Chapter 3 — Appendectomy

_February 26, 1990, McKinley, Ohio_

{psc} The formal funeral for Deputy Sommers was conducted on Monday morning, but I wasn't able to attend due to my shift at the hospital. She received full honors from the Sheriff's Department, the McKinley Police Department, the Harding County Fire Department, and the Ohio State Patrol. The flags at every fire and police station in the county had been flown at half-mast for her, and every member of law enforcement and fire protection had worn a black band around their badges.

At the time I knew the funeral mass was to begin, I was in the lounge. I quietly recited the prayers for the departed, using the standard form rather than the abbreviated form used for non-Orthodox. She had, as I saw it, given her life defending and protecting our patient and the medical staff, and as such, deserved the full prayers. When I finished the prayers, I went to visit Loretta in the CCU.

"How are you doing this morning?" I asked.

"Feeling in both legs, but it's still limited, and I can't move them."

"That's an improvement," I replied. "You and I both know that the kind of improvement you're seeing is a very good sign."

"But not determinative."

"True, but it's a strong indication you'll be able to walk again, though possibly with the need of assistive devices."

"There goes my medical career."

"You don't know that, and neither do I! What have Vanderberg and Cohen said?"

"Wait and see, but they're encouraged by the fact that I have increased sensory function."

"There you go! How long are you in the CCU?"

"Until Friday, most likely, then I'll go to a rehab facility in Columbus."

"I'm going to ask for permission to escort you," I said.

"I appreciate it. Come see me tomorrow?"

"Of course. I'm going to see Shelly now. Is there anything I can get you?"

"A working set of legs."

"In time, Doctor," I said. "You know how this works."

Loretta rolled her eyes, "Easy for you to say from that side of the bedrail!"

"We doctors make the worst patients," I commiserated. "And I was bad before I became a doctor."

"Like most men!"

"Whatever!" I chuckled. "See you tomorrow."

I kissed her cheek, then left the CCU to head to Medicine, where Shelly was in a semi-private room with a young woman suffering from kidney failure.

"Morning, Shelly," I said. "How are you doing?"

"Better now that they moved me here, but I still haven't managed the pizza!"

"I'd _kill_ for a pizza!" Cathy, the young woman in the other bed, exclaimed.

"And I'd be dead if I tried to sneak one in here! Tim Baker would have my butt in a sling!"

"Doctors are just no fun!" Cathy groused.

"Shelly and I are fun!" I countered. "It's the Chief of Internal Medicine who's the problem here!"

"Damn straight!" Shelly agreed.

"Just how much fun?" Cathy asked with an arched eyebrow.

I held up my right hand. "About as far as this ring allows!"

"Wrong hand!" Cathy exclaimed.

"Correct hand for an Orthodox Christian," I replied.

"Well, there goes my idea of trading for a pizza!" she teased, causing both Shelly and me to laugh.

"No offense intended," Shelly said mirthfully, "but fired AND divorced? Nobody is THAT good!"

"You left out 'dead'," I chuckled, "because, despite her protestations of being French, my wife is VERY Russian in certain aspects of her personality!"

"Are you sure about that?" Cathy asked with a smirk.

I laughed again, "Positive, and no, that's not an opening for you to ask for a chance to prove it! Mind if I ask about your condition?"

"Polycystic kidney disease; I'm having a transplant later this week from my cousin. It was delayed by what happened last week. Where you there, too?"

I nodded, "I was in the trauma room Shelly — Doctor Lindsay — had just left, and where the Deputy was shot."

"Holy smokes!" Cathy exclaimed.

"If things go a certain way, Mike might assist with your surgery," Shelly said.

"Well, that would be one way to get him inside me!" Cathy smirked, once again causing both Shelly and me to laugh.

"You, young lady, are dangerous!" I chuckled.

"I'm a college student!" she exclaimed. "We're _supposed_ to be dangerous! Being a sober, responsible adult can wait until _after_ I graduate!"

"What's your major?" I asked. "I mean besides guys…or girls, for that matter."

Cathy laughed, "It would increase my chances of a date on Friday nights! Finance with a minor in computers. I plan to get my MBA and become a CPA, same as my dad."

