Chapter 36 — Inner Peace

_August 8, 1989, McKinley, Ohio_

{psc} "I thought someone dying before my eyes was the worst thing I'd see," Walt said after Lucy Leahy was admitted to pediatrics.

"Lumbar punctures on kids are rough," I replied. "I'll raise you third-degree burns and drowned toddlers."

"You've basically convinced me to stick to surgery," he said.

"Emergency medicine is not for everyone," I replied. "It's not the hardest speciality, and not even the hardest emotionally."

"Which one is that?" Serenity asked.

"In my opinion, it's pediatric oncology. In pediatrics, the little humans mostly get well and go home; in pediatric oncology, they don't. I believe that doctors and nurses on that service are automatically qualified for sainthood."

"I don't think I could do that," Serenity said.

"Me, either."

"Is a lumbar puncture a procedure you could do?" Walt asked.

"No. It's a specialized pediatric procedure. For adults, it's done by Medicine. I've only seen four in two years and six weeks of clinical work."

"What's the worst procedure you'll have to do?"

"An escharotomy," I replied. "That's cutting down burns to minimize the damage from edema or to reduce pressure on the heart and lungs. You haven't smelled anything bad until you smell burnt flesh, and cutting into it is worse. I've observed, but haven't done one. I will, eventually. And now I'm going to make a likely futile attempt at sleeping."

I went to the on-call room and this time I managed to sleep for an hour before I was woken to help treat two firemen and two civilians for smoke inhalation from a barn fire. None of them were serious, and their PO₂ levels weren't too low, nor were their CO levels high, so after an hour of oxygen therapy, they were all released.

"Take your meal break," Doctor Mastriano suggested.

I called up to Medicine and Clarissa was able to take her break, so we met in the cafeteria. We got our food, then went to sit at a table by ourselves.

"How are your students?"

"Three good, one troublesome. You?"

"All four are pretty good. What's wrong with the troublesome one?"

"Her procedure book had about half the typical procedures for a Fourth Year, and when I questioned Leila Javadi about it, she said I should keep a very close eye on her AND shouldn't be alone with her."

"Uh-oh."

"Yeah. The most damning thing Leila said was that Krista was Felicity, but without the skills or intelligence."

"Ouch!"

"I'm sure she'll bitch to someone about me taking my Third Year on the helicopter."

"Too bad you decided to re-marry! You could have been the Flying Monk!"

"Orthodox monks don't wear wimples!"

"What was it this time?"

"Hydrofluoric acid burns to arms, face, and neck. I didn't hear how it happened, but with 30% burns, transport to the burn center is recommended."

"How the heck do you treat that?"

"The firemen cut off all his clothes and flushed him with water, then we applied calcium gluconate gel and transported him. My biggest concern was his eyes, but OSU will have an eye specialist who can handle that better than we can at this point."

"No engine trouble?" Clarissa asked with a sly smile.

"Nope. And I slept on the way back. I figure if Kellie can be that calm, so can I!"

"Am I being replaced, Petrovich?" Clarissa asked.

"A harem of work wives! Now there's an idea!"

Clarissa laughed, "You had that option! But all silliness aside, what are you doing about your student?"

"She'll have her chances. You know I don't believe in the 'all scut, all the time' treatment. And despite that, I'm sure she'll bitch given what Leila said and the fact that she objected when I insisted she learn how to read an EKG and said I'd give her a quiz on Friday. Fortunately, I only have her for twelve hours on my thirty-six-hour shift."

"I dread getting a rehabilitation assignment."

"This one wasn't intentional like Felicity or Tim; I went to Leila after seeing Krista's procedure book. I'll speak to Kylie tomorrow morning about it. Anything interesting on your service?"

"No, and that's exactly the way I like it! I like to have time to think and my idea of a good day is not seeing forty patients for a few minutes and never seeing them again. You, on the other hand, are an adrenaline junkie!"

"And medicine needs both styles," I replied. "I'm happy to be a feeder service for your pill-pushing operation!"

"Now that's low, even for you Petrovich!"

"Right," I chuckled. "Because you've never given me a hard time about anything!"

"Did you get any sleep?"

"On the helicopter, and then an hour. I take it you got more."

"About three hours total. I'm the one the nurses come to, of course, and I catch the consults as well. I heard there's no surgical Resident overnight in the ED when you're there."

