Chapter 76 — Domestic Disturbance

_February 12, 1990, McKinley, Ohio_

{psc} When Julie and I entered Trauma 2, I saw Alana performing CPR while Jake bagged. I said a silent 'Lord, have mercy' and moved close to the treatment table.

"Mike, let's get him on the vent," Alana said.

"Intubation tray!" I said to Kellie, who was already moving to get one.

I looked at the monitor, and it showed no electrical activity, so a shock would not help, and the chances of him coming back were near zero. Flogging him for thirty minutes made zero sense to me, as much as it pained me to think that.

"Should we?" I asked. "Asystole? No electrical activity?"

"Kellie, amp of epi, IV push," Alana ordered. "I'm not giving up yet, Mike."

We were both Residents, and she couldn't tell me what to do, AND this was my patient.

"If the epi gets any response, I'll intubate," I said. "Jake, keep bagging."

Kellie injected the epinephrine and, as I had feared and expected, not even a blip on the monitor.

"He's gone, Alana," I said quietly. "No point in flogging him."

"No defibrillator?" Max asked.

"Ineffective for asystole," I replied.

Alana continued to do compressions, and Jake continued to bag for another thirty seconds with no change, and I decided it was over.

"I'm calling it," I said, looking up at the clock. "Time of death, 07:28. Jake, you can stop."

Alana performed five more compressions before finally giving up.

"He knew," I said gently. "He asked for his priest. You know as well as I do from the inverted T-waves that McKnight is going to find severe coronary disease, which is no surprise after sixty years of pack-a-day smoking."

She took a deep breath and let it out.

"Chart, please," she said to Kellie.

Alana filled out her portion of the chart, I wrote in the time of death, and we both signed it.

"I'll speak to my former father-in-law," I said. "Kellie, get the death kit. Max, help her; Julie, with me, please."

I left the trauma room, and I was positive Viktor knew the outcome from the look on my face, but I had to follow protocol. I gently took his arm and guided him to the consultation room.

"I'm sorry," I said. "He died because his heart stopped, and Alana Pace and I could not revive him."

Viktor nodded grimly.

"Mike?" Ellie said quietly from the door to the consultation room. "The priest is here."

"Ask Father Nicholas to come in, please."

She acknowledged me, left and returned twenty seconds later with Father Nicholas.

"Nikolay Vladimirovich reposed about three minutes ago," I said. "His heart stopped, and we couldn't revive him."

"Lord, have mercy!" Father Nicholas exclaimed.

"You can anoint him right away," I said. "Viktor, I assume you'll want to see your father."

"Yes," Viktor said.

"Should we wait for Yulia or the kids?"

"It's not necessary."

I nodded, and the four of us went to Trauma 2, where Viktor took his father's hand then kissed him on each cheek.

"OK, Father," Viktor said to Father Nicholas.

"Mike, would you assisting me create any problems with the hospital or His Grace?"

"None I can think of," I said.

Father Nicholas took his stole from his bag, kissed it, put it around his neck, then removed the kit he carried that contained chrism and the other things he'd need to anoint Nikolay Vladimirovich. I filled an emesis basin with water, then prepared the portable censer while Kellie, Julie, and Max moved away from the table. Father Nicholas said the prayers for the newly departed, and I gave the appropriate responses,

We had just finished when Ellie let us know that Yulia, Geno, Anna, and Nikolay Vladimirovich's wife had arrived. I considered protocol, which usually limited the number of people to two, and instantly rejected it.

"Viktor, if you want to bring them in, it's OK."

He nodded and left the room, returning a minute later with a grim-looking Geno and three women with tears streaming down their faces. Normally, I'd have left my medical student with them, but in this case, Nikolay Vladimirovich was family, so I stayed. After about ten minutes, we all left the trauma room, and Kellie and Max began the death kit procedures.

"Viktor," I said quietly. "Do you want an autopsy?"

"What do you think, Mike? As his grandson-in-law?"

"I think all they'll find is evidence of a pack-a-day smoking habit. If it were me, I'd decline."

"OK. I'll call and make the arrangements for him," he said. "Thank you, Mike."

"I'm sorry, Viktor," I replied. "I wish there had been something more we could have done."

