Chapter 10 — Dutch Treat

_April 2, 1990, McKinley, Ohio_

{psc} I suppressed a sigh when I walked into the ED just before 5:00am on Monday morning. Two things jumped out at me immediately. First, a nameplate reading _Doctor R. 'Dutch' Wernher, Chief of Emergency Medicine_, had replaced what had been the Attendings' office. Second, a sign on what had been the lounge door read _Attendings and Residents Only_.

I recalled that Doctor Wernher had been in the Navy, and it appeared he had decided to create the equivalent of an Officers' Club in addition to commandeering the only office. I walked over to the nurses' station, where Ellie and two other nurses were standing.

"Do I even want to know?" I asked quietly.

"No," she replied.

"No nurses or medical students in the lounge?"

"No. Nurses are to be with patients or at the nurses' station. Our breaks are scheduled and have to be taken in the cafeteria."

"When does the strike begin?" I asked.

"You're not far off, Mike. But be very careful. Rumor has it he spent two hours bending Cutter's ear about you on Friday."

"Wonderful. Where do the medical students hang out when they aren't busy?"

"Chairs by the ambulance bay."

"OK. Nobody is going off shift, so I'll take the first chart in the rack."

"Mike, you aren't on the ED rotation."

"What the?" I asked.

"I don't know. Doctor Wernher will be here momentarily; you should see him."

"This is going to be bad," I said.

"For everyone," Ellie confirmed.

I considered going to see Owen Roth but decided that might anger Doctor Wernher, so I asked Ellie to let me know when he arrived, then went into the lounge, where I saw Kylie Baxter and Antonio Gómez.

"Hi, Mike," Kylie Baxter said. "Welcome to Hell."

"I got that idea. I'm not on the ED rotation even though I'm assigned here."

"And without Clarissa here, we're shorthanded if you don't see patients."

"I tried, but Ellie told me not to take a chart."

"The nurses are pissed."

"I got that idea as well."

"Doctor Loucks?" a doctor who appeared to be about fifty said from the door to the lounge.

"That's me," I said. "I go by Doctor Mike. You must be Doctor Wernher."

"My office, please."

Kylie had her back to the door so she could roll her eyes without being seen. I followed Doctor Wernher into his office. Judging his personality by the little I knew, I stood straight, not quite at attention, and waited for him to indicate I should sit.

"Shut the hatch and grab a seat," he said.

That one phrase telegraphed one of two possible scenarios — he was through and through military, which did not make sense given he'd been out of the service for nearly twenty years, or it was an affectation to achieve some purpose.

I shut the door, sat down, and waited for him to speak. I wasn't intimidated by silence, and I was positive I could sit quietly and look him in the eye longer than he could do it. As the seconds dragged on, the silence became more and more obvious, but I simply recited the Jesus Prayer and waited him out. I absolutely wasn't going to fight with him, but I also wasn't going to be intimidated by him.

It was about seventy seconds before he finally spoke.

"You're the one with the temerity to design their own Residency program."

"While it's true I lobbied for it here at Moore Memorial, the program was designed and developed by Doctor Albert Barton while he was at Indiana University and implemented at University of Chicago Hospital where he's Chief of Emergency Medicine."

"You know Al Barton?"

"He arranged for a scholarship for me at Indiana University, but I elected to go to McKinley Medical School. He recruited me for the Match, but I elected to Match here."

"MCAT and MLE scores?"

"98th MCAT; 99th MLE Step 1; 99th MLE Step 2."

"You had that MCAT and didn't go to Stanford, Yale, or Harvard?"

"I had no desire to do anything but serve my community," I replied. "There were personal considerations as well."

He shook his head in obvious disapproval. I really wanted to ask what HE was doing at Moore Memorial training students from McKinley Medical School if he thought so little of it, but I held my tongue.

"I'm sure you observed some of the obvious changes I've implemented to bring order to the chaos that preceded my arrival."

"I did," I replied, electing to keep my answers terse.

"Nobody takes shifts in my ED unless they're on my service. And nobody works in my ED without wearing ED scrubs. If you want shifts here, you're ED staff, and you wear blue scrubs. Otherwise, you're surgical staff and are limited to consults in the ED. My staff is also clean-shaven, and men wear their hair cut short. And we do not use informal titles."

Given my beard and ponytail were religious, I knew I was legally entitled to an accommodation, but there was no possible way to raise that at the moment without starting an unproductive argument.

