Chapter 19 — Shit Happens

_April 27, 1990, McKinley, Ohio_

{psc} "Good afternoon," Doctor Cutter said promptly at 3:00pm. "Our first case today is Mr. Ken Webber, who coded immediately following emergency surgery for a ruptured appendix. Doctor Paul Lincoln was the initial receiving physician. Doctor Lincoln?"

Paul got up and moved to the lectern.

"Good afternoon," he said. "Mr. Paul Webber, a Caucasian male aged thirty-six, presented at the triage desk at 21:49 on April 19 complaining of abdominal pain. Triage vitals were normal. I and my students brought the patient to Exam 3 thirteen minutes later at 22:02. A complete H&P was performed, and vitals were all within the normal range for a healthy thirty-six-year-old male.

"No nausea or vomiting were reported. Patient had last eaten just after 18:00. Gross exam revealed tenderness in the umbilical region but no other signs. Given he was afebrile and his Alvarado score was 1, I concluded that the best course of action was to send the patient home, asking him to return if he felt febrile, nauseated, or the pain increased. I conferred with Doctor Boyd, who signed the chart, and the patient was discharged. I went off shift at 06:00 the following morning."

"Were any blood tests run?" Doctor Collins from Medicine asked.

"No. Our protocol for afebrile, non-specific gastric pain is to wait unless a bowel obstruction is indicated. Palpation did not reveal any of the signs, and auscultation revealed normal bowel sounds."

"And you didn't think to run an ultrasound or call for a surgical consult?"

"I did, but again, neither of those are indicated where there are no symptoms or signs except for a generalized complaint about peri-umbilical pain."

"Thank you, Doctor Lincoln," Doctor Cutter said. "Doctor Boyd, do you have anything to add?"

"No. Paul relayed all of that to me, and it is reflected on the chart."

"Thank you. Doctor Mike?"

I touched Mary's arm, and she came with me and we stood together at the lectern.

"Go ahead," I said quietly.

"Good afternoon," Mary said.

"Excuse me," Bill Lawson from Psych said, standing up. "Why is your student presenting?"

"She performed the intake H&P under my direct supervision. With Doctor Cutter's permission, I'd like to use this as a teaching exercise for her."

"Proceed," Doctor Cutter said.

Doctor Lawson glared at me and sat down.

"Thank you," Mary said. "Mr. Webber returned to the triage desk the following morning at 06:08 and was seen four minutes later at 06:12 by Doctor Mike and me. Vitals were taken by both the triage nurse and Nurse Kellie Martin and showed a BP of 120/70, pulse of 72, temp of 38.1°C, and PO₂ of 99% on room air. Mr. Webber complained of a significant increase in abdominal pain, now in the lower-right quadrant.

"Doctor Mike instructed me to take a complete history and physical under his direct observation. Gross exam revealed Dunphy's sign and Sitkovskiy's sign. Alvarado score was 7, indicating acute appendicitis. I proposed CBC, Chem-20, and ultrasound, and Doctor Mike confirmed. Nurse Martin drew blood, and Doctor Mike added a request to type and cross-match."

"Mike?" Clarissa prompted. "Why?"

"Because bounceback abdominal pain is nearly always surgical, and with that Alvarado score, it was obvious to me we were dealing with acute appendicitis, as Miss Anderson indicated. Mary?"

"I performed an ultrasound under Doctor Mike's direct supervision and confirmed an inflamed appendix. Given the obvious condition, Doctor Mike made the decision to send Mr. Weber up for immediate surgery."

"Before the labs came back?" Doctor Baker asked.

Mary looked to me, and I nodded.

"Yes," I said. "Time was of the essence, and we could prep the patient and have him in the OR when the labs came back."

"No tox screen?" he inquired.

"The patient denied any use of illicit drugs and admitted use of Tylenol to Miss Anderson. I did not feel he was being deceptive. His eyes were clear, his nose did not show any signs of inhaled stimulants, there were no lesions in his mouth, and there were no track marks. He was well-groomed, his clothes were clean, he had good hygiene, and his speech was clear."

"Continue, Miss Anderson," Doctor Cutter directed.