"What year?"

"Junior at OSU, but my family lives here, so that's why I'm here instead of there. I took the semester off, but I'll take classes during the summer to make up and should graduate on time."

"My wife is at OSU," I said. "She's a poli-sci major and is planning a Master's in public administration."

"What's her name?"

"Kris Korolyov. She's on what amounts to a five-year plan because we'll have our first child together in June and plan the second one about two years from now."

"First together? You have other kids? Or she does?"

"I have a daughter with my first wife, who died the day our daughter was born."

"Holy smokes!" Cathy gasped. "I don't even know what to say."

"Most people don't," Shelly said. "I can say this because I know Mike really well, but it was just one of those rare, random things which there was no way to detect or prevent. It was genetic, similar to your kidney condition."

"Is it OK to ask what happened?"

"In layman's terms, a blood vessel in her brain burst in an area where it caused her heart to stop."

"Whoa!" Cathy gasped. "Unreal."

"Surreal is more like it," I said. "I was a medical student, and all I could do was stand and watch helplessly as the medical team tried to resuscitate her. I'm sorry to cut this short, but I have to get back to work."

"Sorry if I upset you," Cathy said.

"You didn't. I need to get back to my students. Shelly, I'm glad to see your liver enzymes are completely normal. When are they kicking you loose?"

"Friday."

"And when can you come back to work?"

"I have to complete my psych evals, and Doctor Roth has to clear me medically. I'd be happy for you to do the exam."

"I BET!" Cathy teased. "He's hot!"

Shelly laughed, "And taken! I'm no homewrecker! But I trust him to give me the benefit of the doubt, unlike the headshrinkers."

"Any chance you can see someone outside the hospital?"

"No. Owen got quite a bit of guff for allowing you to do that, but he made it stick."

"I had no idea, but I guess I should have known, given my relationship with them."

"Washouts who couldn't even Scramble for dermatology!" Shelly exclaimed.

"On that note, I'm headed back to the lounge! I'll come see you tomorrow."

"And me?" Cathy asked.

"If you're here, then I will."

"Sadly, for two more days before the surgery, then a weeklong recovery."

"See you both tomorrow," I said.

I left the room and walked towards the surgical ward when my pager went off, signifying a consult in the ED. Rather than stop and use the phone, I simply picked up my walking pace and reported to the nurses' station.

"Doctor Casper needs you in Trauma 2 for a rule-out appy," Karli said.

"On my way."

I went to the lounge and let both Erin and Todd know they could accompany me to the ED.

"Morning, Ghost," I said when we talked in. "What do we have?"

"John Smythe, twenty-six, presents with typical signs of acute appendicitis. Ultrasound scan confirms."

"Let me take a quick look," I said. "You know the drill."

"A snot-nosed Resident has to confirm the diagnosis of an Attending!" Ghost teased.

"Pretty much!" I agreed, stepping over to the trauma table. "Good morning, Mr. Smythe. I'm Doctor Mike from surgery, and as Doctor Casper irreverently put it, I need to confirm that you're a candidate for surgery. As we're a teaching hospital, I'd like my Sub-Intern, Erin, to perform the exam."

"She's gorgeous, Doc!" he said quietly, then louder, added. "Sure!"

"Erin, physical exam and ultrasound, please."

"Right away, Doctor Mike!" she exclaimed, sounding almost giddy.

She performed the basic exam, then, with guidance from me, the ultrasound.

"What do you see?" I asked.

"Enlargement, along with free fluid in the right iliac fossa. That, along with the other symptoms, is determinative. A surgical case."

"Indeed it is. Call upstairs and let them know we'll be bringing him up. Then call for an orderly."

She moved to the phone to place the call.

"Are you going to do the surgery?" John asked me.

"As Doctor Casper put it, I'm still a 'snot-nosed Resident,' so I'll assist, but a fully-trained surgeon will perform the surgery."

"How long have you been a doctor?"

"About nine months," I replied. "Surgeons train for about seven years, some longer, if they specialize. Let me explain the procedure to you, then we'll go over the consent forms."