"It is your ED," I agreed. "Have you spoken to Owen Roth?"

"I've spoken to John Cutter, and I was given a free hand in the ED. There is some debate about your status, but I expect to resolve that today. We can solve it right now, if you want to be an emergency medicine specialist. I have an open Residency spot."

"My Match was for trauma surgery," I replied. "That is what I want to do."

"Then go up to surgery, and we'll call for consults when we need you."

"Yes, Doctor," I said, standing up. "May I be dismissed?"

"Dismissed."

I left the office and walked past Ellie, exchanging a look but saying nothing, and headed for the elevators. I rode up to the surgical floor, stepped out, checked the board, and walked to the scrub room for OR3. I put on a mask and a generic red cap, then stepped into the OR proper.

"Hi, Mike," Doctor Roth said, looking up. "I take it you talked to Doctor Wernher."

"Yes."

"And he kicked you out of the ED?"

"Only after suggesting I move to his service."

"I was afraid of that. Did you get into it with him?"

"No. I was the model of an obedient Able Seaman."

"Good. We'll fix this. For now, handle consults. You don't have med students, but you can use Shelly's Fourth Year. I do need you to do one thing for me."

"What's that?"

"Call Tim Baker and tell him 'Dutch treat'."

"May I ask?"

"He'll pull his Resident. I mean, if we're going to be territorial, we're going to be territorial. Baker is onside. So is Getty. I'll see you after I get out of this guy's guts."

"Thanks," I said.

I went to the lounge and dialed Doctor Baker's direct number and was happy that he answered.

"Doctor Baker, this is Mike Loucks. Doctor Roth said, 'Dutch treat'."

"God damn it!" he growled. "OK. Tell Owen I'll do it right now."

"Will do."

"And Mike, let us fight; you stay out of it."

"That was my plan."

"Good."

He hung up, and I wondered how Doctor Wernher would react to losing _another_ Resident, leaving him short three doctors once Antonio Gómez was recalled. I was reasonably certain how this would turn out in the end, but it could be very ugly in the interim. And it would suck because I would mostly be twiddling my thumbs.

I left the lounge and went to the nurses' station to find out who Shelly's students were.

"Aren't you supposed to be in the ED?" Carol asked.

"Don't ask," I replied. "Who's assigned to Shelly Lindsay?"

"Nick Duran and Penny Lewis. Nick is the Fourth Year."

"Thanks. I have my pager. I'm going to Medicine. If the ED needs a consult, page me, please, and send Nick down to meet me."

"Will do."

I left the surgical ward and made my way to Internal Medicine, where I found Clarissa speaking with Mark King, one of the Attendings. She saw me and held up a finger to let me know she'd be a minute. I ducked into the lounge and got a cup of coffee, tossing a quarter in the jar as I wasn't part of their coffee club. A minute later, Clarissa came in.

"Mark King just told me that Antonio was recalled. What happened?"

"Wernher is trying to remake the entire hospital to his liking. Take a walk in the ED and check out what he's done."

"It sounds like I might need an armed escort. What happened?"

"Well, the Attendings' office is now Dutch Wernher's office, and the lounge has a sign that limits entrance to Attendings and Residents — no nurses or medical students. And that's just the start."

"What the…"

"I was also told in no uncertain terms I can't work in the ED unless I wear blue scrubs, shave my beard, and cut my hair."

"Bullshit!"

"And yet, here I am, waiting on consults rather than working my scheduled ED shift. The nurses are ready to strike because they have to be with a patient or at the nurses' station except for authorized breaks, and medical students are relegated to chairs by the ambulance bay. Roth, Baker, and Getty are all pissed, and that's why Antonio is being pulled. He's not ED staff, so…"

"Jesus. Who is this guy?"

"When he called me into his office, he said, 'Shut the hatch'. He's been out of the Navy for twenty years. Kellie just got out last year, and she doesn't say stuff like that. I think he's aiming to be a hard ass because he called the ED 'chaotic'."

"No kidding it's chaotic! There is no ED on the planet that isn't! It's only a question of whether it's McKinley-level chaos or Cook County-level chaos!"

"He led with me having the temerity to design my own Residency, but I countered, carefully, that it was Al Barton, and that seems to have put that specific complaint to rest because he appears to know Al Barton."

"So now what?"

"I wait for Cutter to solve this. He'll have to because he has three service chiefs who are unhappy, not to mention nurses in the ED. I wouldn't want to take them on!"

