Chapter 31 — You're Quite the Subversive!

_August 2, 1989, Circleville, Ohio_

{psc} "Jesus, Petrovich!" Clarissa exclaimed. "What did she say to that?"

I'd called Clarissa from a payphone before I'd left Lou's, and she met me at the house just after I put Rachel down for her afternoon nap.

"Nothing, really. I didn't expect an answer because I wanted her to think about it."

"You're not concerned she'll change her mind about the hearing for Angie?"

"I'd say she's less likely to do so now because she's on notice about how badly she's screwed up just with me."

"Don't you think you were a bit harsh?"

"Seriously, Lissa? Who else would speak to her that way? I simply took my cues from how Residents and Attendings have spoken to me over the past four years. Think about the situation — she's in independent practice, so who _really_ watches over her? Even the Chief Attendings at Moore are accountable to the Medical Director and their peers in an M & M."

"The Medical Licensing Board."

"Tell me another bad joke! Look how difficult it is in a clear-cut case of malpractice with regard to Angie! And you know what happens to most complaints."

"Closed with 'no further action'. But are you saying nobody should be permitted to practice independently?"

"No, but _some_ kind of oversight is necessary, and the Medical Licensing Board does not have the resources to do it properly. That's why the majority of disciplinary cases are handled internally at the hospital. Egregious cases are forwarded to the Medical Licensing Board, and they do take action, but that's because the reports come from other doctors or the hospital administration.

"Consider Angie's situation, and how well THAT works with no actual oversight. The insurance company paid the malpractice claim with no admission of actual liability or error by Doctor Greenberg. That means other than in the records of his malpractice insurer, it never happened so far as the public record is concerned. We're remedying that, but only because Lara is providing the money to mount a complaint with actual teeth.

"And think about the end result — there is no additional money to be had, as all current and future claims were covered by the payment from the malpractice insurer. So there is no benefit to Angie from the process. The Stephens wouldn't have funded it, because they don't have the resources, and it would have been foolish to spend Angie's settlement to go after Doctor Greenberg's license.

"The system we have, and not just for mental healthcare, is rigged in favor of doctors, and despite the strict licensing regime, there is little actual oversight because the process is designed to limit the ability of the public to hold doctors accountable. I absolutely agree there needs to be a way to limit baseless or frivolous claims, but the current rules make it difficult to address even legitimate complaints."

"Would you be willing to have that kind of scrutiny?"

"So long as we work in a hospital, we will. And it's incumbent on us to ensure that our peers hold us accountable and we hold them accountable. And lest you think I'm tilting at windmills again, I did consider asking for an M & M for my 'alien encounter' patient, but rejected it because it had little chance of success and was not the right battle to fight at that time."

"But isn't it similar to Angie?"

"Somewhat. I made the point the best I could, given the circumstances. It's also the case that Mr. Alien Encounter was off his meds. I didn't know that at the time, but Lydia Samson let me know when she was in the ED for a consult. That distinguishes it from Angie's case because being off her meds _improved_ her situation, whereas that wasn't the case with Mr. Alien Encounter."

"Did you know he was taking medication?"

"No, and he wasn't exactly forthcoming. According to Lydia, he claimed the drugs were part of the government conspiracy that includes Area 51, Wright-Patterson Air Force Base, and anything else to do with the aliens who are among us."

"Just out of curiosity…"

"Do I think there is life on other planets? Probably. Have they visited us? Unlikely. And if they have, they took one look around, shook the dust off their feet, and beat it for a planet with actual intelligent life!'

Clarissa laughed, "There might be something to that."

"But in all seriousness, the cases are distinguishable in that Angie was showing signs which contraindicated her diagnosis, while Mr. Alien Encounter was showing signs that confirmed his diagnosis."

"What was that?"

