Chapter 13 — A Long Night during a Long Shift

_July 4, 1989, McKinley, Ohio_

"I need to discharge Mr. Temple," I said to Doctor Mastriano.

"Do that, then come to my office."

"Yes, Doctor," I agreed.

Mr. Temple had not had a repeat of his syncopal event, nor had he experienced additional bouts of A-fib, so I wrote out the cardiology referral to keep Medicare happy, completed the discharge papers, directed him and his wife to Patient Services, then went to the Attendings' office where Doctor Gabriel was with Doctor Mastriano.

"Give us the room, please," Doctor Mastriano said to Doctor Gabriel.

"Morning, Mike," Doctor Gabriel said.

"Morning, Pete," I replied.

"Rough night?"

"Long, but I'm doing OK."

He left, closing the door behind him.

"If you EVER contradict me or undermine my authority again, I'll bounce you from this program so fast you won't know what happened."

I was tired, and I knew it, and that meant I had to be extra careful in what I said and how I said it, lest I allow fatigue to cause me to say or do something foolish.

"May I please suggest you take this up with Doctor Cutter and Doctor Northrup?" I requested. "My situation is different from all other trauma Residents because of my special program."

"You aren't special. You're a PGY1 and you have neither the experience nor the skills to make the judgments you're making."

"Which is why you slept all night and insisted that I not bother you?" I asked snidely, instantly regretting it.

"This is not about me, Loucks. You directly disobeyed my instructions."

"I'm sorry I mentioned you sleeping all night," I said, intending to twist the knife despite my earlier resolve to be careful. "But, Doctor, I didn't disobey your instructions. You instructed me to call for a consult, which is performed by a surgical Resident. I'm a surgical Resident, and Doctor Roth confirmed that I was authorized to make the assessment."

"You know very well that I meant to have the on-call surgical Resident come down, not to play word games. And then you disappeared for forty minutes!"

"Doctor Blake directed me to scrub in to help with the surgery."

"You're a fucking Intern! You don't touch patients in an OR!"

"I performed a blind pericardiocentesis under Doctor Blake's instruction, with the goal that I'll be able to do those in the ED."

"Not in MY trauma rooms."

"I don't know what to say beyond that you should take it up with Doctor Cutter and Doctor Northrup, or Doctor Gibbs, once she comes back on Friday."

"This is going in your file, Loucks. And I won't stand for a repeat."

"Yes, Doctor," I said, knowing an argument would do me no good.

"You are to confirm every single procedure with me."

"If you insist, I'll be happy to wake you to ask about giving a patient a Tylenol."

"You know what I meant!"

"I heard you say 'every single procedure', Doctor. I'm going to err on the side of caution to ensure there are no misunderstandings or misinterpretations."

"Don't be a smart ass."

"It's not being a smart ass. It's a proper response to being reprimanded for interpreting your instructions in a way you consider incorrect or insubordinate, but which benefitted the patient. May I be dismissed so I may speak with my mentor about this?"

"Doctor Casper is not here."

"No, but Doctor Taylor, is."

"What does he have to do with anything? Casper is your mentor."

"Not Josh Taylor," I replied. "Vince Taylor."

"He's a surgeon, not a trauma specialist!" Doctor Mastriano protested.

"Indeed, and the red scrubs and the 'S' on my badge indicate I'm on the surgical service. May I go?"

"Get out of here!" she growled.

I left and went to the nurses' station and called to see if Doctor Taylor was available. The nurse said he was just about to go into surgery, so I decided to go up and talk with him while he scrubbed.

"Hi, Mike! What's up?"

"Hi, Vince," I replied. "Doctor Mastriano basically put me on double secret probation because I followed the program set by Doctor Cutter."

"She's…no, I can't say that to you. Let me handle it with Doctor Cutter. Can you give me the nutshell in two minutes?"

"Yes."

I explained the events of the previous twenty-four hours, including the contradictory things Doctor Mastriano had said.

"Her shift ends right about now, doesn't it?"

"Yes."

"When are you on with her again?"

"I'm not sure of her schedule, but certainly next week, Monday."