"If you were single, you'd take on all of them!" Clarissa smirked.

"Nope! I'm totally not interested in Jamie!"

Clarissa laughed, "If Lee couldn't entice you…"

"He never _really_ tried. It was just clean fun, or as Sophia called it, homoerotic play!"

"How long do you think this lasts?"

I shrugged, "No clue. I'm following the advice I have from Brent Williams, Owen Roth, you, and Vladyka JOHN. I'll chat with Shelly Lindsay later."

"What was Cutter thinking?"

"I have no clue."

"I need to get to rounds. Lunch?"

"Call me when you have your break; I'm sure I'll be free unless I'm on a consult."

We hugged, and I left the lounge. I walked back to the surgical ward and went to the lounge, where I found Nick and Penny. I'd met Nick, but we'd never been on the same service. I didn't know Penny except by sight.

"Hi, Nick," I said. "I'm sharing you with Doctor Lindsay. You'll accompany me on ED consults today."

"Great!" he agreed. "I thought you were on the ED schedule."

"There was some kind of snafu with the new ED Chief starting today. I'm sure he and Doctor Roth will sort it out. May I see your procedure book?"

He pulled it from the pocket of his short lab coat and handed it to me.

"Where did you Match?" I asked.

"Oncology at Good Samaritan in the Western Suburbs of Chicago."

"Downers Grove, right?" I asked.

"Yes! Are you from Chicago?"

"No. My dad is from Naperville, and a very close friend Matched at Edward Hospital for cardiology."

"Maryam Khoury, right?"

"Yes."

"I had a Medicine rotation with her. She's awesome!"

"That she is!"

I quickly paged through his procedure book and he checked all the boxes, as it were, with more than the average number of procedures. And he'd had an oncology Sub-I, which meant he knew infinitely more about cancer and chemotherapy than I did, even though I was a doctor and he was a medical student.

"Why oncology?"

"My little brother died of AML when he was six."

"Lord have mercy," I said quietly.

"You lost your wife, right?"

"Yes."

"So you know how it feels, at least somewhat. I was ten, and it ripped me apart. I decided then and there I was going to be a doctor and help kids like my brother."

"We've come a long way since the early seventies."

"A bone marrow transplant might have saved him, but finding a donor then was tough, and I didn't match because we had different dads. And the procedure was still highly experimental."

"Mike?" Carol called from the door to the lounge. "ED consult for a rule-out bowel obstruction in Exam 4."

"Thanks, Carol. Nick, let's go."

"Can I tag along?" Penny asked. "Doctor Lindsay is in surgery until at least 10:00am."

"Yes. Carol, if Shelly comes looking for Penny, call the ED, and I'll send her up."

"OK, Mike."

Nick and Penny walked with me to the stairs, which I preferred to the elevator, and we made our way to the ED. When I opened the door to the exam room, I suppressed a groan because Doctor Wernher was the treating physician. That means following policy to a T and being extremely formal. It also meant I needed to send Penny back upstairs.

"Penny, go back upstairs," I said quietly. "I'll explain later."

She nodded, turned, and left.

"Loucks, surgery," I announced. "What do we have, Doctor Wernher?"

"Kenton Jones; age six; presents with abdominal pain with tenderness and guarding; some vomiting reported; no signs of appendicitis."

"Vitals?" I asked.

"Pulse 80; BP 110/70; PO₂ 98% on room air; respiration labored at 17."

"Labs and treatment?"

"Ringer's for dehydration; elevated white count; slightly hypokalemic; all other levels within range."

A high white count was not typical of bowel obstruction and indicated early-stage appendicitis, though that could be a false sign.

"How high is the white count?" I asked.

"14," Doctor Wernher replied.

That indicated a very low-grade infection and might be completely unrelated to the complaint.

"Hi, Mrs. Jones," I said to the black woman sitting in a chair near the bed. "I'm Doctor Mike Loucks from surgery. With your permission, I'd like to examine Kenton."

"Of course, Doctor!"

"Hi, Kenton," I said. "I'm Doctor Mike. How are you feeling?"

"My tummy hurts bad, and I puked twice."

"Can you point to where it hurts?" I asked.

He did, and barring reflected pain or atypical anatomy, he didn't have appendicitis. I performed a basic exam, explaining each thing I was doing to Kenton. I always disliked palpation because I was inducing pain, but a physical exam was indicated and necessary. Kenton winced and moaned but handled it like a champ.