"Because I'm the surgical Resident! PGY1s in surgery actually have less experience than I do because I did two trauma Sub-Is and a pathology Sub-I. Honestly, the new plan of having surgery and medicine Residents do eight-week stints in the ED during their first years is going to make a huge difference."

"And let you bums work no more than eighty hours!"

"The way I described it is that we now have programmed sleeping hours, and you know why."

"Libby Zion."

"It'll change on all other services over the next few years as they hire more Residents."

"How are things with Mastriano?"

"Fine. She's not trying to sleep all night, and she's treating me OK."

"Amazing what double-secret probation will do to an attitude!"

We finished our meals, and I headed back to the ED while Clarissa went back to Medicine.

The morning was fairly routine with my students and I handling nine walk-in cases and one EMS transport. During the afternoon, I had my two Preceptorship students as well, though, as the rules required, they simply observed. When 6:00pm finally rolled around, I went to daycare to get Rachel, who had been dropped off by Kris that morning. She greeted me with a hug and a sloppy kiss on the cheek, and then we left the hospital to head home.

_August 9, 1989, Circleville, Ohio_

"What's your plan for the day?" Kris asked when we got out of bed on Wednesday morning. "Other than seeing the counselor?"

"I'll spend the day with Rachel. We have no place to go and nothing planned after counseling except Vespers tonight."

I got Rachel from her bed, changed her diaper, and then the three of us went downstairs to have breakfast. After breakfast, we said our morning prayers, and then Rachel and I walked Kris to her car so she could head to OSU for her class. Kris and I exchanged a kiss, Rachel hugged her and kissed her, and then Rachel and I watched as 'Mommy' drove away.

We went back inside, I dressed Rachel, then drove to the Korolyov's house to leave her with her aunt for the morning.

"I promise we won't get into too much trouble!" Lyudmila said in a lilting French accent similar to her sister's.

"Somehow, that doesn't reassure me," I chuckled. "I'll be back in about two hours to rescue my daughter!"

I hugged Rachel, she immediately went to Lyudmila, and didn't look back. I rolled my eyes, because I was chopped liver compared to her «tante préférée», who did her best to spoil her rotten. I figured if an aunt wasn't doing that, she was probably doing something wrong, and when my nephew Michael was a bit older, I'd do the same for him and any other kids my sister and Paul had.

About twenty minutes after I left the Korolyov's, I walked into reception at Maryann Manning's office, and five minutes later, she brought me into her private office.

"No," I said.

"'No'?" she asked.

"The answer to your question two weeks ago."

"Are you always this annoying?"

"I'd say if you asked the people who know me best and for the longest time, you'd find the answer to be a resounding, unanimous 'yes'!"

She flipped through her notebook and nodded.

"You say that," she said, "but everything you've said indicates that's how you act now."

"Actually, I'll counter that and say it's how I _react_, not how I _act_. And it's all verbal, and I simply point out the things I find to be wrong. Do I push the edge of the envelope? Absolutely. Do I say too much? I'm sure that's the case. But I don't actually do anything that crosses the line."

"Your line."

"Other than spending too much time with patients and trying to work with patients with mental illness in a way that best suits them, not me, I don't cross the lines set by medical best practice."

"So, why did your mentor send you to me?"

"Because she's concerned that my idealism and my obsession with what happened to my friend Angie will lead me to burn out or become cynical, and that will impact my work and my personal life."

"That is often the case when idealism runs headlong into cold, hard reality. And the key thing is to find a balance where you don't lose your idealism but don't obsess over things you can't change."

"But I can't ignore them, either."

"It's a about balance, Mike. There's a Swedish concept called «lagom» which means moderation, in a way where all things are in balance."

"Orthodox would call that 'inner peace', and it's achieved through 'hesychasm', something my «staretz» has prescribed. Unfortunately, I'm not fastidious about it, and I'm still stuck at stage one."

"It seems to me, then, that you don't belong here and you should see your «staretz» instead of me. When will you see him next?"

"The 10th of next month."

"Let's do this — see him, tell him everything you've told me, and see that he says. Perhaps he'll want to speak to me to gain some insight into treating a doctor who is devout enough to seek spiritual guidance from a monk."

"Perhaps," I replied.

"Call for an appointment after you see him."

"I will. Thanks, and I'm sorry I basically wasted your time."

"You didn't. You spent time contemplating what I said, which is all that I can ask. The solution is found within you, all I can do is provide insight and guidance."