"OK. Who's the senior Attending today with Gibbs out?"

"Brent Williams."

"Explain briefly what happened, and have him clear you to perform the procedures everyone has signed off on. Keep your comments about Mastriano neutral, please."

I nodded, "I will."

"OK. I'll get in touch this afternoon after I speak with Doctor Cutter."

I thanked him, left, and returned to the ED.

"You OK?" Tom asked.

I nodded, "Just part of the turf war, I think. I need to go see Doctor Williams."

I saw him in the Attendings' office, and decided to wait until Doctor Mastriano left before talking to him, so I went to the lounge where Mary was on the couch.

"How do I get off triage and get to work with you more?" she asked.

"There isn't much I can do about the policy," I replied. "Given EMTALA requires us to provide an exam and treat all emergent cases and active labors, we have to have someone trained in H & P handle walk-ins, where before it was done by the clerk, who now has other duties. There's a staffing problem with exclusively using nurses, and that's why more medical students are assigned to trauma now than in the past. Next week, for this shift, Doctor Varma's student will handle overnight, and you'll just have a two-hour shift during the day. Did that happen last month?"

Mary nodded, "Yes, but I also wasn't working with you. You're more willing to allow your students to do procedures than anyone else, and I want to learn."

"I'll do my best when you aren't on the triage desk, but I can't change that."

"It just sucks that Tom got to scrub in on the emergency surgery; no offense Tom."

"None taken," he replied. "But I also won't apologize!"

"Nor should you," I interjected. "Mary, I'll do my best to make sure you get procedures, and we should have plenty of opportunities today, if history means anything. If you'll excuse me, I need to see Doctor Williams. You two should get your breakfast now."

They left, and I found Doctor Williams in the corridor and asked to speak to him.

"I got an earful from Mastriano," he said.

"Vince Taylor in surgery suggested I speak to you about the restrictions Doctor Mastriano placed on me."

"Well, she's not here and if you come ask me about giving a patient Tylenol, you'll regret it!"

"Understood."

"Is it true she blew off a patient with a head injury?"

"She insisted, and wrote on the chart, that I was to wait for his EtOH level to drop before she'd consider any further actions beyond life support."

"He seized and herniated?"

"I didn't get a report from neuro, but that would be my impression based on what I know."

"That's going to be an ugly M & M if he's gorked."

"Yes, it will," I confirmed. "May I raise one other topic?"

"You never stop, do you?" he asked with a sly smile.

"No, which I suspect is part of Doctor Mastriano's problem with me. In any event, this isn't a request or even recommendation, but my Fourth Year asked about less time on the triage desk and more time doing procedures."

"Stop the presses! Breaking news! Medical Student wants more procedures! Film at 11!"

I chuckled, "You kind of mixed your metaphors there with print and broadcast media."

"You are a pain in the ass, Mike!" Doctor Williams declared with a grin. "A great young physician, but a major pain in the ass!"

"All part of my master plan for world domination!" I chuckled.

"I'd actually be OK you with you being Emperor of the World! You care too much about people to be an evil dictator!"

"I suggested you ask Rachel that question in about twelve years!"

Doctor Williams laughed, "I have an eleven-year-old daughter, and I'm positive she thinks I'm a cross between Genghis Khan, Attila the Hun, and Pat Robertson!"

"Two of those aren't so bad," I replied.

Doctor Williams laughed, "Let me guess, you think Robertson is the truly evil one in that trio?!"

"Let's just say that I have significant differences of opinion from the so-called Moral Majority."

"You and me both! And yet, I believe that's the main area of conflict with my daughter!"

"May I ask how old you are?"

"Thirty-three. We had Michelle as my graduation present from UofI. Not the best timing, but I'm very happy we have her. How is your daughter?"

"Asserting her newfound independence," I replied. "Her favorite word is 'no', followed closely by demanding to see her Aunt or her best friend."

"It doesn't get much better! Wait until she discovers boys!"

"Oh, she has, and has ZERO use for them!" I chuckled. "But that will change in about twelve years."