I went over the steps of the procedure, along with the risks, then asked Todd to walk Mr. Smythe through the consent form, which he did. The orderly arrived just as that was completed, I signed the surgical admission form, clipped it onto the chart, then we headed upstairs. After handing Mr. Smythe over to the nurses, my students and I went to scrub.

"How much of this do you feel comfortable doing?" Doctor Aniston asked.

"I know the steps and assisted Doctor Blake as second surgeon on one last July. I've seen several since."

"Not the question I asked," Doctor Anniston said.

"I would be comfortable performing each step, so long as I was under close supervision and could ask for assistance."

"Then you take the lead."

"As a PGY1?" I asked.

"You can say 'no'…"

"Contrary to the opinions of numerous young women over the years, I'm not a complete idiot!"

Erin and the two nurses in the room all laughed, and Todd nodded his commiseration.

"A problem every guy has, no matter what!" Doctor Aniston agreed.

"My gay friends didn't," I said. "But otherwise, yeah."

"Being gay limits your opportunities for being an idiot," Nurse Linda declared.

"Doctor Aniston," I said. "When I assisted Doctor Blake, my medical student was allowed to close the dermis and epidermis. I'd like Miss Jackson to do that; she's signed off for unsupervised suturing."

"Seriously?!" Erin gasped.

"Seriously. Doctor Aniston?"

"Let's see how things go; if there are no complications, I'll allow it. Miss Jackson, you'll suction for us. Now, everyone scrub in!"

We did and went into the operating room together, with Doctor Aniston directing me to the primary surgeon's spot.

Doctor Bernard, the anesthesiologist, raised an eyebrow but didn't say anything.

"Hi, Mr. Smythe," I said. "Contrary to what I said before, I'll be the lead surgeon with Doctor Aniston here watching me like a hawk."

"You're in very good hands, Mr. Smythe," Doctor Aniston said. "We're a teaching hospital, And Doctor Mike is ready for this. He's assisted before and knows the procedure."

"Go for it, Doc!" Mr. Smythe said.

"Put him under, please," I said to Doctor Bernard.

He did, and two minutes later, announced that the patient was sedated and had stable vitals.

"Are you sure about this, Bob?" Doctor Bernard asked. "Mike's a PGY1."

"I'd let him perform the procedure on my son," Doctor Aniston said. "Good enough for you?"

"You're the boss."

"Mike, let's begin," Doctor Aniston said. "Tell me each step before you perform it. If anything out of the ordinary happens, I'll decide if I need to take over. This should be perfectly routine, as he appears in excellent health and is in good shape."

I nodded, took a deep breath, and looked to Nurse Linda, "10-blade, please."

"I'm going to begin with a transverse incision parallel to McBurney's point, incising the epidermis and dermis."

"Proceed," Doctor Aniston directed.

I made the incision as I'd seen Doctor Blake and others do, then handed the scalpel back to Linda.

"Retract, please, and I'll use the Bovie to dissect down to the external oblique aponeurosis, then I'll open the aponeurosis, exposing the internal oblique muscle."

"Continue."

"Bovie, Nurse," I requested.

I successfully dissected down to the muscle, then returned the Bovie and asked for a scalpel to open the aponeurosis.

"Retraction, please," I said to Doctor Aniston who placed a second retractor in the surgical site.

"Now I'll divide the muscles, then locate the appendix," I said.

"Continue," Doctor Anniston directed.

I divided the muscles, and Doctor Anniston shifted the retractors.

"Forceps, please, Nurse."

I grasped the peritoneum with the forceps, made an incision, and located the appendix.

"Suction, please, Erin," I instructed.

She cleared away the fluid.

"Babcocks, please, Nurse," I requested.

Linda handed me the forceps, and I grasped the taeniae coli and advanced until the appendix was externalized.

"Appendix is inflamed and enlarged," Doctor Aniston declared. "Proceed with excision, Mike."

"Next is dissecting the mesoappendix," I said.

"Continue."

I did that, then asked Linda for clamps, which I attached to the appendiceal vessels.

"Next, I'll divide the appendiceal and ligate them with sutures."

"Correct," Doctor Anniston said. "You're doing great, Mike."

I divided vessels, then asked Linda for the needle driver and silk sutures, and used them to ligate the blood vessels, then removed the clamps.