"Doctor Mike reviewed the consent form with the patient, who signed it. We transported the patient to OR 4, turned him over to the nursing team, and then went to scrub. When we entered the OR, Doctor Burnside from Anesthesiology had arrived. Doctor Mike?"

"Doctor Roth had instructed Mary and me to scrub in, which we did, and then, with the assistance of the surgical nursing team, inserted saline IV, administered standard prophylactic vancomycin, and sterilized the patient's abdomen. The patient was stable, and his vitals were consistent with those taken by triage and in the exam room. At that point, Doctor Burnside arrived. Doctor Cutter, do you wish me to continue, or do you wish to hear this part from Doctor Burnside?"

"Continue, please."

"Doctor Burnside entered and stated that Doctor Roth had instructed him to put the patient under, as Doctor Flynn had not yet arrived after being called in. Doctor Burnside administered etomidate and ketamine, followed by propofol, and I intubated the patient and connected the ventilator. The patient's temperature rose almost immediately from 38.1°C to 39°C. His other vitals were consistent with anesthesia limits. I asked the circulating nurse to call for the lab results, and I ordered chemical cold packs under his arms."

"Why was that?" Shelly Lindsay asked.

"I was concerned about a sudden spike in temperature, which occurred within two minutes of the administration of anesthesia and five minutes after vancomycin."

"Did you observe any hives or respiratory problems?"

"None. At that point, Doctor Flynn came into the OR."

"Thank you, Mike," Doctor Cutter inquired. "Anything to add, Ralph?"

"No," Doctor Burnside said as Mary and I returned to our seats. "As Mike said, other than the one-degree temp spike, vitals were stable and well within safe ranges for an adult male under anesthesia."

"Thank you. Doctor Flynn?"

Doctor Flynn moved to the lectern.

"I was the on-call surgeon and was completing my morning exercise routine at home when my pager went off. I called the scheduling nurse, who informed me of the patient's condition. I immediately left home and arrived at the hospital twelve minutes later. Because I had been sweating, I took a quick shower, put on clean scrubs, and entered the scrub room at 06:58, sixteen minutes after I was paged.

"When I entered the OR, the patient had been prepped and anesthetized, and Mike gave me the bullet. Immediately after he finished, Barb Sutton, the circulating nurse, reported that the patient's white count was 8.8, indicating neutrophilia. She also reported the patient's blood type as A-positive.

"Following protocols for emergency surgery, Mike acted as second surgeon and operated the electrocautery, while Miss Anderson handled suction. Nurse Debbie Schmidt handled the retractors. The surgery went according to plan, and when the organ was exposed, Doctor Mike immediately stated that it had ruptured, and I confirmed.

"At that moment, Ralph announced a run of six SVTs but confirmed the patient's blood pressure and sats were still in range. We quickly removed the inflamed organ, then began the peritonitis protocol of triple gastric lavage plus additional vancomycin. We had just completed the lavage when Ralph announced a run of ten PVCs and advised finishing as quickly as possible.

"I completed the closure without further incident and instructed Ralph to cease anesthesia, which he did. I then instructed Mike and his student to escort the patient to Recovery and stay with the patient. I ordered a cardiology consult and directed Mike to keep the patient on EKG.

"At that point, Mike called out V-fib and requested the paddles. He administered shocks of 150, 200, and 250, with CPR between shocks and epinephrine, IV push. With no conversion, I ordered an amp of bicarb and an amp of epi while compressions continued. Mike ordered atropine on a cardiac needle. I questioned him about it and, after a brief back and forth, concurred with his assessment that it was worth trying.

"We continued CPR for another five minutes, interspersed with three more attempts to convert his V-fib, at which point the patient had been down for ten minutes. When the monitor showed asystole and no electrical activity, Mike stated his opinion that after six shocks, three doses of epi, and one of atropine, we weren't going to get him back.

"I examined the patient and appreciated no corneal response and heard no heart sounds. I called time of death at 08:33. I asked Mike to review the case with me from the start, which he did, and then we notified the patient's girlfriend that he had expired on the table. I filled out the appropriate forms, which were turned in to Doctor Roth. As per protocol, the patient was delivered to pathology, along with all surgical materials and the diseased organ."

"How long did you sleep?" Doctor Forth from Psych asked.

