Chapter 44 — Feelings of Guilt

_August 31, 1989, McKinley, Ohio_

{psc} I met Clarissa for lunch just after noon.

"I can't even leave you in the ED without you finding a way to get into trouble!" she said, shaking her head.

"Right, because saying I want to teach my medical student is 'getting into trouble'?"

"Even there you find a way to rock the boat or stir up a hornets' nest!"

"Gee, Lissa, did you give up on me Freshman year?"

"I'd argue that was different, but you won't accept that argument, no matter how well I make it."

"My point is not about specifics, but about giving up too soon. Nobody has given Krista a failing grade, and I honestly don't believe she deserves one now. Right now, I'd give her between a 2 and 3 for her rotation, with a 3 being likely if she continues to improve. A 3 won't end things for her, though it'll make it tough for her to Match to a top program and she'll very likely Scramble to a third-tier program in a rural area, similar to what happened with Melissa Bush."

"How is Melissa doing?"

"I haven't spoken to her again, though I will call her sometime in September to catch up."

"You're a strange guy, Petrovich."

{_ "You have heard that it was said, 'You shall love your neighbor and hate your enemy.' But I say to you, love your enemies, bless those who curse you, do good to those who hate you, and pray for those who spitefully use you and persecute you, that you may be sons of your Father in heaven; for He makes His sun rise on the evil and on the good, and sends rain on the just and on the unjust. For if you love those who love you, what reward have you? Do not even the tax collectors do the same? And if you greet your brethren only, what do you do more than others? Do not even the tax collectors do so? Therefore you shall be perfect, just as your Father in heaven is perfect." _}

"Matthew's Gospel, right?"

"Yes. I figure if I can't take Jesus at His word, well, to paraphrase Paul, I've run a race in vain."

"I noticed you memorize things Jesus said and the Psalms, but not much else."

"David was a man after God's own heart, and Jesus _is_ God. Paul and I have very different ideas on a number of topics, but that's OK because his letters are akin to the canons — specific advice for specific situations, not meant to be generalized. I'm also partial to James and John.

"But coming back to our topic. I don't think it's right to give up on a student like Krista. She's not Tim, who failed rotations. That said, there _is_ an accusation that she used sex to pass a rotation, but barring either confession or the doctor coming forward, it's just rumor. I mention it only because Doctor Northrup brought it up, and it does track with what I told you Leila Javadi said."

"She's never come on to you?"

"No. Ellie and Detective Kleist have actively flirted and want to have a fling; Kellie is absolutely interested, but wisely won't sleep with a married man. And a few med students have flirted or made rare suggestive comments, but Krista never has."

"Who is she assigned to as of now?" Clarissa asked.

"Mostly Paul Lincoln, given the schedule," I replied. "He works more or less opposite shifts to me now and also will next month."

"What do you think Northrup will do?"

"It's an interesting dilemma. He can't really allow students to select their Residents, but I'm likely the only Resident who would give Krista a chance. Think about a formal complaint and how it would work out when she pointed that out AND he denied her request."

"So she's found a way to force his hand?"

"In his position, under the current circumstances, that is what *I* would do, but I'm not sure what he would do. I believe he sees it as a situation where he's damned if he does and damned if he doesn't. On one hand, set a precedent where students are allowed to influence or even select their Residents, which creates a serious problem as students will gravitate to the best teachers through word of mouth; or, on the other hand, have her lodge a complaint that might actually succeed in some kind of formal proceeding."

"Why does this sound almost like the 'wine in front of you' bit from the movie?"

"Because he's basically screwed either way. I think he'll come down on not changing her schedule because, as I've been told time and again, no medical school or hospital has ever lost a lawsuit with regard to training medical students."

"Melissa Bush?"

"I don't think she would have won in the end, but they chose not to take the risk, and to save the time and effort of defending themselves. The fact that she got her act together says the exercise was a success for both sides."

"What will you say if she does make some kind of formal complaint?"

"The truth, and only what I have personally observed. I did that with Doctor Northrup, even after he declared our conversation to be off the record."

"So you'd tell him what you thought versus what you were willing to say if asked?"

"Yes. As Residents, and especially during our Intern year, we're only provisional members of the guild. Doctor Northrup didn't want me to say anything on the record that might cause either of us a problem, and you know who comes out on top in that situation."