"I've heard that before from the counselor who worked with Angie. I'll call you some time after the 10th."

We said 'goodbye', I left her office, and headed back to the Korolyov's to retrieve my daughter. When Lyudmila let me in, I saw Rachel playing with a teenage girl.

"That's my friend Cheryl. We're hanging out today. Rachel could stay if you had things to do."

"I planned to spend the day with Rachel," I said. "So I'd like to take her home."

"«Rachel, ton père est là!» Lyudmila called out.

"Daddy!" Rachel exclaimed.

"You're teaching her French?" I asked.

"«Mais oui!» Lyudmila said with a twinkle in her eye.

"Go to your dad," Cheryl said. "He's a hunk!"

"And he belongs to my sister!" Lyudmila said, suddenly sounding like 'mama bear', but then turned to me and said, "of course, not the better sister!"

I laughed and shook my head as Rachel came over to me. She reached up her arms for me to pick her up.

"Thanks for watching her," I said. "See you at church tonight."

Rachel and I left the house, got into the car, and headed home.

"What should we do now?" I asked my nearly two-year-old toddler after we walked into the house.

"Sing!" Rachel exclaimed. "Daddy git'ar"

"I think we can do that."

"Raffi?" she asked.

"We can watch your Raffi tape as well," I said.

"Yes!" Rachel giggled.

We went into the house and I got my guitar and sheet music, and played Rachel's favorite songs, and after I played for about an hour, I made some tea, gave Rachel a cup of juice and a sliced banana for a snack. With her happily munching her banana, we sat down to watch _Raffi In Concert With The Rise And Shine Band_, which contained her overall favorite song, _Baby Beluga_. When the tape finished, we went to the backyard to play with a ball, then took a walk. When we returned to the house, we had lunch, and then I put Rachel down for her afternoon nap.

Once Rachel was in her bed, I put on one of my Mozart CDs and sat down with the _McKinley Times_. I'd only read the first two pages before the phone rang. I got up and went to the kitchen to answer it.

"Korolyov-Loucks residence; Mike speaking."

"Hi, Mike. This is Leland Crowe from Moore Memorial. I'm sorry to bother you on your day off. Do you have a moment?"

"Yes. What can I do for you?"

"You keep diagnostic notes, correct?"

"Yes, I do."

"Do you keep those notebooks permanently?"

"No. I have them going back about six months. I retain them so that if a case reaches an M&M, I have my personal notes to supplement my memory and the chart. Which case?"

"Mary Josephson, age fourteen."

"I'm not surprised."

"Would you bring me that notebook when you come to the hospital? I'm positive the charts are accurate and I have Doctor Gibbs' statement, but I want to make sure there are no landmines lurking."

"Absolutely. I'll drop it off at your office tomorrow morning."

"Just out of curiosity, do you ever remove pages?"

"No. And each set of notes is dated, with a time, and has the chart number."

"Perfect!"

"Is there an actual problem?"

Mr. Crowe laughed, "No attorney will _ever_ give you a definitive answer to that, as no matter how obvious or cut-and-dried a case might be, there are no guarantees. In my professional opinion, there is no cognizable claim, but in the end, the courts would decide if they could bring a claim or not."

"Let me rephrase — is there anything you feel we did incorrectly?"

"No. Every step was defensible, and the decision to report the pregnancy to Family Services in compliance with the law provides an excellent defense. There is nothing to worry about from your perspective — you had a nurse in the room at all times, and you reported to Doctor Gibbs in line with hospital policy. I'll let you go."

"OK, I'll bring the notebook tomorrow."

"Sorry to disturb you on your day off."

"It's OK. Rachel is napping, and I was reading the newspaper."

We said 'goodbye', I hung up, and went to the study, retrieved the correct notebook, put it in my bag, then returned to reading my newspaper. I finished not long before Rachel woke up, and after changing her diaper and giving her a snack of sliced apples, we went for another walk, then returned home so I could start dinner. Kris arrived home from school, we had dinner, and then left for the Cathedral for Vespers.

After Vespers, we returned home, I read to Rachel, we said our evening prayers as a family, and then Kris and I put Rachel to bed. Once she was in bed, we left her room and I touched my wife's arm.

"What do you say to a bubble bath, lovemaking, and then sleep?" I suggested.

"I say 'yes'!"