I hadn't detected any fatigue in Doctor Flynn, but I knew that was an important question to ask, even if it did come from Psych.

"I had just come off shift, but I had slept a total of six hours overnight on the couch in the Attending's office. My next shift didn't start until Sunday evening."

"And you, Mike?" Doctor Forth asked.

"About six hours," I replied. "My shift began at 05:00."

"Ralph?"

"About eight hours. I had been assisting Doctor Roth with a scheduled surgery, but it was routine, so I called a Resident to complete that surgery and attended the emergency appendectomy."

"Thank you, Doctor Flynn. Paul?"

Doctor McKnight rose and moved to the lectern.

"I'll cut to the chase, he said. 'Shit happens'. Now, let me give you my findings."

That was something Loretta had said to me near the beginning of my Preceptorship, and I'd seen it several times before. I had come to that conclusion myself — that the patient's death was unpredictable and not something that could likely have been prevented. Doctor McKnight continued.

"The deceased was sent to Pathology at 08:48, and per our protocol, I set aside other autopsies to investigate this unexpected death immediately. Post-mortem labs were drawn, a complete autopsy was conducted, and all surgical materials and drugs were examined.

"Other than generalized inflammation of the peritoneum consistent with a ruptured appendix, the gross exam was negative. The same was true for the sections, and I discovered no lesions or tumors. Post-mortem lab test results were consistent with pre-surgical labs.

"The tox screen showed only metabolites of self-admitted Tylenol usage and drugs recorded on the patient's chart and was negative for all other substances for which we can test. All of the vials of drugs administered were correct, matched the serial numbers of vials that were in our inventory, and were uncontaminated.

"As is the norm in cases such as this one, I interviewed the patient's parents, brother, and live-in girlfriend, none of whom could shed any light on the case, nor did any family member report any significant medical conditions or family history of conditions which might have caused the negative outcome. A review of the patient's medical records held by his primary care physician, John Smith, showed no indications of any condition which might lead to arrhythmia.

"Given the symptoms reported by the physicians who attended the case, I conclude that the most likely cause of death was an adverse reaction to anesthesia. Given no physical signs and no respiratory anomalies, I do not believe it was a reaction to vancomycin. No blood was given, so a hemolytic reaction was also ruled out. In my opinion, the delay from the previous night had no bearing on the results of this case, though I cannot prove that."

"Thanks, Paul," Doctor Cutter said. "Comments? Conclusions? Lessons?"

Doctor Wernher rose.

"While I would prefer less earthy language, I believe that per Doctor McKnight's analysis, as well as my investigation, all protocols and procedures were followed. One can certainly quibble about lab tests on first presentation, but a surgical consult would not have changed anything. That said, an ultrasound might have detected the condition sooner, and as such, I intend to require an ultrasound for all cases of abdominal pain where we cannot trace a cause. As Doctor McKnight succinctly stated, earlier diagnosis would very likely not have prevented the adverse outcome."

"I concur," Doctor Roth said, standing up. "A surgical consult during his first visit was not warranted, except in hindsight, and it is unlikely any of my Residents would have ordered an ultrasound when the patient was afebrile, had not vomited, and complained of peri-umbilical pain."

"What do you think, Mike?" Doctor Strong asked.

I chuckled, "I do have the reputation of being freer with the use of lab tests and imaging, but in this case, I'd have done exactly what Doctor Roth said, and would, with the same information, have discharged the patient just as Doctor Lincoln did."

"Doctor Wernher," Doctor Baker asked. "What about lab tests which showed an infection?"

"Let me turn it around — if I called one of your Residents for a consult with the specific report that Doctor Lincoln provided, what would the result have been? I'd like one of your Residents to answer, if you don't mind."

"Doctor Saunders?" Doctor Baker inquired.

Clarissa stood up.

"Very likely, we'd have asked the ED to monitor and run repeat lab tests after two hours, waiting to see if any new symptoms emerged. Past protocol would, in most cases, have been immediate antibiotics, but MRSA has changed that protocol. Had a Medicine consult been requested, the surgery might have occurred an hour earlier, but as Doctor McKnight opined, the results would very likely have been the same."

"Thank you, Doctor Saunders," Doctor Baker said. "I concur with my Resident."