"Nick, ultrasound, please," I said.

He rolled the machine over, turned it on, and set the controls correctly. I took the gel bottle from the warmer, squirted some onto Kenton's abdomen, and then carefully placed the transducer in the most likely spot.

"OK," said. "I see what appears to be a complete obstruction of the small bowel at the junction of the ileum and jejunum. Mrs. Jones, may I see you in the corridor? Nick, please carefully clean the gel from Kenton's abdomen, then join us. Doctor Wernher, please join us."

The three of us stepped into the corridor.

"Kenton needs immediate surgery," I said. "There is a mass in what you would call his small intestine that is blocking it completely."

"What is it?"

"I can't say at this point," I replied. "We'll perform a procedure called a laparotomy, which is surgery to open his abdomen. We'll examine his small intestine and determine the best course of action. Most likely, it will be what's called a resection — we'll remove a portion of his intestine. As bad as that sounds, it's a routine procedure and usually has no lasting negative effects on digestion.

"Once we've removed the section, we'll examine the mass to determine what it is and if we need to perform any additional treatment. The usual time to perform the procedure is about two hours, and recovery is anywhere from two to six hours. If there are no complications, Kenton could go home by Friday."

"Will you do the surgery, Doctor?"

"I'll assist," I replied. "A senior pediatric surgeon will perform the operation. I do need to go over the risks and have you sign a consent form."

"OK," she said.

"Let's go to the consultation room," I said. "Nick, get the consent forms from the nurses' station, please."

"I'll stay with the patient," Doctor Wernher said.

I was thankful for that, as that meant I could be less formal with Mrs. Jones. A minute later, she, Nick, and I were in the consultation room.

"These forms are written in a mix of medical and legal terminology," I said. "I'll explain each and every word if you wish, but I can give you a summary in plain English to start."

"A summary would be fine. I'm a chemistry teacher, so I know many of the words."

"Good. The surgery requires general anesthesia, which has risks, including coma and death. Those are extremely rare, but they do happen, and generally speaking, there is no way to know in advance that someone will have an extremely adverse reaction to anesthesia. For the surgery itself, there is a risk of bleeding, infection, or complications that can lead to permanent injury or death. Again, the risks are small, but they are real. Do you understand?"

"Yes."

"If we don't perform the surgery, Kenton will, in all likelihood, die an extremely painful death. Some bowel obstructions resolve themselves with hydration and the use of a nasogastric tube to relieve pressure, but with a complete obstruction by a mass, that is not an option. Is that clear?"

"Yes. What do you mean by 'mass'?"

"It could be as simple as fecal matter or as complicated as a tumor. We could do a CAT scan to get more information, but, given Kenton needs surgery no matter what, I prefer not to expose him to the radiation, as it won't change our plans or the outcome of the surgery. Do you have any questions?"

"No. Thank you for explaining everything so clearly. You have a great bedside manner, too. Kenton really appreciated you explaining everything. The other doctor didn't do that."

"Thank you. If you'll sign the consent form, we'll get Kenton upstairs. The surgery will likely be later this morning. Did he eat anything today?"

"No. He had dinner last night at about 5:30pm but vomited before bed. He woke up about 4:30am crying, and other than a sip of water, he hasn't had anything else."

"OK. I'll look at the chart, but I want to double-check if he has any allergies or is taking any medication."

"No allergies, and no prescriptions."

"What about over-the-counter or supplements?"

"Nothing in the past two weeks."

"Any family history of which I need to be aware?"

"No, his grandparents are all alive and healthy, and so are his dad and me."

I handed her the clipboard and indicated where to sign, then asked Nick to call upstairs and let them know we'd be bringing Kenton up.

"Mrs. Jones, you can come with us. We have a quiet waiting room upstairs, and there's a phone if you want to call Kenton's dad or someone to support you."

"His dad is in New York on business. I suppose I should call him."

"You can do that upstairs," I said. "The nurses will give you a code to make a long-distance call."

"Thank you, Doctor!"

"All part of the service!"

About ten minutes later, Nick and I helped Kenton scoot onto a gurney. Five minutes later, Kenton was in a room in the surgical ward, where he'd wait for surgery.

"Hi, Mike!" Shelly Lindsay said, coming into the room with Penny.

Shelly had obviously left her surgery, as she had a mask pulled down around her neck and was wearing a surgical cap.

"Welcome back, Shelly."

"Who's our friend with the tummy ache?"

