Chapter 42 — Focus On Learning

_August 25, 1989, McKinley, Ohio_

{psc} "Good afternoon," I said to the assembled incoming class of medical students. "Every morning, when you get up and look in the mirror, you see the person primarily responsible for your medical education. It's not the deans, it's not the professors, it's not the doctors on your clinical rotations. It's you. Period. No exceptions and no excuses.

"You have one simple task for the next four years — learn. And that is on _you_, not on anyone in a long white coat. Yes, of course, we are tasked with teaching you, but, in the end, you have to learn. And that means taking responsibility for learning, even from poor teachers and even in adverse circumstances.

"You cannot succeed by being passive, though you need to temper your aggression based on your skills and knowledge. There will come a time when you have to _demand_ to be taught, and that demand might well be rejected. Don't take a 'no' as a 'no', but as a 'not now'. Ask. Ask again. Ask _why_. Will some doctors and professors find you annoying? Damn straight!

"Just before I left the hospital so I could attend this ceremony, I was told, and not for the first time, that I'm a pain in the ass. I don't take that as an insult, rather, I wear that as a badge of honor. I ask questions, I challenge answers, I make observations. That's all part of learning. And learning continues, even more intensely, when you change from a short white coat to a long one.

"And even when you attain the coveted role of Attending Physician, you will still learn. And you're responsible for that continuing education, be it from journals, seminars, conferences, or one-on-one instruction. If you don't learn, you fall behind. If you fall behind in the next four years, you won't Match. If you fall behind after the Match, you won't become an Attending. And at any stage, you might wash out.

"You'll face many challenges, both in learning to be a physician and in your personal life. You'll encounter many things which can trip you up over the next decade — academics, lab work, clinical rotations, stress, lack of sleep, and physical health. You can earn academic honors and fail clinical rotations. I've seen that happen. You can be a top-ten student and lose your life to stress. I've seen that happen, too.

"Right here, right now, resolve to take control of your medical education. Right here, right now, resolve to challenge us to teach you. Right here, right now, resolve to learn. Right here, right now, resolve to be the best physician you can be, and put together a personal plan to achieve that. Nobody is going to do it for you; only you can do it.

"Finally, never forget that you're asking for admission to a very selective, exclusive guild. To gain admission, you have to satisfy every person involved in your training. Failing to do that means you won't be a physician, no matter how badly you want it. Succeed, and you'll have the most rewarding, fulfilling career in the world."

I left the podium and rejoined the other doctors at the back of the room.

"A Loucksian address if there ever was one!" Doctor Strong said quietly. "A reaction to Krista Sandberg?"

"Yes," I replied, my voice just above a whisper. "I felt they needed fair warning."

"It's an important message," Doctor Lindsay observed.

When the ceremony ended, the medical school deans walked over to where I was standing with the doctors from the hospital.

"That wasn't what I expected," she said with a smile. "We were sure you'd give your usual service speech."

"I felt it was warranted," I replied. "My second option was to focus on Doctor Osler's prescription for medical training."

"He was addressing Residency," Doctor Warren said.

"And yet, it applies just as much to medical students as it does to Residents. You know I'd like to see medical schools be six years, and take High School graduates, rather than those with undergraduate degrees. Two years of classroom work rather than six, and four years of clinical rotations would serve the profession better."

"That would require wholesale revision of the system," Doctor Worth observed.

"And your point is?" I asked with a grin.

"We can't just do that," Doctor Worth said. "Our accreditation depends on following the pattern. Being first risks our students not being selected for the Match due to licensing regulations in fifty different states."

"So confer a Bachelor's degree," I said.

"Which requires basically four years of coursework," Doctor Worth replied.

"It's done similar to how I proposed in Europe," I said.

"Good luck convincing the 'Europe is socialist' crowd to copy _anything_ Europe does," Doctor Strong interjected.

"Europe is _not_ socialist, the perverse fantasies of some Americans to the contrary notwithstanding. And I should know, because I'm married to an _actual_ socialist!"