"Then," Doctor Cutter said, "unless someone wishes to present a plausible alternate theory or point out something we've missed, this one is closed as unexplained post-surgical arrhythmia resulting in death."

That was the only case for the day, so everyone filed out of the auditorium.

"Malpractice suit?" Clarissa asked.

"Always possible," I replied, "but at every step of the way, we did the right thing. I'm sure some hotshot attorney could make hay out of sending him home, which looks bad but really didn't have anything to do with it. Wernher's response really shows that — requiring an ultrasound for all non-specific abdominal pain. But you know why that's not a panacea."

"It's entirely possible it wouldn't have shown on an ultrasound the night before. A CAT scan might have shown it, but we can't go around giving people huge doses of X-rays on the off chance it'll find something. Not to mention we only have one machine. Mary, you did a great job!"

"Thanks, Doctor Saunders!" Mary exclaimed. "I have a great teacher!"

"Don't feed his ego, please!" Clarissa declared.

"Go push pills, Lissa! We surgeons have REAL work to do!"

"«Иди в жопу» (_idi v zhopu_)!»" Clarissa declared.

"Love you, too, Lissa!"

We hugged, and she headed to Medicine while Mary and I headed to the ED.

"What did she say?" Mary inquired.

"'Kiss my ass'," I chuckled. "She's taken up my old behavior where I would only swear in Russian."

"I don't think I've heard you speak Russian."

"I mostly stopped about two years ago, and really, I hadn't used it regularly since around age eight. It was always my second language, and given how highly inflected it is, I make a complete mess of it at times."

"My grandmother taught me some Swedish when I was little, and it's actually very simple. The verbs don't change for person or number, and there are only two genders with regular rules for forming plurals and for articles. Unlike English, it's spoken exactly as it's written."

"English spelling is a nightmare," I stated. "One teacher in High School pointed out that English is basically the only language where a Spelling Bee makes any sense and is any kind of serious challenge. He also mentioned that the first national spelling bee was held in Cleveland in 1908. Where did you grow up?"

"Minnesota, of course, along with the rest of the Viking maidens!"

"You do not want to know the vision that just put in my head!"

Mary laughed, "Hammered metal breastplates that are form-fitting? Ahistorical!"

"Which has zero to do with the image popping into my head! How did you land here?"

"Dad took a job in Toledo, and we moved when I was twelve."

"What's he do?"

"He's a mechanical engineer at the Jeep Toledo Assembly Complex. My mom is a private duty nurse."

"My dad is a civil engineer and is the Director of the Harding County Property Division. My mom is a secretary/paralegal for an attorney. They're divorced, and they each remarried. My stepdad is an attorney, though not the one for whom my mom works. My dad's wife is a homemaker."

"Stepdad but not stepmom?"

"She's four years younger than I am."

"Wow!" Mary observed, raising an eyebrow.

"Yeah."

We reached the ED, and I instructed Mary to get a chart so we could begin seeing patients. There was a backlog as several ED docs had been in the M & M, and that kept us busy until 7:00pm, when I was fortunate to be able to have dinner with Clarissa.

"I figured someone would try to throw you under the bus," Clarissa observed once we had our food.

"There was no opportunity to do so once McKnight made his findings. And even without them, it would have been Paul Lincoln, Chuck Boyd, Ralph Burnside, or Josh Flynn. I was the one who identified the ailment and rushed him to surgery. Lawson and Forth had nothing."

"I was surprised you threw Mary to the lions!"

"What better case for her to present? I mean, I read McKnight's report and I was positive I could let her get her feet wet without suffering withering fire from Friday Afternoon Quarterbacks! Now that she's done an easy one, the difficult ones will be easier."

"And gave you a chance to tweak Attendings and Residents about hands-on training with active participation."

"Because it's the better way," I replied. "It's not new or innovative unless you count doing what the first doctor to start a Residency program did as 'new' or 'innovative'! What I'm doing was proposed a hundred years ago by THE most influential teacher in modern history. The other members of the Big Four at Johns Hopkins were important, too — William Stewart Halsted, a surgeon; Howard Atwood Kelly, a gynecologist; and William Henry Welch, a pathologist."

"Osler was an internist!" Clarissa declared.

"Every famous person has some weakness," I smirked. "That was his!"

