Chapter 25 — Mama Bear

_July 23, 1989, Circleville and McKinley, Ohio_

{psc} On Sunday morning, we attended Matins and the Divine Liturgy at the Cathedral, but skipped lunch so we could take Rachel home for a nap before Ghost and Oksana's wedding, which was being celebrated at Saint Michael the Archangel. Once Rachel was in her crib, Kris and I decided to take a bubble bath together.

"How are you feeling, Mike?" Kris asked as we lounged together in the tub with her reclined back against me.

"Better," I replied. "I enjoy my work and I've adjusted to the hours, though obviously I wish I had more time for you and Rachel."

"You chose this course in fourth grade."

"I did," I agreed. "That doesn't make it easier."

"Is everything OK at the hospital?"

"You mean with Doctor Mastriano? Yes. She's on probation and all the facts and records support me. Even if she's upset with me, there isn't really anything she can do."

"You're sure?"

"Yes. Anything she says or does will be heavily scrutinized, so there's no risk. That said, the Chief of Psychiatry all but ordered me not to testify on Angie's behalf against Doctor Greenberg."

"Can he do that?"

"No. He stopped just short of a threat, saying I was 'throwing away my career' by testifying against a fellow doctor on what was, in the Chief's mind, a judgment call."

"Did you report him?"

"No. That wouldn't be smart, given it would back him into a corner. I'm only going to testify to things I personally observed and will refrain from making any diagnostic comments. Doctor Mercer will corroborate what I say, and that will be enough for Angie to prevail, and at least have Doctor Greenberg reprimanded, and possibly to have his license suspended."

"You're not worried?"

"No, but even if I was, I have an obligation to tell the truth, and Angie really has nobody except me to forcefully advocate for her."

"Her parents?"

"Without my support for Angie, they wouldn't have pressed the malpractice claims or the complaint to the Medical Licensing Board because they didn't have enough information. And that was because Doctor Greenberg and Doctor Mercer were telling them the same thing, and, to be honest, nobody without a personal stake would step into a case such as this."

"Why?"

"Sadly, doctors cover for each other, even in cases of negligence and malpractice. It's wrong, but it's similar to cops covering for each other or politicians covering up their own malfeasance."

"You're on good terms with the police, though, right?"

"Yes, of course, but that doesn't mean I wouldn't call out corruption if I saw it. Isn't that a socialist principle?"

"You know it is!"

"And government corruption was the objection both Jefferson and Trotsky made about bureaucracies!"

Kris laughed, "You do enjoy tweaking me!"

"Yes," I agreed, then gently pinched her nipple.

"Not like that!" Kris declared mirthfully.

"I enjoy both!"

"I think we have enough time…"

We did, and after very enjoyable lovemaking, we showered, then dressed for the wedding. I woke Rachel from her nap, changed her diaper, dressed her, and then the three of us left for Saint Michael the Archangel.

"Are you going to arrange a meeting with Father Nicholas as Father Roman suggested?"

"I think I have to," I replied. "Father Roman advised it, and I'm positive Vladyka would advise the same thing. I'll speak to Father Nicholas after the ceremony, and make the arrangements for sometime next month."

"You're going to see the doctor in prison on Wednesday, right?"

"Yes. Clarissa and I will have lunch that day, so she's riding along. She'll take Rachel to a park while I'm visiting Frank Bush."

"I'm having lunch with a group of girls from the Cathedral tomorrow. Believe it or not, Danijela Dimitrijevic is joining us."

"I think that's a good thing. I still get evil looks from her grandmother."

"Me, too! She feels I cut in line, so to speak."

"Well, I gave Danijela every opportunity, and had she been a bit more patient, Oksana would not have had the opportunity to introduce you to me."

"And?" Kris asked impishly.

"And nothing. I have no regrets and I do not wish anything different had happened after the day after Rachel was born. I'm very happy to be married to you and I am looking forward to giving Rachel a brother or sister or two."

"NO BROTHERS!" Rachel said adamantly.

"You, young lady, have no say in the matter!" I said lightly.