"I'm sure you did everything possible."

"Viktor," Father Nicholas said. "Let's go to your house."

Viktor nodded, and they left.

"You speak Russian?" Julie asked quietly.

"After a fashion," I replied. "I could when I was younger, but I don't use it very much."

"I'm not sure about the question I'm about to ask, but who is Elizaveta?"

"The patient's granddaughter. She and I were married, and she died of an intraparenchymal bleed due to a congenital arteriovenous malformation shortly after giving birth to our daughter about two-and-a-half years ago. Have you studied enough neuro, or do I need to explain?"

"I honestly do not know what that is," Julie admitted. "But first, I am SO sorry."

"Thanks. It's a vascular anomaly where an artery and vein are directly connected rather than via capillaries. Without the capillaries, there is no dampening of the pressure of blood moving from the artery to the vein. That deprives the area around it of the usual function of capillaries, which can lead to a buildup of carbon dioxide and a lack of nutrients for cells.

"Over time, it grows into a nidus, which has no capillaries and is extremely fragile. When Elizaveta's blood pressure went up during labor, it caused the AVM to expand and bleed due to the abnormally direct connections between high-pressure arteries and low-pressure veins. When that happens within the medulla oblongata, it's routinely fatal due to damage caused to the vagus nerve, which is crucial to circulation and pulmonary function."

"I'm amazed how calmly you can say that," Julie observed.

"If you can't, even when it's personal," I said, "don't try to Match for emergency medicine."

"You have to be totally emotionless?"

"No, you have to be able to work under intense pressure and approach your work dispassionately — be rational, logical, impartial, and unemotional. It's the hallmark of emergency medicine, and, to a similar extent, surgery, though there most of the time you have an opportunity to plan and study your procedure and confer with others using a more considered approach."

"OK to ask another question?"

"A large part of your evaluation is the questions you ask," I replied. "You do not need permission to ask me or anyone else. Ask. And insist on answers when appropriate. What's your question?"

"Why give up so easily on your, well, I'm not sure what you'd call him."

"Rachel's great-grandfather," I replied. "And did I give up easily? You've had two cardiology rotations — a Preceptorship and a Clerkship. You tell me."

"I don't know enough to answer for sure, but I do know you can't shock asystole. Well, I mean, you can, but as you said, it's ineffective."

"Speculate. There are enough clues."

She considered for a moment.

"His age and his smoking habit. I have to surmise there was extensive heart damage."

"An inverted T-wave indicates ischemia, though it can't tell us the severity. But you're on the right track."

"With his medical history, no electrical activity, and with no response to CPR or epinephrine, the chances of recovery were small. If he had extensive cardiac damage, he wouldn't qualify for a transplant. That would mean he'd very likely be confined to a hospital bed until he had a fatal MI. And that's why you objected to intubation — he'd have most likely been on a vent for the rest of his life, such as it was."

"Yes. Now think a bit more — would I do that for _every_ patient?"

She considered again and shook her head.

"You knew him, so you felt confident that you were respecting his wishes, especially after what you said about him asking for his priest. With someone else, you might have kept going. But would you have intubated?"

"It's a judgment call. Most people want you to save their loved ones, even if it means they'll only live for a few hours or days in the ICU. I have to consider that when making the decision if I can't ask. Think further about intubation."

Julie was quiet for a moment, then nodded.

"He didn't have an occluded airway, so bagging was as effective as the vent. If Doctor Pace had managed to get his heart beating, he would very likely have been breathing on his own."

"Exactly right," I replied. "You're on track, Julie. Keep it up."

"Thanks."

"Get the chart, and we'll have Doctor Gibbs countersign it."

"I thought Attendings had to pronounce."

"That's the general rule, but I have sign-off to pronounce. I don't do it very often, but this was an easy call from a medical point of view."

"You made it seem easy all around."

"And that is the point I was trying to make before — dispassion. Staying calm under fire, as it were. Think airline pilots dealing with emergencies or the Apollo 13 astronauts, or perhaps more relevant for you, the NASA CAPCOM in Houston on January 28, 1986."

"_Challenger_?"

