Chapter 23: A Nerf Bat and an Olive Branch

July 18, 1989, McKinley, Ohio

"Get any sleep?" Clarissa asked when we met for breakfast very early on Tuesday morning.

"About thirty minutes before the smoke inhalation victims you accepted, and about thirty minutes after. You?"

"About an hour before you called. After that, I was caring for those two. I also spent some time in the ICU because all three of those patients are Medicine patients."

"How's the dad?"

"So far, so good. Jacobs from Pulmonology will evaluate him in about an hour. His monoxide levels have come down, and his PO₂ is at 92%. He inhaled a lot of particulate matter and probably some toxic fumes. The other four are in much better shape, and the mom and eldest son will be out of the ICU this afternoon."

"Good."

"Anything else interesting?" Clarissa asked.

"A subarachnoid hemorrhage that Neuro took. That one didn't look good at all."

"Gorked?"

"I'd say that's the odds-on bet," I replied. "I don't know what the CAT scan showed, but the physical signs were indicative of a major bleed. How is the hypertensive crisis?"

"One foot in the grave. Both feet if he doesn't quit smoking, limit his drinking, change his diet, and exercise. We got his BP out of the stratosphere, but it's still too high."

"And it'll stay there, as you say."

"I just don't get it!" Clarissa said, shaking her head. "If you know it's going to kill you..."

"Because if that's what you've done for your entire adult life, change is hard."

"You'd think staring death in the face would be sufficient."

"You would, but we know it's not. Let's be honest, my behavior during the interregnum was irresponsible and dangerous, given the prevalence of HIV and other 'gifts that keep on giving'."

"I wonder what the incidence of STDs is at Taft, the medical school, and the church?"

"That would be a question for Trina at the Free Clinic," I replied. "I bet she could tell us. But I was extremely lucky."

"I never did know the exact body count..."

"Somewhere around fifteen, I think, not counting you or Lara. I was a bit out of control."

"Given what you went through, you were far more in control than out of control. Sure, you had a lot of sex, but you cared for Rachel, graduated first in our class, passed your exams, Matched, and found the perfect partner in crime for the rest of your life."

"Which doesn't excuse my behavior."

Clarissa rolled her eyes, "Did any of those girls feel used? Heck, did any of them feel anything other than expertly fucked? It might be different if you had lied to them or abused them, but name ONE girl you went after. Just one!"

"You."

"Very special circumstances, and we'd been together before. Besides me? Heck, you lusted for Tasha, and she had to basically drag you to bed! You couldn't even get up the courage to ask her for a date in High School despite the fact you both wanted to fuck each other half to death!"

"Angie."

"Again, special circumstances, but she was already after you when you spoke to her. The guys pointed out she was interested."

"By the way, speaking of Angie, Doctor Mercer called last night."

"Uh-oh."

"She said she wanted to apologize. We're supposed to speak tomorrow."

"Interesting. I assume you'll accept her apology?"

"Assuming it's sincere, of course I will. But I also have to be careful because of the complaint that was filed against Doctor Greenberg."

"What are your plans for tomorrow?"

"A day with Rachel," I replied. "It's basically the only time I have with her when it's just the two of us. I'm not sure what we'll do, well, once I speak to Doctor Mercer in the morning."

"Is Rachel here?"

"No, she's with Anna today so she can play with her girl cousin and hide from her boy cousin. I'll stop by and get her on my way home."

We finished our breakfast and Clarissa returned to Medicine while I headed back to the ED.

"You two should grab your breakfast before the morning rush," I said to Mary and Tom.

They left, and I sat down in the lounge with Doctor Varma.

"Mind if I ask where you're from?"

"Sunnyvale, California," Naveen replied. "My dad works for Apple Computer. You're from around here, right?"

"One county over. I went to Taft and McKinley Medical School. You?"

"UC Berkeley, then OHSU School of Medicine in Portland."

"How'd you end up here?"

"My fiancée is working on her PhD in biochemistry at OSU. I interviewed at six hospitals, and Moore Memorial was my second choice, but I have no complaints."

"Doctor Varma?" Nurse Alice called from the door to the lounge. "EMS four minutes out car versus pedestrian. Doctor Nielson needs your assistance."