"I bet that leads to interesting pillow talk," Doctor Lindsay teased.

"Interns do not have time to talk in bed," I chuckled. "We sleep!"

"Uh-huh."

All the assembled doctors laughed. Given my schedule, I bade them 'goodbye', then left to head home so I could spend a few minutes with Rachel before Kris and I headed to the banquet.

_August 26, 1989, McKinley, Ohio_

Saturday morning was typical, with band practice, grocery shopping, a trip to the bakery, and a stop at the record store. At lunch, we celebrated Rachel's second birthday, though her big party would be on Sunday afternoon after church. Instead of cake, we had cupcakes which Serafima had baked, and Rachel managed to eat more than she wore, unlike her first birthday.

I gave Rachel her bath, then left for my shift at the hospital. As I wouldn't be able to attend the service Viktor had scheduled for that evening, I allowed a bit of extra time so I could stop at Saint Michael the Archangel. I visited with Elizaveta, said abbreviated prayers for the dead, and placed flowers on her grave before heading to the hospital.

At Moore Memorial, I went to the surgical locker room to change, then headed to the ED, where I received the handover from Kylie. There was only one patient waiting on admission to Medicine, and once Kylie had filled me in, I went to find Jake and Heather, my Saturday medical students. I found them in the lounge, but before I could even greet them, nurse Terry let me know Doctor Mastriano needed my help with a central line in Trauma 2.

"I've seen a few, but haven't done one," I said. "I'll need to call for another surgeon to come down to supervise. Let me make the call, then I'll go see her."

I called upstairs, explained what I needed, and the charge nurse said that Doctor Blake would be right down. I thanked her, then went to Trauma 2.

"What do we have?" I asked.

"Jenny Smith, twenty-two; IV drug user, probable heroin OD; no veins for an IV."

"I've only observed central lines. Doctor Blake is on his way down to supervise me. He should be here in a moment. Did you try an ankle?"

"We couldn't get a good vein."

"Status?" I asked as I washed my hands and put on gloves.

"Naloxone in the field; intubated; Foley with decreased urine output; pulse 58; BP 100/60; PO₂ 92%; CBC, Chem-20, tox screen, pregnancy test, full-spectrum STD test."

"There's an MI risk," I said. "Let's get her on a five-lead."

"Kurt," Doctor Mastriano said to her Fourth Year, "Five-lead, please. Terry, set up the ultrasound, then central line kit to Mike, but we'll wait for Doctor Blake."

At the mention of his name, he walked in.

"I hear you need supervision for a central line," he said.

"I've seen three, but never done one."

"What are your risks?"

"Hemothorax, pneumothorax, hematoma, and inadvertent arterial puncture."

"What do you do?"

"Trendelenburg; sonogram to define anatomy if there's time; lidocaine cutaneously, subcutaneously and around internal jugular. Then, using the Seldinger wire technique, insert the guidewire. Next, make a 3mm incision in the skin, cutting away from the wire so as not to damage it. Pass the dilator over the wire and gently but firmly dilate a tract through to the internal jugular. Sponge as necessary to clear the field, then grasp the Seldinger wire and remove the dilator and pass the central line over the Seldinger wire. Once the line is in place, remove the wire. Suture, dress, and connect to the IV."

"Proceed," Doctor Blake directed.

I nodded and, with help from Terry, I followed the steps carefully and methodically, knowing I had a bit of time. I completed the procedure, Doctor Blake checked my work and pronounced the central line was properly inserted.

"Let me have your procedure book, and I'll sign off for you to do this solo."

"Thanks," I replied.

I stripped off my gloves and took my procedure book from my back pocket, and handed it to him. He wrote the procedure, wrote his approval, then signed the book. He handed it back and left the room.

"Anything more, Doctor Mastriano?" I asked.

"Call me Isabella, please. And that's all for now. Thank you."

"You're welcome."