"Kenton Jones, and this is his mother, Alberta."

"Good morning," Shelly said. "I'm Doctor Lindsay, and I'm on the surgical team that will perform Kenton's operation. We'll take him in about 11:00am. About thirty minutes before that, the anesthesiologist will come to see you and give Kenton a mild sedative. Nick, draw for a complete set of pre-surgical labs."

"Right away, Doctor!"

"Mrs. Jones, you can stay here until we take Kenton to surgery, and then you can go to the waiting room."

"She needs to call her husband in New York," I said.

"Penny, would you take Mrs. Jones to the consultation room and get the long-distance code from Carol?"

"Yes, Doctor," Penny replied. "Mrs. Jones, if you would come with me."

"I'll stay until you return," I said.

"Mike, come see me once Mrs. Jones is back," Shelly said.

"Will do," I agreed.

Everyone left except Nick, who drew blood. Once he finished drawing the tubes, he left to take them to the lab.

"Kenton, you're going to need an operation," I said. "I explained everything to your mom. Do you want me to tell you what's going to happen?"

"Yes."

"First, a doctor called an anesthesiologist will come see you. He's the doctor who will put you to sleep for the operation. When he visits, he'll give you a drug called a sedative that will help you relax. Soon after that, we'll take you to the operating room. You'll see lots of equipment and at least three doctors and four nurses."

"Will you be there?"

"Yes, unless there's an emergency, in which case I might have to go down to the ED, what you probably call the 'Emergency Room'. In the operating room, you'll also see a lot of equipment, including machines that will measure your heartbeat and breathing, as well as the machine they use to put you to sleep.

"Once you're asleep, the doctors will use tools to remove a small part of your small intestine, the tube that carries food you've eaten out of your stomach. They'll sew everything back together and send the part they removed to the lab to check it.

"When you wake up, you'll be in a room called 'Recovery' where there will be nurses to take care of you. Nick will probably be there, and I might, too, depending on whether there is an emergency.

"You'll stay in that room for the rest of the day, then, once we're satisfied you're doing well, you'll come back here. Do you have any questions?"

"What does it feel like?"

"Nothing. You'll be completely asleep, and you won't feel anything at all. When you wake up, your tummy will be sore, but they'll give you medicine to take away the pain. You'll have to stay in the hospital for a few days, probably until Friday. We'll know for sure tomorrow morning when you'll be able to go home."

"Do I have cancer?"

"I honestly don't know. That's one of the things the lab test will tell us. Cancer is very rare, and even if what I saw on the ultrasound is a tumor, they are almost always benign, which means they aren't cancer, just a strange growth. Once we remove it, that's it. Right now, don't worry about that. OK? I promise someone will explain everything after the surgery and the tests. OK?"

"Yes."

"What kind of candy do you like?" I asked.

"SweeTarts!"

I had prepped for working in the ED, so I had my fanny pack with appropriate candy selections. I unzipped it and extracted a box of SweeTarts.

"These are for you, but you can't eat them until your mom and the nurses say you can. Promise?"

"Yes!"

"I'll put them on the table here."

"You're cool!"

"I try!"

"I never saw a man doctor with a ponytail!"

"I like to be different," I said.

"Do you have kids?"

"A daughter who is two and a half, and my wife is pregnant with another daughter who'll be born in June. Do you have brothers or sisters?"

"Two older sisters! It's like I have three moms!"

I laughed, "I believe it! I had a younger sister, and she could be pretty bossy even though I was older!"

Kenton's mom returned just then, accompanied by Penny.

"Did you reach your husband?"

"I did. Kenton, there's no way your dad can make it back before you have your operation. He's going to fly home late this afternoon. Doctor, can he visit late?"

"Yes. Visiting hours for parents are unrestricted. I'll make sure the nurses get you a pass so you can get in after 11:00pm."

"Thank you! How long have you been a doctor?"

"About nine months," I replied. "I graduated from medical school at the end of May of last year. Doctor Lindsay has been a doctor for almost six years, and Doctor Anniston, the senior surgeon who leads the team, has been a doctor for more than twenty years. The pediatric surgeon who'll perform the surgery is Pete Barton, and he's been a doctor for fifteen years."

"And the younger man and woman are medical students?"

"Yes. Nick is in his final year and will graduate at the end of next month. Penny has just over a year to go. Nick will be a doctor in Chicago starting in June or July."