"Viktor is loud! Ben is loud!"

Ben was a little boy at daycare who Marcie had said seemed sweet on Rachel, but was as rambunctious as any other male toddler.

"Daddy is a boy. Is he loud?"

"Rachel loves daddy!"

"I love you too! Will you dance with me?"

"Yes!" Rachel giggled. "Like dancing!"

"_She's going to be dangerous as a teenager!_" Kris said, _sotto voce_.

"And our job is to guide her to make good decisions," I replied. "But above everything, the most important thing we can do is love her and teach her how to think for herself."

"What about God?"

"All we can do is live our lives as Christians. Preaching doesn't work."

"Then why visit the doctor in prison?"

"Doing exactly what I just said — showing Christian love. How well do you think it would work if I went in there and beat him over the head with the Gospel? Or the Creed?"

"It wouldn't."

"And it won't work with our kids, either. At one point, when I was speaking to Doctor Mercer, I reminded her of what Saint Seraphim of Sarov said — 'Acquire the Spirit of Peace and a thousand souls around you will be saved'. His advice for how to achieve that was succinct —

{_ 'You cannot be too gentle, too kind. Shun even to appear harsh in your treatment of each other. Joy, radiant joy, streams from the face of him, who gives and kindles joy in the heart of him who receives.

All condemnation is from the devil. Never condemn each other, instead of condemning others, strive to reach inner peace.

Keep silent, refrain from judgment. This will raise you above the deadly arrows of slander, insult, and outrage and will shield your glowing hearts against all evil.'" _}

"That sounds like you."

"I try."

"You do more than try, Mike."

"When I achieve inner peace, I'll let you know."

When we arrived at church, Serafima met us in the narthex.

"May I borrow my goddaughter?" she asked.

"OK to go to Serafima?" I asked Rachel.

"Yes!"

I handed Rachel to Serafima, then chatted briefly with Elias and Subdeacon Mark before the combined betrothal and crowning services. We all gathered for the services, which were identical to every other betrothal and crowning service, save the names of the couple and their sponsors. Just under an hour later, Ghost and Oksana were married, and we all gathered in the parish hall for the traditional reception. When that reception ended, I asked Father Nicholas if we could get together, and after a bit of back and forth, agreed to have lunch on August 16th, the soonest our schedules aligned.

"We have about an hour before the reception at the banquet hall," I said to Kris. "Should we take Rachel to the park? I could use more time outside."

"That sounds good," Kris said. "What about her dress?"

"We'll change her at the park, then put it back on before the reception."

I briefly considered inviting others to join us, but decided I wanted time with my family, as we had so few opportunities to be together. The three of us got into the car and drove to Milton Lake, where Rachel, Kris, and I found a shady spot under a tree. We played with a ball. Rachel, being nearly two, was just becoming coordinated enough to learn to catch and throw, but she clearly enjoyed her time with me.

I did wonder how she'd respond to a baby brother or sister, and suspected she'd get her nose out of joint either way, as she'd no longer be the sole center of attention. That was something to think about, and fortunately would be after I finished my Intern year. I was looking forward to having more kids, and that brought to mind Clarissa, and how a baby we had together would integrate into the family.

But that was for later, and as it was time to leave the park, we changed Rachel, then headed to the reception hall. The food was decent, and I did, as promised, dance with Rachel. Kris had her dances as well, and with her permission, I danced with Clarissa, though Clarissa and I were careful not to dance too close.

Kris, Rachel, and I left as soon as Ghost and Oksana departed, as I had to be at the hospital before 6:00am, and because Rachel was very tired. At home, we said evening prayers, and after putting Rachel in her crib, Kris and I went to bed.

_July 24, 1989, Circleville and McKinley, Ohio_

"Morning, Kayla," I said to Doctor Billings when I arrived in the ED about five minutes before my shift began.

"Morning, Mike. Quiet overnight. One patient waiting for admission to Medicine for gallstones. Probably surgical, but they'll assess upstairs. They said they'd take her about 6:30am."

"OK."