"Paranoid personality disorder. I don't know enough to have a medical opinion, but his behavior did fit the basic DSM criteria. Once he was back on his meds, he became more rational, but it's a good bet he won't remain compliant. It's a similar problem to Angie's in that way. She has always tried to avoid taking the prescribed drugs. And that is likely to be one of Doctor Greenberg's defenses."

"So, how do you counter that?"

"That when she revealed to me that she was not taking her prescribed drugs, I insisted she take them and speak to Doctor Mercer about modifying the treatment regimen, and she complied with my request. She was only taking mild sedatives at the time, not the antipsychotics, and she was perfectly lucid and was making plans. And her approach was VERY different from at Taft."

"Either 'do not touch me' or 'fuck me right now'."

"Yes. She was fully aware of her situation, and her goal of regaining her driving privileges was a proxy for regaining the right to consent so she and I could marry and have kids."

"Are you actually going to say that?"

"Yes. It's in the statement I signed for Tom Kirkland, the attorney from Stefan's firm who's handling the case. And I'll repeat that before the Medical Licensing Board at the hearing."

"But as a private citizen, right? Not as a doctor?"

"Correct. I won't wear a medical coat, and I'll make it clear I'm speaking simply as Angie's friend and won't address anything other than directly observed behavior."

"But you just said something that's not directly observed."

"She told me her goal, Lissa. One that was obvious to everyone, including Doctor Mercer and Father Stephen. And Tom Kirkland has a statement from Father Stephen to that effect, so even if I don't say it, it'll still be entered into the record. And you know it was Doctor Greenberg's declaration that marriage was impossible that caused Angie's relapse. That's a fact, and there is nothing Greenberg can do to counter that fact. It really is a question of what punishment will be meted out."

"You know Lawson is going to come gunning for you."

"He can't really do anything to me, despite his threats. Remember, the facts are all on my side, and his buddy settled a malpractice claim AND is being brought before the Medical Licensing Board. I didn't try to treat Angie, and I sent her to Doctor Mercer as soon as I discovered she was non-compliant with her meds. What is Doctor Lawson going to complain about? That I show love for my friend? That I'm concerned for her welfare?"

"What about your policy violation?"

"Iffy at best, because I didn't prescribe any treatments, I simply made a recommendation to the Psych Resident. I humored Mr. Alien Encounter so I could perform a physical. In that way, it's no different from how we sometimes handle kids."

"Your candy bribes?"

"They work, and don't violate policy. If I'd done anything other than perform the physical and recommended humoring him, then Lawson would have a leg to stand on. As it is, he doesn't. And I have the ultimate out."

"Elizaveta?"

"As one component of extreme stress for which I've sought counseling. What is he going to say? I haven't made any medical errors, and I've had perfect scores on my evaluations. So, even if my judgment about the best course of action for Mr. Alien Encounter was off, the combination of stress and my concern for Angie puts Lawson in an impossible situation. I bet he does nothing, even if Greenberg is disciplined."

"You're counting on him to be rational?"

"Yes. What does he gain by gunning for me? His implied threat didn't work, and Doctor Mercer, Doctor Hoffman, and another psychiatrist hired as an expert witness will all testify to the same things I am. I'm not the lone voice crying in the wilderness. Rosenbaum and Mastriano are a bigger threat, but she's more or less defanged because she tried to contradict Northrup and Cutter."

"You don't think the 'adulterous bitch' will try revenge?"

"How will it look when I stated to Doctor Nielson that I agreed with Doctor Mastriano on how to handle the court order for a blood draw?"

Clarissa laughed, "Not good, for her, that is. I'm curious about that."

"About?"

"Your take on it."

"I have an ethical problem with court-ordered procedures in any instance, and in this case there was a simple solution — transport him to the lockup and have the nurse and deputies there draw the blood. Can you imagine if the patient fought us and had to be subdued in a trauma room? I can't see that ending well."

"I agree. What about the situations we discussed in Practice of Medicine? Jehovah's Witness parents who refuse blood transfusions that will save their kid's life?"