"Coming," he replied. "Sorry, Mike."

"Duty calls," I replied.

He left, and about two minutes later, Tami McCarty came into the lounge.

"I came down to take a woman in labor up to Labor and Delivery and wanted to say 'hi'."

"Hi. How have you been?"

"Good. I started in OB full-time on June 1st. How is Rachel?"

"Growing like the proverbial weed! Walking, talking, and generally acting like a toddler."

"I heard you married in January."

I nodded, "I did. A girl from the Russian Cathedral in Columbus. She's majoring in Political Science at OSU."

"Mike?" Nurse Jenny said, coming into the lounge. "Walk-in with near-syncope and nausea."

"My students are at breakfast, so I'll need a nurse, please."

"I'm all yours!" Jenny declared. "We brought the patient into Exam 2."

I excused myself, then got up and followed Jenny to the exam room, taking the chart from the rack and scanning it. The name was uncommon enough that I made an assumption, which was proved correct when I walked into the exam room.

"Good morning, Detective Tremaine," I said. "Doctor Mike Loucks."

"I remember you from a case about six years ago. A missing student."

I nodded, "You interviewed me in the disappearance of Angie Stephens. What brings you here this morning?"

He smiled wryly, "I was at the coffee shop having doughnuts with my partner, felt light-headed, and felt as if I was going to throw up. The nauseous feeling passed but not the light-headedness and my partner insisted on bringing me in."

Correctly speaking, it was 'nauseated', but I didn't feel it was the time or place to correct him.

"I'll dispense with the cop and doughnut jokes," I said with a smile. "Are you armed?"

"Yes."

"Would you please remove your firearm so we can do the exam? I don't need to take it, but I don't want to take any risks, even with the safety on. Well, a safety, assuming it's semi-auto, not a revolver."

"I carry a Glock 9mm," he said, removing the shoulder holster. "Where should I put it?"

"The nurse can put it on the counter for you."

He handed it to Jenny, and she set it on the counter.

"No vest, right?"

"No."

"Then, if you'd take off your jacket, loosen your tie and unbutton your shirt, I'll examine you."

I did the basic exam and found nothing remarkable, so my first impression was likely some kind of viral infection or inner ear disorder, but I had nothing on which to hang my hat.

"Have you had any medical procedures? Even minor ones?"

"A colonoscopy about three years ago, but that's it, other than my annual physicals."

"Have you recently had a head injury of any kind or been in a fender bender?"

"No."

"Do you smoke?"

"I quit about five years ago using the Kojak method. My dentist hates it, but it worked."

"I'd trade cavities from lollipops against lung cancer or emphysema any day. Do you drink?"

"A beer after work most days, but just one. An occasional glass of whisky."

"Exercise?"

"The gym three times a week, mostly for cardio, recommended by my doctor. Something about sitting on my ass six or more hours a day."

"Any headaches?" I asked.

"Off and on for years, and aspirin always worked. My doctor advised cutting back on caffeine, so I drink decaf half the time, and that's helped."

"How much coffee do you drink?"

"All of it!" he chuckled. "I always have a cup."

"How's your diet besides the police breakfast?"

He laughed, "Believe it or not, we only get doughnuts once a week. Usually, it's a sit-down breakfast. Eggs, bacon, and either toast or waffles."

"And otherwise?"

"Too many burgers and fries," he said. "My doc got on my case about that, but the exercise has taken off some of the weight I put on."

"How much?"

"Gained ten, took off five."

"Over what period did you lose that weight?"

"About two months."

"Any changes in frequency of urination or significant changes in bowel movements?"

"No. Thank God I'm not getting up every two hours to take a leak like my dad."

"Any trouble performing in the bedroom?"

"According to me? No."

Jenny laughed, and I chuckled.

"Have you ever had dizzy spells before?"

"No. First time."

"Any vision changes?"

"A new prescription in May."

"And before that?"

"At least five years."

"Presbyopia?" I asked.

"Sorry, I don't know that word."

"Literally, it means 'elder eyes'. Did your prescription change in general, or is it for reading?"