"Suction, please," I said to Erin.

She did that, and I examined the surgical field.

"No leaks," I said.

"I concur," Doctor Anniston agreed.

"Excision and then invert the stump into the cecum."

"Proceed."

I excised the inflamed appendix and dropped it into a metal basin. Next, using forceps, I inverted the stump into the cecum.

"Very good, Mike," Doctor Anniston said. "No rupture, no involvement of any surrounding tissue. Nice and clear. You may close; your call on closing the dermis and epidermis."

"Erin," I inquired, "tell me how you would close this incision."

"I would begin with an antiseptic lavage, then close each of the three muscle layers separately with running absorbable sutures. There was no rupture, so no drain is necessary. I'd close the dermis with 3-0 subcuticular absorbable sutures, then close the epidermis with basic mattress sutures."

"Very good," I said. "Doctor Aniston, if you would move aside, and Todd, if you would take the suction, Miss Jackson will assist me, then close the dermis and epidermis. Linda, surgical closure tray to me, please."

"A Fourth Year? Suturing?" Doctor Bernard asked.

"Owen instructed us to be more aggressive in our training," Doctor Anniston said. "Miss Jackson is one of our top draft choices for the Match. And we're short surgeons, too. Mike and I are both comfortable."

"It's your rodeo; I'm just along for the ride," Doctor Bernard said.

I closed the muscle layers, then turned the patient over to Erin.

"Erin, step by step," I said. "There are no prizes for speed. If you have questions, ask; if you are not confident, say so, and I'll close the final layers."

"I can do this with your supervision," she said confidently.

"Then proceed," I said.

She took her time, similar to the way I had done the exact same thing back in July, though I'd been an actual Resident at the time. I watched extremely closely, as did Doctor Anniston, to ensure she completed the procedure correctly, and he and I both offered advice as she worked to close the incision.

"Nicely done, Miss Jackson," Doctor Anniston said. "Neat, evenly spaced sutures with good tension."

"We're finished," I said. "Doctor Bernard, please terminate anesthesia. Erin and Todd, once Doctor Bernard disconnects Mr. Smythe, please escort Mr. Smythe to Recovery. I'll be along shortly."

Doctor Aniston and I moved to the scrub room while the others prepared Mr. Smythe for transport.

"There is going to be blowback," I said quietly.

"Well, Frank can complain to his Chief, but Owen cleared this with Cutter, so we're good. How do you feel?"

"Pumped!" I replied. "But not nearly as pumped as Erin! I just hope the Match gods are kind to us."

"Why?"

"She broke up with her boyfriend, who is here in McKinley, just before she had to submit her Match list. She's from Cincinnati, and Shelly is concerned she listed those hospitals ahead of us."

"She could technically resubmit her list," Doctor Anniston said. Wednesday is the deadline for late submissions. She'd need to pay the fee for late registration, but she could submit a revised list."

"Where did we list her?" I asked.

"Third after Ryan Harrison and Mary Anderson."

"That's rough," I said. "Hospital preferences take precedence, and even if she lists us first, a hospital in Cincinnati might snatch her.. We know Mary will Match for Trauma Surgery because we put her first, and she put us first. Can we revise to put Erin second?"

"Let me speak to Owen. Do you know where else Ryan tried to Match?"

"He had five other interviews, all in Columbus or Dayton."

"OK. Erin can't hurt herself if she simply swaps us for another program, but you know the rules, right?"

"Yes. I can't expressly tell her we listed her, but I can encourage her to change her list, which will convey the message."

"Exactly. It's a dumb system, and we really ought to be allowed to tell the students."

"My proposal is that a hospital receive two or three draft choices for students at their affiliated medical school. That would save everyone time and effort because we know Mary Anderson knows she's going to Match for the only available slot for trauma surgery. It's really silly to pretend that position is actually competitive."

"That's actually a good idea, which is why it will never fly!" Doctor Anniston said with a grin.

"Trotsky was right!" I said with a grin of my own.

"Trotsky?"

"He said the bureaucracy would betray the revolution, and he wasn't wrong."

"Amen, Brother. Go change and check on your patient. Leave me your procedure book, and I'll fill it out."