"I'm guided by the Orthodox understanding of medicine, but I also cannot let my faith determine what is or isn't acceptable for someone to believe. It's a difficult call given he competing interests, but in the end, I think I'd err on the side of giving the transfusion. That said, if the kid was old enough to give their opinion, I'd take that into consideration as well."

"What about a court-ordered abortion? Like the one performed on Liz."

"I refuse to perform elective abortions, period. In my view, mental health is not a consideration. That said, you know I don't believe that decision can ever be up to anyone except the woman and her doctor. I simply can't, in good conscience, impose my views on others with regard to medical procedures with are legal under our system, and the Supreme Court has made it clear that a specific medical procedure cannot be made illegal, at least during the first trimester."

"Do you agree?"

"Does it matter? I have a say about my body, not about yours or anyone else's. When I can get pregnant, then it will be up to me. I believe I have the right to give my opinion, but not the right to decide. And that's how _all_ medical procedures are handled. We can't force any patient to accept any treatment, nor can we be forced to provide it, except in very limited circumstances, and with an appropriate court order. But even with the order, no physician can be compelled to perform the procedure.

"With regard to medically necessary abortion, it's one thing for me to say that I'm willing to die for my faith; it's a very different thing for me to say a woman should die for _my_ faith. That's the error the Romans make in the way they handle abortion both theologically and in their hospitals. Orthodoxy objects to abortion, but treats it as it does any other act of 'missing the mark' — based on the totality of the gravity of the act and the circumstances."

"I've read that some Orthodox bishops want it made illegal."

"And they are within both their legal and canonical rights to advocate that. In the end, though, it comes down to having a responsibility to shepherd their flock, and that includes a proper response to 'missing the mark'. But we're WAY off topic!"

"Yes and no," Clarissa replied. "We will have to face all manner of ethical dilemmas, and Mr. Alien Encounter was the first of many."

"You're forgetting my encounters with some young women from Saint Michael."

"The ones you fucked or the ones you encountered in a medical setting?" Clarissa asked with a smirk. "And I think those two sets overlap, if I read the tea leaves correctly!"

"Smart ass!" I chuckled. "No comment."

"Uh-huh."

She was correct, in that I'd encountered Irina at the Free Clinic and had also been intimate with her after Elizaveta's repose.

"Whatever, Lissa! That's all in the past now."

"How much does Kris know?"

"Very little, by her own choice, as I think you and I discussed."

"Yes, I was just curious if that had changed. You know I won't say anything."

"Nothing has changed. In that way, she's more mature than Elizaveta, who was always trying to figure out who I'd been with. It still bugged her even after two years of marriage. That said, Kitten was exactly who I needed at the time, and I wouldn't do anything differently."

"Your relationship with Kris is very different."

"It is, and it's more of a partnership with shared goals, which is exactly what I need now. I think the past month has proved much of my thinking about relationships to be correct, and only a strong, independent woman could deal with the situation. Elizaveta would have struggled, but found her way through. Kris doesn't struggle."

"Because she still lives what amounts to an independent life," Clarissa observed.

"Yes and no. She's accepted responsibility for Rachel, and you know full well from the past two years that parents don't have a life independent of their children. Rachel is the most demanding person in my life, and everything I do has to consider her, even if the demands of medicine interfere. The balance is difficult."

"Which is my main reason for waiting to finish my Residency before I have our baby. I'll make an appointment with a fertility specialist in about eighteen months to work out a plan with the goal of having our baby about three-and-a-half years from now."

"Perfect timing, given Kris and I will have two kids in the next three years, assuming nature cooperates."

"Circling back to the reason you called, how did you leave it with Doctor Mercer?"

"That we'd speak again after the hearing on the 23rd. Fundamentally, I don't trust her at this point, and it will take time and effort on her part to regain the trust."

Clarissa looked at her watch and said, "Tessa's shift ends in fifteen minutes, and I want to be home when she arrives."