"Or sooner. My daughter decided they were interesting just before her eleventh birthday."

"Lord have mercy!"

"You can say that again!" he replied, then immediately said, "STOP!"

"What? " I asked with a 'What, me worry?' look.

"You were going to actually say it again! I could tell by the look on your face!"

"My reputation precedes me. OK to get my breakfast?"

"Yes. Make sure your students eat."

"I sent them to have their meal when I came to speak with you."

"When are you with Mastriano again?"

"I honestly don't know. I only looked at my schedule.

He pulled open a drawer and pulled out a calendar.

"Saturday," he said. "I'll speak to Doctor Gibbs and Doctor Northrup and let them decide what to do."

"Thanks, Brent."

"You're welcome. Naveen has walk-ins, so you're on trauma and monitoring as soon as you come back."

"OK."

I left the Attendings' office and hurried to the cafeteria where I got eggs, bacon, yogurt, toast, and coffee, then sat down with Mary and Tom, who were already eating.

"How much trouble are you in?" Mary asked.

"The usual amount," I replied. "It won't affect anything for the rest of this shift."

"Tom wasn't sure exactly what happened."

"Neither am I, in the sense that everything seemed more or less OK with Doctor Mastriano during my shift on Saturday."

"She slept all night?" Mary asked.

"I'd prefer we didn't discuss what Doctor Mastriano did last night," I said. "As I mentioned, there's something of a turf war between the ED and Surgery, and it's best if we all keep our heads down as best we can. I'm kind of stuck in the middle with a balancing act, and I need to let the Attendings and Chiefs fight this out and try not to be hit by friendly fire, so to speak."

"But the new specialty makes so much sense!" Mary protested.

"So did hand washing and the germ theory of disease," Tom interjected. "And I'm sure you remember that from Practice of Medicine."

"I just don't get it," Mary said, shaking her head. "Just because something is new doesn't mean it's bad."

"No, but what's the number one rule of thumb in medicine?" I asked. "Not what they taught you in Practice of Medicine, but in reality?"

"Go with what works," Mary replied.

"Exactly. So if something works, the system is designed to stick with it until it's proved that there is a better way. Sometimes that's easy, usually around pharmaceuticals. Sometimes it's difficult, such as with new surgical techniques. Can you tell me why?"

She thought about it for a moment, then nodded.

"Because the system is designed to protect physicians who follow a specific standard of care, and looks askance on variations from that standard, even if they're successful."

"Why?"

"To prevent a 'Wild West' environment where anything goes and there are no standards."

"Yes, and think about what that means for emergency medicine. What's different there?"

"You don't have time to think in many cases."

"Right. What do you know about succinylcholine and etomidate?"

"They're used for intubation," Mary said.

"Why?"

"Adverse effects are exceedingly rare, they're short-lived, and have standard dosage for adults."

"And the value of that?" I prompted.

"You save precious seconds and don't have to worry about contraindications."

"Correct. So if someone came up with a new drug, how would that be received?"

"Skeptically because what we have works and is very, very low risk."

"So even something that is somehow better would be difficult to adopt. Why?"

"Because the new benefits are unlikely to be sufficient to take the risk."

"Yes. And what mentality does that engender?"

"Semmelweis," she replied.

"Here endeth the lesson," I said with a smile. "We need to finish eating and get back."

"Sean Connery in _The Untouchables_?" Tom asked.

"Yes," I replied.

We finished our breakfast and headed back to the ED where Doctor Fitzgerald and Doctor Lews had come on shift alongside Naveen Varma and me, which was the normal daytime contingent of PGY1s, with Doctor Williams as the Attending and Doctor Gabriel as the senior Resident. The Attendings would work between twelve and eighteen hours, while senior Residents worked between eighteen and twenty-four, and the PGY1s, as much as thirty-six hours. The only doctor with regular hours was Doctor Gibbs, who, as the Chief Attending, worked between ten and twelve hours Monday through Friday.

"Mike," Doctor Williams called out, seeing us walk into the ED.

"Yes?" I inquired.

"Hand lac in Exam 6 if your student wants a procedure."