"How was Ghost's wedding?"

"Literally, if you've seen one Russian Orthodox wedding, you've seen them all! There's no variation permitted."

"So you have to use traditional vows?"

"Orthodox don't use vows the way other Christians do. The prayers are always the same, and have been for the best part of sixteen hundred years. We basically follow the practices of the Hagia Sophia in Constantinople, and much of what they did was handed to them by even earlier traditions."

"Istanbul?"

"That's a recent name, and literally derives from the Greek phrase 'to the city' or, colloquially, 'the big city'. Orthodox nearly always refer to it as Constantinople. But even that is a new name, as the city was originally Byzantium, from which we derive the term 'Byzantine Empire', though that's a misnomer, as it was the Roman Empire and never ceased to be. The capital was moved from Rome long before Rome fell.

"To complete the short history lesson, it was known as 'New Rome' and later the 'Second Rome', with Moscow being the 'Third Rome', reflecting the seat of the most important bishops in Christianity."

"Not the Pope?"

"Not from our perspective, but that's an even LONGER history and theology lesson!"

"Pass!" Doctor Billings said. "I find it fascinating, but I need some sleep!"

She left, and I went to find Bob and Len, who were in the lounge with Doctor Nielson and a woman I didn't recognize.

"Mike, this is my wife, Shelly," he said. "Shelly, Doctor Mike Loucks."

"Nice to meet you," I said to the pretty strawberry blonde who I estimated was about five months pregnant.

"Shelly's here for a pre-natal check with Alice Carmichael."

"Isn't it a bit early for that?" I asked.

"Shelly teaches English at the High School, and she's teaching summer school, so Alice did us a favor by setting up a 6:15am appointment here."

"Speaking of which, I should go upstairs," Shelly said to Perry. "I'll let you know before the ultrasound starts."

They exchanged a kiss, and she left.

"When did you guys meet?"

"About a month before I Matched at Cook County. We hit it off right away and were married that summer. She finished her degree just as I finished my Residency and did her student teaching in Columbus. She was hired at the High School the following year."

That made her about ten years younger than him, which seemed fairly common with doctors. Ghost was about eight years older than Oksana, and I was about eight years older than Kris.

"Cool. Excuse me, if you would."

"Sure."

I went over to Bob and Len and asked if they'd had breakfast. They hadn't, so I had them take turns, and both were back before 6:45am. We handed the gall bladder patient to Clarissa and then began taking walk-ins. The first one was a second-degree burn and was routine. When we returned, there was a hand lac, which upon evaluation, I decided Bob could handle, so I had him and Len take the young man to Exam 6 for sutures.

"What else do you have?" I asked Jack, the Fourth Year at the desk.

"Fourteen-year-old with severe nausea."

"Sudden onset?" I asked.

"Last couple of days. Her mom was concerned, so brought her in."

"Only in the mornings?" I inquired.

"I, uhm, didn't ask. You think it's morning sickness?"

"Fidgety fourteen-year-old presenting with nausea this early? It's a thought. How is the mom?"

"Mama bear," he replied.

"Wonderful," I replied. "Let me get a nurse and we'll take her."

I went to the nurses' station and asked Ellie for a nurse, and was assigned Kellie, which made me happy, as I was sure she and I could cooperate to find out if my suspicions were true without provoking 'mama bear'.

"Mary Josephson?" I called out.

"Here," a woman of about forty with a pretty girl with long blonde hair next to her said.

"If you'll come with us, please, we'll get Mary checked out."

Mrs. Josephson and Mary followed Kellie and me to Exam 4, where I had Mary get onto the table.

"What's bothering you, Mary?" I asked.

"She's been sick to her stomach the last few days," Mrs. Josephson said before Mary could answer.

I smiled and turned to Mrs. Josephson, "Thanks. I've found that this works better if the patient answers. Would that be OK with you?"

Mrs. Josephson eyed me suspiciously, but nodded and said, "Yes."

"Mary?"

"I've been throwing up the last three days," she said.

"Before you eat, after you eat, or both?"