"Thanks," I replied.

That was a nice thing to have, but I needed more practice, better training, and my Board certification before I could perform even that simple procedure on my own. That said, I was WAY ahead of any other Resident, including some PGY2s who were on the 'old' program.

I went to the locker room, changed into fresh scrubs, put on my baptismal cross and wedding ring, then headed to Recovery. I verified Mr. Smythe's vitals, then asked Todd to sit with him while Erin and I stepped into the corridor.

"Thank you, thank you, thank you!" she gushed. "I'd hug you, but the rules…"

"I appreciate the sentiment," I replied. "What you just experienced is Moore Memorial changing the way surgical training is done. You did something today most PGY2s haven't done — full closure on a procedure. You won't see that at any other hospital, and we hope you Match here. I'm not sure if you're aware, but you can change your Match program rankings until 5:00pm on Wednesday. If you didn't list us first, we hope you'll consider paying the small fee and changing your rankings."

"I want to ask a question that I don't think I can ask," Erin said.

"And it's one I cannot answer if you do ask. You're an intelligent young woman who's in the top five in her class, so I think you can infer what you can't ask, and I can't say."

"I'm going to assume someone told you I came to the medical school because of my boyfriend, and that we broke up."

"That is the scuttlebutt. I also know you interviewed at several hospitals in Cincinnati because you're from Milford."

"You're very well-informed!"

"If you haven't noticed, the hospital grapevine is very effective!"

"Oh, I've noticed! If I wanted to change my ranking order, what would I need to do?"

"I believe you'll need to fax it to them by Wednesday at 5:00pm Eastern time. There's a phone number on the letter you received saying you were registered to check the process."

"Is there a way to guarantee I Match here?"

There was, but because she wasn't first on our list, the only way to ensure she could Match was to list _only_ Moore Memorial, which was a risky proposition if, somehow, she didn't Match with us.

"Only a risky one," I replied. "I don't advise it."

Erin nodded, "Let me think about it."

"That's all I can ask. Go sit with Mr. Smythe and call me when he comes around. Todd can have his lunch."

"OK."

I headed to the nurses' station, arranged for a room for Mr. Smythe, then went to the lounge. About forty minutes later, Erin called to say Mr. Smythe had come out of his anesthesia. I checked him, signed the chart to release him, and then had Erin call for an orderly to take Mr. Smythe to his room. I sent her to lunch, then called to see if Clarissa was available. She wasn't, so I went to the cafeteria alone, and when I saw Ghost, I went to sit with him and Maria Vega from Internal Medicine.

After lunch, I let Doctor Aniston know about my conversation with Erin, and he promised to speak to Owen Roth once the lengthy surgery he was performing was complete. The afternoon was routine, with three consults, two of which resulted in admission for surgery, but not emergency surgery, and those cases would be dealt with on Tuesday or Wednesday. At 5:00pm, I left the hospital and headed home to Kris and Rachel.

_February 27, 1990, McKinley, Ohio_

"How in the world did you get to do an appy and a Fourth Year close?" Shelly Lindsay asked incredulously when I walked into her semi-private room on Tuesday.

"I'm just that good," I replied haughtily but with a smirk. "Who blabbed?"

"Erin, when she stopped in to see me before she went home yesterday. She was so happy that if you weren't married and it wasn't against the rules…"

I laughed, "Yeah, yeah."

"Wait!" Cathy interrupted. "It's against the rules to fool around?"

"Doctors with medical students, yes; patients, too!"

"While they're under your care," Shelly said with a smirk, stirring the pot.

"Troublemaker! And to answer your question, despite my reputation, I didn't ask. Bob Anniston asked me. Well, about the appy I brought up. I asked if Erin could close the dermis and epidermis, and she did show her gratitude in a very satisfying way!"

"Smart ass!" Shelly declared. "I know it wasn't that because you're faithful to a fault!"

"I fail to see how fidelity can ever be a fault," I replied. "But, no, of course not. She paid the late fee and re-ordered her ranking list for the Match. Owen re-ordered our list to put her second. That gives us a good chance of getting her, though you know there are no guarantees. I wish we had my draft picks."

