same way that Reagan made 'liberal' an epithet."

"Mike?" Nurse Jamie, the one male nurse in the Emergency Department, called from the door to the lounge. "EMS five minutes out with an altered teen."

"Thanks," I said, then turned to Felicity, "Game time."

The two of us joined Doctor Billings in the ambulance bay, and she gave us our marching orders while we waited for the Fire Department squad to pull up. The crew was my favorite 'inside joke' at the Fire Department. Their names were John and Roy, but their surnames were not Gage or DeSoto. I was positive that the scheduler at the Fire Department had put them together on purpose.

"Amy Upton," John said. "Seventeen; found altered by her parents; strong smell of EtOH on her breath; pulse 82; BP 110/80; PO₂ 97% on air; GCS 9."

"Trauma 2!" Doctor Billings ordered. "Mike, differential for EtOH on exhalation?"

I answered as we began moving the semi-conscious young woman to the exam room.

"Consumption of alcoholic beverages, diabetic ketoacidosis, medication interaction, or Sjögren syndrome. Some mouthwashes will leave an alcohol odor, but wouldn't cause disorientation."

"Tests you would order?"

"CBC, Chem-20, EtOH, tox screen, pregnancy test, and an immediate glucose stick. Exam should include checking for dry mucous membranes, and if warranted, a contrast dye test using a rose bengal stain."

We moved Amy from the gurney to the trauma table, and I attached the pulse oximeter clip while Doctor Billings began her exam. John and Roy turned to leave, but she stopped them with a question.

"Parents?" Doctor Billings asked the paramedics.

"About five minutes behind us, according to the radio call from the Sheriff," Roy said.

"Any drug containers, bottles, or anything like that at the scene?"

"Not visible to us," he replied. "You can ask Deputy Sparks when she arrives."

"Pulse 78; BP 100/70; PO₂ 97% on air; GCS 12," I reported.

"IV is in," Jamie announced. "No obvious track marks on either arm. Drawing blood now."

"Heart and lungs are clear," Doctor Billings announced. "Pupils sluggish."

"Glucose is 125," Felicity announced. "That rules out ketoacidosis."

"Get the blood to the lab, please. Wait for the EtOH."

"Yes, Doctor!" Felicity declared.

As soon as Jamie completed the blood draws, Felicity took the tray from him and left the trauma room.

"Mike, go see if the parents are here, please. If so, bring them in so I can ask questions."

"Right away!" I confirmed.

I left and went to the admit desk to look through the plexiglass. I saw Deputy Sparks with a man and woman, so I went out the door.

"Deputy Sparks, are these Amy Upton's parents?"

"Hi, Mike. Yes. Hal and Roberta Upton."

"Mr. and Mrs. Upton, if you'd come with me, Doctor Billings would like to ask you some questions."

"How is she?"

"Doctor Billings will answer your questions," I replied. "I'm a medical student."

I escorted them to the trauma room, and Deputy Sparks followed us.

"Doctor Billings, these are Amy's parents, Hal and Roberta Upton," I said.

"Hi," Doctor Billings said. "Is your daughter on any prescription medication?"

"No," Mrs. Upton replied.

"Does she have a drinking problem?"

"I don't think so," Mrs. Upton replied. "She drinks an occasional beer and had champagne at New Year's."

"Do you keep alcohol in the house?"

"Who doesn't?" Mr. Upton replied. "Whisky and vodka, plus beer."

"Does your daughter have any medical conditions?"

"No," Mrs. Upton replied. "What's wrong with her?"

"We're running tests, but the most obvious answer is excessive consumption of alcohol. She's in no immediate danger, so if you'll have a seat in the waiting room, we'll let you know when the test results are back, which will be less than thirty minutes. Mike, escort them out, please."

I did so, followed by Deputy Sparks, then returned to the trauma room.

"Let's get a Foley in, please," Doctor Billings said.

"OK to take the time to remove her jeans rather than cut them?" I inquired.

"What? You don't want a complaint about $200 Calvin Klein jeans being ruined?" Doctor Billings asked.

"You heard about the formal complaint with regard to the sweater?"

"Everyone has. We had a good laugh. Go ahead. Jamie, assist."

The two of us carefully removed the expensive designer jeans from Amy's body, and Jamie set them aside. I immediately noticed something concerning.

"Blood on her panties, and she's not wearing a pad," I said. "And I see minor bruising on her inner thighs."

"STOP!" Doctor Billings commanded, and both Jamie and I stepped back.

She walked around and looked and frowned.

"Mike, get a rape kit; Jamie, see if Deputy Sparks is still in the waiting room. If so, ask her to come in, but do not say why."

"Yes, Doctor!" we both replied.

I went to the nurses' station and retrieved the keys from Colleen, the charge nurse for the shift, then went to the secure storage area to retrieve a rape kit. I returned the keys to Colleen, asked for the Polaroid camera, and took both it and the rape kit into the trauma room just as Deputy Sparks walked in.

"What's the problem?" Deputy Sparks asked.

"We removed her jeans to insert a urinary catheter and detected blood on her panties and bruises on her inner thighs. We have to treat this as a rape unless we find evidence to the contrary."

"Shit!" Deputy Sparks exclaimed. "OK. I need to call dispatch and get a crime scene unit to the Upton's house, and have someone question them. I need to do that immediately. They live in the city limits, so I'll call for a female McKinley officer to witness the rape kit. I can have one of them here in ten minutes, if that's OK?"