"Mostly before, but I feel kind of sick all day."

"Is it as bad in the evening? You know, around bedtime?" I asked, trying to avoid using 'morning' or 'breakfast' as I didn't feel things would turn out well if Mary was pregnant.

"No."

"Have you had a fever, cough, or runny nose?"

"No."

"What about hitting your head or being in an accident?"

"No."

"Any trouble hearing? Or do you have ringing in your ears?"

"No."

"Do you wear glasses or contacts?"

"No."

"Are you seeing double or is anything blurry?"

"No."

The one-word staccato answers gave me the strong impression that Mary suspected the same thing I did, and the question was how I could ask the key questions without setting off 'mama bear', as I felt even asking the question would cause a severely negative response.

"Are you on any medication or taking any drugs, vitamins, or supplements?"

"Just a vitamin every morning," Mary replied.

"A multi-vitamin with iron," Mrs. Josephson interjected. "Her doctor recommended it."

"Is she anemic?"

"The doctor didn't say."

"OK," I replied, then turned back to Mary, "Let me examine you, please. If you could untuck your blouse and open the top two buttons, that'll be enough for me to listen to your heart and lungs."

While she did that, I washed my hands and put on exam gloves.

I ran through the usual set of exams — auscultation, ears, eyes, nose, throat, glands, palpation, and checking distal pulses, then had Kellie take Mary's blood pressure and temperature.

"I don't see anything obviously wrong," I said. "Mrs. Josephson, I'd like to draw some blood and get a urine sample and run some tests, please."

"What do you think is wrong?" she asked,

"At this point, I don't have any indications of the obvious things, such as a virus or appendicitis or food poisoning, so the next step is either 'wait and see' or blood tests. It's your choice, of course, though I'd recommended the tests."

"What would they show?"

"Any abnormalities in her blood chemistry, with the main thing I'd look for is an increased white cell count, which would indicate some kind of infection."

"Go ahead."

"Kellie, CBC, Chem-20, hCG, and urinalysis."

I hoped that using 'hCG' rather than saying 'pregnancy test' would work, and it appeared to, as Mrs. Josephson didn't react. Kellie wrote it on the chart and handed it to me to sign, which I did. While Kellie drew the blood and obtained a urine sample, I went to check on Bob and Len. There were no concerns, and I asked Len to come back to Exam 4 so he could take the blood and urine to the lab.

"How long will this take?" Mrs. Josephson asked.

"We should have the results in about an hour," I replied. "If you'd like to get coffee, the cafeteria is straight down the corridor. Kellie will stay with Mary while you go."

"You won't treat her without my permission, will you?" Mrs. Josephson asked.

"Only in the event of an immediate, critical illness which would put her life at risk. I don't see any indication of that necessity. Otherwise, as she's a minor, we'd need your express permission, which is why I asked you about the blood and urine tests, not her."

"Maybe I will get some coffee," she said.

"Turn right out of the room, follow the corridor to the other end of the hospital, and it'll lead you straight into the cafeteria."

She left, and I looked to Kellie and said, "NVP."

That was 'nausea and vomiting of pregnancy' and was the medical term for 'morning sickness'.

"Mary, have you started having your periods?" Kellie asked.

Mary bit her lip and nodded, and I knew right then what the tests would show.

"When was your last period?"

"The end of May."

Which was exactly the right timing, as NVP typically began in the fourth week of pregnancy, and if I was right, Mary would have conceived mid-June, either on or just after her fourteenth birthday.

"Is there any chance you could be pregnant?" Kellie asked.

Mary didn't answer, but the tears streaming down her face told the story. Kellie and I exchanged a look, and I nodded, got up, and left the exam room. I went to check on Bob and signed off on the sutures, and he streeted the patient. I asked him and Len, who had returned from the lab, to wait in the lounge, and seeing Mrs. Josephson coming back, I went into the exam room where Mary had stopped crying. When Mrs. Josephson came in, Kellie and I excused ourselves, saying we'd check on Mary in about twenty minutes, and then went to the consultation room.