"Yes. CAPCOM said in an even, dispassionate voice: _'Flight controllers here are looking very carefully at the situation. Obviously, a major malfunction. We have no downlink.'_ And then, a few seconds later, equally dispassionately: _'We have a report from the Flight Dynamics Officer that the vehicle has exploded.'_ Do you think he had no feelings and no emotion about his seven friends dying?"

"I'm sure he did, but he didn't show it."

"Exactly. Get the chart, please."

She retrieved the chart from Trauma 2, then walked with me to the Attending's office.

"I pronounced a patient," I said, handing her the chart. "Alana Pace was there."

Doctor Gibbs scanned the chart.

"Only a single dose of epi? And only three minutes of CPR?"

I nodded, "Asystole on the monitor with no electrical signals and no spontaneous breath. I made a judgment call on behalf of Elizaveta's dad; it was his father."

"Rachel's great-grandfather?"

"Yes. A pack-a-day smoker with inverted T-waves. He was alert enough to ask me in Russian to call our priest, which I did. Alana evaluated him and was preparing to take him up to the cath lab for an emergency cardiac ultrasound when he coded."

"It is a judgment call, but you know a personal relationship cuts both ways, right?"

"Yes, I do. I knew Viktor's thinking on the matter, and I felt my patient knew he was dying. I took into account his age, his smoking habit, and the chances he'd recover, and felt that with no response to CPR and epi, flogging him made no medical sense. Viktor declined an autopsy based on what he knew about his dad's smoking habit."

"OK. If you are comfortable and the family is comfortable, I don't see any concerns."

She scribbled notes on the chart, signed it, and handed it back.

"How is your former father-in-law?"

"Our priest arrived, said the prayers for the newly departed, then he escorted Viktor and the others home. I did my part; now the priest has to do his."

"You're learning."

"I always knew, Lor. I just didn't like it. I still don't. The difference is now I accept it and don't fight it."

"That'll be the day!" Doctor Gibbs declared.

"Yeah, yeah," I chuckled.

"Go heal the sick!"

Julie and I left the Attending's office, and I handed the chart to Nate, then instructed Julie to take the next walk-in chart and call me when she was ready. She did so, and I went to the lounge and dialed the number for the Chancery in Columbus. The secretary answered, and I was fortunate she could put me right through to Vladyka JOHN.

"Master, bless!" I said when he came on the line.

"The Lord bless you, Michael. How are you?"

"I'm fine, Vladyka, but I'm calling with some sad news. Nikolay Vladimirovich Kozlov reposed about thirty minutes ago following a heart attack."

"Lord, have mercy on his soul! I assume Viktor knows?"

"Yes, he was here, along with other family members. Nikolay Vladimirovich was lucent enough when he arrived to ask for Father Nicholas, who arrived just after Nikolay Vladimirovich's heart stopped. He and I said the prayers for the recently departed, and Father Nicholas escorted the family back to their house."

"Thank you for letting me know, Michael. I'll speak to Father Nicholas and Viktor Nikolayevich."

"You're welcome, Vladyka. I will see you on Sunday."

"Before you go, how is Angela, from your perspective?"

"About the same," I replied. "Kris, Rachel, and I will have dinner with her family on March 3rd."

"Good. I'll let you go and see you Sunday."

We said 'goodbye', and I hung up. I got some coffee, and about ten minutes later, Julie came into the lounge and said she was ready to present.

The rest of the day was far less eventful, and before I left for home, I called Father Nicholas to learn the arrangements for Nikolay Vladimirovich. The funeral would be on Thursday morning, with a vigil the night before, and the burial would be in the parish churchyard, not far from where Elizaveta lay.

_February 14, 1990, McKinley, Ohio_

Kris and I had agreed we wouldn't celebrate Western Valentine's Day, so nothing special was said on Wednesday morning when I left the house to drive to the Free Clinic. I was very happy to be back there but not nearly as happy as Gale Turner, who greeted me warmly.

"I'd feel terrible stealing you permanently from the hospital, but patients rave about how great you are, and Trina sings your praises constantly, as do the nurses."

"Thanks. I promise, when my schedule allows, I'll give you a few hours a week of volunteer time, but my surgical training starts in earnest in June, and the exchange program is for PGY1s only."

