Chapter 87: This Attitude of Yours Is Very Tiring

May 4, 1989, McKinley, Ohio

"This actually works out to your advantage," Kris observed when I sat down to eat breakfast after arriving home on Thursday morning. "You don't work tonight, you work the day shift tomorrow, then have next week off."

"It does. I was fortunate that Kylie asked me to swap shift assignments in Pediatrics, which was actually to my advantage, as it defeated the attempt by the doctor to prevent me from attending church for two solid months. But, from her perspective, it was to her advantage because it allowed her family to properly care for her mom during chemo and radiation therapy."

"How is her mom?"

"Cancer free so far," I replied. "The aggressive treatment paid off, though most often it doesn't, and the patient never regains any quality of life, even if the cancer doesn't return. Fundamentally, treatment for certain types of cancer is an attempt to almost kill the patient in the hope that the cancer can be stopped. It's a bad bet in the majority of cases. That said, treatments and therapies are improving, so there is hope."

"What would you do?"

"Evaluate the odds of recovery or remission, the quality of life both with and without treatment, and the long-term prognosis. Then I'd sit down with you and we'd decide what to do. And the immediate circumstances might matter, too, if one choice would let me live long enough to attend Rachel's wedding or see my first grandchild."

"That makes sense. How long do you plan to sleep?"

"Just four hours," I replied. "I'll get up around noon because I can be in bed by 11:00pm tonight, which means I'll get about six hours of sleep."

"Did you hear more about that girl who was raped?"

"No. There haven't been any arrests, but the full results of the rape kit won't be available until next Monday."

"Do you think her dad did it?"

"I have no idea," I replied. "There is circumstantial evidence, but it could just be an odd coincidence. The real question is the lorazepam because that requires a prescription, whereas chloral hydrate can be obtained for use outside of medicine. I think if they find the source of those, they'll have a good idea of who did it. I know they've interviewed her a few times, but I don't know anything about what was said."

"There hasn't been anything in the newspaper."

"As far as I'm aware, there was no radio call which referenced a sexual assault, and unless some reporter really dug into it, it would just appear to have been a teen who drank to excess. Nobody at the hospital is permitted to reveal any information, and the cops don't want to give away anything while they're investigating. Her parents know, of course, because she's a minor, was altered, and had obviously been assaulted."

"So you have to tell?"

"It's a fine line," I replied. "We don't reveal anything about sexual activity, birth control, or pregnancy. If we find evidence of rape, we encourage the woman to report it, but we can't force her to. We'd refer her to a social worker in most cases, and they'd handle it. In this one, because there was clear evidence of a rape, and the patient was incoherent, Doctor Billings exercised her judgment and informed the Sheriff's Deputy."

I finished eating, then Kris, Rachel, and I said our morning prayers. Kris left for school, and a few minutes later, Serafima and John arrived. I went up to bed and slept until noon, as I'd planned. When I went downstairs, Serafima and John left, I had lunch with Rachel, then spent the afternoon with her.

That evening, after dinner and evening prayers, Lyudmila came to the house to watch Rachel while Kris and I headed to Hayes County High, where we joined the other members of Code Blue. Our performance was well received, and Kris and I sang Endless Love as the final song of our encore. As soon as we'd taken our bows, Kris and I left and headed home. My mother-in-law was waiting with Lyudmila to take her home, and as soon as they had left, Kris and I headed to bed.

May 5, 1989, McKinley, Ohio

"How was the gig?" Kylie asked.

"It went well, and it hit me how much older I am than High School kids."

"Your wife is a High School kid!"

"And far more mature than most! She's also eighteen, and some of the girls at the Prom were fifteen or sixteen. I'm more than ten years older than they are."

"And the next thing you know, you're going to be demanding they get off your lawn, right?"

I laughed, "Or I'll call them 'meddlesome kids'!"

"Scooby Doo! I loved that show when I was little."

"Seriously, though, with medical school graduation just two weeks away, it seems like High School was a lifetime ago. It's been eight years for us, after all."

"True," Kylie agreed. "Like you, I thought it would never end."

"What's on the board?"

"Toddler with croup waiting on a Pedes consult; nonagenarian feeling lightheaded being observed; severely lacerated foot due to a misplaced Lego block."

"Ouch!" I grimaced.

"Let's just say that I bet Junior will have his Legos taken away if he fails to pick them up again. Dad is not amused."