We got up, and I walked Clarissa to the door, we exchanged a hug, and I watched as she walked to her car and drove away. I had some time to simply relax, so I put on music, put my feet up and chilled until Rachel woke up from her nap. I'd just finished changing her diaper when Kris arrived home.

"How did things go?" she asked after we exchanged a hug and a kiss.

"About as I expected," I replied. "Clarissa was here this afternoon, and we talked it through."

"That bad?"

"I basically read off Doctor Mercer and wanted Clarissa's opinion and advice. I want yours, too."

"Let me change and then you can tell me."

She went upstairs and came back down in short-shorts and a tight white t-shirt, obviously not wearing a bra.

"And I'm supposed to be able to think coherently with you dressed that way?" I asked with a silly smile.

"Given you're male, coherent thought is difficult under the best of circumstances!" Kris teased.

"Yeah, yeah," I chuckled.

We sat down on the couch with Rachel playing on the floor in front of us, and I described my conversation with Doctor Mercer and the debrief with Clarissa afterwards, though I had to finesse the situation with Samantha.

"She would have objected to us marrying, wouldn't she?"

I nodded, "I'm positive she would have. Her arguments would have been slightly different, but along the same lines."

"How is it that she can only seem to apply what she considers to be 'normal' without considering the individual?"

"It's the training," I replied. "While she's not an MD, she was trained in a way analogous to our clinical rotations, and doctors are repeatedly reminded that the 'standard of care' is how they'll be judged. That means if you follow the guidelines, you will never, ever get into serious trouble because 'standard of care' is a sufficient legal and ethical defense. That's how Doctor Mastriano avoided any liability for the death of the patient."

"But she was disciplined!"

"For substituting her judgment about my training for that of Doctors Northrup and Cutter."

"So she killed the patient, and that's OK?"

"No, it's not, but because of the way the system is set up, discipline in cases where you follow the standard of care has to be limited. There are competing impulses, mostly driven by malpractice claims — what's called 'defensive medicine' and rigorous adherence to the standard of care. And 'defensive medicine' has costs, both in terms of resources expended and in subjecting a patient to what might be unnecessary tests.

"For example, in the Emergency Department, the standard is to run a full trauma panel on patients brought in by ambulance. I had a patient where that was totally unnecessary, so I didn't order it. If something had gone wrong, I could have been held responsible for not running the tests, even though it made perfect sense not to run them. I believe I could defend not running them, but nobody would every question me if I did, even if they were unnecessary. My beef with Doctor Mercer is she relied too heavily on 'standard of care' as a defense, but as I said to her, that's a product of our training and of the environment in which we work."

"So you're a rebel?" Kris asked.

"Only insofar as I'm looking out for the best interests of my patients or identifying flaws in the system. And it's not that I would ignore the standard of care, because I wouldn't. But it's only a guideline, except in one instance — malpractice. Going beyond the standard of care might get me a talking to about expending resources, but my concern is, and always will be, the best interest of my patient.

"As for defensive medicine, it takes resources which could be put to better use. I understand why it happens, and unless there are real reforms to the system, it's not only going to continue, but get worse. Once somebody has a condition where a CAT scan might have saved their life, and their family sues, and obtains a settlement, we'll be doing routine CAT scans, which are far more expensive than a trauma panel by at least an order of magnitude, if not significantly more."

"You know my answer!" Kris said with a smile.

"And you know my response! We already have 'socialized medicine', what we don't have is single payer or complete government control. And I'm not sure either of those would improve things overall. It all comes down to one thing — are the doctor and patient allowed to determine the best course of treatment without any interference by bureaucrats, be they employed by the government or an insurance company?

"The problem with that, of course, is how to pay for it. And, in the end, no matter what system you have, resources are limited and someone has to decide how to allocate those resources. It doesn't matter to the patient if it's the Medical Director, the County Board, the Federal Government, or an insurance company who denies the allocation of resources."

"But wouldn't it be more efficient without the insurance companies?"

