Chapter 65 —Get Back On The Horse

_December 4, 1989, McKinley, Ohio_

{psc} "Mike," Mallory said just after 8:30pm, "I have the phone call you were expecting. Line 3."

"I'll take it in the consult room."

I went to the consult room, closed the door, picked up the handset, and pressed the button for line 3.

"Mike Loucks," I said.

"Hi, Mike. It's Father Roman."

"Father, bless!"

"The blessing of the Lord be upon you. What's on your heart?"

"Two things, one of which is easier than the other. With your blessing, I'll take the easier one first."

"Go ahead."

"The easy one is that recently I've struggled with communicating with one of my mentors. I quickly get my back up and push back hard on things which, ultimately, are beyond our control."

"Is this the same one with whom you had difficulties with because she wouldn't speak up in your defense?"

"Yes. I thought we had moved past that, but events conspired to have her ask questions, and I reacted badly."

"And, of course, you used the prayer techniques as I instructed you, right?"

His tone of voice indicated he believed the opposite to be correct, and he was right.

"Of course not, or we wouldn't be having this conversation."

"The answer is within you, Mike," Father Roman said.

"I know. I felt I needed to confess, and I won't see you until after Nativity. I promise to keep working on it."

"Good. What was the second thing?"

"A patient died from something I did," I said.

"An error?" Father Roman asked.

"A choice," I replied. "Doctor Casper, the Attending on the case, is convinced she would have died either way. Intellectually I know he's right, I'm struggling with it."

"Are you able to explain in layman's terms?"

"Yes. A young woman who was stabbed multiple times in the chest and stomach was brought in by paramedics. She was given blood by the paramedics, who had also applied pressure bandages. When we received her, I put in a large-bore IV directly into the woman's jugular, so we could give her blood quickly. In addition, a breathing tube was inserted, and she was connected to a ventilator because the amount of oxygen in her blood was low and dropping.

"There are a number of settings on the ventilator to control how much oxygen is provided, but there are limits to how high those settings can safely be set. The blood accumulating in her chest was putting enough pressure on her lungs that the ventilator was not working effectively, and the pressure could not be increased to overcome it. That meant she needed a chest tube to relieve the pressure.

"I knew right away that could cause a problem, in that the same blood that was making it hard for her to breathe, even with the ventilator, was compressing blood vessels and limiting bleeding. I reminded Doctor Casper of that fact, and he instructed me to insert the chest tube. I followed his instructions, and as soon as I made the incision in her side, a large volume of blood flowed out, causing her blood pressure to drop to nothing and her heart to stop almost immediately.

"I completed the procedure, we gave her blood as quickly as possible, including using a system that pumps it in, and performed CPR. It was ineffective, and after a brief conversation between Doctor Casper and me, we agreed we should cease treatment, as there was no hope she could ever recover due to blood loss. Doctor Casper announced the decision and declared the patient was dead. Both he and the nurse noticed I was struggling emotionally, and he suggested I call you."

"He's Orthodox?"

"Married in," I replied. "He married Kris' cousin Oksana. He hasn't been chrismated yet, but will be on Holy Saturday."

"I'm sorry to divert the conversation, but did they have a wedding in the temple?"

"Yes. And the answer to your next question is that he is the person I mentioned when we discussed my dispute with Father Nicholas about the necessity of chrismation before marriage."

"What else happened?"

"I did leave out that I prayed for the patient and for the medical team before, during, and after. I should have mentioned that, but I was, in effect, giving a layman's version of the treatment, and I cannot include 'prayed for patient and staff' on a chart."

Father Roman laughed softly, "No, I suppose you can't, even if it is completely relevant. What alternatives did you have?"

"None, really. I did leave out what I had said to Doctor Casper just before the ambulance arrived — that we needed a fully trained surgeon for a patient with such severe injuries, and what I was able to do was limited."

"No fully trained surgeon was in the hospital?"