"I bet. Did you do the suturing?"

"No, Doctor Casper did it because it was a more complicated repair. The guy has a sprained ankle, too."

"How's the health of the ninety-year-old?"

"He's actually ninety-nine, and I hope I'll be as healthy as he is when I'm seventy, let alone nearly a hundred! Strong distal pulses; good oxygen saturation; no history of heart trouble; lungs clear. His only noted problem is slight anemia. The cause of the near syncope hasn't been determined."

"Besides being freaking ninety-nine-years old?" I asked.

"Not a diagnosis, according to Doctor Casper!"

I chuckled, "Right up there with 'natural causes' no longer being a valid finding for an autopsy. Everything has to have an underlying condition. Doctor McKnight finesses it by including 'due to advanced age' in the prose, but he has to code the reports with something specific such as 'MI', and that's what shows up in CDC and Medicare stats, creating a misleading picture."

"You mean the difference between Mr. Carlson suffering cardiac arrest and you or me?"

"Exactly. If that were to happen to us, we ought to be recorded in the stats that way. But at ninety-nine? It's not heart disease, as you said, but it'll be classified that way, despite him being a centenarian. What's the plan?"

"Right now, just oxygen, EKG, and observation. No signs of stroke or high cardiac enzymes, and respiration is strong with PO₂ at 99% on nasal cannula. It was 95% on room air, and the oxygen is simply because we don't have a working theory besides 'old'."

"OK. Go home, get some rest, and I'll see you at my house at 7:00am on Monday for study group."

"Thanks again!"

"Sorry, before you go, how is Tim doing?"

Kylie rolled her eyes, "Still bitching that his reviews were unfair. I've followed your advice and said he has to take it up with the doctors who wrote the evals or his advisor. He has an appointment to see Doctor Collins later this morning, but he's still on pure scut, and I think Doctor Gibbs intends to keep him on that for the rest of the month. I can't say I disagree, and Felicity is the perfect example of how to turn around subpar evals."

"Did she get any procedures last night?"

"A Foley on an MVA who went up to surgery around 1:00am, but died on the table. Tough to survive going through the windshield."

"That he was alive when he arrived here is a miracle in and of itself," I replied.

"I'm outta here!" Kylie declared. "See you Monday!"

She left, Felicity came in to say 'hi', then headed home while I went to check on the three patients Kylie had turned over to me. A glance at the board showed it had been a busy night, as there were four other patients on the board, meaning we basically had a 'full house' in terms of trauma and treatment rooms. Fortunately, the 'Lego injury' was ready to be discharged, which would clear an exam room, and the croup could be sent up to Pediatrics if we needed the trauma room.

"Good morning, Mr. Bentz," I said to the red-haired man with the lacerated foot and sprained ankle. "I'm Mike, a Sub-Intern. How are you feeling?"

"I've had better mornings!" he groused. "But OK."

"You're ready to go home," I said. "Have you used crutches before?"

"In High School, when I sprained my knee playing baseball."

"Do you feel comfortable using them?"

"Yeah, no sweat."

"And someone is here to drive you home?"

"My brother."

"Then allow me to take your vitals, fill out the discharge forms, have Doctor Casper sign them, and we'll get you on your way."

"Thanks."

I performed the exam and recorded the vitals, then left to get Doctor Casper's signature. Once he'd signed the forms, I went to the supply room and retrieved a pair of crutches, filled out the necessary form for patient billing, clipped it to the chart, then returned to Mr. Bentz.

"Ibuprofen or acetaminophen for pain, keep it dry, and see your personal physician in a week for evaluation. If you notice any discharge that isn't clear, or any odor, see your personal physician or come back here. You shouldn't put any weight on your injured foot until cleared to do so by a physician. Any questions?"

"Only if you'd like to buy a used Lego collection!"

I chuckled, "I hear you, but my daughter isn't even two, so the blocks are too small for her. Let me call an orderly to wheel you out."

"I can use the crutches."

"I'm sure you could, but policy says an orderly will wheel you to the door so you can get into your brother's car."

I went to the phone, placed the call, and waited for the orderly, who arrived about five minutes later with a wheelchair. He and I helped Mr. Bentz into it, I propped the crutches on one of the footrests, and Mr. Bentz took hold of them. Once they'd left, I went to check on the toddler with croup and encountered Doctor Rosenbaum, the doctor who had tried to mess with me on my Pediatric rotation, along with a Third Year I didn't know.