I left and went to find my students who were just coming out of the exam room with the patient being admitted to Medicine. They walked over to me, allowing the orderly and the Third Year from Medicine to escort the patient.

"What schedule do you two have for next month?" I asked.

"We're both on 0600 to 1800 Monday through Saturday," Heather replied. "Basically, we'll be with you on every shift except the one where you're at the clinic."

I hadn't checked on any of the medical student schedules except Krista's and hadn't been surprised that she was on shifts that mostly didn't overlap with mine. I didn't like that, because I felt nobody would even give her the shot she deserved, even if she was ultimately unqualified.

Unfortunately, I wasn't likely to be able to do anything about similar situations in the future, as I wasn't an ED Resident, despite working in the ED. That meant I would never be Chief Resident on either service, as I'd serve my third year of Residency as a Surgeon, and the ED Chief Resident was always a third year. Because I wasn't a dedicated surgeon, and would spend most of my time in the ED when I wasn't in the OR, I wouldn't be the Surgical Chief Resident, either.

That didn't particularly bother me, as it would mean administrative work, which I didn't particularly enjoy, and I didn't feel not being a chief would interfere with my career progress. I most likely wouldn't be Chief Attending either, though I could, ultimately, be Chief of Emergency Medicine, but that was more than ten years away.

We had a busy afternoon, with nothing remarkable, and I had no trouble meeting Clarissa for dinner at 6:00pm. After dinner was equally busy, but also unremarkable, and I left the hospital just after midnight.

_August 27, 1989, McKinley, Ohio_

Sunday morning was typical with Kris, Rachel, and me attending Matins and Liturgy at the Cathedral. We didn't stay for the meal after liturgy, as we had to be home to set up for Rachel's party. We had help from Elias and Serafima and Lyudmila, and everything was ready at 2:00pm when the first of Rachel's dozen toddler guests began arriving along with their parents. Rachel's most important guests were Abi Green, Larisa Antipov, Viktoria Kozlov, April Webber, and three girls from daycare — Melanie, Kathy, and Jennifer. She was far less happy to see Viktor Gennadyevich, my brother Pete, my nephew Michael, and my godson Michael.

Rachel was also happy to see Clarissa and Tessa, though she was happiest about her Aunt Lyudmila, as they seemed to be forming a strong bond. That was a good thing, though I could do without Lyudmila teaching Rachel to speak French, which she was doing simply to annoy me. Of course, being able to speak a foreign language was an advantage, and French was far more useful than Russian, so it wasn't _really_ a bad thing.

The kids all had a wonderful time, and I spent most of my time with Joel, Elias, and Subdeacon Mark, as all the other kids had been brought by their moms, with the exception of April and Peter, who had come with my sister. The other invitees — Viktor and Yulia, my mom and Stefan, and Kris' parents, all arrived for dinner at 5:30pm. My dad and Holly had been invited, but had declined.

After dinner, cake, and presents, we said evening prayers with everyone, including those who weren't Orthodox, and then all of Rachel's guests left. She had her bath, we read _The Bears' Picnic_, and then we put her to bed.

"Care to come to bed to see if we can arrange for a sibling for our daughter?" I asked Kris.

"Three times to make sure?" she asked invitingly.

I happily took her hand and led her to the bedroom.

_August 30, 1989, Lucasville, Ohio_

My Monday to Tuesday shift had been relatively calm, and I'd managed to get some sleep on Monday night. Now, on Wednesday, after spending the morning at home with Rachel, we left to have lunch with Clarissa and then drive to Southern Ohio Correctional Facility so I could see Frank Bush. I endured the usual security checks and questions, and eventually was ushered into the visitor's room. Two minutes later, Frank Bush was escorted in and sat down across from me.

"Thanks for the book," he said. "I'm enjoying it."

"You're welcome. How have you been?"

"I have a completely regimented day with no freedom. How do you think I've been?"

"I was more concerned about your physical and mental health," I replied.