"No. Once the surgeries for the day are done, there are only Residents at the hospital. The Attending physician on call only needs to be able to arrive at the within fifteen minutes of being paged. Generally speaking, that's sufficient given the time it takes to stabilize a patient for surgery."

"Were there things you could have done if you'd had more training?"

"More than likely not, but I won't know until we have our Morbidity and Mortality Conference, referred to as M & M Conference. That's a weekly review of interesting or difficult cases where a large group of doctors from every service discuss how to improve medical care and identify errors or weaknesses in the procedures or actions of a member of the medical staff."

"I'm quite surprised that there isn't a surgeon on duty at all times."

"There is, but surgeons who are in the hospital, including me, are only qualified to perform certain emergency procedures, including chest tubes, central lines, and tracheostomies. The central line is what I described earlier as a large-bore IV. A tracheostomy is inserting a breathing tube through the neck, rather than through the mouth. There are a few other procedures, but those are the most important ones.

"Things will change in less than two years when our new Emergency Department opens, at which point we'll begin the process to be certified as a Level I trauma center. That certification requires fully trained surgeons to be in the hospital at all times, not simply be on call. But, as I said, in this case, I don't believe it would have helped."

"What are you struggling with?"

"That a patient died as a result of a direct action on my part. Intellectually, I know I did the right thing, but my heart is heavy."

"You've had patients die in your presence before, right?"

"Yes, but this was the first one from something I did."

"I'd be concerned if your heart wasn't heavy, Mike. Being involved in someone's death ought to weigh on you. If I recall correctly, you had similar feelings the first time a patient died in your presence."

"Yes, I did."

"And you're certain that you did the right thing?"

"I don't see how I could have done anything else," I replied. "Doctor Casper agrees."

"The only advice I can give you is to pray, as the true danger lies on the other side — when you feel nothing at all. You've said the heaviness in your heart about patients who have died is minimal, but still there, and it's impossible for death not to affect you if you are spiritually healthy. We can discuss this further, if you feel it necessary when you visit after Nativity, but what you are feeling is a good thing, Mike. Your goal is not to allow it to overwhelm you."

"Thanks, Father."

"Make sure you speak to your mentors, especially the doctor who is a catechumen. They'll all have experienced what you have, and can help you with it. Now, I need to pray and go to bed. I'll see you at the end of the month."

We said 'goodbye', I hung up, and went to find Ghost to let him know I'd spoken to Father Roman.

"I'm sure Father Roman gave you good advice," Doctor Casper observed, "but I want to add something important — don't allow this to make you hesitant or doubt your skills as a physician. Patients die, as you well know, and some of them simply cannot survive their injuries or ailment. The key for a successful physician is to understand and accept that even if he or she does everything correctly, some patients will die. What we can't allow or accept is having that cause us to behave in such a way that a patient dies who we should have saved."

"Hi, Mike," Doctor Varma said, coming up to us. "Ready for the handover?"

"We'll talk tomorrow, Mike," Ghost said. "Do the handover and go home and get some sleep."

"Will do. Thanks, Ghost."

He walked away, and I turned to Doctor Varma.

"Problems?" Naveen asked.

"No. Just discussing a stabbing victim who bled out before we could stabilize her. There are two on the board — concussion being observed and showing no symptoms, who can be released at 9:30pm, and a kidney stone waiting on a nephrology consult in Exam 3."

"OK. I have it. Have a good evening."

"Thanks."

I left the ED and headed upstairs to the surgical locker room, where I showered and dressed before leaving the hospital to head home.

At home, I read to Rachel, then we said our evening prayers together as a family, and put Rachel to bed.

"Who is that extra person you added to our prayer list?" Kris asked when we sat down together in the great room to relax before bed.

"A patient who died while I was working on her. She had been stabbed at least eleven times and died while I was working with Ghost to try to save her life."

"You don't normally add patients who died to our prayer list."

"This one was different," I replied. "We had only bad options, decided on the one that had even a remote chance of success, and she died from the procedure. She would certainly have died otherwise, but it felt as if I had killed her. I hadn't, of course, but it felt like that because it was literally what I did that caused her to die. I called and spoke with Father Roman."