"We have more paperwork for Medicaid and Medicare than we do for insurance claims, and it's likely to get worse."

"I'm not going to win this argument with you, am I?"

"Not unless you find a way to provide unlimited resources! Until then, our argument is about how best to allocate the limited resources and who does the allocation. With your permission, I'll change topics and ask how class was today."

"I'll allow it," Kris replied. "Class was fine. I did receive my grade report from my first class and I earned an A."

"No surprise there!"

"What did you want to do about dinner?"

"Pasta and salad?" Kris replied. "We can have dessert later, after Rachel goes to bed."

"And what exactly did you have in mind for dessert?" I asked with a sly smile.

"I'm sure you'll find something tasty! I know I will!"

_August 3, 1989, McKinley, Ohio_

"Morning, Kylie," I said to her after checking in with Doctor Williams on Thursday morning. "How was last night?"

"You'd have thought it was a full moon! Three being observed and four waiting for admission. I got zero sleep in the last thirty-six hours!"

"Ugh. Run me through the patients, please."

"Two on banana bags awaiting discharge, probably around 9:00am. Some kind of drinking contest gone wrong at a bachelor party. Third awaiting discharge fell and hit their head, mild concussion and observation will be done around 7:00am. Two admissions for surgery — one hot appy who'll go up around 10:00am because the on-call team had a stabbing victim they took up about ninety minutes ago. Some kind of domestic dispute which resulted in a meat fork to the gut."

"You had that one, too?"

"I had all the fun. The two other admissions are an apparent suicide attempt with sleeping pills. They're stable and are on a seventy-two-hour psych hold. They'll go up soon, now that vitals are stable after treatment with activated charcoal and lavage. Fourth one is a broken ankle that needs surgery. Ortho was down, but didn't give an ETA on when they'd take him. He just had another dose of morphine."

"Sounds like a fun night."

"That's only the half of it! A gunshot wound went up to surgery just after midnight, a pair of MVAs, a fatal MI and another six 'treat and street'."

"What the heck happened?"

"Who knows? It's only a waxing first quarter moon, so the _lunatics_ shouldn't be out!"

"Go home, take a bath, and get some sleep!"

Kylie glanced around to make sure nobody was in earshot.

"I need some of that relaxation therapy you used to provide, and there are no good candidates."

"I wish I could help, but…"

"Obviously," Kylie interrupted me with a smile, "There is no freakin' chance I'm going to have an affair with a married man, even if you would, which you won't. I'll leave that to idiots like Mastriano!"

"Go get some sleep and I'll see you at our next turnover on Monday morning."

Kylie left, and I met Bob and Len in the lounge, and we went to check on the patients they'd treated together with Kylie and other doctors overnight. I assigned them to ensure the patients waiting on admission were scheduled to go up, and updated the charts on the patients waiting to be discharged.

I'd just finished updating the charts when Ellie let me know the paramedics were bringing in two victims from an MVA, so Bob, Len, and I joined Doctor Williams in the ambulance bay.

"Len, you come with me," Doctor Williamson said. "Mike, we'll take the first patient; you and Bob have the second."

It turned out that neither patient had been critically injured, as both had been wearing seatbelts and the collision was relatively low speed. After a basic exam, I cleared the patient's c-spine and removed the cervical collar. With no injuries beyond minor bruises and a mild cervical acceleration-deceleration injury, colloquially 'whiplash', I wrote up the discharge notes and presented to Doctor Williams, who approved releasing the patient. His patient had similar minor injuries and was released as well.

By 9:00am we'd admitted or released all the overnight patients except the appy, and we'd treated four walk-ins with minor complaints. I had just sat down in the lounge when Nate opened the door.

"Mike, Sheriff's Deputies bringing in an arrestee with a rapid pulse and complaining of a headache."

"Cruiser or ambulance?" I asked.

"Cruiser. Ten minutes."

"Ten minutes? Why so long?"