I was concerned about his spiritual health as well, but I didn't feel he was ready to hear anything like that just yet.

"Physically, no complaints, but prison is mind-numbing. I have an advanced degree, so Ohio won't allow me to take correspondence courses on their dime, and I have no personal resources. Pretty much the only intellectual stimulation is books, and as much as I like to read, there comes a point when it no longer helps."

"I thought you played chess," I countered.

"I'm not particularly popular with the small group of dedicated players."

"Would you like to play while we talk?"

"Sure."

I got up and asked the guard for a chess set, which he provided, and Frank and I began playing while we talked.

"What book can I get you next?" I asked.

"_A Time to Kill_ by John Grisham or _The Russia House_ by John le Carré."

"I'll get both of them for you," I said. "If you wanted to take a correspondence course, what would you study?"

"History has always been a hobby of mine."

"Let me speak with someone at Taft and see what I can arrange. I can't promise, but I will try."

"The cynic in me wants to know what you get out of this?"

"It's not about what's in it for me, it's about fulfilling Jesus' instructions in the parable of the sheep and the goats —

{_ All the nations will be gathered before Him, and He will separate them one from another, as a shepherd divides his sheep from the goats. And He will set the sheep on His right hand, but the goats on the left. Then the King will say to those on His right hand, 'Come, you blessed of My Father, inherit the kingdom prepared for you from the foundation of the world: for I was hungry and you gave Me food; I was thirsty, and you gave Me drink; I was a stranger, and you took Me in; I was naked, and you clothed Me; I was sick, and you visited Me; I was in prison and you came to Me.'

Then the righteous will answer Him, saying, 'Lord, when did we see You hungry and feed You, or thirsty and give You drink? When did we see You a stranger and take You in, or naked and clothe You? Or when did we see You sick, or in prison, and come to You?' And the King will answer and say to them, 'Assuredly, I say to you, inasmuch as you did it to one of the least of these My brethren, you did it to Me.' _}"

"You don't think I knew that and had to quote it?" Frank asked.

"I think you know the words, but you don't know the spiritual truth. As Keith Green reminds us, the *only* difference between the sheep and the goats is what they did and didn't do."

"Works righteousness."

I shook my head, "Not according to James. We can discuss it if you wish, but I only cited the verses because you questioned my motivation."

"How are your friends?"

"If you mean Robby and Sophia, they're married and likely moving to California so she can serve her Residency at a hospital specializing in pre-natal surgery."

"He walked away from the lifestyle? Commendable."

I wasn't about to take that bait, as that conversation could have no positive outcome.

"Saturday was my daughter's second birthday," I said, changing the subject.

"They grow up so fast. One day Melissa was in a crib and, seemingly, the next she was in medical school. It was the same for James."

I won the first chess game as white, then Frank won the second as white, and I won the rubber match as black as we drew for pieces. While we played, we discussed my Residency, and he reminisced about his as well. By the time we finished the third game, our time was almost up.

"I'll let you know what Taft has to say," I said. "And I'll get those books ordered for you. My next visit will be on a Sunday afternoon in September. I suspect three weeks, but it could be the last Sunday of the month. Is there anything you need?"

"Not that I can think of," he replied.

"If you're interested in understanding me, there are some other books I could send you."

"Trying to convert me?"

"No, just trying to answer your question of 'why?' and give you some insights you might not otherwise have. I'll send them, and you can decide if you want to read them or not, and if you want to share them with others or not. I think you'll gain a very different view of what I believe than the one you, Tim Saddler, and others have in mind."

"Why not?"

"Then I'll send you _Becoming Orthodox_, by Father Peter Gillquist who was part of Campus Crusade for Christ before he converted; _Common Ground_ by Jordan Bajis, which explores the common faith between Evangelicals and Orthodox Christians; _The Eucharist_ by Father Alexander Schmemann; and two books by Vladimir Lossky — _Orthodox Theology_ and _In the Image and Likeness of God_."