"It sounds as if you think she's going to get screwed."

"I think she put herself into a position where it was possible, and given she doesn't compare favorably with the other med students assigned to the ED, she's going to receive a sub-par evaluation, and might even fail. I'll object to failing her, but the thing is, this will be her second sub-par evaluation, and that's the kiss of death for any program other than the kind Melissa found in her second attempt."

"What would it take to fail in your mind?"

"Tim Burg deserved to fail; Krista doesn't, at least at this point. Someone, somewhere along the way, decided she wasn't worth teaching, and that stared a downward spiral."

"Or, the rumor about her sleeping with an Attending to get a passing grade is true, and _that_ is why she's being treated the way she is."

"I have no way of knowing, and as such, I won't consider it as material to anything."

"But if it were true…"

"Then she'd deserve to fail and the Attending ought to be suspended."

"Fat chance."

"I know."

We finished our lunch, and I returned to the ED, and had Krista take her meal break while I supervised Al suturing a leg lac. The rest of the afternoon was quiet, and, as promised, Doctor Northrup asked to see me just before 6:00pm. I checked with Doctor Gibbs, then went up to Doctor Northrup's office. As he had earlier, he signaled me to shut the door.

"I spoke to John Cutter, Ron Getty, and Tim Baker to get their input. The consensus is we can't, at this late date, change the schedule, especially for a sub-par student. And before you object, you did say she was clinically challenged. Are we going to have a problem?"

"No," I replied. "I understand your decision, and will obviously abide by it, and not publicly contradict it, but I don't agree."

"I understand. You'll find, in the course of your career, many instances where you don't agree with decisions that are made. How you respond is key — it's OK to disagree, but it's not OK to stir up dissension."

"I understand."

"I will instruct Paul Lincoln to give Ms. Sandburg the benefit of the doubt, and not simply assign her scut. She is also free to attempt to trade shifts, but I suspect she won't meet with much success."

I was positive that wouldn't happen, as there was no chance Jake Green would switch with her.

"OK. I consider this matter closed."

"But you're unhappy," Doctor Northrup observed.

I nodded, "Yes, but I'm not in charge, and I'm not the one who has to make those calls. I've given my feedback. If this were a medical question, I'd be much more forceful."

"As I would not only expect, but demand. All reports I have are that you're doing an excellent job. Keep it up."

"Thank you."

I knew I was dismissed, so I left his office and returned to the ED, meeting Krista, who had obviously been summoned, on the stairs. I acknowledged her, but didn't say anything, as it wasn't my place. There was nothing pressing, so I was able to take my dinner break and meet Kris and Rachel in the cafeteria.

"How did your test go today?" I asked once we had our food and had sat down.

"It was easy," Kris replied. "You know I can read, speak, and write English, so that wasn't even a challenge. And I only had to answer ten questions from the list they provided and I am positive I answered all ten correctly. I should hear sometime in the next three weeks, then I simply need to appear to take the oath at a scheduled ceremony."

"When are those?"

"At varied times. Once my application is approved, I'll do my best to work around your schedule."

"I'm curious, but will you take the standard oath?"

"No. I'll say 'solemnly affirm' rather than swear, and I won't say 'so help me God'."

"What about bearing arms in defense of the US?"

"I can use the modified version which says that I will perform non-combatant services, which I am sure you would insist on if you were drafted."

"Well, I'd certainly be a doctor, but before I graduated, I'd have asked to be a corpsman or something similar, rather than carry or use a firearm. I take it your parents will apply once you're approved?"

"Not until after I take the oath, according to Mr. Burge."

"Daddy?" Rachel said.

"Yes?"

"Home?"

"Not tonight," I replied. "Daddy has to take care of sick people. Daddy will be home tomorrow night. One more sleep and one more nap."

"I think your idea that we shift her bedtime is exactly right," Kris said. "She really misses you."

"As we said, she didn't sign up for this the way we did, and at two, she doesn't understand. Fortunately, I'll have at least two months of the new schedule, and that will take us a third of the way through my Intern year."

"Maybe have lunch with her more often when she's in daycare here?" Kris suggested.

"I think I'll do that. I just hate that for two years she's paid the price for a decision I made seventeen years ago."