"Hi, Kenton!" Nurse Amy said, coming into the room. "I'm Amy, and I'll be taking care of you until surgery! Doctor Mike, I see you're back to your old antics!"

"Guilty as charged," I chuckled. "Mrs. Jones, the SweeTarts on the table are for Kenton once you and the nurses say it's OK. I reward brave young patients with their favorite candy."

She laughed, "I think we can see our way clear to allowing him to eat them as soon as the nurses say it's OK."

"Oh, sure, now _we're_ the bad guys," Amy said mirthfully.

"Mrs. Jones, I'll come back in a bit," I said. "If you need anything or have any questions, press the call button or ask any of the nurses."

"Thank you, Doctor."

Penny and I left the room and met Nick, was was returning from the lab. The three of us went to the lounge, where we sat down.

"Sorry about the ED," I said to Penny. "The new ED Chief is a stickler for protocol, and the protocol is one medical student on a consult. Given the circumstances, I didn't feel I could ask for an exception."

"How did you know his favorite candy?" Penny asked.

"I'm just that good," I said with a grin.

Nick laughed, "I heard about that from Doctor Baxter in the ED – he carries the ten most popular candies in his fanny pack and has spares in his locker. They call him 'Kid Whisperer' because, for some reason, kids love him. And it's not bribery because he rewards good behavior after the fact."

"Talk to the kids," I said. "They understand way more than most adults give them credit for understanding. And treat them like the individuals they are, not as some kind of extension of their parents. Penny, you missed it, but when I examined Kenton, I explained each thing I was doing and why and developed trust. Now, if I tell him something, he's going to believe me. I explained the surgery to him in detail a young kid could grasp. You saw him — he's calm and ready for his surgery."

"Most doctors don't do that, do they?" Nick asked.

"Not with kids. They talk to parents, and the kid is treated almost as an object. What I've found is that kids are much braver than adults if you talk to them and explain things to them. Remember that."

"Mike?" Kylie said from the door to the lounge. "Got a sec for a private conversation?"

"Yes," I replied.

We left the lounge, and the Residents' office was unoccupied, so we went there.

"This has to be quick because I'm on a fifteen-minute break," she said. "Medicine just pulled Antonio, so we're really shorthanded and worse, Ellie just informed Doctor Wernher that the nurses are going to enforce all provisions of their contract with regard to overtime and nurses from other services covering the ED.

"Fighting policy with policy," I replied. "I know about the notice provision for OT, which they almost always waive, but what's the other rule?"

"You know how, at times, we'll borrow an ICU or Medicine nurse when we're short-staffed, with supply nurses covering those services?"

"Sure, similar to how we Residents do it."

"Those all need to be approved by the Nurse Manager, who just happens to be Ellie's best-friends mom."

"And she'll turn down all requests?"

"No waivers of the requirement for emergency medicine certification or currency — having worked at least one ED shift in the past six months."

"This is not going to end well," I replied. "Patients are going to suffer. What the heck was Cutter thinking?"

"I heard through the usual Residents' gossip chain that Wernher asked for a free hand when he was hired, and Cutter agreed, thinking that meant Wernher would get the lay of the land and propose changes. That changed on Friday morning when Wernher came to see Cutter and dropped his bomb."

"Wonderful. Now what?"

"No clue, but the rumor is you're the main bone of contention. Well, your role."

"Well," I said, "there's always Chicago."

"What?!"

"I bet you anything you care to wager, I could pick up that phone, call Doctor Albert Barton at University of Chicago Hospital, and have a Residency slot tomorrow. And one for Clarissa Saunders, too.

"Take me with you? Please?"

"It's an idle threat," I replied. "Yes, I _could_ do that, but I'm not about to cut and run, not to mention everything else that keeps me here. That said, if a rumor were to spread that I _had_ called Doctor Barton…"

Kylie smirked, "I know just who to drop that tidbit to, and it'll never be traced back to the source. Anyway, I need to get some juice, so I have to run, or I'll miss punching the time clock."

"Please tell me you're joking."

"I am, but I'm not, if you get my drift."

"Unreal. I take it nobody is supporting Wernher?"

"If they are, they're keeping it to themselves. Kellie is fit to be tied that a Navy man would be such an asshole."

"I can imagine. Just keep your head down."

"No kidding!"

We left the office, and I returned to the lounge while Kylie headed to the cafeteria. If what Kylie was saying was true — and I had no doubt that it was — things were going to become very ugly in the ED.