"You know I might not read them, right?"

"I know. If you decide not to, then donate them to the prison library. I enjoyed our visit."

"It's the one thing that breaks the monotony here."

"I'll see you in September," I said. "If you need anything, write or call, please; I'll accept the collect call charges."

We shook hands, which I was allowed to do as a chaplain, and he was escorted from the room. A guard escorted me out, and I had to wait about ten minutes before Clarissa and Rachel arrived from the park where they'd gone to wait. Clarissa got out so I could get into the driver's seat and she went around to the passenger's side.

"Hi, Rachel!" I said, getting into the driver's seat.

"Hi, Daddy!"

"Did you have fun with Clarissa?"

"We played!"

"Great!"

"How did it go?" Clarissa asked.

"He's opening up more," I replied. "We discussed his Residency, and I saw a slight spark of life in him. He said prison was mind-numbing, and I believe it. Just my few interactions with him so far have made it clear that prison is not the correct solution for most crimes, and for those where it's necessary, then it needs to be rehabilitative, not penal."

"Manson?"

"The classic question, but he, too, is made in the image and likeness of God. We have no idea what might happen with any prisoner who is given proper care, both physical and psychological, and who we attempt to rehabilitate. Our job is to provide those things, what the prisoners do with them is up to them. I object to any dehumanizing or inhumane treatment."

"That does fit your nature. Still thinking of prison ministry?"

"Down the road, yes. Let's get through our Intern year first!"

"You seem very happy."

"I am. I'm doing exactly what I wanted to do since I was ten, I have a wonderful daughter, a wonderful wife, and wonderful friends. I was a bit melancholy on Saturday when I stopped by Elizaveta's grave, but it passed almost as soon as I stepped into the hospital."

"That's your true element. How are things with Mastriano?"

"She's softened ever since I backed her up a few weeks ago."

"Rumor has it she broke things off with Rosenbaum," Clarissa said.

"I try to avoid the whole _Days of our Lives_ or _General Hospital_ gossip circle!"

"I overheard two nurses."

"I hope it's true, but in the end, it's none of my business. Back to happiness — are you happy?"

"I'm a doctor, we're practicing together, I have Tessa, and you and I are going to have a baby. I'm not sure how I could be happier!"

_August 31, 1989, McKinley, Ohio_

"May I speak to you privately for a moment, Doctor?" Krista asked just after I arrived at the hospital on Thursday morning.

"Let's go to the temporary Resident's office," I suggested.

We left the lounge and went to the temporary Resident's office, and I asked Krista to leave the door open.

"What can I do for you?"

"You're the only one who is giving me a chance, and I think Doctor Gabriel purposefully assigned me to a shift that doesn't match yours."

I suspected she was correct, but I had to be very careful about how I answered.

"I can't speak to Doctor Gabriel's motives or thinking," I said. "He made the schedule without input from me, except insofar as he asked me about my choice of shifts. I didn't know which shifts you would have, and he didn't mention anything to me about you or about anyone else's schedule."

"Did you know the schedules were changed last week?"

"No. I only looked at it last Friday. I can't speak to any changes because I didn't know until you just told me."

"I'm positive you think I've been treated unfairly."

"The only thing I can say is that I've done my best to help you succeed. I honestly can't speak to anything I haven't seen. Have you spoken to Doctor Baxter, Doctor Billings, or Doctor Gibbs?"

"But what do you think?"

"I make a point of only stating what I know or can reasonably deduce from things I've actually observed. I know it sounds as if I'm being evasive, but I honestly can't speak to what happens with other doctors when I'm not there to observe."

Krista frowned, "I should have expected that answer. I'm sorry I put you on the spot. If I ask Doctor Northrup to change my schedule and assign me to you, would you support that?"

"I won't object," I replied. "But I also can't interfere. Make your case, and if Doctor Northrup asks if I'll accept you, I'll say yes."

"Is there anyone you'd lobby for?"