"That's good. How are you feeling now?"

"It's fading, and it's not all that dissimilar to the first time a patient died in front of me as a medical student, though it is somewhat stronger because I was directly involved. Father Roman basically said to keep doing what I'm doing, that is, praying, and Ghost spoke to me about not allowing what happened to interfere with treating patients."

"He was afraid you would be tentative?"

"Yes. In the end, Father Roman's larger concern was that I might become too emotionless and not feel something when a patient died."

"Which is a real possibility given your personality," Kris observed.

"Yes. I also spoke to him about my dust up with Loretta the other day."

"Dust up?"

"Kerfuffle? Set to?" I teased.

Kris slapped me softly on the arm, "You can't explain by using other slang words I don't know!"

"Sure I _can_, if my goal is to tease you!"

"Michael Peter Loucks!" she said with a smirk.

I laughed, "I wondered when I'd get the full 'three name' treatment!"

"If you take me upstairs, we can kiss and make up!" Kris offered.

There was no possible way I could refuse that offer, so I scooped up my squealing, squirming wife and carried her to the bedroom where I ravished her before we fell asleep cuddled together.

_December 5, 1989, McKinley, Ohio_

"Are you OK?" Shelly Lindsay asked when I saw her in the locker room on Tuesday morning.

"Yes. Who talked to you?"

"Ghost called me. It was bound to happen, eventually. I remember the first time it happened to me, when I was a PGY3, and I had just resected a portion of necrotic small bowel when the patient coded from an unrelated thrombosis."

"So now we're exchanging 'first time' stories?" I asked with a smirk.

Shelly laughed, "Three days before I turned eighteen, at Senior Prom."

"The Summer after I graduated from High School; I was eighteen-and-a-half."

"If you can tease, you're OK," Shelly observed. "According to Ghost, she had no chance."

"I counted eleven distinct abdominal stab wounds and there may have been more. Not to mention lacerations on her hands and arms, which I'd suggest were defensive."

"That she didn't bleed out before she arrived here is a minor miracle in and of itself. Any idea what happened?"

"The cops arrested the boyfriend," I replied. "That's all I know. I was going to stop in and see McKnight later this morning to ask about the autopsy."

"According to Ghost, your technique was textbook."

"I was more curious about whether or not she was pregnant. The cops asked that question."

"You're thinking she refused to get an abortion, and the boyfriend objected?"

"Stabbing her repeatedly is more than 'objected'," I countered.

"Obviously," Shelly acknowledged, "but you know what I meant."

We finished changing into our scrubs and left the locker room together.

"I'm here to talk anytime you need me."

"Thanks, Shelly," I said, then walked to the stairs so I could go down to the ED.

"Morning, Jody," I said to Doctor Billings. "What do you have for me?"

"An empty board and an empty waiting room! I just discharged a rule-out MI. I'm heading home to get some sleep!"

She left, and I went into the lounge, poured myself a cup of coffee, then went to the Attending's office.

"Morning, Perry," I said. "Anything I need to know?"

"It was a relatively quiet night, so nothing at the moment."

"The waiting room is empty as well, so I'll be in the lounge."

I left the Attending's office and went to the lounge where I sat on the sofa and began reading the _McKinley Times_. The lead article was about the stabbing, and didn't have much information beyond what I already knew. The one extra piece of information was that the victim's sister had called 9-1-1. Jenny and Kelly came in a moment later.

"Morning," I said. "Any charts in the rack?"

"It's a ghost town out there!" Jenny said.

"Nah, he went off shift at midnight," I replied with a smile.

"BOO!" Jenny intoned.

"Mike?" Ellie called out from the door to the lounge. "EMS four minutes out with an MI. Perry wants you to handle it."

"OK. I need a nurse."

"I'm all yours!" she declared.

"Jenny, Kelly, let's go!" I said.