"These are progressive bifocals, and I needed them for reading."

"Fairly common for men over fifty," I observed. "Any problems with your hearing?"

"According to whom? My wife? My captain?"

I chuckled, "I was thinking more about doctors."

"No."

"Tinnitus or 'ringing' in your ears?"

"Twice when I've had to fire a gun without ear protection."

"When was that?"

"Once as a patrol officer about thirty years ago, once eight years ago."

"How long did the tinnitus last?"

"Less than a day both times."

"Any changes in how you feel during your workouts? Changes in your breathing? Or trouble walking or standing?"

"No. None of those."

"OK. The next thing we'll do is draw blood. Are you still feeling light-headed?"

"It's not as bad when I'm lying down, but yes."

"Jenny, nasal cannula, please, then draw blood for a CBC, Chem-20, ABG, cardiac enzymes, and metabolic and glucose panels."

"Right away, Mike."

"Detective, I'm also going to get an EKG."

"OK. Mind telling me what all those other tests are?"

"A CBC is Complete Blood Chemistry and looks at the number and types of cells in your blood; Chem-20 measures twenty different components of blood, including calcium, sodium, and electrolytes; ABG is arterial blood gas and tells us about oxygen and other gasses in your blood; cardiac enzymes are markers for heart attacks, though I don't think you're having one; the metabolic and glucose panels tell us how your body is processing glucose and eliminating waste, as well as your cholesterol. The nasal cannula is oxygen, and that's simply out of an abundance of caution."

"What do you think is wrong?"

"This is the shotgun approach to non-specific syncope — fainting or lightheadedness — and nausea. The most common diagnosis with those symptoms is a virus or a mild inner ear disorder. The challenge is that neither of those can be directly diagnosed in most cases, so we run all the tests to rule out the other things."

"So, like eliminating suspects?"

"Something like that, yes."

"You understand why we liked you for that disappearance, right?"

"For the same reason," I replied. "With the basic information, you look for reasons why it's not the boyfriend with whom the young woman had a fight before you'll stop thinking it's the boyfriend. And the reason is that, more often than not, it actually is the boyfriend. So, in that sense, it's the same way we deal with differential diagnosis. Let me get the EKG pads on you, and Jenny will draw the blood."

Ten minutes later, the blood was drawn, and I had five minutes of EKG strip, which showed no specific anomalies, his pulse was 75, his BP was 120/70, and his PO₂ was 99%.

"Everything looks good so far," I said. "Would you sit up and tell me how you feel?"

He did, and I could tell he was still suffering from lightheadedness.

"My head spun a bit, and I felt queasy," he reported.

"OK. At this point, just relax, and we'll wait for the blood work to come back. Jenny, I, or one of my students will check on you while we're waiting, and if you need anything, just press the purple button on the wall there."

"Thanks, Doc."

Nurse Jenny and I left the room, and she touched my arm.

"Care to explain?" she asked.

"A young woman with whom I was close disappeared after we went jogging. It turned out, when all was said and done, she was diagnosed with schizophrenia, but nobody knew it at that point. It was no fun at the time, but Detective Tremaine was doing his job."

"How is she?"

"Medicated, but able to work a data entry job, go to church, and practice Aikidō."

"That's better than many."

And it should have been even better, but I didn't want to get into a lengthy discussion about Angie with anyone not directly involved.

"It is."

"What do you think? I mean, about the detective?"

"Exactly what I said — the probable cause is a virus or inner ear disorder."

"And if it's not that?"

"Any other diagnosis is pure speculation," I replied. "Let's wait and see if we find any clues in his blood work. Get that blood to the lab, and we'll see what they say. Actually, here come Mary and Tom, so you can have Tom take the tubes to the lab."

She handed Tom the tray, and I filled Mary in on the case and asked her to check on Detective Tremaine every fifteen minutes until the blood came back.

"If there are no clues in the blood," I asked as we went to the lounge, "what would you do next?"

"Well, from what I've been taught, there's no reliable way to prove it's a virus or inner ear disorder, so with normal blood chemistry, you have to be thinking about the possibility that it's a tumor or some kind of neurological problem, including an aneurism, stroke, or some other problem."