"You and every hospital associated with a medical school! I'm assuming you had a very careful conversation?"

"Yes. She drew the correct inferences."

"Can the outsider inquire what the heck you're talking about?" Cathy asked.

"When medical students are close to graduation," I replied, "they interview with hospitals for Residency programs. After those interviews, the student prepares a ranked list of programs where they would like to Match. The hospitals prepare lists of students they would like to hire. All of that is fed into a big computer which spits out a list of Matches such that it is impossible for anyone to have a better available Match. It's something you might be aware of with a minor in computers — the stable marriage problem."

Cathy nodded, "OK, I know that one. From what you're saying, you can't share the information?"

"The student can tell the hospital that they listed them and in what ranked order, but the hospital is forbidden to tell the student that they are on the list, let alone their rank on it. That's meant to prevent gaming the system. If I, as a student, know for a fact that a hospital listed me in their first slot, I could submit a list of one hospital and be guaranteed one of those two spots."

"That only works if the hospital's list is given more weight. Otherwise, you could have multiple students put the program first, and some other factor would be needed to decide."

"Hospital preferences are paramount," I replied. "The one possible exception is a married couple, as they are matched together in the same hospital or the same city, which changes the calculations a bit, though a strong and weak partner cannot improve the weak partner's Match."

"So what happens if you don't like where you Match?"

"You're out of luck," Shelly said. "It's there or nowhere. If you decline, you can't Scramble or Match. It's possible to find a program after everything is done, but it'll be a lesser program in an undesirable location. You know, dermatology in International Falls, Minnesota, or something like that. It's not like a sports draft where you can hold out, either. In order to participate in the Match, you agree to accept the assignment at the salary offered. If you don't, you're basically out. Permanently."

"So what did you say, if I can ask?" Cathy inquired.

"I simply talked up our program and said we'd be pleased to have her and reminded her she had until 5:00pm Eastern tomorrow to change her list."

"And that doesn't break the rules?"

"No," Shelly said. "A hospital may express interest in the student beyond inviting them for an interview. What they cannot do is promise the student a listing, reveal that they are on the ranked list, or reveal the ranking order."

"Doctor Mike, was this your first choice?"

"Absolutely, and I was positive I was theirs. I mean, how could I not be when I designed the new program that was created!"

"Mike cheated!" Shelly exclaimed. "And we're ALL jealous about that!"

"I'm only jealous about his wife!" Cathy declared.

"You and half the nurses in the hospital!" Shelly exclaimed. "The other half simply don't care that he's married!"

"And on _that_ note, I'm going back to the surgical ward! See you both tomorrow."

"Do you get to participate in my surgery tomorrow?" Cathy asked.

"No. I can't do scheduled procedures because I have to be on-call for the Emergency Department. I'll come see you on Thursday, OK?"

"OK."

I left the room and headed back to the surgical ward.

_February 28, 1990, McKinley, Ohio_

Because of my revised schedule, I had rearranged my call with Doctor Mercer to be at lunch rather than in the morning.

"How has your week been?" Doctor Mercer asked.

"Fine."

"No nightmares or feelings of dread?"

"No. I know this might sound odd, but it feels like just another day in the ED."

"Which means either you have ice water in your veins or you're suppressing your emotions."

"Given my history, I'm going to go with the former. Nobody shot at me, Doctor Mercer."

"Fran, please. But you saw someone shot and killed in front of you."

"I did. And over the past five years, I've seen over a hundred people die before my eyes, sometimes after bloody accidents, sometimes after horrible burns, sometimes from brain bleeds."

"You did have an emotional reaction to that one."

"Yes, of course. You know the automatic defense mechanism of doctors who work in the ED — we have to turn off our emotions. People who can't, don't make it."

"Yes, and many of them bottle it and resort to alcohol or illicit drugs to compensate."

"Prayer and church do that for me," I replied. "They always have; well, except when church was the stressor. But given my role, that's no longer the case and unlikely to recur."

"There's no chance of you being ordained again?"

"It's generally against the canons and would require extreme «ekonomia» by Bishop JOHN, and that would create a potential firestorm. But even if he were willing to do that, and he might be, Kris would refuse."

"Would that cause tension in your marriage?"