"No. I've told students who have asked to be assigned to me to ask the Chief Resident. I don't want to be accused of favoritism. I've been accused of being on the receiving end of that accusation, and it's ugly."

"You don't feel you were given extra privileges?"

"I _earned_ them," I replied. "And that's what I've been trying to tell you from the get-go. Each success builds on previous success. It started with academics, but then my wife and I ate more bananas than I could count because I was practicing suturing every single day, so that when I had my first opportunity, I nailed it. Because of that, I was permitted to do other procedures, and my success doing those procedures led to others, and so on and so on and so on. Remember the first thing I noticed?"

"You said that my procedure book was light."

"Which conveys a message to anyone who reviews it. Remember what I said about Matching?"

"That it would be a problem if I didn't fill it out by the end of this rotation. That's what I want to do, but I'm not being given the chance."

"Have you spoken to Doctor Billings or Doctor Baxter?"

"No. I think they're both writing me off and it's not fair."

"You should speak to them," I replied. "But go make your case to Doctor Northrup. He's usually in around 8:00am, but his assistant is in at 7:30am, and she can tell you when you can see him. I'll cut you loose for that."

"Thanks."

We left the temporary office, and I saw four charts in the walk-in rack, which meant Doctor Varma would be swamped, so I instructed Krista to get the first chart, bring the patient in, do an H & P, then come get me. I went to the lounge and asked Al to observe, fulfilling the advice Leila Javadi had provided. About ten minutes later, Al came to get me and said Krista was ready to present.

"Mr. Ramsey," Krista said, "this is Doctor Mike."

"Hi," I said.

"Hi, Doc."

"Krista?" I prompted.

"Mark Ramsey, thirty-three; presents with a tick attached to the back of his neck; pulse 78; BP 120/80; temp 37.8°C; no other complaints."

"Proposed treatment plan?" I asked.

"Clean with alcohol; forceps removal, straight line without rotation; clean with alcohol again; prophylaxis with broad-spectrum antibiotics."

I nodded, "Approved. Mr. Ramsey, we're a teaching hospital, and I'd like Krista, who is a Sub-Intern, to remove the tick. Are you OK with that?"

"Sure," he agreed.

"Krista, proceed; do you know the correct antibiotic and dose?"

"No."

"With no admitted allergies, 500 megs vancomycin initially, then 125 megs four times per day for 10 days."

I wrote the order on the chart and then sent Al to ask a nurse to get the appropriate vancomycin capsules. He'd need a prescription, which I'd need to have Doctor Gibbs or Doctor Nielson write, as I couldn't do that, per hospital rules, until I received my medical license. I observed as Krista removed the tick and disposed of it by placing it in a vial and disposing of it in the hazardous waste bin.

Al returned with the vancomycin, which Mr. Ramsey took. I then excused myself to get the prescription form from Doctor Gibbs, and once I had it, I returned to the room. I filled out the discharge form and handed it and the prescription form to Krista.

"You're all set, Mr. Ramsey," Krista said. "Take the full course of antibiotics, even if you don't feel sick. Follow up with your personal physician as soon as possible, and if you do feel sick, or the wound becomes painful, please come back to the Emergency Department right away. Do you have any questions?"

"Is it OK to wash my hair?"

Krista looked to me.

"There is no reason not to," I said. "The wound is small and will heal quickly."

"Thanks, Doc. Thanks, Krista."

"Al will escort you to Patient Services," I said.

We all left the room, Krista updated her procedure book, and handed it to me to sign.

"Thanks," she said.

"You're welcome. Remember, you build on each success."

"If I'm given the chance," she replied.

I nodded in response, as Doctor Casper walked up to us and I didn't feel like getting into a discussion with him about Krista.

"I need a surgical consult," he said. "Hot appy."

Which was one of the simplest surgical procedures, but I wouldn't be allowed to perform the surgery, which would have been true even if I'd been assigned to the surgical service. It would be nearly two years before I'd do any kind of invasive procedure beyond chest tubes, central lines, and pericardiocentesis.