The three of us got up and followed Ellie to the ambulance bay, donning gowns, gloves, and goggles.

"Jenny, EKG and monitor. Ellie, O₂ hookup, then draw for ABG, Chem-20, CBC, and cardiac enzymes. Kelly, IV saline TKO, then I'll talk you through a Foley if one is necessary. Otherwise, watch Jenny hook up the EKG and monitor, and you'll do the next one."

All three of them acknowledged my orders, and about ninety seconds later, the EMS squad pulled into the ambulance bay. Ken hopped out of the cab and called out the patient's condition as he made his way to the rear doors of the squad.

"John Baxter, forty-six; non-responsive; complained of chest pains while eating breakfast, then collapsed. BP 160/100; pulse thready at 110; PO₂ 93% on ten liters by mask."

"Trauma 1!" I declared.

Ken, Larry, Ellie, my students, and I quickly moved to Trauma 1 where I gave the count to move the patient from the gurney to the trauma table. Ellie quickly switched the O₂ from the portable bottle to the hospital system while Jenny cut Mr. Baxter's shirt so she could attach the EKG pads.

"IV is in!" Kelly declared.

"Get a 16 French Foley," I said. "It has an orange sleeve on the distal end, and is in drawer A. The packet is marked with large numerals and says 'Male'."

I quickly listened to Mr. Baxter's heart and lungs, working around Jenny as she attached EKG leads.

"ST elevations on the monitor," Jenny announced. "PO₂ 91%; pulse 110; BP 160/100."

"Call Cardiology! Ellie, 250mg ASA IV push! Kelly, use surgical scissors to cut away Mr. Baxter's pants, please."

"How?" Kelly asked.

"Cut from cuff to waist on the outside of each leg. Quickly! No prizes for neatness! Then cut away his underwear in a similar way."

She did as I instructed, and I realized we needed a larger catheter.

"Forget the 16," I said. "He's larger than average; get an 18. It has a red sleeve."

She retrieved the larger Foley as Ellie injected the ASA. I walked Kelly through the procedure and she did a competent job for a first time.

"Now, check the collection bag and announce status," I said. "It's either 'urine in the bag' or 'no urine in the bag'. If there is urine present, note if it's cloudy or has a pinkish tinge. If so, you'll be asked to dip it for blood."

She examined the bag and announced, "Urine in the bag. It looks clear to me."

I confirmed her report.

"Pace, Cardiology!" Doctor Alana Pace said, coming into the room with her student. "What do we have, Mike?"

"Jenny?" I prompted

She gave the vital information and Alana performed her exam.

"Cath lab, stat!" Alana declared. "Ted, call upstairs and tell them we're coming!"

"Kelly, get a gurney," I ordered. "Jenny, portable monitor and you escort the patient with Doctor Abbot; Ellie, portable oxygen."

Everyone sprang into action and two minutes later, Mr. Baxter was on his way to the cath lab.

"He looked pretty healthy," Kelly observed after we left the trauma room. "I mean, except for the obvious heart attack."

"Tell me the likely causes for a coronary event in a male in his forties."

"Coronary occlusion due to high cholesterol would be the primary one. It could also be genetic."

"And what else could cause thrombosis?"

"I haven't done my cardiology rotation," she replied. "I'm not sure."

"There are close to three dozen possible causes, though we can eliminate some of them because he's male. You should remember at least some of them from physiology."

"Birth control pills, but as you said, not in a male. Hyperthyroidism. Low blood pressure. Well, that last one isn't the case because his blood pressure was high."

"Which is also a risk factor for a STEMI — ST Elevation Myocardial Infarction. There's a big one you're missing."

She thought for a moment, then said, "Undetected diabetes mellitus."

"Yes," I replied. "Write the Foley into your procedure book, please. I'll guide you through a few more, and it's different for females, obviously."

"Obviously! How do you know the correct Foley size?"