"I have this," Doctor Rosenbaum said tersely.

"OK," I replied, leaving the room, then going into the trauma where Mr. Nick Carson was lying on the treatment table.

"Hi, Mr. Carson," I said. "I'm Mike. How are you feeling?"

"Still a bit dizzy and lightheaded."

"OK to check your heart and lungs?"

"You a new doc?"

"In about two weeks," I replied. "I'm at the very end of my training."

"Might as well. Maybe you can figure out what's wrong! Sometimes a new perspective is good!"

"I'll do my best," I said. "If you allow me to do a complete exam, I will."

"Sure. None of the other members of the brain trust knows what's causing it!"

I did a complete H&P, re-asking all the usual questions, and learning in the process that he'd been drafted in 1918, but hadn't been sent to Europe until December, after the Armistice had been signed. He'd stayed in, had transferred to the Army Air Corps and had been stationed in Hawai´i when the Japanese bombed Pearl Harbor. Except for that attack, he'd never seen combat, as he'd been brought back to the states and assigned to train aircraft mechanics.

"Find anything?" he asked.

"You might be the healthiest person I've ever seen in the Emergency Department, doctors included," I said. "Let me confer with Doctor Casper."

I left the room and went to find Doctor Casper, who was sitting in the consultation room reviewing a chart.

"Hi, Mike," he said when I walked in.

"Hi, Doc. Mr. Carson is the healthiest person I've seen since I started my clinical rotations."

"Has me completely stumped, too."

"What's next?"

"Neuro consult," Doctor Casper replied.

"Tumor?" I asked.

"That's one possibility, but he has no other symptoms or deficits. What else is in the differential?"

"Ear infection, but his ears are clear and not even a hint of pink or bulging."

"You did a complete exam?"

"A full H&P once Kylie told me nobody had found anything. Other than hearing about his time in the Army, I didn't learn anything."

"Other differentials?" Doctor Casper inquired.

"Inner ear disorder?"

"That's where my money is," Doctor Casper replied. "But I have no proof."

"Ménière's disease?"

"That was my first thought, but he has no tinnitus, is not hypersensitive to sound, and has no hearing loss."

"No kidding! I was surprised he doesn't have a hearing aid!"

"Honestly, if neuro can't find anything, I'm going to write 'old age' on the diagnosis line and let Doctor Northrup deal with it!"

"That'll go over like a lead balloon," I replied.

"Most likely I'll give a preliminary diagnosis of Ménière's and tell him not to drive."

"I was completely surprised that he still drives. TIA or stroke can mimic Ménière's."

"And are there any signs of either of those?"

"No. Nothing in his blood work indicates that. He has no cognitive deficits, and his EKG is textbook sinus rhythm."

"So that's where we are. Sometimes we have no answers. I'm going to suggest neuro do a CAT scan simply to rule out a tumor, but at ninety-nine, they aren't going to treat it if they find it. Risk management would never sign off on that, even as good as his health is."

I nodded, "At ninety-nine, the risk factors of surgery are so great and life expectancy so short that it makes no sense. That said, Mr. Carson could easily live another ten years."

"Or literally drop dead tomorrow from old age."

"That is the rub, and one more problem with statistics," I said, suppressing a sigh, thinking of Angie.

"How is your friend with schizophrenia?" Doctor Casper asked, seemingly reading my mind.

"She's doing as well as can be expected. I'll see her in a couple of weeks when I'm in Goshen to play at their Prom. How are the wedding plans coming along?"

"Oksana's mother and her aunt are handling things, so I figured you'd be clued in!"

"I avoided being involved in my own wedding planning, so there is no chance I'm going to even ask about yours!"

"The only fly in the ointment is that Father Nicholas is insisting I be chrismated before the wedding."

"You were baptized, right?"

"As a baby, yes. Lutheran, but it didn't really take."

"It's the act that matters in this case, and at the risk of having my priest and bishop on my case, I'm going to say there is literally no canonical requirement for you to be chrismated. An Orthodox wedding is considered valid so long as one party is Orthodox, the spouse has been baptized in the name of the Trinity, and there is a crowning ceremony in the temple."

"Funny how that hasn't been mentioned."

