Chapter 89: It Takes a Special Kind of Crazy

May 15, 1989, McKinley, Ohio

"Hi," I said to the teens in Exam 4. "I'm Mike. What seems to be the problem?"

"The problem is this asshole taking advantage of my daughter!" the irate dad interjected.

"Mr.?"

"Ferguson."

"Mr. Ferguson, I need both Matt and Marcia to relax. If you want to stay, you need to relax, too."

"RELAX? SERIOUSLY! SHE'S FIFTEEN!"

Felicity came into the exam room just then, which allowed me to attempt to defuse the situation.

"Jamie," I said, "please escort Mr. Ferguson to the waiting room. Mr. Ferguson, when I've resolved this, I'll bring the kids out."

"This way, Mr. Ferguson," Jamie said.

Fortunately, he didn't resist and left the room with Jamie.

"Tank ya," Marcia mumbled

"I think I may have only bought Matt a stay of execution," I said. "Let me take a look and see."

I washed my hands, then put on gloves so I could examine the teens' braces. The wire of Matt's braces had come loose from a bracket on his tooth and somehow hooked into a bracket in Marcia's mouth. I decided the best course of action was to see if I could unhook it, rather than cut the wire, as a loose wire wouldn't present a risk of cutting his mouth before he could see his orthodontist.

"Felicity, curved Kellys, please. I'm going to try to unhook them, rather than cut them. No need to open the procedure tray, just get a pair from drawer 1A."

She retrieved the instrument and handed it to me, just as Jamie came back into the exam room.

"He's pretty agitated," Jamie said. "You might want to consider allowing Matt to stay until his parents can come get him."

I nodded and said, "OK," then turned to the teens and said, "Just hold still."

It took a bit of manipulation, and a bit more force than I'd expected, but I managed to free the wire. The teens were wearing only lower underwear, so I asked Felicity to get two sets of scrubs — medium for Marcia and large for Matt.

"Thanks," Marcia said.

"Let's talk before I send you to your dad," I suggested.

"About?" Matt said warily.

"First, anything you say in here is private, and per hospital policy, I cannot reveal it to anyone, not even your parents. Are you two using birth control?"

"Rubbers, Matt replied.

"And you know that STDs, what you might call 'VD', can be transmitted in ways other than intercourse?"

"How?" Marcia asked.

"Any exchange of bodily fluids," I replied. "If you guys are exclusive, and neither of you has had any other partners, the risk is minimal."

"So, like swapping spit?" Marcia asked.

"Generally, no, unless you have an open sore in your mouth. Making out is very safe, but it's extremely possible to contract an STD through oral sex. The other thing to know is that unless you handle rubbers properly, you can still become pregnant or contract an STD. Jamie, can we get two copies each of the STD brochure and the Free Clinic brochure?"

"I'll be right back with those," Jamie replied as Felicity returned with the scrubs.

The teens put on the scrubs, then I completed the two charts, noting their birthdays.

"One more point," I said, "and no judgment, but you two need to be aware of something important. Marcia, you're only fifteen, and Matt, you're about to turn eighteen. The age of consent in Ohio is sixteen, and while they generally do not go after teenagers, once Matt turns eighteen, Marcia, your dad could file a complaint. I don't know what might happen, but it is possible for Matt to get into real trouble once he has his birthday in July."

"Seriously?" Marcia asked.

I nodded, "Seriously. Until you turn sixteen in September, the State of Ohio says you cannot consent to sex with someone over eighteen. And it's even a bit more complicated, because if you're sixteen or seventeen, your dad could still complain, and it's possible for charges of 'contributing to the delinquency of a minor' to be brought."

"That's dumb!" she protested. "It's my body and my choice!"

"I understand how you feel," I said. "I'm just letting you know that now that your dad knows, you have to consider all of these things. I'm no expert, so you should speak to someone at the Free Clinic. I'd offer to let you speak with the social worker, but she doesn't arrive until after 7:00am, and you two need to get to school. May I ask what happened?"

"Matt, uhm, snuck into my bedroom so we could, you know, and everything was fine until the stupid braces stuck together. My dad found us together and was afraid to try to unhook the braces when they didn't just come apart."

"OK. We're finished. Matt, you should see your orthodontist right away. Do you want to call your parents?"

"Yeah, I guess so."

"Jamie, if you'd take Matt to the consultation room so he can use the phone, I'll have Doctor Gabriel sign off, then Felicity and I will escort Marcia to her dad. I'm going to pass on asking him to stop in at Patient Services."

"Good choice," Jamie said with a slight smile.

"Thanks, Doctor," Matt said.

"Sub-Intern," I replied. "That's a trainee doctor, which I'll be for another ten days."

Jamie and Matt left, and I went to Doctor Gabriel to report.

"I didn't need to cut the wire," I replied. "I managed to unhook it using curved Kellys," I said. "The male patient is with Jamie and is calling his parents; the female patient is with Felicity. I'll release her to her dad once you sign the charts."

He looked them over, signed them, and handed them back.

"Good job on having the STD and birth control talk. I figured they might be more receptive to someone closer to their age."

I laughed, "You're only two years older than I am!"