"She doesn't want us to tell her mom," Kellie said.

"I'm not sure we have a choice," I replied. "Hospital policy is fifteen and up, and it's going to be tough to get a social worker to speak to her without her mom in the room. Do we know anything about the guy?"

"A classmate. They were playing 'Spin the Bottle' and 'Truth or Dare' at her birthday party and hormones took over."

"So close in age?"

"Yes. They'll both be Freshmen in the Fall."

"No indications of abuse or force?" I asked.

"No," Kellie replied. "It was pure hormones. I know how that is! I had a scare at fifteen which taught me to be VERY careful. She said it happened again a few days later."

"I know about hormones in High School," I replied. "But I was frustrated until after graduation! Anyway, if the tests come back the way we think they will, I don't see that we have much choice."

Kellie frowned, "No, we don't. Do you want to ask Doctor Nielson or Doctor Gibbs?"

"Even if we get an exception, then what? She needs either pre-natal care or the services of the Free Clinic."

"I had you pegged as solidly 'Pro Life'."

"Because I am," I replied. "But I'm also a physician with a duty to my patients and with an admission that as evil as I think abortion is, it's not up to me. I won't impose my morals on anyone, though I would counsel for adoption if I was asked."

"You don't want it banned?"

"Did the fact that it was illegal stop it?"

"No, of course not. It just made it extremely dangerous. What do we do?"

"Get the blood test results and present them," I said. "Then refer them to Family Services or the Free Clinic."

"What about having the social worker in the room?"

"We'd have to wait until 9:00am for that, and we'll have the blood tests back by 7:30am. I think you and I have to do it, and do our best to calm both of them down. I take it Mary is not in denial?"

"No," Kellie said. "She knew, even if she didn't have proof beyond having had sex and having missed her period. On the bright side, we don't have to involve the law even though she's under the age of consent because the boy is fourteen."

We walked out of the consultation room and we saw Mrs. Josephson and Mary, leaving the exam room.

"Mrs. Josephson?" I called out.

"We're leaving!" she declared. "Cancel those tests!"

"I'm not allowed to do that once they're on the chart," I replied.

"Then tear up that chart!" she demanded.

"I can't do that, either," I replied. "It's a legal document."

"My husband is an attorney, so we'll just see about that! I want to see whoever is in charge!"

"That would be Doctor Gibbs," I said, then turned to Kellie, "Would you ask Doctor Gibbs to come to the consultation room, please?"

I felt that was better than trying to convince Mrs. Josephson to return to the exam room.

"Right away, Doctor," Kellie said, becoming formal.

"Mrs. Josephson, let's go to a small meeting room so you can have the conversation with my supervisor in private."

Thankfully, she acquiesced to the request, and I escorted her and Mary to the consultation room that wasn't doubling as the Resident's office. Kellie returned with Doctor Gibbs and we huddled in the corridor before going into the room.

"Mary Josephson, fourteen, with morning nausea, a missed period, and recent unprotected sex. I ordered a pregnancy test, along with CBC and Chem-20, and the patient's mom is trying to take her AMA. She also demanded I stop the tests and tear up the chart. When I said I couldn't do those things because the chart was a legal document, she threatened legal action, saying her husband is an attorney."

"No positive pregnancy test as yet?" Doctor Gibbs asked.

"No. Kellie?"

"She admitted two instances of unprotected sexual intercourse," Kellie said. "The timing is consistent with her missed period and nausea."

"Does Mom know?" Doctor Gibbs asked.

"No. I used a bit of subterfuge by asking Kelle for hCG and then suggested Mrs. Josephson get coffee while we waited for the blood and urine results. When she left, I asked about possible pregnancy, and when the patient began crying, I left and allowed Kellie to handle it. No signs of abuse, no other symptoms, generally healthy, and the patient reports her partner was the same age."

"Technically not AMA," Loretta observed. "But the same result. I'm going to surmise the mom guessed and wants no records."

"I'd say that's a safe bet, Doctor," Kellie interjected.

"What was your plan, Mike?" Doctor Gibbs asked.