"Yes. And?"

"EEG, CAT scan, or lumbar puncture would be the next diagnostic steps, so a Neuro consult."

"What about monitoring and, if it resolves, streeting him with a referral to his family physician?"

"You're worried about the cost of the tests if it's simply viral?"

"I don't give a fig about the cost of the tests, but a CAT scan induces significant ionizing radiation, and a lumbar puncture is very uncomfortable at best."

"We were warned in Practice of Medicine about the cost to the hospital of advanced tests."

"Well, I know the cops have good insurance, so it's not the hospital that would be on the hook, but even then, I don't care. That's for the bean counters. If I think a test is warranted and it's not against standard hospital practice, I'm going to run it. If it is against standard hospital practice, then I'm going to be..."

I paused to see how they would respond.

"A forceful advocate for your patient," Mary said, completing the thought.

"Yes," I confirmed. "What do we do if the blood tests are all negative diagnostically?"

"Did you do reflex and muscle tone tests?" Mary asked.

"No. That would be the next step before a consult."

"He had good distal pulses, right?" she asked.

"Yes, and he's about twenty pounds over his ideal weight, but he's in good shape for fifty-three. And if the reflex and muscle tone tests are diagnostically negative?"

"EEG because it's non-invasive and doesn't use ionizing radiation."

"And if that shows nothing?"

"Then one of the invasive tests."

"Or street him," I said.

"That seems counter to your usual thinking," Mary protested.

"Now, why might I do that?" I asked.

Mary laughed softly, "Devil's Advocate, right?"

"The question is whether or not you can defend your decision. You haven't seen me have a strong disagreement with an Attending over a diagnosis, but they do sometimes happen, and you have to be able to defend your position and support your conclusions. Think about the M & M."

"Have you had those disagreements?"

"Not specifically adversarial, but differences of approach and opinion. In the end, the Attendings make the decision on how to proceed, and you have to consider how hard you want to push and how certain you are that you're correct. And that was why it was legitimate for Mastriano to question me and override me."

"But she was wrong."

"Yes, but at the time, I couldn't prove I was right. That said, I was concerned enough about her decision that I had her write the order on the chart."

"So she couldn't deny it later, right?"

"If you are ever told by anyone, including me, to do something you believe is wrong, make sure it's in writing."

"You would listen."

"That's true, but that doesn't mean I'd agree with you, nor does it mean I'm going to be right every time. Don't put me on too high a pedestal because I won't survive the inevitable fall."

"So, what will you do?"

"Neuro consult," I replied. "It's the ED equivalent of dropping back ten yards and punting. I don't have the experience to diagnose the kind of thing we're discussing, and neither does Doctor Gibbs. We'll punt it to Neuro and let the experts decide the next steps. And don't be surprised if Doctor Gibbs suggests streeting him with orders to take it easy for a few days and follow up with his physician."

"She seems more like you than like Mastriano."

"Yes, but the difference is Attendings do have to care about allocation of resources and also have a lot more experience than we do. Yes, Doctor Gibbs has only been out of medical school for six years, but those six years are huge. Think about what you've learned in the last six weeks, then multiply that out."

"Got it. Let me go check on the detective."

I nodded, and she left, returning about five minutes later, along with Tom.

"No change," she said. "EKG still shows sinus rhythm, vitals are good ... sorry, pulse 72, BP 120/70; PO₂ 99% on nasal cannula."

"Then we wait for the blood work."

"Mike?" Ellie said from the door to the lounge. "Doctor Gibbs needs you. EMS three minutes out with car versus pedestrian."

"Another one?" I asked.

"Bad day to walk the streets of McKinley, I guess."

"Thanks. Mary, Tom, let's go."

The pedestrian's injuries were serious but not life-threatening, and he was admitted to Ortho with a badly broken leg. I'd sent Mary to check on Detective Tremaine twice, and the lab results had come back just before we transferred the accident patient.

"Nada," Tom said. "Everything is completely in range across the board."

"Anything close to the limits?" I asked.

"No. All mid-range. Basically textbook readings."

"Mary?"

"Neuro consult for sure."