"Let's go take a look," I replied. "Krista, get the next walk in, please."

She grabbed the next chart, and I followed Ghost into Exam 4.

"Mr. Andrews, this is Doctor Mike, a surgical Resident. He's going to examine you and confirm my diagnosis."

"Hi, Mr. Andrews," I said.

"Hi, Doc. Will you do the surgery?"

"No. I'm assigned to the Emergency Department to evaluate surgical cases. One of our senior surgeons will perform the procedure."

I conducted a basic exam, including palpation of his abdomen, then used the ultrasound and appreciated an inflamed appendix, something that wasn't always possible.

"He needs to go right up," I said. "The inflammation is severe. I'll call upstairs."

"Ellen," Ghost said to his Fourth Year. "Call for an orderly, stat."

I went to the phone and called the scheduling nurse and let her know I was sending up a hot appy, and she assigned the patient to OR4. I let Ellen know when she returned, signed the chart, then left the room. I saw on the board that Krista had taken her patient to Exam 1, so I went there where she and Al were completing the initial exam.

"Mary, this is Doctor Mike," Krista said. "Mary Hartman, nineteen; complains of headache, fatigue, and weakness. Pulse 80; BP 120/70; PO₂ 98% on room air. No other complaints. Her roommate at Taft brought her in."

The patient was very thin, and I had a sneaking suspicion.

"Hi, Mary," I said. "I'm going to do a quick exam to confirm what Krista reported."

"OK," Mary agreed.

I auscultated her heart and lungs, finding nothing remarkable, as I'd expected. I then used an otoscope and when I examined her mouth, I saw obvious signs of enamel erosion from her teeth.

"Krista, glucose stick test, please," I requested.

"What's that?" Mary asked.

"I want to get a quick read of your blood sugar," I replied. "When did you eat last?"

"Breakfast when I got up about ninety minutes ago, before I ran."

And I had a strong bet she'd eaten, then purged. If she'd eaten, her glucose should be between 130 and 180, but I made a bet with myself that it would be low.

"75," Krista reported.

"That's awfully low for having eaten an hour ago," I said. "What did you have to eat?"

"An apple," she replied.

Apples had fairly high fructose content, though absorption was attenuated by the fiber they provided. That said, her blood sugar should have been higher.

"What about dinner last night?" I asked.

"Chicken Caesar salad," she replied.

"Are you dieting?" I asked.

"Always," she replied.

"I'm a bit concerned about your low blood sugar. That would explain your headaches, fatigue, and weakness. I'd like you to eat some peanut butter and crackers, and drink some apple juice, and we'll check your blood sugar again. That will tell us if your body is having trouble processing carbohydrates. I'll also have blood drawn, OK?"

"Yes, Doctor," she replied.

"Is there any chance that you might be pregnant?"

"No. None."

"Are you taking any medications?"

"No."

"Krista, Chem-20 and glucose panel," I said. "Al, get some peanut butter crackers and a bottle of apple juice, please. We'll do a repeat glucose test thirty minutes after she eats."

Al went to get the food while Krista drew the blood. I had Al take it to the lab, and Krista and I waited while Mary ate the crackers and drank the juice. Once she finished, Krista and I left the room, promising to return in about thirty minutes.

"What am I thinking?" I asked her.

"I honestly don't know. I mean, obviously, her blood sugar is low, but you clearly have something in mind."

"Tell me what you observed."

"Nothing remarkable," Krista replied. "Her pulse is a bit high, but otherwise, nothing."

"That's what you _didn't_ see. What _did_ you see?"

"A college-age girl who appears to be healthy," Krista replied. "But I clearly missed something."

"Some subtle clues," I replied. "First, she's very thin. Second, there was evidence of enamel erosion on her teeth when I examined her mouth."

"Bulimia?" Krista asked.

I nodded, "It's a strong possibility. What are the characteristics?"