"Nah," I replied. "What med student _ever_ wants more procedures?"

He laughed, "OK, _because_, not _if_."

"Mary, do you feel comfortable doing the procedure with Tom, explaining what you're doing and completing the discharge?"

"Yes!" she exclaimed.

"Then we'll all go in and I'll stand in the corner and observe. Introduce yourself as a Sub-Intern, but don't explain what that is unless asked. If they ask, you say it's a 'trainee doctor'. Introduce me as your supervisor, and Tom as a new student."

"Yes, Doctor!"

"Then let's go."

The three of us went to Exam 6, stopping at the door so Mary could review the chart which was in the holder on the wall.

"Forty-two-year-old male," she said. "Bagel-slicing accident; five centimeter lac on his palm with no tendon involvement and clean margins."

"Before we step in, what are you going to do?"

"Appreciate the wound; irrigate; inject lidocaine, probably times five; paint with Betadine; suture with 4-0 nylon; apply a clean dressing."

"Good," I confirmed. "Tom, what else?"

"Verify his tetanus. Mary should also ask about negative reactions to local anesthesia and allergies."

"Very good. I'll stand aside and only step in if I see something that concerns me."

We went into the room and Mary introduced herself, Tom, and me as I'd instructed. She proceeded exactly along the lines she'd suggested and did an excellent job suturing. Tom administered a tetanus shot, and then Mary discharged the patient.

"How does it feel to be a doctor?" I asked Mary after we returned to the lounge.

"That's the first time I was ever allowed to do everything from start to finish."

"And you did an excellent job. Write it into your procedure book and I'll sign it. Do one more like that, and I'll sign off for you to do them without observation. Tom, you'll get your chance before the end of the month as well."

"Thanks," he replied.

"Doctor Mike?" Nurse Ellie said from the door to the lounge. "EMS five minutes out with failure to fly."

"Thanks, Ellie. Which room?"

"Trauma 4. I'll send you Nancy."

"Thanks."

"Failure to fly?" Tom asked.

"Kid, usually between four and eight, almost always a boy, who fell out of a bunk bed or something similar," I replied. "Let's go."

Five minutes later, the EMS squad arrived.

"Danny Baldwin, six; fell from his bunk bed; BP 110/70; pulse 90; PO₂ 98% on room air; contusion on forehead; no other obvious injuries; unconscious for about two minutes; GCS 11 on arrival, 14 now; cervical collar. His parents are right behind us."

"Trauma 4!" I ordered, and we began moving. "Hi, Danny. I'm Doctor Mike and we're going to take good care of you."

"My head hurts!" he said.

"We'll do our best to fix that!" I said. "Mary, primary survey, please. Tom, pulse oximeter only."

"Trauma panel?" Nurse Nancy asked.

"I think we can dispense with that for the moment," I replied.

The four of us, plus the two paramedics, gently moved Danny to the trauma table.

"Danny, this is my friend Mary," I said. "She's going to check your eyes, ears, nose, and mouth, and listen to your heart and lungs. My other friend Tom is going to put a clip on your finger to measure how fast your heart is beating."

"Will it hurt?" he asked.

"No."

Mary, who already had on gloves, picked up the otoscope and put on a fresh speculum, and began her exam.

"No CSF in either ear; pupils reactive; nasal passage clear and free of fluids; throat clear."

"OK. Tom, Babinski, please. Danny, my friend Tom, is going to rub the bottom of your feet."

Tom did the test and reported his findings.

"Normal flexor, both feet."

"Indicating?" I asked.

"No spinal damage, but it's not definitive."

"Correct. Danny, I need to check your neck," I said. "I'm going to ask my friend Mary to hold your head and you need to keep very still."

"OK," he said.

Mary stabilized Danny's head, and I carefully loosened the cervical collar and appreciated his spine and neck muscles.

"No indication of trauma," I said.

"Everything OK in here?" Doctor Williams asked from the door of the trauma room.

"Just completing the primary exam, and about to remove the cervical collar."

"Proceed," he said. "Call me if you need me."

I removed the collar and asked Bobby to slowly turn his head from side to side.