"Seriously? The guy who you revere the same way you revere your icons was _weak_ because he specialized in internal medicine?"

"You know I'm yanking your chain, Lissa! But the point is, what I'm asking for is to follow Osler's model. And if you think about it, that's the point of Preceptorships. There isn't much that can be done there, though I think two four-hour shifts would be better. But, once a student passes the first step of the medical licensing exams, it should be seriously hands-on, and PGY1s should practice more like I do than like the other surgical PGY1s. For you, what's the practical difference between you and an Attending besides experience and an FDA license to prescribe Schedule drugs?"

"Not much because we're more diagnosticians and as you tease, more about administration of medication. Nobody does many procedures, and that's why they're having us all do ED rotations and paramedic ride-alongs. Is Mary going to do that?"

"Yes, because I requested it. Ride-alongs will not be the norm for surgical Residents. They will have eight weeks in the ED, sometime during PGY1 or PGY2. Pedes will do the same thing, preparing for the permanent pediatrician in the ED once we're Level I."

{_ Doctor Mike Loucks; ED stat! Doctor Mike Loucks; ED stat!" _}

My pager went off almost simultaneously with the emergency signal.

"I'll box your dinner and bring it to you," Clarissa offered. "Go!"

I got up and hurried down the long corridor, past the main lobby, and down another corridor to the ED.

"What do we have, Mary?"

"The fire department pulled someone out of a fully involved structure fire. EMS said massive third-degree burns. One minute out."

"Call and have them warm up the air ambulance. We're likely going to Columbus."

"WE?!" she asked excitedly.

"We! Make the call and join me in the ambulance bay. We may have to do an escharotomy."

She went to the phone and I hurried to the ambulance bay, grabbing a gown, gloves, goggles, and a mask, knowing it would help with the smell.

"What do we know?" I asked Isabella.

"Adult male victim, estimate sixty-percent full-thickness burns to arms and torso."

That meant a mortality rate of about forty-five percent,

"I asked Mary to have the chopper warmed up."

"Good move. You're the only qualified Flight Surgeon on duty, right?"

"I believe so."

Mary joined us just as the EMS squad turned into the driveway.

"Mary," I said, "call upstairs and let Doctor Thornton know we're leaving the hospital and why, then meet us in the trauma room."

The squad was moving faster than usual and skidded to a stop. Roy jumped out.

"Bad one, Doc!" he said as he moved to the back of the squad and opened the door. "Phil Grant, thirty-one; third-degree burns on his arms and most of his torso; smoke inhalation; ankle BP 80/50; tachy at 130; intubated; PO₂ 92% on portable vent; 5mg morphine; IV saline right leg."

"Trauma 1!" Isabella declared, then gave orders to the assembled team.

We quickly moved the patient to Trauma 1, and I began a burn assessment.

"Mike, he'll need a large-bore IV," Isabella said.

"I have jugular access," I said. "Burns only extend to the clavicle. He's going to need an escharotomy on both upper arms and the chest. I'll do that first, then the IV because if we give him fluids, the eschar will impede breathing and circulation."

"Do your thing!" she declared.

Mary came into the room, and I very much wanted her to help, but she couldn't use a scalpel for another five weeks.

"Mary, watch and learn, please," I said. "Rebecca, cutdown tray to me, please. I'll also need large-bore jugular IVs."

"Right away, Mike!"

"Mary, we incise the burnt skin down to the subcutaneous fat and into healthy skin lengthwise, if possible. The goal is to relieve the constriction of his chest and allow for better respiration. We're going to do his upper arms, too, to prevent circulation problems in his lower arms. When you cut, you need to take care to avoid nerves and veins. Watch and one of us will supervise you performing this in the future. Watch very closely, please."

"I, uhm, need a mask," she said, going over to the dispenser on the wall and putting on two.

I knew exactly how she felt and thought about a second one, but I couldn't breathe well enough through a double mask for my liking.

I made the necessary incisions, one on each upper arm, along the bicep, and two vertically just outside each nipple. Once that was completed, I inserted two large-bore IVs, one into each jugular, and instructed Rebecca to attach saline.

"Billie," I said, "antimicrobial dressing, please. Vancomycin, 100mg IV push, then drip at 10mg/min via the leg."