"Referral to the Free Clinic and Family Services. Reporting is discretionary, and I suggest not reporting this given the ages and circumstances."

"No alcohol or drugs?" Doctor Gibbs asked.

"Just hormones," Kellie said.

"OK. Let's go speak with them. Kellie, you join us."

The three of us went into the consultation room and I shut the door behind us.

"Mrs. Josephson, this is Doctor Loretta Gibbs, Chief Attending. She's in charge of the Emergency Department today."

"This doctor is running tests without my permission!" Mrs. Josephson said before Doctor Gibbs could speak. "I want it stopped and all the records destroyed!"

"Mary," Doctor Gibbs said, "was your mom in the room when the nurse drew the blood?"

"DON'T ANSWER THAT!" Mrs. Josephson ordered. "JUST BE QUIET!"

"Yes," Mary said anyway.

"MARY! I SAID BE QUIET!"

Mary began sobbing, and Kellie handed her some tissues.

"Mrs. Josephson," Doctor Gibbs said, "hospital charts are legal records and we're forbidden from destroying them. They are not public, and nobody has access to them without a court order except medical staff, the patient, or their parents, if they're a minor."

"My husband is an attorney, so we'll just see about that! We're leaving!"

"That is your right," Doctor Gibbs said. "That said, if you leave before the test results come back, and they show what Doctor Mike and Kellie suspect, we're required to report it to Family Services."

"Don't you dare!" Mrs. Josephson said.

"The only way to avoid that is to wait for the test results and have a consultation about them, at which point we'll provide you with information and options."

"This is none of your business! If you report this, I'll sue!"

"Which," Doctor Gibbs replied, "is your prerogative. Kellie, get an AMA form, please."

"What's that?" Mrs. Josephson demanded as Kellie left the room.

"It's a form we fill out when a patient leaves 'Against Medical Advice'. You'll need to sign it."

"I'll do no such thing! And you can't keep us here! That's kidnapping!"

Technically, it was illegal restraint or something similar, as I'd been taught how to respond to possible kidnappings in our practice of medicine, and they involved taking someone from one place to another, which we hadn't done, as Mrs. Josephson had brought Mary to the hospital and had walked to the exam room with her.

"You can, of course, refuse to sign, but the three of us will sign it and file it with the hospital administration."

"I SAID NO RECORDS!" Mrs. Josephson insisted.

"I understand, but we have legal requirements," Doctor Gibbs said. "We could all lose our licenses, or worse, if we don't follow them."

"I'll get your licenses revoked!"

"I can see we're not going to make any progress here," Doctor Gibbs said. "I'm informing you that you are taking your minor daughter from the hospital against medical advice, and I encourage you to reconsider."

"We're leaving!" Mrs. Josephson declared. "Mary, let's go!"

She basically dragged her sobbing daughter from the consultation room and out the doors to the waiting room as Kellie returned with the AMA form.

"Well, that went well," I sighed.

"And exactly how do you think you'd react if Rachel were to become pregnant at fourteen?" Doctor Gibbs asked with a slight smile.

"Don't ask," I replied flatly.

"Exactly. As loving and kind and caring as you are, you'd still react badly. Your personality and demeanor are such that you might not show it outside, but inside you'd be looking for your shotgun."

"Perhaps," I replied. "But that would also be hypocritical."

"Dads are like that," Kellie said. "I had one! It's normal."

"Me, too!" Doctor Gibbs said. "Unfortunately, in this case, Mrs. Josephson made her predicament worse. Had she simply stayed for the confirmation test, we'd have referred her to a social worker and the Free Clinic. Now we'll have to report it because we'll have a positive pregnancy test for a fourteen-year-old and can't bypass reporting by discussing it with the girl's parents. If she were fifteen, it would be a judgment call, but not at fourteen without parental notification."

"That's likely to end very badly," I observed.

"Maybe so, but you know the law expressly says sixteen and we're given leeway with fifteen-year-olds who are mature, and who, in our medical judgment, are capable of making a decision. With girls under fifteen, we really have no alternative except parental notification and referral. As much as I hate to say it, we have to cover our butts."