"The opposite, actually. It would save me from having to refuse my bishop!"

"So it's not something you want?"

"Not a chance. And I really prefer not having to say 'no' to my bishop, especially when he blames me for his enthronement!"

"How are you to blame?"

"I orchestrated it together with my grandfather! I knew he was a godly man as a celibate priest and was exactly what was needed after the nightmare with his predecessor. Bishop JOHN is looking to get even!"

"You're joking!"

"Of course I am! But it's a joke between him and me as well. I know, at some point, he's going to ask, and I can truthfully say that Kris is adamantly opposed to the idea."

"How are things at the hospital?"

"Very good. On Monday, I performed the first-ever appendectomy by a PGY1."

"Be careful you don't overreach, Mike."

"It was a textbook case, and one of our most senior surgeons was right there with me, and I had to declare each step before I started it. It was a perfectly routine procedure. Part of it is my special training program, part of it is that we're shorthanded because our best Resident is recovering from surgery after being shot, and part of it is that I'm just that good!"

Doctor Mercer laughed, "Well, you have the surgeon's ego, that's for sure!"

"And you know I said that to tweak you."

"You did, but you also believe it and have confidence in your own skills, or they'd never have let you do it."

"That's true. I gave my Fourth Year a chance to do something that most Fourth Years never do — suture. There was a bit of blowback, but because the Medical Director and Chief Surgeon had approved, nothing came of it."

"Blowback?"

"The anesthesiologist objected to a PGY1 and a Fourth Year performing the entire procedure. He complained to his Chief, who lodged an objection with the Medical Director. Nothing came of that because of the approval, but also because my training program is special. I was already doing procedures that weren't the norm for PGY1s in the ED. And that's going to be the case for the new PGY1 in June or July, depending on when she chooses to start."

"Change is difficult for most people, and doctors tend to be very averse to changing training programs."

"Tell me about it! I'm in a completely new program, and I've heard the complaints. But I don't mind because the doctors who matter are behind the changes. There are other changes, too, which make a lot of sense, including having Residents in Internal Medicine complete an eight-week rotation in the ED during their first year, and are covered by someone from the ED. The same is true for pediatric Residents, but that was postponed to next year because of scheduling concerns in Pedes."

"Have you talked through the events of the day minute by minute?"

"Twice. Once with law enforcement, and then once with the internal review."

"How did you feel while doing that?" Doctor Mercer asked.

"The only word I can think of that applies is 'clinical'."

"I'd say that's par for the course for you. Is there anything you feel you need to talk about?"

"Not really, no."

"I have a question, which I probably should have asked before, but after you read me off last August, I'm somewhat surprised you got in touch."

"Put that PhD to work and figure it out," I challenged.

She was quiet for a full minute before she answered.

"Because for me, you're a known quantity, and you could be yourself without raising any red flags. And after you read me off and challenged my methods, you were positive that I wouldn't say anything I couldn't defend before the Medical Board. And if you were your typical self, I'd sign off because I could say that you were acting 'normal', for want of a better word."

"Exactly right. But there's one other important point, which you probably either won't get or, if you do, would be reluctant to say."

"That pretty much telegraphs it," Doctor Mercer said. "The one topic I always avoid, if at all possible. Your faith."

"And I'm going to remind you that healing, of whatever kind, has to be holistic — body, mind, and soul, or spirit, if you prefer. I've forgiven you for Angie because you engaged in a public act of «metanoia», but that only goes so far. After the hearing, you told me that Doctor Paulus had taken you to task. So I come back to the question I asked you in Lou's last August — what are you going to do about it?"

"Whatever else is true, I have to follow the standard of care, just as you do. I know you're a major rebel, and you push the edge of the envelope, but you also have limits and restrictions. You seem to think I don't, and that's simply not the case. I do agree that, at times, I had tunnel vision, but my outcomes were, in the main, positive.

"My difficulty was always with the outliers, and it still is. You and one other male patient defy basically any categorization, and trying to apply _any_ norms to either of you failed miserably. What that tells me is that when a patient defies categorization, I can't apply any of the standard methods. I doubt that answer will satisfy you, but that is as far as I can go."