"Vancomycin, 100mg IV push, drip at 10mg/min via the leg; antimicrobial dressing," Nurse Billie repeated.

She and a nursing student quickly and efficiently set up the IV and dressed the escharotomy.

"What do you think, Isabella?"

"EKG is worthless with those burns, but his sats are holding at 92%. I think you have to take him."

"Billie, call for the chopper. We'll meet them on the roof. Mary, with me. Isabella, see you at the helipad!"

"I'll send Billie with you; she'll bring the drug box."

Mary and I left, and we made our way to the Flight Surgeon's locker.

"Put on a blue trainee jacket and a helmet," I said.

I put on a red jacket with 'Flight Surgeon' emblazoned on the back and put on a helmet. I helped Mary select a correctly sized helmet, then we headed to the elevator.

"What do we do if the patient codes?" she asked.

"Pray," I replied.

Ten minutes later, we loaded the patient into the chopper, then Mary, Billie, and I climbed in. I hooked up to the intercom system and showed Mary what to do. We put on our lap belts, and a few seconds later, the pilot announced our departure.

"Hayes County Air Ambulance departing Moore Memorial Hospital for Ohio State University,"

I pressed the intercom button and said, "Mary, the blue button is for the medical staff; the red one is for the flight crew. Press to talk. You'll hear the flight crew in your helmet, but you can turn that off by moving the switch next to the red button."

"Got it," she said over the intercom as the helicopter lifted off the helipad.

I monitored the patient the old-fashioned way, checking his pulse manually, auscultating his heart and lungs, and using the readout on the ventilator to monitor his breathing. Using the stethoscope meant taking off my flight helmet for about thirty seconds each time, but that couldn't be helped.

I alternated with Mary so that she did every third check, and we delivered the patient to OSU without incident. As soon as the chopper departed OSU, I did what I always did — closed my eyes and napped. This time, I wasn't rudely woken by a klaxon, and we landed safely on the heliport at Moore Memorial about seventy-five minutes after departing.

"Write this in your procedure book for my signature," I said. "This flight, combined with your upcoming paramedic ride-alongs, means you need two more flights to be certified."

"So cool!" she exclaimed. "I certainly chose the right doctor to be a mentor!"

"I told Doctor Wernher you're every bit as good as I was as a Fourth Year."

"That's high praise," Billie said. "There isn't a better doctor in the hospital than Mike. If I were injured or dying, he'd be the one I wanted. Period."

"You and every other nurse!" Mary teased.

Billie laughed, "I, like you, am no home wrecker! But I'd absolutely go for it in other circumstances!"

"Good to know," I chuckled.

"Not everyone is as obvious as Ellie!"

I snorted, "Could they be?"

The three of us went to the flight locker and returned our gear, and then, as it was after 9:00pm, I left the hospital and headed home.

_April 28, 1990, McKinley, Ohio_

On Saturday morning, after a leisurely breakfast, Kris, Rachel, and I drove to Taft for band practice.

"Do you know your schedule for the Fall?" Kim asked as I unpacked my guitar and music.

"It should be a normal second-year surgical Resident's schedule, which means 5:00am to 5:00pm, Monday through Friday."

"Are you OK with Code Blue taking gigs?"

"I'd say after September 1st would work best."

"OK. I'll start looking. Would you be willing to play at Taft the last week in August?"

"That should be OK."

We had a very good practice session, and after we left, Kris, Rachel, and I went to Kroger and the bakery, then headed home. We ate lunch, I read to Rachel, then put her down for a nap.

"Do you mind if I take a nap?" Kris asked.

"No, of course not. Want some company?"

"Not _that_ kind of nap!" Kris said lightly.

"I know. I can read or find something else to do."

"No, come snuggle with me, please. I'd like it."

We had a nice nap but stayed in bed after we woke up.

"Besides being tired, how are you feeling?"

"I feel good. I just hope Charlotte Michelle isn't as stubborn as her second cousin about being born!"

"Babies have minds of their own," I replied. "That's why I had to deliver Tommy!"

"How do you think Rachel will react to Charlotte sleeping in the crib?"