"She enjoys visiting Abi one day a week and being with Serafima another day, and she has her friends in daycare."

"I know, but she clearly wants her dad."

"And if you continue to beat yourself up for a decision you made when you were ten, where will that leave you? And where will it leave her?"

"You're right, of course. That doesn't make it any easier."

"And yet, as they say, the die is cast. The Rubicon was crossed long before she was born."

It was more complicated than that, but I couldn't say it out loud. My original plan had been to marry after my Intern year, which would have avoided the situation, but saying that would convey regret that I had Rachel, something I could never do. Nor could I say anything that would convey regret that I had Kris, despite the circumstances that had led to our marriage.

"I promise not to obsess about it," I said. "It's just that she tugs at my heartstrings."

"That's how it should be, shouldn't it?"

"Yes, of course. It's just that her little life has been difficult."

"Has it? Or do you think it's been difficult? She is a very happy toddler, with lots of friends. She doesn't know what happened. Her life is what it is, and you should be proud of what you've accomplished as a dad, despite all the adversity with which you've had to deal."

"You're right, of course."

"Keep saying that!" Kris said with a smile. "I like hearing it!"

"I'm sure!" I chuckled.

"How was your day?"

"Routine, and not too busy, though we lost a seventeen-year-old who wrecked his car early this morning."

"What is it with boys driving fast?"

"Don't ask me! I've never had a single traffic ticket. I left those to Jocelyn, who collected them like kids collect baseball cards!"

"How is your medical student?"

"She tried a Hail Mary today and didn't connect?"

"A 'Hail Mary'? The prayer?"

I chuckled, "Good thing American football wasn't on your citizenship test! It's a last-minute attempt to score by throwing a long pass into the end zone in the hopes one of your team will catch it, or the defenders will commit a penalty."

"Such a silly sport! You should play proper football! Or at least rugby football! And stop calling cars going around in circles 'racing'!"

"Ovals," I chuckled. "Ovals. But NASCAR does race on road courses a few times each season, I think."

"Formula One is proper racing."

"Listen to the Euro-snob!" I teased.

"There is no city in Ohio which even comes close to Paris!"

"Most people here would take that as a compliment!"

Kris laughed, "Of course they would! They're mostly Germans, after all!"

"As an Ohioan, I do have to point out that there are no Skyline Chili restaurants in Paris!"

"You say that like it's a bad thing!" Kris teased.

"Those are fighting words, Missy!" I growled.

Kris laughed, winked, and we continued eating. When we finished our meal, took a short walk with Rachel, and then my wife and daughter headed home. I walked back to the ED and found Serenity and Al waiting for me. About two minutes later, Joyce, a new clerk, let us know EMS was bringing in an MI. Serenity, Walt, and I gowned, gloved, and headed for the ambulance bay, along with Nurse Alice. The patient arrived in full arrest, and despite our best efforts, we couldn't revive him.

"Time of death, 19:17," I announced.

My students and I left the trauma room while Alice began the death kit. I asked Joyce if the patient had any next of kin and she said his wife and son were in the waiting room. I asked Serenity to bring them to the consultation room, and once she had, I relayed the news.

I realized I was becoming anesthetized to death, and I wasn't sure I liked it, despite it being necessary to be able to do my job. Each death weighed less and less, though I understood that the family and friends of each patient who died felt the full weight of their loved-one's passing, and I had to show empathy while remaining detached, which was no easy task.

Once I left the family in the hands of the chaplain, I completed the chart and filled out the physician's portion of the death certificate. I needed Doctor Taylor to sign the chart and the certificate, which he did, then I took the chart to Joyce, who would ensure it was recorded in the computer and then given to whichever Attending was responsible for the chart review.

The rest of the evening was relatively quiet, and I managed to sack out in the on-call room just before midnight.

_September 1, 1989, McKinley, Ohio_

"How was your day?" Kris asked when Rachel and I arrived home on Friday evening.

"Calm, actually. I managed to get about four hours of sleep, and Rachel and I had lunch together today."

"I'll take her so you can go change. We're staying home, right?"

"Yes. I don't want to foist Rachel off on anyone, given she clearly wants to spend time with me. Not to mention you and I have some business to take care of!"