"Oh, I know! We'll miss you when your rotation ends in May."

"I enjoy the work here, though it's not nearly as exciting as the ED."

"Something for which I thank my lucky stars every single day!" Gale declared.

I left his office and went to the small break room, where I greeted Trina and the nurses, and two minutes later, I saw my first appointment of the day — a Taft student looking for birth control pills.

"Good morning, Grace," I said. "What brings you to us today?"

"I want to go on the Pill," she said.

"Are you currently sexually active?" I asked.

"Yes," she replied.

"Are you using some form of protection?"

"Er, no."

"Just one partner?" I asked.

"Does that matter?"

"I'm assessing your risk for sexually transmitted diseases, and we may need to do a pregnancy test as well."

"Pregnancy test?"

"Have you had a period since the last time you had unprotected sex?"

"No."

"When is your period due?"

"This weekend."

"I'd like to do a pregnancy test and test you for sexually transmitted diseases. I can't make you have the STD test, but because you've had unprotected sex since your last period, I need to do a pregnancy test before I prescribe birth control pills."

"Uhm, OK on the pregnancy test, I guess."

"Michelle," I said to my nurse, "Draw for RPT, please. Grace, while she does that, I'll ask you some health questions, and then I need to do a brief exam — listen to your heart and lungs and check your blood pressure. OK?"

"Yes."

Michelle prepared to draw the blood, and I began my abbreviated history and physical.

"You're nineteen, right?"

"Yes."

"Any history of high blood pressure, blood clots, or breathing trouble in your family?"

"My grandpa takes pills for his blood pressure," she said.

"Do you know for how long?"

"A couple years," she replied.

Michelle couldn't leave me alone, so she called Mary to collect the blood sample and run the rapid pregnancy test.

"How old is he?"

"Sixty-eight."

"Anyone else?"

"No."

"Any family history of diabetes?"

"No."

"When was your last physical?" I asked.

"The one for school, and it was in July."

"Have you had a gynecological exam since you became sexually active?"

"No. I haven't seen a gynecologist since I was fifteen."

"You really should have an exam annually, and now that you're sexually active, have a Pap smear. I'm going to take your blood pressure and listen to your heart and lungs. Would you untuck your shirt and unbutton the top two buttons, please."

She did as I asked, and her blood pressure, lungs, and heart were all within normal ranges. As I finished, Mary came in and handed Michelle a printout, which she handed to me.

"Grace, there's a hormone in your blood that we measure called hCG — human Chorionic Gonadotropin. If you aren't pregnant, your level is around 5; yours is 60, which indicates you are probably pregnant."

"What?!" she gasped. "No!"

"If you miss your period, that's strong confirmation, but we'll want to do another test because there are a few other things that might cause it. For now, though, with these results, I can't prescribe birth control pills."

"I, uhm, don't know what to do," she said, almost in tears.

"There are a number of options," I said.

She sobbed, "I can't have an abortion!"

"OK," I said. "We can provide you with referrals to social workers, adoption agencies, and an obstetrician."

"My dad will kill me," she sobbed.

Something told me her statement wasn't hyperbole, and Michelle and I exchanged a look.

"Let me get someone to talk to you," I said. "A Nurse-Practitioner who has a sympathetic ear and who can discuss things with you. Michelle will wait with you."

Grace nodded, and I left the room and went to find Trina, who was just finishing with her patient. Once the patient was shown to reception, I explained the situation. We returned to the treatment room, I introduced Trina, and then Michelle and I left.

Michelle went to reception to check if there were any patients, and I handled a routine refill of birth control pills for a Junior from Taft. I felt the entire process was foolish, as any pharmacist or pharmacy tech could check blood pressure and ask the required health questions. It was a foolish waste of time and money to require a checkup with a doctor for something as simple as oral contraception.

"It's bad," Trina said, coming into the break room. "She comes from a hyper-religious family, and at a party about a month ago, someone convinced her to take MDMA, and under the influence, lost her virginity and ultimately had sex with three guys, none of whom she can identify. She was afraid she might be pregnant but was afraid to ask about that, so she said she wanted birth control pills, thinking those would end the pregnancy."

"Lord have mercy," I said. "Now what?"