"For women, it's almost always 14, unless they're significantly taller or heavier than average, then you go with a 16. For men, it's 16, or 18 if they're significantly above average in height or weight, or have above average genital size. Foley catheters for males are, as you can imagine, longer than female ones due to anatomical considerations."

"Is it OK to feel weird doing that?"

"Yes. I did. And the first one I ever saw done was on a fourteen-year-old girl during my Preceptorship. That was disturbing; now it's routine."

"Mike, got a minute?" Doctor Nielson asked, coming up to us.

"Sure, Perry, what's up?"

"You're primary on trauma today," he said. "Paul and Susan will handle walk-ins."

I nodded, "OK. I just sent a STEMI up to the cath lab with Alana Pace."

He walked away, heading back to his office.

"Isn't an Attending supposed to be primary on trauma?" Kelly asked.

"Normally, but I suspect this is because of what happened yesterday."

"Oh?"

"A bad trauma with an adverse result, and the Attendings are making use of the 'get back on the horse after you fall off' theory."

"You made a mistake?"

"No, I did exactly the right thing, and the patient died as a direct result of what I did."

"Wait! That makes no sense!"

"When Jenny comes back, I'll explain, because it's important."

About five minutes later, Jenny returned, and the three of us went into the lounge. I explained what had happened with the stabbing victim and how it had affected me.

"I guess I don't understand why it affected you that way," Kelly said. "From what you said, she was going to die, anyway."

"Doctor Mike, is it OK if I answer?" Jenny inquired.

"Sure."

"Linkage and presence," Jenny said. "You can draw a direct line from Doctor Mike's action to her death. Yes, you can draw it back to the bastard who stabbed her, but Doctor Mike's timeline starts the moment the paramedics pulled up. Whatever happened before is ephemeral; Doctor Mike making an incision that caused her blood pressure to bottom out was real. His psyche reacted to what he saw and what he did, not what had happened before, and linked the events to each other. And they are linked, but they're in a lengthy chain of events that led to her death, and that chain starts with whatever caused her boyfriend to stab her and ends with Doctor Casper pronouncing the patient."

"Minor in philosophy or psychology?" I asked.

"Double minor! A biochem major, of course."

"What specialty?" I asked.

"Anesthesiology. 'Painless' was my favorite character in the movie _M✶A✶S✶H_!"

"Kelly, any thoughts on a specialty?"

"Not yet," she replied. "I only decided to try for medical school after my second year of college. A chemistry professor at Bowling Green suggested it. My undergrad degree is in chem with a minor in computers. I was a computer science major until that professor encouraged me to think about medical school."

"You don't actually have to decide for another year, as you can simply use a standard set of rotations for Fourth Year — trauma, medicine, cardiology, surgery, pediatrics, and OB/GYN."

"That's what Doctor Crane suggested."

"Any idea where you want to Match, Jenny?"

"Somewhere warm! I'm thinking Florida, South Carolina, or Georgia."

"Kelly?"

"I'm from Akron, and I think I want to stay in Ohio. Mind if I ask where you applied?"

"Here, Ohio State, UC, Indiana, and Pittsburgh, but I wanted Moore Memorial, and they wanted me."

"You were valedictorian and didn't consider Stanford, Johns Hopkins, Mayo, or Cleveland Clinic?" Jenny asked.

"I did, briefly, consider Stanford and Emory for medical school, but decided I was going to stay in the area. I was born one county west, and I think this is where I belong, providing the best possible medical care to my community."

"Can I ask something about the MI we just treated?" Kelly inquired.

"Sure," I agreed.

"Isn't an Attending supposed to sign off on any treatment?"

I nodded, "Yes, and Doctor Nielson will review and sign the chart. I'm cleared to perform pretty much any trauma procedure, including surgical procedures such as chest tubes and central lines, without needing to be supervised. The law and hospital policy use 'supervised' and 'authorized' but don't require direct supervision, nor limit authorization to specific procedures.