Kris laughed softly, "So, making love to me is work?"

"No! But I'm concerned about the 'tape recording' feature that someone seems to have installed in our daughter!"

Kris laughed again, and went upstairs to change into shorts and a t-shirt, then went down to the kitchen to help with the final preparations for dinner. I helped Kris finish making dinner, then the three of us ate. After Kris and I cleaned up, I read two books to Rachel, then played my guitar for her. We said our evening prayers together, and then I gave Rachel a bath and put her to bed.

"I think I need a bath," Kris said invitingly.

"Before or after?" I asked.

"Before, I think, so we can just fall asleep after we make love."

We went to our room, I drew a bath, added bubble bath, and then Kris and I undressed and got into the tub.

"Did having lunch with Rachel help you feel better?" Kris asked as we lounged in the warm, sudsy water.

"Yes, and it did assuage some of the guilt, but it's only a partial solution."

"Mike, you need to forgive yourself the way you forgive others. What you're doing isn't sinful, so it should be even easier."

"As the saying goes, 'easier said than done', but I understand. I think I'll feel better starting Sunday because I'll have time for her every day. And equally important, time with you every day."

"And I will be happy to have you home more."

"When would your period normally start?"

"Around the 16th," Kris replied. "Are you expecting me to be pregnant?"

"If you aren't, it won't be for lack of trying!"

Kris laughed softly, "And we should try three times tonight to improve our chances?"

"I certainly got enough sleep last night that we can do that."

"Great!"

_September 2, 1989, McKinley, Ohio_

Kris, Rachel, and I had our usual Saturday morning — band practice, shopping, the bakery, and lunch together. I left my wife and daughter about 11:40am, and headed to the hospital for my final shift of the August rotation, even though it was September on the calendar.

"Doctor Mike, do you have a moment?" Jake asked after I'd done my handover with Kylie.

I acknowledged Jake's request, and after checking in with Ghost, Jake and I went to the temporary Resident's office.

"What can I do for you?" I asked.

"Krista Sandberg asked me to switch shift schedules with her," Jake said. "She indicated she had your approval."

"Only to ask," I replied. "I'm neutral on who's assigned to me because I have to be."

"I don't want to switch, but she strongly implied that's what you wanted."

I shook my head, "You need to do what best suits you, just as she does. I need to teach whoever is assigned to me, and I'm not supposed to play favorites, though I do provide students who show aptitude and skill with more opportunities, as is the norm."

"OK. Then I'm going to tell her 'no'."

"As is your prerogative. Shall we go see some patients?"

"Yes," Jake replied.

"Get the first chart in the rack, take Heather with you, and do an H & P, please."

"Right away, Doctor."

I went to speak to Ghost, and about ten minutes later, Heather came to let me know that Jake had finished his exam. That began a busy shift which saw us treat ten walk-ins and handle two EMS runs before I finally took a dinner break just before 8:00pm. Because Clarissa had more flexibility, she delayed her meal break to match mine. For the next month or two, our shifts would only overlap on occasion, and that meant we'd have to make time to see each other outside the hospital, something which was difficult given my situation.

I was paged right at the end of my meal break as there were three simultaneous EMS transports inbound. Clarissa handled returning my tray, and I moved as quickly as possible without running the full length of the corridor, managing to glove and gown and join my students and Nurse Terry in the ambulance bay just as the third squad arrived.

"Stan Lowe, forty-nine; gunshot wounds to the abdomen and leg with no exit wounds; pulse 110 and thready; BP 60 palp; resps slow and PO₂ 92% on five liters; unit of plasma and IV saline; 5 megs morphine."

"Trauma 3!" I ordered. "Terry, another unit of plasma and type and cross-match; Jake, Foley; Heather, EKG and monitor. Move!"

We quickly moved the patient to Trauma 3 and the six of us moved him to the treatment table. The patient would need to be intubated before surgery, but his PO₂ was high enough that I could worry about other concerns, and his slow resps were likely related to the morphine, though significant blood in his abdominal cavity could put pressure on his diaphragm. He'd absolutely need an ex-lap, but I had to get his blood pressure up if he was to have any chance of surviving surgery. I found no other wounds.

"Blood in the bag!" Jake announced, which was no surprise.