_August 10, 1989, McKinley, Ohio_

"Morning, Lor," I said when I arrived in ED on Thursday morning.

"Morning, Mike. Did Mr. Crowe reach you?"

"Yes. I have my diagnostic notebook. I'll take it upstairs at 8:30am so I can hand it to him or his secretary directly."

"Don't worry about this. He'll swat it away without working up a sweat. I've seen several complaints like this, and I'm positive the only reason it's come this far is that the dad is an attorney."

"I'm not fretting over it," I replied. "I just wanted to let you know. I need to go do the turnover with Kylie."

"Go heal the sick!"

I left the Attending's office and found Kylie in the lounge and received the handover of two patients waiting on admission — one to Pediatrics and one to Medicine. She asked to speak to me privately, so I followed her to the locker room.

"What did you do to Krista?" Kylie asked, as she began undressing.

I turned, so I wasn't looking directly at her.

"I noticed her procedure book was light, then spoke with Leila Javadi, who warned me that she's Felicity without the intelligence and skills, and also warned me not to be alone with her."

"OK, I didn't get _that_ angle, but she certainly thinks you're sidelining her. She bitched about Al getting procedures and getting the helicopter. She said she thinks you're sexist."

"That would be her best line of attack, but I'm not going to put her on pure scut, even though that's the norm for someone like Krista. How did she do during the past twelve hours?"

"I think Leila's analysis is accurate," Kylie said. "Krista doesn't know as much as she thinks she does, nor does she know as much as she should."

"Fixable?"

"Probably not by you, because of how she feels about you, and I honestly don't think she's worth the effort. Give her the procedures she can do, challenge her to learn, but in the end, it's on her."

"That was my initial strategy. I challenged her to study the EKG section of the cardiology book and that I'd quiz her today. I also instructed her to find out who Sir William Osler was."

"Your hobby horse! Not that I disagree with you about the implications of that quote."

"I plan to suggest his seminal work be made mandatory."

"You just love to stir up the hornets' nest! Now I need a shower, so unless you're going to join me…"

"You know the answer to that."

"Of course!"

She went to the shower, and I left the locker room and went to the lounge, where Krista and Al were waiting.

"Good morning," I said. "Krista, who is Sir William Osler?"

"He founded Johns Hopkins and created the first Residency program."

"Yes. Did you discover anything else about him?"

"As in?" she inquired.

"His methods?"

"You mean learning in the wards, not in the classroom?"

"Yes. That was the point I made earlier. I'd maintain that actual learning begins with clinical rotations. Being able to pass tests is what allows you to actually start learning to be a doctor. Did you review the EKG sections in your cardiology textbook?"

"Yes."

I pulled three sample strips from my pocket and handed them to her.

"Describe these, please. Just in general terms, not a diagnosis."

She looked at them for about a minute before answering.

"This one is sinus tachycardia," she said. "And this one has ST elevation. And the last one is V-Fib."

"Good. Those three things are the most likely arrhythmias that you'll see. At this point, you don't need to know the specific causes, just be able to call out what you see. Al, did you memorize the pad placement and leads for a five-lead?"

"Yes. Right side, white; left side, black; fourth intercostal, brown; right below the ribs, green; left below the ribs, red."

"Very good. A good way to remember them is smoke over fire, clouds over grass, chocolate on the chest."

"That's cool! Thanks."

"Al, check on the admissions; Krista, get the first walk-in chart and get basic vitals and confirm their presenting complaint. Al, you can meet us after you check on our patients."

While I wasn't going to give Krista pure scut, I was going to give her opportunities with walk-ins, where, for the most part, she couldn't do any real harm. I waited five minutes, then headed to Exam 3, stopping to receive an update from Al about the admissions, both of whom would go up in the next ten minutes. He followed me into the exam room.

"Mr. Harrington, this is Doctor Mike Loucks."

"Good morning, Mr. Harrington. Krista?"

"Tom Harrington, fifty-eight; tachy at 116; diaphoretic; complains of headache, fatigue, lightheadedness, and blurred vision."

"Thanks, Krista. Mr. Harrington, when did these symptoms start?"

"I've felt tired the last few days, had the headache last night, and when I woke up this morning, I felt lightheaded and had blurred vision."

"When did you notice your heart rate changing?"

"This morning. Doc, I need to lie down. I feel as if I'm going to pass out."

"Go ahead. Al, let's raise his feet, please."