"No idea. That's what they said on comms. They'll come to the ambulance bay to avoid the waiting room."

"OK."

Just under ten minutes later, Bob, Kellie, and I met the Sheriff's cruiser in the ambulance bay. Deputies McCallum and Sommers got out of their cruiser and Deputy Sommers, a female deputy, opened the back door. They helped a handcuffed female who appeared to be around twenty and who was clad in jeans and a t-shirt from the back seat.

"Name?" I asked.

"Shauna Percy," Deputy Sommers replied.

Bob pushed the wheelchair over and after the deputies switched the cuffs so her hands were in front of her, he helped her into the chair.

"Let's take her to Trauma 4," I said. "Bob, EKG and monitor; Kellie, Chem-20, EtOH, and tox screen."

When we arrived in the trauma room, we helped Ms. Percy onto the treatment table.

"I'll need the cuffs off, please," I said.

"Will, stand at the door," Deputy Sommers requested of her partner.

Once he moved to guard the door, Deputy Sommers removed the cuffs, admonishing her prisoner to behave.

"Hi, Shauna," I said. "I'm Doctor Mike. What's the problem?"

"Besides these two rousting me?"

"That's something to take up with an attorney or a judge," I said. "How are you feeling?"

"I have a bad headache, my heart is racing, and my hands are shaking."

"We're going to draw blood, hook up a heart monitor, and I'll examine you, OK?"

"Yes."

"For the EKG we'll need to remove your t-shirt, but you can keep your bra on. Kellie?"

Kellie helped Ms. Percy remove her t-shirt, then lie back. Bob attached the EKG leads and monitor, and Kellie drew blood. I performed the exam and noticed dilated pupils, and the monitor showed tachycardia, hypertension, and A-fib, and her respirations were fast and deep. My money was on some kind of stimulant, most likely amphetamines.

"When did you start feeling bad?" I asked.

"This morning."

"How long ago?"

"A couple of hours."

"What did you take?" I asked.

She didn't answer, but Deputy Sommers held up a baggie with capsules. I took the baggie from her and examined the capsules.

"Dexedrine," I said. "That's consistent with her symptoms. Shauna, how long have you been using?"

"Since High School," she said reluctantly.

"How old are you?"

"Twenty-one."

"Have you had the symptoms before today?"

"No."

"Did you take more today than you have in the past?"

"Yeah, because I didn't feel it."

Signs of dependency and tolerance, which meant she was likely to suffer withdrawal symptoms, including severe depression. She'd need medically managed recovery once her system had processed her most recent 'hit' of the drug. Assuming, of course, she was interested in quitting.

"How many?"

"Four."

"Your symptoms are consistent with an overdose of dextroamphetamine, or 'dexies'. Are you taking any other drugs or medications of any kind?"

"Birth control pills."

Which also could raise blood pressure, and the combination of those and dexedrine were responsible for her BP of 160/100, which was very high, but would likely resolve without medical intervention once the effects of the dexedrine wore off. I considered giving her medication for hypertension, but she wasn't in crisis, which would be systolic pressure greater than 180 or diastolic pressure greater than 110.

"Your symptoms should wear off in a few hours," I said. "Do you want to go into a drug program?"

"She's under arrest," Deputy Sommers interjected.

"I understand, but her withdrawal will need to be medically managed. I'm not sure the jail can manage that with just a nurse and a small infirmary. Shauna, do you want to quit?"

"If I say 'yes', do I stay here?"

"That's not up to me," I replied. "I'll call for a consultation from Internal Medicine and Psych, and have a social worker come see you. They'll decide if we need to keep you or not."

"I want to quit," she said.

"Fuck," Deputy McCallum swore.

"Can we step out for a moment?" I asked. "Just right outside the door."

Deputy McCallum and I stepped into the corridor.

"You know I'm required to ask those questions, right?"

"Yeah, Doc, but we were hoping to turn her."

"Pushing?" I asked.