"I've built enough trust with trauma and surgical Attendings to work independently, and I have the necessary signatures and authorizations in my procedure books. The key is them trusting I'll ask for help when I need it. The interesting thing is that with the new trauma surgery program, there are procedures I'm permitted to do which trauma Attendings are not — basically anything with a scalpel."

"That's so weird," Kelly observed.

"Actually, it isn't," I replied. "What do the red scrubs signify?"

"A surgical Resident! You aren't a trauma Resident."

"Correct. The new trauma surgery program is part of the surgical service because of the policy that only surgeons may supervise surgeons. I'm assigned to the ED, which means that when I'm on shift, I provide the surgical consults and perform the surgical procedures, rather than calling someone down from the surgical ward. It helps staffing in both areas. In the long run, there will always be a trauma surgeon on shift, and consults will be a thing of the past."

"How does that training work, then?" Kelly asked.

"Two years in the ED handling trauma, then six years becoming a general surgeon, but with assignment to the ED when I'm not in surgery. It's an eight-year program, rather than seven for general surgeons and three for trauma specialists."

"How many Resident spots will there be?"

"In the end, four, plus one Attending to supervise. The next slot opens in June 1991, which is when you Match. I'll mention that the competition will be fierce, if it's something that interests you."

"Only one?"

"Yes. There are similar programs at a number of hospitals and others are developing them. One way to deal with the limited slots is to Match for surgery and then request training as a trauma surgeon. It's not guaranteed, but it's possible. Assuming, of course, that interests you."

"Anything that let me work with you would be awesome!" Kelly declared. "Everyone says you're the best teacher in the hospital! I was able to handle the Foley because you have a reputation for not being overly critical."

"I can be as critical as the next doctor," I said. "But I find mentoring works far better than a dressing down."

"Mike," Ellie said from the door of the lounge. "MVA, one victim, paramedics three minutes out. Becky will work this with you."

"Thanks."

She left and my students and I hurried to the ambulance bay, donning gowns, gloves, and goggles on the way.

"I assume you notice I'm assigned experienced nurses," I said to Kelly.

"Is that a way to say I'm old, Mike?" Becky interjected.

"No, Mom, it's not!" I teased.

"I thought we agreed 'older sister'!"

"We did, but that isn't as funny as saying 'Mom'!"

"You're going to be in deep sneakers, Mike! There is no other trauma surgeon to care for YOU!"

"Now you actually sound like my little sister!"

"She yanked your chain?"

"Constantly, but I gave as good as I got! There's EMS, so game faces on!"

"Orders, Doctor Mike?" Jenny asked.

"It depends on the severity of the accident. They'll transport any accident victim who requests it."

When the squad slowed to a stop in front of us, Bobby jumped out of the cab.

"Stefano Gianis, seventy-one; low-speed MVA versus parked car; no obvious injuries; complains of weakness and dizziness; no observed LOC; BP 130/80; pulse 90; PO₂ 99% on nasal canula."

"Trauma 2," I declared. "Mr. Gianis, I'm Doctor Mike. We'll take good care of you!"

We began moving towards Trauma 2.

"Jenny, EKG and monitor; Kelly, IV Ringer's; Becky, O₂ then CBC, Chem-20, and ABG."

We reached the Trauma room and carefully moved Mr. Gianis to the trauma table. Bobby and his partner left, and the medical team began working.

"How are you feeling, Mr. Gianis?"

"Dizzy and I have a mild headache."

"Becky, 250mg ASA IV push," I said as I began the exam.

"Normal sinus rhythm," Jenny announced. "BP 120/80; pulse 84; PO₂ 99%."

I auscultated his heart and lungs, checked his eyes, ears, nose, and mouth, then palpated his stomach and checked his distal pulses and muscle tone.

"Can you tell me what happened, Mr. Gianis?"

"I was driving on Elm and suddenly felt dizzy and lost control of the car."

"Forgive me for asking this, but it's necessary — do you know where you are?"

"The ER at the county hospital."

"And the date?"

"Tuesday, December 5th."