"Obviously, it's preferable for you to be chrismated, but you come to church regularly, and I'm sure you've agreed with Oksana that your kids will be baptized. While it's not common in our parish, the Greeks have quite a few mixed marriages, mostly Roman Catholic men who marry Greek Orthodox women. The men usually don't convert, but do attend church and raise their kids Orthodox."

"How much trouble would there be if I said 'no'?"

"I'll be dressed down if they know I told you, which they will. But don't worry, because I've been dressed down by bishops before! Ask Oksana what she thinks, and then decide what to do. In the end, no matter what choice you make, it has literally zero effect on your eternal fate. That comes down to answering one simple question — do you truly love God? If the answer is 'yes', it doesn't matter if you never set foot in an Orthodox church. If the answer is 'no', going to church every single day for your entire life, going to confession, and receiving the Eucharist will not save you because you reject God's out-poured love."

"The Icon of the Last Judgment, right? With the river of fire?"

"Exactly. There are icons which depict clergy, including bishops, in Hell. As Keith Green opined, going to church doesn't make you a Christian any more than going to McDonald's makes you a hamburger!"

Doctor Casper laughed, "Nice."

"Silly analogies aside, the icon should tell you everything you need to know."

"Thanks. I'll speak to Oksana. Anyway, call me when Neuro arrives."

"Will do. Rosenbaum is with your croup patient. He chased me out when I went to check."

"He chased me out, too. I'm not sure what his problem is, but he's the worst example of a pediatrician I've ever seen, at least with regard to how he treats people. Reportedly, he's an expert diagnostician and clinician, but has zero interpersonal skills."

"So, like a surgeon?" I asked.

Doctor Casper laughed, "Present company excepted?"

"My bedside manner and my interpersonal skills are not typical of a surgeon."

"No, they aren't, but you're more like me and Pete. Loretta is more serious."

"BJ Honeycutt seemed to strike the right balance between Hawkeye Pierce and Frank Burns."

"Hawkeye was suffering from clinical depression for almost the entire series, and Frank Burns, well, anyone banging Margaret Houlihan should have been WAY less uptight!"

I chuckled, "True."

"Ghost?" Doctor Lucy Vanderberg said from behind me. "You called for a consult?"

"Mike, fill Vandy in, please."

I ran through everything I'd just discussed with Doctor Casper, including our discussion of the differential diagnoses.

"I'll have a tough time getting a CAT scan approved," Doctor Vanderberg said. "I can try, but Medicare won't agree without something substantial. Let me examine him, but I tend to agree that 'old' is the correct diagnosis. I'd add a cane for safety to your suggestion he not drive. But let me see if I can find anything. Mike, with me, please."

We left and walked towards the trauma room.

"Where's your med student?" I asked.

"Prepping a craniotomy for a tumor excision," she replied. "I decided to do this before surgery, because otherwise it would potentially be another five or six hours."

We went into the room, and after Doctor Vanderberg introduced herself, she did a complete neuro exam, and I scribed for her.

"We're going to discuss this as a team, and Doctor Casper will come speak to you."

"Sure thing, Doc," Mr. Carson said. "Got any cute nursing students who can do an exam?"

Both Doctor Vanderberg and I laughed.

"I'll see what I can do for you!" Doctor Vanderberg said.

We left the trauma room and went back to the consultation room.

"Do a CAT scan," Doctor Vanderberg said. "I'll sign off and take the heat from the administration if Medicare or the VA turn down reimbursement. There is no way I'm not doing everything I can for a guy who is sharper and in better health than most people thirty years younger!"

"Put it on the chart, and we'll take care of it," Doctor Casper said.

I handed the chart to Doctor Vanderberg, who wrote out the order and signed it, then handed it back.

"Call me when the scan is complete," Doctor Vanderberg said. "I'll probably be in surgery, so I'll review it once I'm finished."

"Call and set it up, Mike," Doctor Casper said. "Thanks, Lucy."

Doctor Vanderberg left, and I went to the nurses' station and called radiology to arrange for a CAT scan. After verifying the patient information, I was given an 11:00am slot. I informed Doctor Casper, and then we informed Mr. Carson, who asked how the machine worked.

"It's basically an X-ray machine with variable depth," Doctor Casper said. "That means it can display very specific slices of your brain, giving us a very detailed view."

"That sounds expensive."

"It is, but our goal is to figure out what's wrong with you."