"I think if we emphasize that Rachel is a big girl and the big sister, she'll be fine with her little sister sleeping in the crib. In fact, I suspect the 'big girl/big sister' gambit will cover a multitude of sins."

"Sins? Charlotte?"

"Ours for introducing competition for Mama's and Papa's attention! And don't worry, in about twelve years, Rachel will be able to list all my failings as a dad, probably right around the time she has her first boyfriend!"

Kris laughed, "She's very much Papa's girl, so I don't think so."

"We'll see. Nearly every girl I know had some kind of conflict with one parent or the other."

"Who didn't?"

"Katy Malenkov is the primary one; she had no conflicts. Other girls had only minor ones, but they did have them."

"Neither I nor Lyudmila have conflicts with our parents."

"European sensibilities versus American ones, I suspect."

"Probably so. Rachel and Charlotte need to be raised as strong, independent women."

"You do realize that describes Elizaveta to a 'T', right? She simply made different choices. But one thing you could never say about her was that she was weak or dependent. I know you don't approve of her choices, but that didn't make her weak."

"Sorry," Kris said. "I didn't mean…no, actually, your criticism is warranted."

"I completely understand and respect your views, but you do have a surgeon's level of arrogance about French culture and sensibilities."

Kris laughed softly, "So we're perfect together, then!"

"We are. You are exactly the person I need in my life,"

"And you are the one I need in my life. How do you propose to limit the conflict between us and our children?"

"I think following the model Katy's parents used, and to some extent, the model Lara's parents used. Both were treated more like adults than kids as teenagers and given more freedom to make their own decisions. That was actually where the conflict with my parents began — when they refused to see me as an adult. The weird thing was, that before I graduated from High School, they did treat me as an adult."

"Did that change because of what happened with Liz?"

"I think that was just what revealed it. Before I graduated, I more or less did what my mom wanted, not because she wanted it, but because I felt it was the best course of action. As soon as I chose a course of action which differed from what she felt was best, the conflagration erupted. The two of us mostly seeing eye to eye gave the illusion that I was being treated as an adult and had the freedom to act."

"Parents here exert far too much control over teenagers," Kris observed. "The things Tasha has told me are outrageous."

"They were. For Elizaveta, it was similar to my experience — she saw mostly eye-to-eye with her mom but wanted to exert the freedom which she appeared to have, but actually didn't. That led to open warfare, with Viktor and me caught in the crossfire. It didn't help that Elizaveta and I were living in the cottage and that, to some extent, my options were limited because Viktor was paying for medical school."

"Could you have managed without that?"

"Yes, by using grants, scholarships, and loans, but you know how debt-averse I am. The only debt we have is your car, and it's my intent to never borrow money to buy a car in the future. That's why we're saving toward a minivan for you for when Miss Rachel has two siblings. We'll have a mortgage on our house, but that's inevitable unless you have the kind of money Lara's family has. Fortunately, interest rates are half of what they were when I was in High School and are likely to be lower still when we're ready to buy a house in about two years."

"Around the time we have our second baby together, right?"

"Yes. Things might be a little tight while you work on your Master's, but taking the tax advantages into account, it'll work because my pay increases each year according to a published schedule. Even better, once we become a Level I center, certain specialties will receive higher pay, including trauma surgeons, mainly because the hospital needs to retain us."

"What's happening with the nurses?"

"Nothing good. I don't see how a strike can be avoided unless the County comes up with more money. But you know how that goes — either taxes will have to be raised, or something else will have to be cut. The new surgical wing will help, as it will allow for more elective surgeries."

"What are those?"

"The specific definition is surgery that is scheduled at the convenience of the doctor and hospital and in line with the patient's desires, rather than being urgent or emergency. In common parlance, it means cosmetic surgery, tubal ligations, hysterectomies, some heart surgeries, and some orthopedic surgeries. Mostly, they're quality-of-life surgeries.

"Another thing that will happen once the new surgical wing is constructed is an expansion of the cardiology department. Both of those will actually be net positive to the hospital's balance sheet. Emergency services — the ED, surgery, and OB — are the big cost centers, and that's going to get worse. As I mentioned to Mary, when the clinic closed, we lost over a million dollars in available healthcare funding, very little of which was paid for by taxes."

"It's outrageous what happened!"