"Does that hurt at all?" I asked.

"No, but it feels like somebody is pounding on the inside of my head."

"We'll give you some medicine to help. Mary, which analgesic?"

"Liquid ibuprofen or acetaminophen; I know your preference is for ibuprofen, so I'd go with that."

"Dosage?"

"OK to look in my book?" she asked.

"Yes. With kids, we always look it up because drug dosage and contraindications are different from adults."

She quickly paged through her notes, then said, "Estimate about 22 kilos, so 10 milliliters PO."

"Nancy, would you retrieve the ibuprofen for Mary, please?"

"Right away, Doctor."

"Mary, complete the exam, please."

She palpated Danny's abdomen, checked for signs of other injuries, then asked Danny about being in the hospital or going to the doctor, to which he said just for his shots.

"What's your diagnosis, Mary?" I asked when she finished.

"Mild concussion."

"And what would you do?"

"Monitor for two hours then release with instructions to see his family physician, and return if has dizziness, nausea, double-vision, or any other signs of neural compromise."

"And that contusion on his forehead?"

"Ice, as needed, if he'll tolerate it."

"What are you missing?" I prompted.

Mary thought for a moment, "I think that's it."

"Possible skull fracture?" I asked.

Mary frowned, "I should have thought about that. Skull series?"

"Maybe," I replied. "What would be my concern?"

"X-ray exposure. But don't we need to know?"

"It would be preferable, yes, but we need to discuss it with his parents, as well as find out if he's had other x-rays recently."

"What about the new CAT scan?" Tom asked.

"It uses ionizing radiation just like an x-ray," I said. "In fact, more. What we really need is one of the new Nuclear Magnetic Resonance Imaging systems that don't use ionizing radiation; they use magnetism, instead. Unfortunately, they're only in research centers and very large hospitals."

"How do we get one?" he asked.

"It's about money and space, the same as every other thing we need. Would you go see if his parents are in the waiting room and escort them back?"

"Right away!" he replied.

Nancy returned with the liquid ibuprofen and Mary administered it via a small plastic cup, just as Tom brought in Danny's parents.

"Mr. and Mrs. Baldwin," I said. "I'm Doctor Mike."

"How is he?"

"Other than a headache for which we've given him ibuprofen, which is the active ingredient in Advil, everything seems fine. We would like to take a series of x-rays of his head to check for a skull fracture, but I need to ask about other x-rays he's had recently."

"None," Mr. Baldwin said. "No broken bones and his dentist said no x-rays until Bobby has his adult teeth, unless there's a problem."

I nodded, "That's a good policy. There's nothing dangerous about the x-rays, so long as he doesn't have too many. Is it OK to send him to Radiology for x-rays of his head?"

"Yes," Mr. Baldwin said.

"Tom, call Radiology and then take Danny for his x-rays. Wait with him and let me know when the radiologist has the wet read."

"Right away, Doctor," Tom said.

"Mr. and Mrs. Baldwin, one of you can go to Radiology with Danny, and as soon as we get the results, I'll come speak to you."

"Thanks, Doctor."

"You're welcome."

I wrote my orders on the chart, signed it, then said, "Mary, with me, please; Nancy, Tom will handle things for now."

The three of us left the room and Mary and I went to present to Doctor Williams.

"OK to present the case?" I asked.

"Go ahead."

"Mary?"

"Danny Baldwin, age six; fell from a bunk bed; contusion on the right temple; upon exam, no indications of spinal injury; ibuprofen administered for headache; skull series ordered. If no cranial compromise, monitor for two hours, then release with concussion protocols."

"Very good," Doctor Williams said. "Social Services?"

"In my judgment, not necessary," I said. "No signs of abuse or other injuries. He's well-nourished, communicative, and minus the contusion on his temple, completely healthy. No previous hospital visits and he reports only going to the doctor for his shots and checkups. He's seen a dentist recently as well."

"OK. Continue. If the skull series shows anything, what's your plan?"

"Mary?" I prompted.

"Neuro consult," she replied.

"Just so. Let me have the chart, please."