"Tell Steve Adams hello for me," I chuckled.

"How the…" Doctor Mercer began but then stopped mid-syllable. "Sorry, I can't say anything."

"It's OK, Fran," I said. "I dated Dona Bingham, and Angie's friend Anna was one of Steve's girlfriends. I met Larry Higgins in Cincinnati when I interviewed at UofC, and I've spoken to Doctor Al Barton. I met Steve's then future wife, Jessica, when she was a Second Year at Indiana University, and my current Fourth Year played on the Milford Chess team when he was there. I also met his Swedish girlfriend, Pia, when Elizaveta and I were in Europe."

"Oh for Heaven's sake!" Doctor Mercer laughed. "I'd accuse you of pulling my leg, but if you know those names… Have you met him?"

"No. I expect, someday, we'll cross paths, But given everything they've told me and your reaction when I asked about the rules to 'strip chess' when I was a Sophomore, I put it all together. Given the rumors I hear, he had to be the other patient."

"You know I can't discuss that!"

"Of course. Anyway, going back to my holistic point, you admitted your error, and as such, what's in the past is in the past. A clean slate, as it were."

"Forgive and forget?"

"In essence, yes, though 'forget' doesn't mean quite the same thing as 'not remember', but instead means 'not hold against'. To say otherwise would create an impossible contradiction."

"How so?"

"How could an omniscient God forget anything?"

"An interesting point," Doctor Mercer said. "But what about asking God to remember?"

"In that case, it means 'call to mind' or 'give conscious thought to'. Think about how we use it — if we remember something, it's because it wasn't in our active memory but lying passive or dormant until called upon. We have many memories like that – they're stored and never come to mind unless triggered by some event or we set our mind on them. So, God knows all, but we're asking him to actively think about us. And that's true in both our faiths.

"What I'm saying is that human beings, besides being _Homo sapiens_ are also _Homo religiosus_, not in the medieval or liberal Protestant understanding of that word, but that the taxonomic 'wise man' is also 'religious man', or perhaps better _Homo pnevmatikós_ or 'spiritual man', mixing Greek into the Latin for clarity of what I mean. You can't treat the «ψυχή» (_psychí_) without also treating the «σάρκα» (_sarka_) and the «πνεύμα» (_pnévma_) — psyche, flesh, and spirit. I'd go further and say you have to treat the «νους» (_nous_) as well."

"That's the concept of the true mind, right?"

"Yes. The mind's eye, if you will, without which we cannot fully apprehend God's energies, or what Roman Catholics and Protestants incorrectly refer to as 'grace'. It is the part of us that, according to Buddhism, can achieve total awareness or enlightenment — the «ātman» or essential self. But the theology lesson isn't important. What's important is treating a patient holistically.

"I know your arguments against my position, and in one sense, I agree, but in another, I strenuously disagree. Do you have to walk a fine ethical line? You bet! But could you treat me in ANY way without understanding my faith? I don't believe so, and I would wager you've had other patients with strongly held religious views. Ignoring that does the patient a disservice and could even cause harm. I think we can dispense with the obvious examples, don't you?"

"There's no need to rehash the conversation from August. I hear you, Mike, but that's a minefield."

"And one you're called to traverse. Find a way, Fran. If I can do it, you can do it. But it's impossible for you to treat _Homo pnevmatikós_ without taking his _pnévma_ into account."

"All good points. And based on our conversation, I'm going to say we don't need to speak again on the topic of the shootings. I would like to talk from time to time; in fact, Doctor Paulus suggested it."

"And that caused you to think she's certifiable, right? At least for an instant?"

"Longer," Doctor Mercer said with a soft laugh. "But she said something important — you challenge me, and I've always learned more when I'm challenged."

"I think that's true for most of us," I replied.

"Have you seen Angie?"

"At church a few weeks ago, and Kris, Rachel, and I are having dinner with her and her family on Saturday."

"Let me know how she's doing, please."

"I will. I'm sorry to end this call, but I need to grab a quick bite before my lunch break ends or I'm paged."

"Call me in a few weeks, please."

"Will do."

We said 'goodbye', I hung up, and went to the cafeteria to grab a sandwich and an apple.