"Mary is sitting with her. I called for a social worker who is on their way here. That's all we can do for her, really. I agree she really believes her father will harm her, and the circumstances seem to back her up."

"Do we call the cops?" I asked. "She was raped."

"I agree, but we'll leave that to Family Services. The last thing we want to do is deter anyone from coming to the clinic because they think we're narcs."

"That makes sense."

The rest of the day was routine, with the usual mix of birth control and minor injury visits, and at 5:00pm, I left the Free Clinic to head home for dinner. After dinner, Kris, Rachel, and I drove to Saint Michael for Vespers and a vigil for Nikolay Vladimirovich.

Unfortunately, I hadn't been able to find anyone to take three hours of my morning shift on Thursday, which meant I wouldn't be able to attend the funeral service. Kylie had been willing, but that would have violated the minimum hours off rule, and with short notice, we couldn't find a way to work around it.

After the vigil service, I spent a few minutes speaking with Joe, whom I hadn't seen since Elizaveta's funeral, and then Kris, Rachel, and I headed home.

_February 15, 1990, McKinley, Ohio_

On Thursday morning, I left home a few minutes early so I could stop at Saint Michael the Archangel and quietly read Psalm 50 in front of Nikolay Vladimirovich's open casket as Viktor and others kept the vigil. When I finished, I lit a votive candle, which I placed in the stand next to the casket, then left the church to head to the hospital.

I had my handover with Sue Townshend and received a pair of patients who were waiting on admission to Medicine, checked with my students, then went to the Attending's office to see Doctor Gibbs.

"Morning, Lor."

"Morning, Mike. Come and shut the door, please."

I did and then sat down across from her.

"I'm putting together our list for the Match. I assume you agree completely with placing Leticia Jefferson first on our list?"

"Absolutely," I replied. "Did you speak to her?"

"I called the top six candidates and encouraged them, within the bounds of the guidelines, to list us. She indicated very high interest. Unless you want to call your friend to gauge her true feelings, I have to go with putting her first."

"I think the gamble is worth it."

"What are your thoughts about listing Mary Anderson?"

"If she puts trauma surgery first, surgery second, and us third, the chances are so small as to not waste a spot. Owen is listing her first for the trauma surgery spot and second for the surgery slot. There are no married applicants for trauma surgery, so barring some gremlin in the computer or some weird alignment of the planets, so I don't want to waste a slot."

"That's what I figured," Doctor Gibbs said. "I can't see any way she doesn't match for trauma surgery, and if, as you say, some bizarre quirk knocks her to second, she'll take the surgical spot and transfer to trauma surgery next year. My second choice is local talent — Callie Newsom."

"I can't argue with that at all. Known quantity, and she and I worked well together when I was a complete newbie."

"You haven't been a newbie since the tumor case during First Year!"

"Right place, right time," I replied.

"Third is the other local talent on the list — Karl Schmidt."

"Ahead of Ryan Harrison?" I asked.

"I think it's foolish to list Ryan in the top six. He's going to Match with surgery, so I'll list him below the line."

"That makes sense."

"I have five possibles for the next three slots — Mike Jorgensen from Indiana, Narasimha Murthy from Loyola, Michelle Bentham from UCLA, Julie Plemons from UC, and Mai Liu from OSU."

"Pete Gabriel spoke highly of Murthy, so I'd list him fourth. The others are tossups, though I'd put Mai Liu and Mike Jorgensen ahead of the other two, and in that order."

"No problems. I already spoke to Pete, and he's good, too. I had Jorgensen ahead of Liu, but Pete suggested the other way around."

"I'm with you. What are you doing for the 'field'?"

"Listing the other candidates who scored at least 35, in order by scores, though Ryan Harrison is the first below the line. Odds are, at least one of them will Match here, probably two. I'm sure you know there's a risk for anyone except the top slot, which is almost guaranteed if the student puts us first."

"Are any of them married?"

"No. Did Owen have to deal with that?"

"Yes. There's one married couple, and they both want surgery. He listed them both for the fourth and fifth slots because it's 'all or nothing'."

"They're only applying for surgery slots?"