"I'd have to look them up," she said. "But I know it's about vomiting after eating."

"That's part of it, yes. It's characterized by binge eating followed by purging or fasting. Think about her complaint and how little she's eaten in the past twelve hours, the condition of her teeth. That's a strong indication. But there's one contraindication."

"What's that?"

"She's extremely thin. Does that change our diagnosis?"

"I thought anorexia didn't involve vomiting."

"There's a subtype of anorexia that involves purging. There was another clue for anorexia — she runs. Anorexics often exercise excessively."

"How did you know so quickly?"

"That's the key to emergency medicine," I replied. "All her symptoms pointed to low blood sugar. Given how thin she is, I had a suspicion, and checked her teeth. Assuming she is bulimic or anorexic, what would you do?"

"It has to be a psych consult, right?"

"Bulimia is generally related to depression, anxiety, or bipolar disorder. We don't know the cause for anorexia, but it's also treated by counseling. Before we call psych, there is one other card to play, which I strongly prefer. Any ideas?"

"Not that I can think of."

"A consult with a nutritionist. They'll do a complete survey and give us a good idea if we're on the right path. It _could_ be something else. Once the blood work comes back, we'll call for a consult. The nutritionist/dietician starts at 8:00am, so it won't be too long a wait."

"Is this going to count against me?" Krista asked.

"No. You're still learning diagnostic skills. May I give you some advice?"

"Sure."

"Focus on learning. That means asking questions, even if you feel you might look bad. If you _don't_ ask questions, you aren't going to learn."

"Mike?" Nate called out. "Doctor Gibbs needs you in the ambulance bay. High-speed MVA. Two minutes."

"Thanks, Nate. Krista, let's go."

We gowned and gloved and entered the ambulance bay just as the EMS squad was turning into the driveway. I took a moment to look across to the field where the new Emergency Department wing was slowly taking shape, then cleared my mind to focus on receiving a patient who had likely suffered severe trauma. When the squad rolled to a stop, Bobby jumped out.

"Seventeen-year-old male; high-speed, single vehicle MVA; unbelted; severe trauma to the head; GCS 4; crush injuries to the chest and left extremities; BP 60/20; pulse thready at 120; PO₂ 91% on five liters; saline IV and a unit of plasma."

"Trauma 2!" Doctor Gibbs ordered.

Bobby, Sam, Doctor Gibbs, Kellie, Angela, Matt, Krista, and I quickly moved towards the trauma room.

"Mike, assess for chest tube and internal bleeding," Doctor Gibbs ordered. "Angela, type and cross match and hang another unit; Kellie, full trauma panel; Matt, intubate; Krista, switch the five-lead to our unit, then Foley."

We all worked together to move the patient from the gurney to the trauma table, and once Bobby and Sam moved out of the way, we began work. I quickly assessed the patient needed both a chest tube and surgery for internal bleeding, but we had to stabilize him first.

"Sinus tach," Krista reported.

I glanced up at the monitor to confirm and saw no other anomalies.

"Get the Foley in," I instructed. "He's going to need an ex-lap and a chest tube. Recommend pressers, Loretta. He won't survive being opened up with his blood pressure bottomed out. Recommend a second unit as well."

Doctor Gibbs gave the orders, and I called for a chest tube tray.

"Blood in the urine bag," Krista announced.

"Forget it," Doctor Gibbs announced. "Both pupils are fixed and dilated and I see CSF in both ears."

"Mannitol?" I suggested just as the monitor blared.

"V-fib!" I declared. "Shock him?"

"Crash cart!" Doctor Gibbs ordered. "Charge to 180!"

Three successive shocks of 180, 200, and 250, with doses of epi between them, didn't resolve the V-fib. A few seconds after the last shock, the monitor blared again.

"Asystole," I reported.

"Let him go," Doctor Gibbs said. "There's no point in flogging him."

I reached over and silenced the monitor.

"Time of death, 07:22," Doctor Gibbs announced.