"No, hooking. But we busted her on a stop and frisk because she was behaving erratically. We want the guy who provides her the drugs for that, but more because he's running underage hookers. But nobody will talk."

"This is legit? You aren't trying to overcome my rep as a 'bleeding heart'?"

Deputy McCallum laughed, "You do have that rep, but you also take good care of us, so we're not going to give you too much shit. I know you have a job to do, but so do we."

"Not to tell you how to do your job, but get the County Prosecutor to come see her and cut a deal that puts her in detox and a recovery program. I think she might cooperate if you do that."

"I wouldn't bet on it."

"If you were hoping withdrawal would encourage her to talk, then ethically, I have to find a way to keep her here."

"The Sheriff is going to be pissed."

I shrugged, "He has his job, and I have mine. And my job is to provide her with medical help and ask social services to help her get into a program. Either way, she's staying for at least four hours while she comes down, because we have to watch her blood pressure and arrhythmia. Let me go report to Doctor Williams and see if he agrees."

"He's the biggest bleeding heart here!"

I smiled, "I think you'll find that to be a common feeling amongst trauma docs," I replied. "Give me five minutes."

He went back into the trauma room and I went to the Attending's office.

"OK to present?" I asked Doctor Williams.

"Yes. What do you have?"

"Shauna Percy, twenty-one; presented with hypertension, tachycardia, A-fib, headache, and tremors. Dexedrine overdose; using for at least three years and signs of dependency. In the custody of the Sheriff. Also taking birth control pills. Requested detox."

"Blood work?"

"Sent to the lab; Chem-20, EtOH, and tox screen."

"Vitals?"

"BP 160/100; tachy at 110; PO₂ 99% on room air."

"Proposed treatment?"

"Monitor and treat symptoms if they become life threatening. Medicine and Psych consult and referral to the social worker. I'm also going to suggest full-spectrum STD testing as she's accused, among other things, of prostitution."

"Approved. Anything else?"

"No. It'll be up to Medicine and Psych if they admit her, but she's been using long enough that her withdrawal symptoms are going to be serious and I'm not confident the nurse at the County Jail can properly care for her. But that's not something I get to decide."

"Unfortunately, because I think you and I would both admit her and keep her for a week or so, then get her into an outpatient program. But it's not up to us."

"Mind if I play my cards in a specific way?"

"Shut the door," Doctor Williams instructed.

I did.

"What?" he asked.

"Instead of calling for a general consult, I want to ask Clarissa Saunders to come down. She'll be on the same page, and once she and I agree, then we call the social worker, and finally call Psych."

"I like it. Slightly off the usual flow, but given Psych doesn't like us very much at the moment, a wise course of action. Chart?"

"My fault?" I asked as I handed him the chart.

"No, it's been building for a time. You were just the latest incident, and your earlier run-ins with Lawson exacerbated it. But it's been going on for years because they reject so many patients we think need psychiatric care. Off the record, I supported your approach, and I think you're doing the right thing for your friend."

"Does everyone know about that?" I asked.

"Lawson made a stink about it with Northrup and Cutter, who told him, politely, to pound sand. Do you know his history?"

"No."

"He failed to Match and had to Scramble, and the only Residency he could find that would take him was psych. He applied to eight surgical programs and was rejected by all of them. Rumor has it that the hospital in Detroit where he served his Residency wouldn't hire him as an Attending."

"That explains a lot. Thanks for that insight."

"Let me know if you need help, but for dexedrine, it's palliative care and treatment of symptoms if necessary."

He made notations on the chart, signed it, and handed it to me.

"Thanks, Brent."

I left the office and rather than go to the trauma room, I went to the temporary Resident's office and called Clarissa.

"I'm not doing consults this morning," she said after I explained what I needed.

"Who's your Attending?"

"Subramani."

"Tell her I need a favor and get her permission to come down."

"Lawson is going to lose his shit!"