"Yes. It'll really come down to the order they choose, and Owen is semi-confident because they're from Delaware, near Columbus. But we could lose them to OSU."

"It would be so much easier if we could simply tell students we were listing them!" Loretta said.

"And that would open the system to being gamed by hospitals," I said. "I think the system we have is better than the one it replaced, but I think I'd also change it so that you could come to an agreement with up to two of what you called 'local talent' and have them sign a binding contract that guaranteed their spot and removed them from the Match, similar to how 'early acceptance' works with universities."

"That would be perfect and would prevent losing a top prospect due to the vagaries of the system. Anything else you'd change?"

"I think the Scramble could be replaced by a second run — take everyone who failed to match and all open programs and run it again. I bet that would match a good chunk of people to their preferred specialty, though obviously not at their choice of location."

"That would make it less of a mess! OK. I have a total of fourteen students listed for six slots. I think we'll fill all the positions."

"Owen listed three for the trauma surgery slot and twelve for the four surgical spots. His number one choice for surgery was Ryan, who was second to Mary for trauma surgery, and she's second on the surgical list. He's taking no chances. And it's that situation where everyone would be better served if we could just sign Mary in advance and not waste anyone's time or risk the computer deciding to have a moment of confusion."

"I heard they've conducted testing, and the results are identical with identical input, which is what you would want. Supposedly, there is a minor chance that the order students and programs are entered can affect the outcome."

"I don't know enough about computer programming to evaluate that statement in any way, shape, or form!"

"Me, either! I'm going to fax our list to the NRMP. Last chance for any changes."

"None from me, and if Pete Gabriel signed off, we're good."

"Go heal the sick!"

I left the Attending's office and found Laurie and Max, who let me know that Clarissa had admitted both patients, and they'd been moved to Medicine. I instructed Laurie to get a chart and perform an H&P, then call me. I went into the lounge to get coffee and saw Ghost had the same idea.

"Morning!" I said.

"I figured you'd be at the funeral."

"I wanted to be, but I couldn't find anyone to cover the morning, and my daughter's great-grandparents don't count for bereavement leave."

"You would think 'by marriage' would survive the death of a spouse, but if it included people related before divorces, it could get out of hand."

"I did stop at the church this morning to light a candle and read Psalm 50. I saw Oksana was there, and Kris will take Rachel to the funeral service, as she doesn't have class this morning. Is Oksana due before or after Pascha?"

"Her calculated date is Bright Monday."

"Cutting it close! She's going to be miserable on Pascha if she hasn't delivered."

"And do you honestly think you could keep a Russian woman from church on Pascha?"

"Oh, hell no!" I chuckled, then switched to a faux Russian accent, "Russian woman, strong like ox!"

"I have $20 in my pocket that says you don't dare say that to Kris!"

"She'd laugh at me and remind me she's French."

"Her little sister is going to break hearts, that's for sure!"

"And break balls!" I chuckled. "She practicing on me!"

"How _is_ Rachel doing with her French language course?" Ghost asked with a goofy smile.

"Exactly. Rachel finds it hilarious to use French as often as possible. The conspiracy is complete!"

"Doctor Casper?" his student Natalie said. "I'm ready to present."

"Duty calls," Ghost said.

He left, and about a minute later, Lauren let me know she was ready to present.

"Before I forget," she said, "you remember I'm out on Monday and Tuesday to interview, right?"

"Yes. Max will just have to pick up the slack!"

I followed her into Exam 4 and began my day of treating patients.

_February 16, 1990, McKinley, Ohio_

"There is a complete draught at the theatre," Clarissa observed as we walked out to our cars on Friday just after 5:00pm.

"That will be remedied in about two weeks," I said. "I'm really looking forward to _The Hunt for Red October_!"

"You really liked that book."

"And the other Clancy novels, though they've moved more heavily into political intrigue, which isn't my preferred genre."

"No kidding! Do you even have time to read?"

"Not really. I haven't read a book in the past year. It's all _JEM_, _Lancet_, and _JAMA_."

"See you at the Chinese restaurant?"

"Absolutely. Oh, before I forget, is Code Blue going to play at the music festival?"

"Yes. Kim called and let me know she had worked it out with Johnny. She also arranged with him to record our two Prom gigs and burn CDs that can be sold at the music festival."