"Trendelenburg?" Krista asked.

"No, just his feet."

Al adjusted the bed to raise Mr. Harrington's feet.

"Mr. Harrington, have you been sick recently? Or noticed any changes in your bodily functions?"

"No," he replied.

"Any injuries or strenuous activity?"

"No."

"Are you a diabetic?"

"No."

"Any recent dental work or medical procedures?"

"None. Just my annual physical for work in March."

"I'd like to do an exam, including listening to your heart and lungs, and checking your glands and abdomen, among other things."

"Sure, Doc."

I washed my hands, put on gloves, and began the exam. I found nothing out of the ordinary except his tachycardia and contemplated the next steps. The symptoms were such that the differential diagnosis list was, in effect, the entire diagnostic handbook.

"I don't find anything obvious from my exam," I said. "The next step is going to be blood tests. Before I order those, would you describe what you've done the last few days?"

"What do you mean?"

"Did you work? Take regular meals? Do anything out of the ordinary?"

"Breakfast, lunch, and dinner pretty much like clockwork; I've worked every day this week. I'm a construction foreman. I go to bed around 10:30pm and get out about 5:30am."

"Coffee?"

"Yeah, I take a full thermos to work every day."

Too much caffeine might explain his symptoms, but most likely wouldn't have been sudden onset.

"Has that changed recently?"

"Not in the last forty years since I had my first job as a gofer."

"Your appetite is good?"

"Absolutely. I've actually felt a bit hungrier than usual recently."

"Have you changed your diet at all?"

"I added a mid-morning and mid-afternoon snack about two weeks ago. Usually an apple or banana in the morning and peanuts in the afternoon."

"OK," I said. "I want to do three things — a complete set of blood tests, an EKG, and also a rapid glucose test."

"What's that?"

"To check your blood sugar. Your symptoms all line up with a condition known as hypoglycemia — low blood sugar. Let's do the EKG first. Al, would you hook up the monitor?"

I supervised him and saw what I would call textbook pad placement. He attached the leads correctly, then turned on the monitor, which showed exactly what I'd suspected — sinus tach. After observing for a full minute, I had Al shut off the machine and disconnect the leads, but leave the pads in place in case we needed them.

"Other than your heart beating fast, your EKG is normal," I said. "We'll do the blood tests now. Krista, glucose meter, lancet, test strip, and alcohol wipe, please. They're in drawer C-2. Al, once I do this, draw for CBC, Chem-20, ABG, and glucose panel."

Krista got the equipment for me and I drew a drop of blood onto the test strip and waited for the meter to register.

"58," I replied. "Did you eat breakfast?"

"No," Mr. Harrington replied. "I wasn't feeling well."

"What about dinner last night?"

"Steak, corn on the cob, bread, and pie for dessert."

"Your blood sugar is a bit low," I said. "We'll give you something to eat and then re-check your blood sugar. Al, draw the blood. Krista, get Mr. Harrington a package of cheese crackers and a bottle of apple juice from the supply room."

"What's wrong?" Mr. Harrington asked.

"I don't know just yet; that's the point of the blood tests."

"What could be wrong?"

"As I thought to myself when I heard your symptoms, they ruled out almost nothing. Let's see what the blood work says, so we can narrow it down to something other than the contents of the diagnostic handbook my students have in the pockets of their lab coats."

"Can I ask why you have on red and everyone else is wearing blue?"

"I'm a surgical Intern," I replied.

"Who'd you piss off to get sent to work in the ER?"

I chuckled, "Nobody. My specialty is trauma surgery, which is a surgeon who is assigned to the Emergency Department. When there aren't trauma cases, I see patients who walk in as you did this morning. Let's get your blood drawn, and then eat what Krista brings you. I'll come check on you in a bit."

"Thanks," he replied.

I left the room, passing Krista, who went into the room. I filled out the chart, then went to the phone at the clerk's desk and dialed Internal Medicine and asked for Clarissa.

"Petrovich? What's up?"

"Phone consult," I said. "I'm not ready for anyone to come down yet, but I want to run something by you."

"Sure, what?"

I walked her through my H&P, and my 'treatment', such as it was, and asked what she thought.

"Not a diabetic, right?"

"Right."

"No signs of drug or alcohol abuse?"

"None."

"And this is recent onset, right?"

"Yes."