"Jake, call upstairs to surgery; he needs an ex-lap to see what kind of damage the bullet did."

"Right away!" he exclaimed.

"Tachy at 125," Heather announced. "BP 70/30; PO₂ 93%."

"He needs more volume," I said. "Squeeze in the rest of that unit of plasma! Terry, set up the rapid infuser for that second unit."

"They need to call in a surgeon," Jake reported. "The other two transports need surgery as well."

"This guy won't live if he has to wait. Once the second unit is in, we're taking him up."

An alarm blared.

"BP just bottomed out!" Heather declared, then a second later announced, "Asystole!"

I had good money on traumatic rupture of his aorta, and even if he were open on a surgical table, mortality was north of ninety percent.

"He's hypovolemic," I said. "CPR and let's hang two more units on the rapid infuser."

As we sprang into action, Doctor Mastriano came in and I quickly gave her my assessment. We worked together, but the situation was hopeless, as we couldn't replace the blood loss quickly enough.

"Ruptured aorta," Doctor Mastriano observed about ten minutes after she'd come into the room. "Call it, Mike."

"Time of death, 21:12," I declared. "Do we know what happened?"

"Deputies were servicing a warrant," she said.

That surprised me, given no Deputy had come into the trauma room. That almost guaranteed that the other victims weren't Sheriff's Deputies.

"The first two victims?" I inquired.

"Unrelated MVA."

"Which Deputy is here?"

"None, yet," Doctor Mastriano replied. "The report is that the man's son has them in a standoff."

I updated the chart while Nurse Terry began the death kit. Once the chart was completed, my students and I left the room and immediately encountered Deputy McCallum.

"He didn't make it?" he asked.

"No. McKnight will tell us definitively, but he bled out, likely due to a ruptured aorta."

"Well, shit," he sighed.

"Problem?"

"I can't talk about it right now," he said. "Let me call it in. OK to use the consultation room?"

"Yes."

I had a feeling from his reaction, combined with what Doctor Mastriano had said, that it was what law enforcement called a 'bad shoot'. He went to the consultation room, and I took the chart to Joyce.

"Report is he was coming out of the house unarmed and a Deputy fired on him," she said quietly.

I nodded, "That fits Deputy McCallum's reaction."

"There are three charts in the walk-in rack. Doctor Varma has two already."

I instructed Jake and Heather to take the next chart and went to the lounge to use the restroom and get a drink of water, then joined them in Exam 3 for a patient with blurred vision and a headache. Thirty minutes and a neuro consult later, the patient was admitted for testing and observation with what I suspected was a brain tumor.

The rest of the evening was uneventful, and just after midnight, I headed home.

_September 3, 1989, Columbus, Ohio_

The events which had led to the patient who'd died of the gunshot wound appeared in the Sunday edition of the _McKinley Times_. The Sheriff's Department had, together with the FBI, gone to serve a warrant on a 'fugitive from justice' — a twenty-year-old college kid accused of two kidnapping rapes in Boston. The man who died in the ED was his father, and had come out of the house unarmed as law enforcement was arriving, and a Deputy had, for some reason, fired on him.

"What will happen to the Deputy who fired the shots that killed him?" Kris asked as I pulled out of the driveway for the drive to church.

"It'll depend on the outcome of the investigation, but usually the police are exonerated of criminal charges. Usually the most that happens is the Deputy would lose his job."

"Even if he shot an unarmed man for no reason?"

"He'll give some reason, and most of the time, prosecutors defer to the judgment of the officer involved. Not always, but that is the norm."

"The police here are too free with their use of guns."

"I don't disagree," I replied.

"Changing subjects, what time do you need to leave tomorrow morning?"

"By about 4:30am," I replied. "That gives me enough time to get to the hospital, change, and get to the ED by 5:00am. I'll set my alarm for 4:10am, shower, dress, and be on my way. I'll say my morning prayers in the car on the way to the hospital."

"OK. Rachel's schedule is matched to yours. Serafima will pick her up tomorrow before I leave for class, and I'll drop Rachel at Abi's on Tuesday morning on my way. Wednesday, you'll take her to the hospital daycare. Thursday she's at Serafima's again, and the Friday you'll take her to the hospital daycare."

"Thanks for making those arrangements."