"Now _that_ is cool! You'll have a record label!"

I laughed, "I don't think 'McKinley Music and Movies' is going to compete with Sony or Polar or Apple Records!"

"Polar?"

"I should never have said that because I'm not going to live it down — that's ABBA's record label."

Clarissa laughed, "Doctor Blahnik tempted you, and you fell into the trap!"

"And what a wonderful trap it was!" I grinned. "Her, not the music!"

"Oh, please! You admitted _Chess_ was brilliant."

"It was. See you at the restaurant!"

_February 18, 1990, McKinley, Ohio_

On Sunday, after church, Kris, Rachel, and I headed home to prepare for our dinner party with Robby and Sophia, Ghost and Oksana, and Loretta and Bobby. This time, though, Rachel would stay with us, and I hoped she and little Bobby didn't get into it.

"How were your interviews?" I asked Sophia when she and Robby arrived, the first to do so.

"Great! I think I'm in very good shape with the Match. I do NOT recommend flying to the West Coast and back twice in six days!"

"Not to mention it being on our dime," Robby said. "I have to say the rules seem dumb."

"I don't disagree, but as I said to Doctor Gibbs earlier in the week, it's better than the old way. I doubt there's a perfect system that would address all the concerns. Sophia, do you think you'll get your first choice?"

"They sure seemed to like me, and they called me to follow up the day after I flew home."

"That's a good sign. At this point, though, all you can do is wait."

"You said the wait from Tuesday to Thursday was easy," Robby said.

I nodded, "Knowing I had Matched was what mattered. Sure, something bizarre could have happened, and I might have matched at UC or Pittsburgh, but Matching is what matters."

"I agree," Sophia said.

The doorbell rang, and I let in Ghost and Oksana, and about two minutes later, Bobby, Loretta, and Bobby Junior arrived. I was surprised when Rachel was friendly with Bobby Junior, and the two of them went off to play.

"Should I buy my shotgun now?" I asked Loretta.

She laughed, "You did tell me she mostly doesn't like toddler boys!"

"She has good taste!" Bobby declared.

"What are you worried about, Mike?" Ghost asked. "Rachel is being trained by Lyudmila!"

"Which frightens HIM just as much as it should any little boy who shows interest!" Loretta smirked.

"Yeah, yeah!" I chuckled.

"Sophia, you didn't interview at all at Moore?" Doctor Gibbs asked.

"No," she replied. "Only with hospitals in the Bay Area. We're basically committed there."

"Why is that?" Bobby asked.

"Robby has a research and teaching position at Stanford that will lead to a full professorship with tenure, and I wanted a specific program in San Francisco that is developing _in-utero_ surgical procedures to remedy a number of defects. That meant only applying to other programs in the Bay Area. I had seven interviews across the two trips."

"Lor, have you heard anything about the Chief of Emergency Medicine position?" I asked.

"Other than the interviews I had with Cutter, the Medical Director, and the medical panel, no."

"Who's on that panel?" Ghost asked.

"Roth, Baker, and Getty," Loretta replied. "I know there are other candidates, but nobody has said anything one way or the other."

"Well, you know _our_ take," I said firmly.

"And it's appreciated!"

We had a great afternoon and evening, and after our friends had left, we completed our usual family routine of reading to Rachel, saying our evening prayers, and then putting Rachel to bed.

"Bubble bath, then cuddling?" Kris asked.

"That works for me!"

"Does it? I haven't felt like making love the past week or so."

"Yes, it does. I love you."

"May I say something that I don't mean to be negative but might sound that way?"

"Yes," I agreed.

"Don't you have needs? You seem to only be concerned about my needs, not your own."

"_'Husbands, love your wives, just as Christ also loved the church and gave Himself for her, that He might sanctify and cleanse her with the washing of water by the word, that He might present her to Himself a glorious church, not having spot or wrinkle or any such thing, but that she should be holy and without blemish. So husbands ought to love their own wives as their own bodies; he who loves his wife loves himself. For no one ever hated his own flesh, but nourishes and cherishes it, just as the Lord does the church.'_"

"OK, but is that healthy?" Kris asked. "I don't mean spiritually, but mentally and physically?"