"You won't find anyone at Moore Memorial who doesn't agree. In the end, I think the county will have to act because it's far more expensive to treat those patients at the hospital than in a clinic, and EMTALA ensures they have to be seen and evaluated, and stabilizing treatment has to be provided. Practically, that means everyone is treated. There is an urgent care clinic just south of McKinley, but they do not offer low-cost or no-cost services because they're a private organization."

"Doesn't the same law apply to them?"

"No. It only applies to hospital emergency departments in hospitals that accept Medicare, which is pretty much all of them. At the risk of starting a political fight, that's because the federal government cannot regulate private hospitals unless they take federal money. Uncompensated care has doubled in the past ten years and is projected to double again in another ten. That money has to come from somewhere and the only place it can come from at the moment is paying patients.

"When everything is taken into account, the hospital tax levy on property in the county would have to more than double in ten years to even come close to covering the losses. And before you say that a national program would help, it's the national program — Medicare — that is the most aggressive in terms of limiting costs.

"That allows the national government to keep the Medicare taxes lower and push the costs onto private healthcare, which allows politicians to demagogue about rising healthcare costs. And single-payer doesn't solve the problem; it just changes the character of it and who collects the socialized costs and how they're allocated. It can never be 'free' nor can it be 'unlimited'."

"I must be very predictable," Kris said. "You answered my objections, even if the answer is unsatisfactory."

"I predict we're going to love each other for the rest of our lives."

"I like that prediction!"

"Papa?" Rachel called from the door to the room. "Potty!"

"Papa's girl!" Kris teased.

I laughed, got up, and helped my daughter use the potty.

_April 29, 1990, Circleville, Ohio_

On Sunday, Jenny Leonard and her parents joined us for dinner at the house.

"Hi, Jenny!" I said when I greeted them at the door. "Good afternoon, Mr. and Mrs. Leonard."

"It's Bob and Cindy," Mr. Leonard said. "Good afternoon, Doctor."

"Just Mike here at home, please. Won't you come in?"

The three of them came in, and I introduced Kris. Rachel already knew Jenny, as she'd met her at the hospital, so I introduced Rachel to Jenny's parents. I offered them drinks, and poured lemonade for each of them as they'd requested.

"Thank you so much for everything you've done for Jenny," Cindy Leonard said. "It's been difficult for her."

"I'm right here, Mom!" Jenny declared. "And Doctor Mike knows!"

"She's a teenager in every way!" Bob said.

Jenny rolled her eyes, and I saw just a hint of rebellion I knew was there but which she would have to suppress, at least somewhat, to achieve her goal.

"She's earning good grades and seems to have her act together," I observed. "She has a long tough road ahead of her, made more difficult because she's a young woman. But she certainly has the wherewithal to do it, and I look forward to teaching her at Moore Memorial in the future."

"Is it really that difficult for women in medicine?" Bob asked.

"Not as difficult as it was, and things continue to change, albeit slowly. Of the fifteen doctors on the surgical staff, only one, my mentor, is female. Our new crop of Residents has four women. That's a positive development, but there are no female department heads and very few female Chiefs, either Attendings or Residents."

"What's the difference?" Bob asked.

"The progression is medical student, then Resident, then Attending. A Resident is an MD but who is not fully trained in their specialty. The length of Residency programs varies from three to ten years; mine is seven or eight, depending on how you count. Residents are supervised by Attendings, and Residents do most of the training of medical students. Chiefs are basically managers of their peers."

"How did you decide on your specialty?" Cindy asked.

"When I was ten, a girl was injured on the playground. She was bleeding profusely from a cut, and I used my shirt to apply pressure the way I'd seen on TV. I ended up with my name and picture in the newspaper for saving her life. That's when I decided I wanted to practice emergency medicine. The surgical part came later because that specialty didn't exist in 1973. In a strange twist of fate, I helped save that same young woman's life once again at Moore Memorial back in January."

"Jenny said you had a tragedy of your own."

I nodded, "I did, and that's what allowed us to connect."

"Could you tell us what happened?"

"Rachel," Kris said, "come with me to the kitchen, please, and help with dinner."

They got up and left.

"She doesn't know what I'm about to tell you," I said, then related what had happened with Elizaveta.