He scanned it, wrote some notes, signed it, then handed it back.

"Good job, Miss Anderson," Doctor Williams said.

"Thank you."

"Mike, how are you holding up?"

"Tired, but I'm OK. You remember I have four hours off for my gig at Milton Lake, right?"

"Yes. Kylie Baxter is covering for you, right?"

"Yes. She'll be here at noon, and I'll be back by 4:00pm to finish out my shift."

"Off at 1800, so you'll miss all the fun of July 4th!"

"Where 'fun' means dealing with people who would win awards for proving Darwin was right!"

Doctor Williams laughed, "That's one way to look at it! Dismissed!"

Mary and I left the Attendings' office and were immediately stopped by Ellie.

"Can you take an ankle injury?" she asked.

"Yes. We're waiting on x-rays for the failure to fly."

"What is it with boys and bunk beds?" Ellie asked.

"What is it with boys and _anything_?" Mary asked.

"On that note…" I chuckled.

"Exam 2 is open," Ellie said.

Mary and I went to the triage desk and asked for the chart for the ankle injury.

"Seventeen-year-old female," Nanette said. "Track star out for her morning run, encountered a dog, stumbled, and landed badly. Vitals normal. Ecchymosis and swelling appreciated on exam."

"Thanks," I said, accepting the chart. "Mary, get a wheelchair, please."

She retrieved one and then we went out to the waiting room and walked over to the only teenage girl who was with a woman I suspected was her mother.

"Alicia Sanderson?"

"Yes," she said.

"I'm Doctor Mike and this is Mary, a Sub-Intern. We'll help you into the wheelchair and get you to an exam room and take a look at your ankle."

"I can walk with my arm over a shoulder," she said.

"I'm sure you could, but hospital policy dictates a wheelchair."

"Just do that, honey," her mom said.

She glared at her mom, but didn't object to Mary helping her into the wheelchair.

"Can I come with her?" her mom asked.

"That's up to Alicia," I said.

"She's a minor!" her mom protested.

"Yes, and according to the State of Ohio, at age sixteen, she's entitled to make the decision for herself so long as she's not mentally impaired. You can object to treatment, but if she wants it, generally, we're required to provide it by law."

"How is that possible?" her mom asked.

"Because she's in the ER, by law, we're required to provide an exam and treatment. Alicia?"

"Mom, chill," Alicia said. "I'm fine. Just stay here."

Her mom was clearly unhappy, but absent finding Alicia incompetent to consent to an exam, Alicia had the choice.

"We'll update you as soon as we know more," I said. "Mary, let's go."

We went to Exam 2 and Mary helped Alicia onto the exam table while I washed my hands and put on gloves.

"What happened?" I asked.

"I'm on the track team and run cross-country. I'm training over the Summer, which means running 10K every morning. I was close to the end when a neighbor's stupid little dog ran right under my feet and caused me to stumble. I landed badly and my ankle turned. I thought I was OK at first, but then couldn't put weight on it. My neighbor helped me home and Mom brought me here. How long before I can run again?"

"Let me examine you first," I said. "Once we have a diagnosis, then we'll discuss the next steps and rehabilitation. Are you taking any medications?"

"No."

"Any illegal drugs? Including performance enhancers?"

"Not a chance. They drug test at competitions and I'd be banned."

"Any recent illnesses or hospitalizations?

"No. I don't get sick and this is my first injury beyond a muscle pull about four years ago while playing soccer."

"Same leg?"

"No, the other one. Hamstring."

"Are you allergic to anything?"

"My little brother!" she declared.

I chuckled, "I think my little sister had the same opinion of me growing up. OK to do an exam? I need to listen to your heart and lungs, get your BP, then examine your ankle."

"Sure."

She was wearing a thin, cotton t-shirt, so there was no need to have her remove it or even lift it. I auscultated her heart and lungs, finding everything to be normal, then took her pulse and BP, both of which were low, but which was normal for an athlete who ran long distances.

"Lie back, if you would," I said.

She did as I requested and I checked both ankles, appreciating significant swelling, tenderness, and ecchymosis.