"You think the mom would claim we hid the pregnancy?" Kellie asked.

"In a heartbeat," Doctor Gibbs said. "When I was doing my OB/GYN rotation during Third Year, we had a mom similar to this one who lost her mind and claimed we never told her that her fourteen-year-old daughter was pregnant. The girl had suffered a ruptured ectopic and died."

"Lord have mercy."

"Denial is not just a river in Egypt," Doctor Gibbs said. "Fill out the AMA form, you and Kellie sign it, then bring it to me. I'll make sure it's filed with legal. When the tests come back, fill out the contact report for Family Services and take it to Jeanne Wilders."

"Wonderful."

"I agree, Mike, but we don't have a choice."

She left and Kellie and I filled out the AMA form and contact form. Kellie and I both signed the AMA form, and she took it to Doctor Gibbs' office. The lab results came back a few minutes later, and confirmed that Mary was pregnant, so I signed the contact form and then walked down the corridor to Jeanne Wilders' office.

"Hi, Mike!" she said. "Oh, sorry. Doctor Loucks!"

"Doctor Mike, if you have to use the title, but just 'Mike' is fine."

"How are you?"

"Good."

"And your daughter?"

"Growing like the proverbial weed! I don't get to see her enough."

"The lament of every Intern who has children. Is there something you need?"

"Me, no? I have a contact form for a pregnant fourteen-year-old whose mother dragged her away AMA before we had the test results."

"Consensual? And I don't mean that in a legal sense."

"As far as we can tell, yes. She told Kellie Martin that she had been playing 'Spin the Bottle' and 'Truth or Dare' at her birthday party and hormones took over. She had another consensual encounter a few days later."

"Happy birthday," Jeanne said sarcastically.

"Yeah. Mom was out of the room when the girl admitted her encounter to Kellie, but deduced the problem and demanded we cancel the tests and destroy any record we'd seen the girl. She then refused to sign the AMA form and basically threatened to sic her husband, who is an attorney, on us."

"She made her problem infinitely worse," Jeanne observed.

"We tried to explain that, but Mrs. Josephson, the mom, wasn't thinking clearly."

"I'm not sure I'd think clearly if my teenage daughter were pregnant, and I'm trained to handle things like that!"

"As Doctor Gibbs pointed out, it's different when it's your own kid."

"Let me have the form and I'll put the wheels in motion. How old was the partner?"

"Same age. Mary said they'll both be Freshmen in the Fall."

"Then I don't have to involve law enforcement. You know the guidelines there, right?"

"Close in age, and over thirteen, and it's at your discretion."

"And medical findings except the pregnancy?"

"No. She's perfectly healthy, properly developed, well-nourished, and there were no signs of injury or abuse. I did not do a gynecological exam."

"You wouldn't normally, right?"

"Correct. Only in the case of some kind of trauma or an abnormal sign, and even then, I'd call for an OB consult if it wasn't life-threatening."

"That guideline hasn't changed, then."

"No. And I did have Kellie Martin in the room with me at all times."

"Good. OK. If I need anything, I'll let you know."

I left her office and returned to the ED and let Doctor Gibbs know I'd handed in the form.

"I'm sure I don't have to remind you not to discuss this with anyone except me or Jeanne Wilders."

"You don't, but I also know you have to say it when there's a threat of legal action, even if it's obviously BS. I strongly suspect that right about now, Mrs. Josephson is regretting not taking Mary to see her gynecologist."

"I'd say that's a safe bet."

"Mike?" Kellie said from the door. "Nate just let me know there's an MI three minutes out."

"OK," I said. "Let Bob and Len know, please."

"Already did!" she replied.

I left Doctor Gibbs' office, gowned and gloved, and headed for the ambulance bay with Kellie. Bob and Len were there waiting, and I gave my preliminary orders. A minute later, the EMS squad rolled up and stopped.

"Patient arrested about a minute ago," Bobby exclaimed, hopping out and moving quickly to the back of the squad.