"I have Brent Williams' signature on the chart," I said. "He approved my plan, and besides, what can Lawson _really_ say? I called consults in the order I felt best suited the patient. Not to mention she needs to come down before Psych sees her. So I just called you based on her symptoms and then social services to set up the appointment. Can I help it if Jeannie Wilders was free immediately?"

"Nice, Petrovich. You're quite the subversive!"

"Get Avni to sign off, please."

"I'll call you right back. Where?"

"Trauma 4."

We ended the call, and I went back to Trauma 4.

"Shauna, I'd like to run full-spectrum tests for sexually transmitted disease. That would involve both blood draws and swabs of your mouth, genitals, and anus."

"Because they said I hook?"

"No judgment on my part. You don't have to agree, but I strongly recommend you have the test. I can have a nurse do the swab and all the men will leave the room."

"Shauna," Kellie said, "Doctor Mike is giving you good advice. If you've had multiple partners, you really should be tested. I can perform the swabs if you don't want him to do it."

"You think I have VD?" Ms. Percy asked.

"I don't know if you do or not," Kellie replied. "But it appears that you're engaging in high risk behavior, and amphetamine usage lowers inhibitions and causes risk taking."

The phone rang and Bob answered it, then signaled it was for me. I walked over and he handed me the handset.

"Loucks," I said.

"Saunders. I'm all yours!"

I chuckled, "If only that were true!"

"Be right down!"

We ended the call, and I went back to the treatment table.

"That was my colleague from Internal Medicine. She's going to come down and examine you. She's the one who'll decide how long you need to stay. Once she's finished, we'll call a social worker. Eventually, once the drugs wear off, you'll talk to Psych. Do you want the STD tests?"

"Yeah."

"OK. Kellie will draw blood and do the swabs once Doctor Saunders examines you."

Clarissa arrived two minutes later, and I repeated the information I'd given her over the phone as it was protocol for a consult to state the vitals in the room when the consulting physician arrived.

"Shauna, this is Doctor Clarissa Saunders," I said.

"Hi, Shauna, can you tell me what you took and how much?"

"Four dexies about two hours ago."

"And you're a regular user?"

"Yes."

Clarissa performed her exam, then asked a series of questions similar to the ones I'd asked.

"I'd like to admit her and keep her overnight," Clarissa said. "Two hours after ingesting the pills her BP shouldn't be this high. It's likely an interaction with her birth control pills, but we can't be absolutely sure."

"Will you take her now?"

"Yes. I'll call Jeannie Wilders once we get Shauna upstairs."

"Thanks, Lissa. We'll do the STD tests, then Bob will bring her up."

"Shauna, I'll see you shortly," Clarissa said.

She left, and Bob, Deputy McCallum, and I left the trauma room, leaving Kellie and Deputy Sommers with Ms. Percy.

"OK to use the phone?" Deputy McCallum asked.

"Use the one in the temporary Resident's office. It's former Consultation 2."

He walked away and went into the room.

"What did I miss?" Bob asked.

"Ask me later once the patient is upstairs."

He nodded, "Got it."

About five minutes later, Deputy McCallum returned.

"A deputy prosecutor is going to come here and see if we can deal."

"Good," I replied.

Two minutes later Kellie called us back into the room, and after updating the chart, we disconnected the monitors and helped Ms. Percy into the wheelchair.

"Thank you," she said, smiling at me. "I appreciate it."

"Get into a program and stick with it. You're young and have your whole life ahead of you."

They left, accompanied by the deputies and I went to let Doctor Williams know what had transpired.

"Clarissa admitted Ms. Percy based on hypertension more than two hours after ingesting the drugs."

Doctor Williams nodded, "Defensible. Good work, Mike."

"Hopefully she'll stick with the program and turn her life around."

"Hopefully, but that's up to her, not us. Need anything else?"

"Not at the moment. I saw a number of people in the waiting room, so I'll catch some of those."

"OK. Come see me when you need me."

"Will do."