"Which does make you closer, does it not?" Doctor Gabriel asked with a smile.

"Technically."

"Any concerns?"

"Just the girl's dad's reaction," I replied. "But it's pretty typical, so I'm not too worried."

"OK. Street 'em."

"Will do."

I returned to the exam room, and Felicity and I walked Marcia to the waiting room where her father was waiting.

"Where's that little shit?" Mr. Ferguson asked.

I decided a bit of subterfuge was better.

"He's under eighteen, so we're contacting his parents. He'll be released to them."

"He's not going to escape the consequences of this! Marcia, I'll deal with you at home! Let's go."

They left, and Felicity and I went back into the ED.

"He's pissed," Felicity observed.

"I agree, but I don't think she's at risk, so a referral to Family Services would create bigger problems for everyone."

"But him?"

"All we can do is leave that to his parents," I replied. "No threat of physical harm was made, so we don't have to report it."

Jamie came over to us and let me know that Matt had reached his parents and that someone was coming to pick him up. I thanked him, then Felicity and I went back to the lounge. A few minutes later, Kylie came in.

"Morning, Mike!" she exclaimed. "I saw the board is clear."

"You missed the half-naked teens with locked braces," I chuckled.

"I thought that was a TV trope!"

"It is, but believe it or not, it happened! Felicity was a witness, as was Jamie."

"Wait! Half-naked?"

"The guy snuck into the girl's room at her house for some 'quality time' before school."

Kylie laughed and shook her head, "I bet THAT went over well!"

"Her dad brought them in, and he was not amused."

"I bet! Anything else?"

"Drunk driver with a badly fractured wrist and forearm and a severe forehead lac. He's with Ortho now, and will see plastics later. Then he's going to jail because the nineteen-year-old driver of the other car was dead at the scene."

"God damn drunk drivers!" Kylie growled.

"No argument from me," I replied. "There are three others awaiting discharge, but they aren't ours."

"Did you see Tim?" Felicity asked. "He should be here by now."

"No," Kylie replied. "I didn't see him when I came in."

"I better go see if he's in the locker room or somewhere so I can get out of here at 0600."

She left, and Kylie poured herself some coffee and sat down on the couch next to me.

"I realized yesterday that I'll have a month's seniority over you," Kylie said with a sly smile.

"That and 95¢ will get you a cup of coffee at Frisch's," I chuckled. "And PGY2 years all start on July 1st."

"A minor detail!"

Felicity came back into the lounge and said that Tim had called in sick, and Doctor Gabriel had agreed it was OK for her to leave. The two of us went to the locker room to change into our street clothes.

"Would they really prosecute that guy?" Felicity asked.

"I don't know," I replied. "I just know what I've read in the papers and what I've heard from the social worker here at the hospital. The thing is, they could, which means he's at real risk when he turns eighteen."

"That's so dumb, given the relationship clearly isn't abusive."

"I don't disagree, but the laws have become stricter in that area in the past five or six years. And society seems to be trending towards more controls on teens than we had in the 70s. I honestly think Europe has it right, but most people here wouldn't agree."

"I tend to agree with you, especially with regard to birth control and access to abortion."

We finished dressing, then left the hospital. I headed home for breakfast and sleep.

May 16, 1989, McKinley, Ohio

"Hi, Mike," Doctor Gabriel said when I checked in with him just after midnight. "Grab a seat."

I did as he asked.

"After your shift, you need to see risk management. They'll have someone available at 0600."

"Why?"

"Your braces couple. The dad complained that you gave his daughter 'sex brochures'."

"Per policy," I replied.

"Yes, of course. You didn't do anything wrong. They just need to dot the i's and cross the t's. They'll speak to Felicity right after they speak to you, and to Jamie when he goes off shift. Just tell them what you did, and there won't be any recriminations. You absolutely followed policy."

I smiled wryly, "I'm used to causing trouble by doing the right thing."

"What have I missed?"

"Nothing that happened here at the hospital," I replied. "It was at church, and at Taft when I was an undergrad. Do you think there might be a policy change?"

"I seriously doubt it. Not handing out information on STDs in the age of HIV infections would be negligent. I'd do it even if it were against official policy because it's downright stupid, and bordering on malpractice to not do so. And we only give out that information to teens who disclose that they're sexually active, and I'd say given her dad caught these two in flagrante delicto, that's a certainty!"

"I agree. Let me go check on the MI and the broken foot."

"Let me know if anything has changed with either of them."

"Will do."

I checked on the two patients, and nothing material had changed. The MI was waiting on transfer to Cardiology, which would happen as soon as the on-call Resident returned to escort him to the ward; the broken foot was being cast by an Ortho Resident and Nurse Wendy, and would be released. There was nothing for me to do for either of them, so I went to the lounge where Felicity was sitting.

"Rumor has it that Tim met with a lawyer yesterday," she said.

"Well, if he wants to ensure he never graduates, that would be the way to do it. If he has contacted an attorney, and the attorney is competent, he'll advise Tim to negotiate a repeat of Third Year. Any other course of action is a guaranteed failure. My advice to you is to not discuss it with him at all."

"I haven't."