"How bad is your pain?" I asked.

"Scale of one to ten, about a six," she replied.

"We'll need to get an x-ray of your ankle. Is there any chance that you're pregnant?"

"Is that an offer?" she asked with a smirk.

Mary laughed, but I managed to maintain my composure.

"It's a standard question we ask before we order x-rays or medication."

"No. I had my period late last week."

"Then Mary will take you for an x-ray. Would you like some Advil?"

"I took Tylenol at home and it helped some."

"Mary, ice pack for Alicia's ankle, then call Radiology for an ankle series. I'll update her mom."

"Right away, Doctor."

I left the room and went to the waiting room to speak to Mrs. Sanderson.

"Her ankle is likely only sprained," I said. "We're sending her for x-rays to confirm that diagnosis."

"How long will that take to heal?"

"For a mild to moderate sprain, she should be able to walk on it in about two weeks, but it will be around twelve weeks before she can return to running."

"Three months?! School starts before then!"

"I understand. I'll refer you to a sports physiologist who can give you a better idea and provide rehabilitative therapy which can improve the recovery time."

"And if it's broken?"

"Potentially much longer," I replied. "But let's not get ahead of ourselves. My exam and what Alicia said makes me believe it's a Grade 1 or Grade 2 sprain, and those are in line with the recovery period I mentioned before. It will probably be an hour before we know for sure."

"I'd like to sit with her."

"Let me ask, and if she agrees, I'll have a nurse bring you back."

"Thanks, Doctor. Can I ask how old you are?"

"Twenty-six," I replied. "I'm a first-year Resident."

"Is that why you're wearing red, instead of blue like everyone else?"

"No. I'm a surgical Intern assigned to the ER," I replied, using the common public reference to the Emergency Department. "Our surgeons wear red."

"Why are you in the ER not surgery?"

"I'm training to be a trauma surgeon, that is, someone who can perform emergency surgical procedures in the ER. It's a relatively new specialty."

"Too bad you aren't ten years older!" she said.

"I'll take that as a complement, but my wife and daughter might have a problem with that comment!"

"You aren't wearing a ring!"

"We generally avoid jewelry on our hands due to wearing exam gloves. I have my ring on a chain around my neck when I'm working in the ER. Let me go see if Alicia is willing to have you sit with her."

I left the waiting room amused by the fact that I'd basically been hit on by both a mother and daughter. I went into the exam room and asked Alicia about her mom and she relented, so I left and asked Ellie to send a nurse to bring Mrs. Sanderson to Exam 2.

"Doctor Mike?" Tom called out.

"Yes?"

"X-rays for our failure to fly are negative for skull fracture."

"Good. How is your patient?"

"No signs of impairment and no complaints other than his headache, though the ibuprofen has made it hurt less, according to him."

"OK. Let's update his parents and we'll monitor him for two hours, I'll have a nurse take vitals every twenty minutes, and then we'll discharge him."

We went into the trauma room and I explained the x-ray results to Danny's parents, and that we'd keep him under observation for two hours. Once they were satisfied, I asked Ellie to have a nurse take Danny's vitals, then went to the lounge to get a cup of coffee. I filled a mug, sat down, and had just taken my first sip when Ellie came to the door.

"EMS four minutes out with a twelve-year-old with a hand injury," Ellie said.

"Fireworks?"

"Firecracker exploded in his hand."

"Wonderful. Did they say how bad?"

"All his digits are still attached, but I don't know more."

"OK. Mary, get Tom and meet me in the ambulance bay. Ellie, who's my nurse?"

"Me, if you'll have me!" she said with a twinkle in her eye. "I need to see two patients a day to keep up with my license requirements."

Of course, she'd put just enough emphasis on 'have' to make it a double entendre, but I let it go as occasional teasing was OK, so long as she wasn't actively trying to seduce me. I took a sip of coffee, put the mug down, knowing it would be cold before I returned, then headed to the ambulance bay, putting on a gown and gloves on the way.

"You totally didn't react to the girl with the sprained ankle hitting on you," Mary said.

"Not the first time I've been flirted with by a patient, or a mom."