"Doctor Mike," Nick said, "Carol said you had a phone call while you were speaking to Doctor Baxter."

"Thanks."

I went to the nurses' station to get the message and saw it was from Gale Turner's attorney, and had a note that it was OK to call during the evening, which I felt was the better option. Before I could walk away, the phone rang, and Carol signaled for me to wait.

"Stabbing victim needs a chest tube in Trauma 1," Carol said, replacing the phone.

And instead of me being in the ED with my medical student where I could act immediately, we'd lose two precious minutes.

"OK. I'll get Nick, and we'll head right down."

Just under two minutes later, Nick and I walked past a Sheriff's Deputy into Trauma 1, where Ghost and Paul Lincoln were working on a man who appeared to be in his mid-twenties and was dressed in an orange jail jumpsuit.

"Hi, Ghost. What do you have?"

"Ken Brooks, twenty-two; right-side penetrating trauma; collapsed left lung; BP 90/50; tachy at 110; PO₂ 92% on O₂ by mask. No defensive wounds."

"Chest tube tray to me," I said to Becky. "Nick, seal the wound with a defib pad, please."

I quickly performed the thoracotomy, inserted the chest tube, and connected the Thora-Seal. Once that was done, I listened to Mr. Brooks' breathing.

"Good bilateral breath sounds," I announced.

"PO₂ coming up," Erin said. "93%…95%…96%."

"I'll take him," I said. "Do we have any medical history?"

"No."

"How much blood have you given him?"

"Just one unit of plasma by the paramedics. Blood loss isn't significant."

"Shiv?" I inquired.

"That's what the Deputy said."

"OK. Nick, call upstairs and tell them we have a penetrating trauma that will need surgical repair. Vitals are stable, and blood loss is minimal. Then, call for an orderly. I'm going to talk to the Deputy."

I stepped out.

"Deputy…" I read his badge, "Cullen. Your prisoner needs surgery to repair the injury. We're going to take him upstairs shortly."

"He's not a risk," Deputy Cullen replied. "No cuffs, and I'll come with you and stand outside the OR."

His demeanor told me that there was more to this, as inmates were almost never left un-cuffed during transport. I wondered if he was some kind of undercover officer, given a recent report about drugs being smuggled into the jail.

"OK. We'll take him up in about ten minutes. I'm not sure if he'll go right into surgery or if he'll have to wait."

"No problem, Doc. He's not in any danger, right?"

"I re-inflated his lung, and it looks to be a simple repair. He hasn't lost much blood, which is a positive sign."

"Thanks, Doc."

I stepped back into the room, and Nick let me know that we'd have an OR in fifteen minutes. I consulted with Ghost, and we decided we'd keep the patient in the ED until the OR was free.

"How bad?" I asked quietly.

"Ugly," he replied. "Just keep your head down. That's what I'm doing. The nurses are about to stage an armed rebellion."

"Never, ever piss off the nurses," I said. "Ever."

"Mike is very, very wise," Becky said, having moved closer to us.

"I saw quite a few people in the waiting room when I walked by," I observed.

"It's taking four or five hours before we can see walk-ins because we're short two doctors on this shift and three overall."

"I tried to take a chart this morning, but Ellie refused because I wasn't on the ED rotation. Cutter will have to do something."

"At least three Board members back Wernher, believing we're 'out of control' and that the nurses and Residents push the Attendings around."

"Not true, but the picture does become clearer."

"I assume you heard about Gale Turner."

I nodded, "I went to see him. I looked him in the eye and bluntly asked. He says it's fabricated, and given other things I've heard from reliable sources and things I've observed, I think he's telling the truth. It's all about forcing the clinic to close."

"The damage done will be incalculable," Ghost observed.

"I know," I replied. "But I'm not sure what we can do about it without funding, and you know that's a very sore point with the County Board and the voters. There is no appetite for raising taxes even to fund basic services."

"We're nearly all conservative Democrats here," Ghost observed. "We want fiscal responsibility, but we also believe the government should be doing more to ensure a true safety net exists. The problem is property taxes are extremely regressive and sales taxes are as well. But there is no appetite for a county income tax."

"People will be dumping tea in the river and waving the Gadsden flag if anyone proposes that."

"Which means we're stuck relying on charitable contributions to fund family planning services."

The orderly arrived with the gurney, and the team in the room moved the patient to it. Nick and I escorted the patient to the surgical ward, with Deputy Cullen following behind us.