"The plan is to say evening prayers together around 9:30pm, right?"

"Yes. We'll keep that consistent every day to accommodate Rachel having a regular schedule. We can say morning prayers together on Wednesday, but that's the only day."

"Unless you object, I'm going to stay in bed when you get up, but I'd like you to kiss me goodbye."

"Where?" I asked with a sly smile.

Kris laughed, "You'll be late to work if it's anywhere but my lips!"

"That is the downside."

"Did your student switch shifts?"

"No. The student she asked to switch with her declined, which I expected him to do. There was literally nothing in it for him, and it wasn't anything like the situation I had with Kylie, where it was compassionate on my part, but also created a situation where I could attend services."

"That was the nasty doctor who tried to prevent you, right?"

"Yes. But fortunately, he's on another service and I have literally nothing to do with him unless he comes down for a consult."

"And the psychiatrist?"

"That entire service dislikes me, but, in the end, my interactions with them are limited, and they can't initiate them."

"Changing topics, I think Rachel might be ready to be toilet trained."

"Probably. We'll need to get a potty chair for her. The current thinking is to put her on it for a few minutes every few hours, telling her that pee goes in the potty, and so on. Do you want me to bring home the brochure from pediatrics?"

"I have zero experience with teaching toddlers to use the toilet, so that's probably a good idea."

"I'll get one tomorrow. I have zero experience in that area as well!"

"You've done a very good job with Rachel despite having no experience raising children."

"And you've done a very good job with sex despite having no experience!"

Kris laughed, "And _that_ is a topic for a drive to church?"

"Well, if poo is an OK topic, I believe making love should be as well!"

Kris and I shared a laugh, though we did begin to focus on our destination, and five minutes later, with the levity behind us, I pulled into the parking lot across the street from the Cathedral. When we entered the nave, we lit candles as we usually did, and I let Subdeacon Nathanial know that I wanted Father Luke to hear my confession. Immediately after Matins started, Father Luke came out to hear my confession during the changing of the Psalms.

"What is on your heart, Michael?" he asked.

"A feeling of guilt that I'm neglecting Rachel," I replied. "She's starting to vocalize that she misses me when I'm working my thirty-six-hour shifts."

"You knew about those before she was born, did you not?"

"Yes, I did, and I signed up for them; Rachel didn't."

"Is it your thinking that what you're doing is somehow sinful?"

"I'd say it misses the mark of what I believe would be good parenting."

"Do you believe any parent is ever perfect?" Father Luke asked.

"I'd say it's doubtful."

"And you're doing your best, given your circumstances?"

"I think so; Rachel doesn't."

Father Luke laughed softly, "One thing you'll discover throughout your life is that your children are very good at pointing out your failings in as much detail as you can stand, and then some! I believe the rubber will meet the road in about twelve years when you do not feel at all guilty for acting in a way with which she disagrees."

"I can wait," I replied. "I suppose the true source of the problem is feeling guilty."

"And that's a good thing, Michael, in that you're aware of the impact of your calling on your family."

"I made a point of discussing it with Elizaveta before we married and Kris before we married, and they both had a choice."

"Don't get me wrong, Michael; I understand why you feel the way you do. Let me ask this — would you be a better parent if you gave up medicine?"

"Probably not, because I'd be denying my calling."

"Things change in the future, right?"

"It'll be better after this first year and get progressively better to where I'll work an average of fifty to sixty hours per week."

"How is your prayer life?"

"I'm consistently following the rule Father Roman gave me."

"And fasting?"

"To the extent possible, given my crazy schedule and ensuring proper nutrition."

"Is there anything else on your heart?"

"No, Father."

"When will you see Father Roman again?"

"Next Sunday."

"Good."

He prayed the prayer of absolution, and I returned to my spot next to Kris and Rachel. When Matins and the Divine Liturgy ended, Kris and I chose to head home so we could spend time together as a family.

_September 4, 1989, McKinley, Ohio_

On Monday morning, I arrived at the hospital at 4:50am, went to the surgical locker room to change into scrubs, then reported to the ED for my shift.

"Morning!" Kellie exclaimed. "I matched my schedule to yours as much as possible."

"People are going to talk," I replied with a smile.

"Let 'em. You and I both know the score."

"Let me see Paul for the handoff," I said.