"Bob, chest compressions," I ordered. "Get on the gurney as soon as they get it out of the squad.

Thirty seconds later with Bob on the gurney doing chest compressions and Bobby's partner Sam bagging, we moved toward Trauma 2.

"Will Breckenridge, fifty-two, collapsed in his driveway," Bobby said. "BP 80 palp, pulse was thready at 80; diaphoretic; PO₂ was 91% by mask."

We quickly transferred the patient to the trauma table, with Len taking over compressions while Bob hooked up the EKG and I intubated and hooked up the ventilator.

"Asystole," Bob called out.

"Kellie, epi down the tube!" I ordered.

She quickly complied and there was no change on the monitor.

"Len, stop compressions," I instructed.

He did, and I listened and shook my head, "Nothing. Kellie, another dose of epi, IV push."

She did that and there was still no change. I asked Len to stop and once again auscultated and heard no heart sounds. I checked the patients pupils and once again shook my head. The EKG showed a flatline, so defibrillation would be ineffective.

"He's been down six minutes," I said. "Kellie, would you get an Attending, please?"

She left and returned with Doctor Nielson.

"Arrested during transport," I said. "Two doses of epi in; no heart sounds; no pulse; no shockable rhythm; pupils fixed and dilated."

He checked for heart sounds, checked the patient's pupils, then looked at the EKG.

"Call it."

"Time of death, 08:42," I said.

"I'll get the death kit," Kellie said.

"Thanks," I replied.

I made notations on the chart then left the room with Bob and Len following.

"My dad is fifty-two," Len observed quietly.

"So is mine," I replied.

"That guy looked pretty healthy."

I nodded, "Not overweight, and he appeared to be in decent shape, but as you know there are no external signs of arteriosclerosis and a host of other cardiac problems. And we won't know what did him in until Doctor McKnight does an autopsy.

"Mike?" Ellie said. "The MI's wife is in the waiting room."

"OK. Name?"

"Evelyn Breckenridge."

"Thanks. Call for the chaplain, please."

"One moment."

She placed the call and three minutes later, the chaplain for the day, Robert Hamilton, a Lutheran pastor, arrived.

"Bob, we'll be in the consultation room. Please bring in Mrs. Breckenridge. You know how to answer, right?"

"That I'm not a doctor and you'll explain everything."

"Exactly."

"Len, let Kellie know we might bring in his wife, then come to the consultation room.

"Will do," he replied.

Bob went to the waiting room and Len did as I asked before joining Robert and me in the consultation room.

"Fifty-two-year-old male collapsed in his driveway," I said quietly to Robert. "Arrested during transport and arrived with no vitals. We were unable to revive him."

"OK," he agreed.

"Doctor Mike," Bob said coming into the room with a woman of around fifty. "This is Mrs. Breckenridge."

"Hi, Mrs. Breckenridge," I said.

"How is my husband?" she asked nervously.

"Have a seat, please," I suggested.

She sat down and Robert and I followed suit while my students stood along the wall.

"Mrs. Breckenridge," I said. "When the paramedics arrived at the hospital with your husband, he was receiving CPR. We immediately took him to a treatment room and began life-saving procedures. We used all our skills and abilities, including drugs and equipment, but we could not restart his heart and he died. I'm sorry."

She put her head in her hands and began crying.

"This is Robert Hamilton," I said. "He's the hospital chaplain and will help you. If you'd like to see your husband, we can arrange that."

She took some tissues Robert offered her and blew her nose, then asked, "Can you take me to him?"

I nodded and Robert assisted her, allowing her to lean on him, and we went to the trauma room, stopping just outside the door.

"You're going to see a tube in his mouth," I said. "Along with wires and other equipment."

"OK," she said.

We went into the room where Kellie was going through the death kit, but had covered the patient with a clean, white sheet. Mrs. Breckenridge wailed loudly and quickly moved to her husband's body, and laid across his chest.

"I've got this, Mike," Robert said quietly.

"Thanks."

I motioned to Bob and Len, and we left the room.