"Thanks. Have you experienced any dizzy spells recently?"

"No."

"Any history of heart trouble? Or vision trouble?"

"Nothing wrong with my ticker; I needed a new prescription last March, but otherwise, no."

"Are you on any medication?"

"No."

"Do you smoke or drink?"

"I quit smoking about fifteen years ago. I drink ouzo occasionally, but not a lot."

"How much did you smoke?"

"About half a pack a day of unfiltered Camels."

"Did you eat breakfast this morning?"

"Yes. About an hour ago, I guess."

"Becky, glucose stick, please. Mr. Gianis, we're going to check your blood sugar."

"What do you think is wrong?"

"That's what we're trying to figure out. Your vital signs are normal, and so is your muscle tone. Any number of things can cause dizziness, ranging from something as simple as an ear infection to some kind of neurological problem. Have you been sick at all?"

"No."

"Do you see a physician regularly?"

"I've been seeing Evgeni Petrov every year for fifty years."

"Evgeni Vladimirovich is a good friend and mentor," I said.

"Ah, you must be the Doctor Mike he refers to as the best doctor in the state!"

"I'm not sure that's true! Has Evgeni Vladimirovich changed your medication or diet recently?"

"No."

"Are you fasting?"

"No, I'm Greek!" he chuckled. "I leave that to you Russian zealots!"

I chuckled, "Guilty as charged."

"Glucose is 127," Becky announced.

"Which is in the right range for having eaten recently. Kelly, call for a neuro consult, please."

"What do you suspect, Doc?" Mr. Gianis asked.

"Given I've found nothing else obvious, I'm calling a neurologist who is much better at diagnosing the cause of your dizziness."

"What was the drug?"

"ASA, which is equivalent to aspirin, and it's given to anyone who might be having a stroke. I don't see any evidence, but it can safely be given to almost anyone over eighteen. It will also help with your headache. I need to go speak to my supervisor, but Nurse Becky and my students will stay with you. I'll be right back."

"Three lovely young ladies? Theosis!"

I laughed, "I can't disagree!"

I left the room and went to find Doctor Nielson.

"OK to present, Perry?" I asked from the door to the Attending's office.

"What do you have, Mike?"

"Seventy-one-year-old male; low-speed MVA versus parked car; no obvious injuries; complains of weakness and dizziness; no reported LOC; BP 120/80; pulse 84; PO₂ 99% on nasal canula. No signs or symptoms on exam; EKG is normal; glucose normal post breakfast; IV Ringer's and ASA 250 megs proactively. I ordered a neuro consult."

"What the heck are you doing in here then?"

"It's not about being gun-shy! When I have a symptomatic patient and no plausible diagnosis, I want to check with my Attending to make sure I'm not missing anything."

Perry smiled, "I was positive you would figure out our strategy."

"Get back on the horse," I said. "I didn't bug you for the STEMI that was so obvious my Fourth Year diagnosed it. Alana Pace took him up to the cath lab."

"No deficits of any kind on your septuagenarian?"

"No. Normal pupillary response, good muscle tone, good distal pulses, oriented times three. I ordered a complete trauma panel, but my gut says it won't show anything obvious."

"What does your gut say it is?"

"Vasovagal response or orthostatic hypotension. He's of the right age. The only thing that gives me pause is that he smoked until about fifteen years ago — about ten unfiltered Camels a day."

"Four out of five doctors choose Camels!" Perry said with a smirk.

"And the fine print 'of doctors who smoke unfiltered cigarettes'! The headline of that ad was intentionally misleading!"

"Obviously. Along with the claims about menthol cigarettes being good for your throat! Sure, the menthol did the whole 'Vicks VasoDrops' thing, but that hardly made up for the carcinogens! Anyway, I think you're on the right track and with no specific symptoms, ASA and either a neuro or a cardio consult is the right course of action. I lean towards your choice of neuro, but wouldn't argue with cardio."

"Six of one, half-a-dozen of the other," I agreed.

"How are you doing?"