I chuckled, "Is this your French way of telling me I should _ask_ for a blowjob?"

Kris laughed, "You have never, even once, asked; I've always offered."

"Which meant I didn't have to ask!" I replied. "But, I can take a hint. Bubble bath, cuddling, and a blowjob?"

"Two?" Kris asked with a sly smile.

"I won't object!"

"Then let's go upstairs!"

_February 19, 1990, McKinley, Ohio_

Monday morning was routine, with a steady stream of patients, but it wasn't rushed or crazy. I had lunch with Shelly, Karl, and Leila, then had a quiet afternoon, with only a smattering of walk-ins and a single EMS run. I had and early dinner with Clarissa and Sophia, then returned to the ED.

"Mike," Jackie, the Clerk, said as I walked in, "I was just about to page you. EMS is transporting multiple victims from a domestic disturbance. No word on condition or total number, but at least three. I've already notified Nielson, Billings, and Foulks. Doctor Gibbs had me call for a surgeon and backup from Medicine. She's staying past the end of her shift."

"OK," I said.

Laurie and Kelly joined me, and we hurried to the ambulance bay, grabbing gowns, gloves, and goggles on the way. We joined a gaggle of doctors, nurses, and students in the ambulance bay to await the EMS squads.

"Did Jackie have any more information?" Doctor Nielson asked.

"Just at least three victims of a domestic dispute," I replied.

"OK. You provide surgical support unless we have four victims."

"Got it."

From the sound of the sirens, I made at least three emergency vehicles, but I couldn't tell the difference between the Sheriff's cruiser sirens and the EMS squad sirens. I did hear at least one air horn, but that was to be expected. As soon as the squads turned onto the access road from Ohio 11, I saw two, followed by a pair of Sheriff's cruisers. About twenty seconds later, the first squad pulled up, and Roy jumped out.

"Female, seventeen; multiple gunshot wounds — shoulder, chest, stomach; BP 70/30; pulse 110 and thready; PO₂ 88% on ten litres; unit of plasma and unit of saline for volume."

"I have this!" Perry exclaimed. "How many total victims?"

"Three; fourth was DOA."

"Trauma 1! Mike, with me."

Perry, I, and our three students, along with Nurse Amy, rushed the young woman to Trauma 1, with Perry giving orders as we moved. The patient had an obvious sucking chest wound, so I called out to Becky, who was manning the nurse's station, that I needed her, and she joined us.

The eight of us worked to stabilize the young woman, and my part was inserting a central line for the rapid infuser, then performing a thoracostomy. I didn't get good breath sounds even after hooking up the Thora-Seal, so Becky and I replaced a pressure bandage with a defibrillator pad to temporarily seal off the wound, and that allowed the lung to re-inflate.

"Is she going to make it?" Deputy Sommers asked, coming into the room.

"We don't know yet," Doctor Nielson replied. "We're still trying to stabilize her."

"What do you have, Mike?" Shelly Lindsay asked, coming in with her student.

"Three gunshot wounds; the shoulder is bloody but through and through; chest penetrated the right lung with no exit wound; stomach wound on the right, likely organ damage. Chest tube is in, but BP and PO₂ haven't come up yet despite two units of plasma and a liter of saline."

"Perry?" Doctor Lindsay asked.

"You'll have to decide, Shel. She's unstable, but unless those bleeders are tied off, we won't be able to keep up with the blood loss."

"OK. Let me check the other patients, but I think she goes up first."

She left the room, and almost immediately I heard a loud commotion in the corridor with shouting and a crash, followed by a distinctive sound that nobody could miss — the obvious report of a gunshot.

"Get down!" Deputy Sommers said to all of us.

"We're caring for this patient," I protested.

More yelling and a second gunshot reverberated.

"Get behind that table!" Deputy Sommers ordered.

We all reluctantly moved behind the trauma table, which provided some shielding, and crouched down. Deputy Sommers drew her service pistol, crouched, and carefully opened the door. A gunshot rang out, blood splattered the wall, and Deputy Sommers collapsed backwards, blood spurting from a head wound.

Two seconds later, there was a fusillade of shots, then an eerie silence.