"So it's not likely congenital, as it would have shown up when he was a kid. The most likely cause is an infection or sepsis. Get the blood work done and see how he responds to the food, checking every twenty minutes."

"Will do. What else might it be?"

"If his Chem-20 and CBC are normal, and his A1C and serum glucose are low, you want an endocrinology consult. If there's anything abnormal in the Chem-20 or CBC, call me."

"Yes, but what diagnoses?"

"Pull out your handbook!" Clarissa declared.

"Right, because the symptom cluster excludes about ten percent of the handbook!"

"If it's not infection or kidney or liver disease, you're looking at some kind of tumor or endocrine system failure. You should know that!"

"And right here is why we specialize. I have so much to remember for trauma that I've noticed peripheral knowledge is fading. I challenge you to come down and intubate, insert a chest tube, or perform a blind pericardiocentesis!"

Clarissa laughed, "I'll pass! I'll leave that to you adrenaline junkies! Call me when you have your lab results if you aren't sure if it's Medicine or not."

"Medicine is the dumping ground for patients nobody else wants!"

"Oh, shut up!" Clarissa exclaimed. "Call me when you know anything! Oh, wait, that would be never!"

"Very funny, Lissa!"

"Let's have lunch or dinner if you can escape the madhouse."

"The inmates are absolutely running the asylum!"

We both laughed, said 'goodbye', and I hung up.

"How's Mrs. Doctor Loucks?" Nate asked.

"Same as always!" I chuckled.

I returned to the exam room to verify the blood had been drawn and that Mr. Harrington had eaten his cheese crackers and had drunk his apple juice. Once I confirmed that, I wrote the orders for the repeat glucose stick test onto the chart and instructed Krista to perform those tests every twenty minutes.

"Do you have someone here with you, Mr. Harrington?"

"My wife."

"We can bring her in if you want."

"Please."

I instructed Al, who had returned from taking the blood to the lab, to find Mrs. Harrington and he brought her into the room. After a brief recap, I promised to check on him, then my students and I left the room.

"What do you suspect is wrong?" Al asked.

I shrugged, "What I said is true — take out your diagnostic handbook and look up the symptoms. They cover about ninety percent of what you see in there. And despite the physical exam, I can't rule out infection, sepsis, a tumor, or a host of other conditions.

"I called Doctor Saunders in Medicine and ran it by her, and our next step is based on the blood test results. If there are elevated or low levels for liver or kidney function, or abnormalities in the CBC, then it goes to Medicine. If not, then it goes to endocrinology because the most likely problem is overproduction of insulin, which could be caused by a tumor or a hormone imbalance.

"There's an important lesson to learn here. Care to speculate what that might be?"

"Not to say anything to a patient about a diagnosis when you aren't sure?" Al suggested.

"That's true, because we don't want to worry them unnecessarily, but not the point I was making. You can take a second shot at it."

"I'm not sure," he admitted.

"And that's a perfectly acceptable answer, not just as a medical student, but as a doctor. Does that give you a clue?"

"You called another Doctor because you wanted a second opinion."

"Exactly. Never be afraid to ask and never be afraid to admit you don't know, and absolutely never be afraid to ask for help. Even if you're given a hard time, which is _always_ the case with Doctor Saunders, that's better than not asking and missing something or making an error."

"During my Preceptorships, they implied strongly that we're supposed to know literally everything."

I nodded, "And the MCAT and MLE test for book knowledge, and are basically a way of weeding out students without the intellectual chops to be a physician. As I've said, the first two years of medical school are actually an entrance exam. In June, you actually began training to be a physician.

"The point of the questioning during your Preceptorships is to see if you had the initiative to study without being told. How many times were you caught out before you realized you needed to study the procedures beforehand?"

"The first two times," he admitted.

"Then what?"

"A Fourth Year clued me into the trick of checking on the scheduled surgeries for the day and studying the night before."

"And on a clinical rotation for surgery, you get the procedures the night before, study them, and be ready to answer, because if you can't, you'll receive a sub-par evaluation."

"But shouldn't you know the diagnoses?" Krista asked.

"For some things, yes; but we don't ever make final determinations on anyone who is admitted. Why is that?"

"Division of labor, right? They made a point in practice of medicine that, except for a GP, everyone has an area of specialization."

"Yes, though I'd say Family Medicine is a specialization, and some hospitals are now offering Residencies in that specialty. They may be generalists, but they specialize in primary care just as in the ED we specialize in immediate care. There's another reason that's related."