Mary laughed, "No way!"

"She asked how old I was and said it was too bad I wasn't ten years older."

"Mother-daughter fantasy?" Mary teased.

"Not anywhere on my list," I replied. "There's a lesson, though, and that is that you need to be stoic in those instances."

"Sorry. I guess I shouldn't have laughed."

"What did I miss?" Tom asked.

"An object lesson," I said. "When I asked a seventeen-year-old female patient if she might be pregnant before I ordered x-rays, she asked if it was an offer. Mary laughed, which she shouldn't have. I simply ignored the obvious flirtation and replied that it was a standard question before x-rays.

"You both will be hit on or flirted with by patients at some point, and you need to be very careful how you respond in those circumstances. What you don't want to do is encourage them, or turn the exam into something that borders on sexuality, or worse, is blatantly sexual."

"I heard you dated a patient," Mary countered.

"After she was no longer a patient," I replied. "I kept the exam completely formal, and she approached me later, after discharge. It's a fine line, I admit, but the key is to keep the exams professional and to not get involved with a patient while they're a patient. And, it's better if they're the one who approaches you after the fact. It's not a violation of policy to become involved after, but if you were, for example, to get their phone number from their records, that's an ethics violation."

"Can I ask a question about that?" Tom inquired.

"Sure."

"How did you handle your OB rotation? I know what they said in Practice of Medicine, but I'm not sure I can simply convince myself that it's 'just anatomy'."

"I had similar concerns," I replied. "And I was very uncomfortable the first time I observed a Foley catheterization of a teenage female. I know this might sound bad, but in the end, it literally is just anatomy and you don't really notice. And, to be honest, I was actually more uncomfortable the first time I handled a penis other than my own. That was WAY stranger and FAR more uncomfortable than seeing female anatomy."

"Uh, yeah," Tom said. "I can see that."

"What is it with guys being so freaked out about that?" Mary asked.

"Honestly?" I replied. "It's probably the social taboo and the fact that teens equate ANY contact like that to be 'gay' and are merciless in their harassment of gay males."

"Men are wimps," Ellie declared mirthfully. "But Mike does have a point, and I think he's probably right. As for being uncomfortable, I think everyone is, at least at first. You either get past it, or you find another profession. Sure, you can find a specialty where it's rare that you would do those things, but you can't graduate from med school without learning those procedures."

The ambulance pulled into the driveway and came to a stop in front of us. The paramedic jumped out and gave the vitals, and described a wound which included burns and minor evulsion.

"Hi, Timmy," I said as we wheeled the patient to Trauma 4. "I'm Doctor Mike. How is your hand?"

"It hurts!"

"What happened?"

"I lit a firecracker, and it exploded before I threw it."

I performed the exam, and after irrigating the hand, I decided to call for a plastic surgeon to examine Timmy's hand. He arrived about ten minutes later, and after conferring, we agreed he'd take Timmy on his service. I went back to the lounge, emptied the cold coffee from my mug, refilled it, then went to use the phone in one of the consultation rooms to call Tom Kirkland, the attorney who was handling Angie's complaint to the State Medical Licensing Board.

"What specifically, do you think he did wrong?" Mr. Kirkland asked after some basic preliminary questions about my relationship with Angie.

"When Angie decided she was going to do whatever was necessary to get to a point where we could marry, she was thinking about the future, outside the moment, had made a plan, and was successfully executing it. That is absolutely not a sign of someone who is suffering from full-blown schizophrenia and is a strong indication that something has changed. In my opinion, Doctor Greenberg ignored that, and that is where the malpractice claim arises."

"You're asserting that she showed signs of recovery and he purposefully and intentionally ignored them?"

"I am, and I'm willing to testify to that."

"You understand what that might mean, right?"

"I do. And I'm willing to take that risk."

"Good. I'll be in touch soon."

"What do you think the chances are?"

"Of a reprimand? Very high. If what you said is accurate, and I have no reason to believe it's not, there's actually a chance of a suspension or revocation of his license. Not a good one, but a chance."

"That's all I'm asking."