"I'm OK. I spoke with my «старец» last night, which helped, and Shelly Lindsay this morning."

"_Staretz_?"

"It means 'Elder' and refers to a monk who provides spiritual advice. Mine is at a monastery in Michigan."

"Is that something everyone in your church does?"

"No. Most people receive spiritual advice from their parish priest. It won't surprise you that I'm a special case!"

Perry laughed, "No, it won't!"

I left the office and returned to the trauma room, and a minute later, Doctor Lucy Vanderberg arrived.

"Hi, Mike. What do you have?"

"Hi, Lucy. This is Mr. Gianis," I said, then described his symptoms and my findings, or better, lack thereof.

She introduced herself, performed a basic exam, then some further tests for neurological deficits, including asking Mr. Gianis to touch his nose, and so on. Once she finished, she asked me and my students to step into the corridor.

"I can't take him at this point," she said. "I recommend monitoring him for another ninety minutes, and if symptoms clear, release him to his personal physician. If they don't clear, or his blood work shows something, give me a call."

"What's your diagnosis?"

"Right now, I'll go with disequilibrium."

"Thanks. I'll let you know."

She walked away, leaving me with my students.

"Do you know why I went to Doctor Nielson?" I asked.

"Because you had no diagnosis and nothing beyond reported dizziness and headache to go on," Jenny replied.

"Exactly. And that's the way to build trust. I went to him, presented, and when he asked why, I stated that I might be missing something. He and Lucy, Doctor Vanderberg, agree that I didn't. Of course, it's possible all three of us missed it."

"So just observation, right?" Kelly asked.

"I'm going to change it up a bit," I said. "I need to make a phone call."

"Who?" Jenny inquired. "I mean, if it's OK to ask."

"His physician who's a member of my diocese and who I know very well. I'll ask him to come in, which he will."

I went to the consultation room and looked up Doctor Evgeni's number in my small address book and dialed it. He answered on the 2nd ring.

"Good morning, Evgeni Vladimirovich, this is Mikhail Petrovich calling from the hospital."

"Good morning, Petrovich! How are you?"

"Well, thanks. I have one of your patients here, Stefano Gianis. He was brought to the ED after feeling dizzy which caused him to be involved in a minor traffic accident."

"How is he?"

"Other than complaining about a minor headache and dizziness, he has no complaints. I performed a trauma exam and found nothing remarkable, so I called for a neuro consult with the same results. We're waiting on labs now, and our plan is to monitor him for another ninety minutes to see if the dizziness resolves. If so, we'd release him with instructions to see you. I think it might be beneficial if you came in."

"Of course. I still have privileges. Give me twenty minutes and I'll be there! Thanks for calling me, Petrovich!"

"You're welcome, Vladimirovich!"

I hung up, chuckling at the use of names the way old pals would, despite Doctor Evgeni being almost three times my age. Jenny, Kelly, and I returned to the trauma room where Mr. Gianis was being monitored by Becky.

"Doctor Vanderberg and I discussed your case, and we're in agreement that right now, we need to wait for the blood work to come back from the lab, which will be another twenty minutes or so. In the meantime, we'll continue to monitor your heart and blood pressure. I did place a call to Doctor Evgeni, and he decided to come in to see you. Based on what we know so far, I believe he's best suited to get to the bottom of this."

"Thanks, Michael…"

"Petrovich," I replied.

"I assume it's OK to call you that?"

"Yes, of course. Becky will stay with you while I fill out some paperwork. I'll come back if you need me, or when Evgeni Vladimirovich arrives."

Jenny, Kelly, and I left the trauma room and went to the lounge so I could update the chart.

"What's with all the Russian stuff?" Kelly asked.

"I'm half Russian," I replied. "And attend a Russian Orthodox Church."

"Do you speak Russian?"

"Badly," I replied. "I was taught when I was little, but I don't use it very much these days."

I completed the chart, and we waited in the lounge until Nate let me know that Doctor Evgeni had arrived.