"I'm not sure I should say what I'm thinking."

"On the contrary," I said. "If a doctor, nurse, or professor asks you a question, you answer it, even if you think they might not like the answer."

"That you don't have the knowledge or experience to make the diagnosis."

"Bingo. I'm trained, and being trained, to recognize and treat acute, emergent cases that are an immediate threat to life or limb. Diagnosing a tumor or a systemic problem is not something I'm trained to do. It's possible I'll come to that conclusion, but if I find an elevated white count, what's the correct procedure?"

"To call for a consult."

"Yes."

I checked my watch and sent Krista back to do another glucose stick test.

"60," she replied.

"OK. It's only been twenty minutes since he ate, so let's check again in twenty minutes. For now, grab the next chart and bring them in. Al, did the patients go up?"

"Yes, both of them."

Five minutes later, I went into Exam 1 to see the patient Krista had brought in.

"Doctor Mike, this is Becky Matthews,"

"Hi, Becky," I said to the young, blonde woman who I guessed was about twenty, was holding her left arm with her right hand.

"Should I worry about the red shirt treating me?" she asked.

I chuckled, "_Trek_ medical is usually blue, though at the risk of associating myself with a certain doctor I despised, Pulaski wore red scrubs when she operated on Picard."

Becky rolled her eyes, "Star Fleet has exactly one competent heart surgeon in the entire quadrant?"

"I hear you! Krista?"

"Becky Matthews; nineteen; complains of significant shoulder pain after a fall; vitals normal."

"Specifics, please."

"BP 110/70; pulse 72; PO₂ 99%."

"Becky, do you think you can take off your t-shirt?"

"I can't really move my arm, so no."

"Then we'll need to cut it so I can examine your shoulder."

"Two bucks down the tubes!"

"I'll get you a red scrub shirt to replace it."

"Cool!"

"Al, go up to the surgical locker room and get a small red scrub top, please."

"Right away, Doctor!"

He left, and I had Krista carefully cut the sleeve and shoulder of Becky's t-shirt. It was obvious from just a visual exam that she'd dislocated her shoulder.

"I believe you've dislocated your shoulder," I said. "We need to get x-rays to verify, then we'll have someone from Orthopedics reduce it."

"Reduce?"

"Put it back in place. Most cases are simple and we can simply manipulate your arm to put your shoulder bones back in place. The x-rays will tell us if there are any complications."

"OK."

"An important question — is there any chance you could be pregnant?"

"I'm on the Pill."

"Which is very effective, but not absolute. Have you had sex since your last period?"

"Yes."

"Krista, draw blood for a rapid pregnancy test, please."

"Why?" Becky asked.

"Because on the off chance you're pregnant, we don't want to zap you with x-rays. If you are pregnant, then we'll call Ortho to evaluate you, likely with ultrasound, to see if we can avoid the x-rays."

"Oh, sure, ruin my entire day!"

"The odds are on your side. With proper use, one woman in a hundred will become pregnant at some point over the course of her use of oral contraceptives. Would you like something for the pain?"

"Yes, please."

"OK. While Krista draws the blood, I'll have a nurse get you some ibuprofen."

I wrote all the orders on the chart, then left the exam room. I asked Ellie to have a nurse bring 600mg of ibuprofen to Becky, then went to check on Mr. Harrington.

"How are you feeling?" I asked.

"No change," he replied. "The girl was in before and checked my blood sugar."

"It's still a bit low," I said. "Just rest and we'll have the full lab results back in about twenty minutes."

"Thanks."

I returned to the room where Becky was as Wendy was administering the ibuprofen. Krista had a nursing student carry the blood to the lab as we had a female patient and policy didn't allow me to be alone with her. Al returned with the red scrub top, and I set it aside until Becky could put it on.

"Once the results come back, which will take about fifteen minutes, we'll determine the next steps."

"OK," she agreed.

"One thing I mention to all sexually active patients is that oral contraceptives are not effective against sexually transmitted diseases. I can provide you with a pamphlet on 'safe sex' from the McKinley Free Clinic if you want."

"That's where I got the Pill, and they gave me the pamphlet."

"OK. See you in about fifteen minutes."

We left and Krista went to do another glucose stick test.

"65," she said when she came back out.

"Coming up, but not enough. Chase the labs, please."