I walked over to where Paul Lincoln was standing near the board.

"Two waiting on Medicine," he said. "They'll go up around 6:00am. Exam 2 is gastro, IV rehydration underway; Exam 4 is an adrenal mass. Krista is coordinating with Medicine."

"Thanks. Did Doctor Northrup speak to you about her?"

"Yes."

"Just give her a fair shot, please."

Paul nodded, "I will. Anything else?"

"You can take off. I've got it, thanks."

He left, and I went to check in with Doctor Boyd, who'd be going off shift at 6:00am when Doctor Gibbs would come on. Doctor Boyd had no special instructions, so I reviewed the charts for the two patients, then confirmed with Krista she had things under control. The next hour was quiet, and Krista managed to send both patients upstairs before the end of her shift.

Jake and Heather started their shifts, and for the first time since I'd begun my clinical rotations, no medical students were sitting at the triage desk. It was now fully staffed by nurses, and we'd be starting to train paramedics. In addition, Residents from Medicine would be assigned to the ED for eight-week stints. Starting in January, the same would be true of surgical Residents.

The other big change was the EMS/Police radio system was being installed at the Clerk's desk, though it wouldn't be live for a few weeks. And, longer term, each of the ten-year-old EMS squads was being replaced with new Advance Life Support squads, which would have more equipment and supplies, and allow the new procedures we were teaching to be performed.

Changes were coming fast and furious, and the biggest one was yet to come — the new trauma wing, which was taking shape just across the driveway from the ambulance bay. It would have six dedicated trauma rooms, fourteen beds in an open ward separated by curtains, two private exam rooms, a dedicated suture room which would double as a treatment room, a centralized nurses' station, and a waiting room that would be twice as big as the current one. All the trauma rooms and six of the ward beds would be 'telemetry' beds, which would allow a nurse at the nurses' station to monitor a dozen patients' vital signs simultaneously.

All of that, though, was at least eighteen months away. In the here and now, Jake, Heather, and I had patients in the waiting room. As was my usual practice, I had them retrieve the first chart, bring the patient in, and notify me when they were ready.

"Carol Klein," Jake announced after introducing me, "sixty-eight; fell during her morning walk and struck her head; minor contusion on her right temple; complains of dizziness and nausea; pupils slightly sluggish; pulse 68; BP 120/70; PO₂ 98% on room air. General good health; no recent ailments; uses naproxen for mild rheumatoid arthritis."

I acknowledged him, spoke to Mrs. Klein, performed a basic exam, then stepped into the corridor with my students.

"Proposed diagnosis?"

"Concussion," Jake replied.

"Proposed treatment plan?"

"Monitor and release if symptoms don't worsen; advise to follow-up with personal physician."

"Heather, is there anything you'd add or do differently?"

"Given her age, perhaps a baseline EKG? That was suggested in our Practice of Medicine course for anyone over sixty-five who shows signs of possible subdural hematoma."

I nodded, "Solid, defensive medicine, and easy enough to do. Jake, deliver your diagnosis. Heather, set up the EKG and attach a strip to the chart. No need for continuous monitoring."

I updated the chart, signed the order, then we went back into the exam room. Jake delivered his diagnosis, and explained that Heather would take an EKG. Mrs. Klein didn't ask any questions, so I left my students to accomplish the EKG, and about ten minutes later, they came to report no anomalies. I examined the strip and agreed.

"Ask Ellie for a nursing student to sit with Mrs. Klein," I said. "Do we know who brought her in?"

"Her husband is in the waiting room."

"Check with her and if she's amenable, you can bring him in. Let me know if they have any questions."

Jake acknowledged my instructions, they left to carry them out, and I went to see Doctor Gibbs to present the case.

"You had Jake do the workup," she said. "Why not have him present to me?"

"He's bringing in the patient's husband and arranging for a student nurse to sit with her. I'll have him present in the future."

"Treatment plan approved. Good call on the baseline EKG."

"That was Heather. I hadn't planned to do it, but she suggested it based on something that was said in her Practice of Medicine course. It makes sense, obviously, and it's good defensive medicine."

"Make sure she knows that."

I smiled, "I complimented her on suggesting it and used 'defensive medicine' when I did."

"Go heal the sick!"