"I wasn't saying you had, just that you shouldn't. No good can come of that discussion. It's why my only response to him when he complained about unfair treatment was to take it up with Doctor Collins and Doctor Mertens, the Dean of Clinical Instruction. That should be your sole response as well. That said, if it is something you've personally witnessed, by all means, offer your opinion, but only if you have first-hand knowledge."

"But you've given me advice on how to deal with doctors, nurses, other medical students, and patients."

"Yes, that's true, because it's either general advice, or you've asked a specific question about a specific situation you've described. Tim said his evaluation from Doctor Collins was 'unfair', and because I wasn't involved in Tim's rotation, there is literally no way I can know what happened nor the reasoning behind Doctor Collins' evaluation."

"Mike?" Nurse Wendy called from the door to the lounge. "Doctor Abbot from Cardiology is here to admit Mr. Suarez."

"Be right there," I said.

Ten minutes later, Mr. Suarez was on his way up to Cardiology, with Felicity and Paul Black, a Third Year, accompanying Mr. Suarez to the ward per our usual protocol. Felicity returned about five minutes later, just in time to help me discharge Mr. King, the man with the broken foot.

"You do the discharge," I said to Felicity. "I'll only step in if there's a question you can't answer or a problem."

"OK!" Felicity replied.

We went into Exam 3, and Felicity asked Mr. Black for permission to examine him, recorded the discharge vitals, and went over the discharge instructions. Once that was complete, she called for an orderly with a wheelchair who arrived to push Mr. Black to the waiting room so that his son could take him home.

"How'd I do?" Felicity asked when he had returned to the lounge.

"You did it exactly the same way I do it," I replied. "And that's a good thing from my perspective."

"Your policy of always asking before touching a patient is an excellent one. I never really thought about it until I heard you do it and asked."

"It puts the patient in control," I replied. "So much happens to a patient in a hospital that they often feel helpless. The simple act of asking for permission to touch them changes the power dynamic slightly, and that's important. I wouldn't think of touching someone without permission outside the hospital or a doctor's office, so why would I do it in those locations, except in extremis?"

"I always thought that people gave their consent by showing up, and that they assumed that they'd be touched."

"I'm sure some do, and maybe even most, but think about the two scenarios — in one, you're the subject of whatever examinations, tests, and treatments a doctor wants to run; in the other, you're a partner in your diagnosis and treatment. The difference between 'I am going to draw blood' and 'Is it OK if I draw blood?' is subtle, but important. The same goes for explaining what we're doing, no matter how long it takes, with the obvious exception of immediate risk of life. A perfect comparison is in-hospital childbirth in the 1950s and 1960s versus now."

"Something done to women for the convenience of the doctor as opposed to a natural process with which the medical team assists."

"Exactly right."

"Mike Loucks, changing medicine one med student at a time!" Doctor Casper said from where he was relaxing on the couch.

"You don't disagree, do you, Doctor Casper?" Felicity asked.

"No, I don't. Mike's reminding us of something that is often forgotten in a busy ED, where our job is to move 'em through like an assembly line."

"But is that our job?" I asked. "There's a difference between efficiently treating and either admitting or discharging patients and acting out of expediency."

"You know the answer to that, Mike."

"Lack of resources," I replied. "The root cause of nearly every shortcoming I've ever identified. When we don't have enough beds or doctors, we don't have a choice but to act expediently when we should be acting expeditiously."

"What's the difference between those two?" Felicity asked.

"Being expedient means acting in a way that is most convenient or advantageous to us, which can sometimes result in sub-optimal outcomes. Being expeditious means doing something with speed and efficiency. It's another subtle difference, but 'expeditious' implies a good outcome, while 'expedient' doesn't."

"Or," Doctor Casper said, "as they put it in a management course I took as an elective, 'good, fast, cheap — pick two'. Or, more pithily, 'you get what you pay for'. The problem with emergency medicine is that we have to be good and fast, and that is not cheap. Guess what the real constraint is?"

"Money, of course," Felicity replied.

"Right the first time," Doctor Casper replied. "If we had infinite money, we could be good and fast; we don't, so one of those has to suffer. Again, guess which one?"

"It has to be 'good'," Felicity replied, "because we can't really sacrifice 'fast' in emergency medicine."

"I'll counter slightly," I said, "and say that it's when we move too fast that the majority of sub-optimal outcomes occur. The problem is, at least as I see it, you don't always know when you're moving 'too fast'."

"That's right," Doctor Casper said. "And why sometimes 'stop and think' is the correct course of action. We have what you could call 'pre-programmed' actions, things we do because the success rate is so high and the risk of adverse effects so low. Once you've done those things, you need to take a breath and think about your options. I know from your perspective, Felicity, it doesn't seem as if we're doing that, but we are, at least in most cases."

"I've found that the 'pre-programmed actions', as you called them, give me time to think," I replied. "I learn to do them on autopilot, but without being careless or inattentive, but because I know the correct intubation procedure starts with succinylcholine and etomidate in standard doses, I can order those without having to think about it, freeing myself to think about other things. Ditto connecting the EKG — it's automatic at this point, or 'pre-programmed', if you will, so I can ask 'what next?' while I do that."