"Mike," Nate called out. "Paramedics four minutes out with a possible MI."

"It's going to be one of those days! Krista, forget what I just said. Nate, would you chase the labs for Mr. Harrington in Exam 3 and let me know when the lab calls with the results of the RPT for Exam 1."

"Will do."

Krista, Al, and Kellie all accompanied me to the ambulance bay to wait for the squad to arrive. I gave preliminary orders, and we were ready when Bobby jumped out of the cab.

"Male, mid-forties; found down on the sidewalk; CPR performed by civilians; no pulse; epinephrine times two; IV saline TKO."

"Al, get an Attending! NOW!" I ordered.

Bobby and his partner pulled the gurney from the back of the squad and I jumped onto the gurney and began compressions, taking over from the fireman who had been performing them in the squad. They pushed us towards the trauma room and I called out orders.

"Kellie, amp of epi IV push. Krista, take over bagging in the room. Ellie! Another nurse!"

In the room, I got off, and we transferred the patient to the trauma table and I got on and resumed compressions as Doctor Gibbs came into the room along with Wendy.

"Found pulseless," I declared. "Epi going in. Wendy, ABG, Chem-20, cardiac enzymes, and tox screen!"

"Al, take over compressions," Doctor Gibbs ordered. "Mike, intubate."

We swapped places, she gave a quick listen, then Al began CPR. I performed rapid sequence intubation and hooked up the vent, then asked Al to hold compressions and listened for breath sounds.

"Bilateral breath sounds!" I announced. "Resume compression. Krista, EKG."

A bit of contortion was necessary, but she managed, then turned on the monitor.

"PEA!" I declared. "Kellie, atropine, IV push!"

"Defib?" Krista asked.

"Not for PEA," I replied.

"Atropine is in!" Kellie announced.

"No change!" I declared.

"Hold compressions," Doctor Gibbs ordered about thirty seconds later. She listened, then ordered "Resume compressions."

"Another meg of epi?" I asked. "Plus bicarb?"

"Kellie, do that!" Doctor Gibbs ordered. "Krista, swap with Al. Al, call Cardiology and tell them to get down here, NOW!"

"Epi and bicarb are in!" Kellie announced.

Krista took over compressions while Al went to the phone.

"No change," I announced.

"We need to know the underlying cause!" Doctor Gibbs declared.

The probable causes were a list of 'Hs and Ts', six conditions with each letter, and I quickly ran through them in my head — hypovolemia; hypoxia; hydrogen cation excess, commonly known as acidosis; hyper- or hypokalemia; hypothermia; hypoglycemia; tablets or toxins, meaning drugs or poisons; tamponade; tension pneumo; thrombosis; thromboembolism; trauma.

Bicarb would have solved the acidosis problem, and there were no signs of bleeding, external or internal, ruling out hypovolemia. His PO₂ was 92%, ruling out hypoxia. The problem with calcium was it could go either way, which meant we needed labs to know. The same was true for 'tablets or toxins'.

"Tension pneumo, cardiac tamponade, MI, or thromboembolism," I replied.

"Strong, Cardiology!" Doctor Strong announced as he came in.

"Forty-three-year-old male," I announced. "Found down on the sidewalk; CPR performed by civilians and firefighters; PEA; epi times two, atropine times 1, bicarb times 1."

"Your list is right," Carl said. "Continue compressions, 1 meg of epi every three minutes. Syringe with a cardiac needle and electrical lead to Mike!"

"Tamponade?" I asked.

"It's either that, a blood clot, or an embolism. If it's not tamponade, we're not going to fix this."

"Stop compressions," Carl ordered. "Go, Mike!"

I began the procedure while Doctor Strong listened to the patient's heart, checked his jugulars, and his eyes.

"Only a tiny amount of fluid," I said as I drew back the plunger on the syringe.

"Resume compressions!"

"Al, take over!" I instructed.

Two more amps of epi changed nothing.

"How long has he been down?" Doctor Strong asked.

"At least twenty minutes," I replied. "Probably closer to thirty."

"One more round of bicarb and epi," Doctor Strong said.

That was done and still there was no change.

"We're out of options," Doctor Strong said. "Halt compressions. If his heart doesn't start on its own, we're done."

It didn't and about four minutes later, the monitor finally showed asystole.

"Call it, Mike," Doctor Strong instructed.

I said a silent prayer for the patient's soul, then said, "Time of death, 07:28."