Chapter 29: I Agree With Doctor Mastriano

July 31, 1989, McKinley, Ohio

"I may have to take off on the 21st of next month," I said to Doctor Gibbs on Monday morning. "The INS sent subpoenas for both Kris and me to appear for interviews. She's going to ask her attorney to request that INS conduct the interviews here at the hospital, but I suspect that will fall on deaf ears."

"An actual subpoena?"

"Yes. Both letters are entitled Subpoena ad testificandum, a command to appear and testify."

"Bring me a copy and you can have the time off. Finding coverage is our responsibility, not yours. That's hospital policy with regard to subpoenas. It's meant mostly for medical cases, but it doesn't say that in the policy manual."

"I'll probably only need about twelve hours," I replied. "The appointment is at 9:00am and I can't imagine it would go past 5:00pm, and I can be here by 6:00pm. We will see if the interview can be moved, but if not, then I'll take advantage of that policy."

"Any concerns?"

"No. The main thing they're looking for is evidence of a sham marriage. According to our attorney, the fact that Kris has her Green Card and legally adopted Rachel is dispositive, though the government will go through the motions to ensure it's not a sham."

"Do they really ask questions about sex?"

"According to our immigration attorney, not in our case. That appears to be a key deciding factor for many situations, but it's silly because a bit of planning can defeat any questions they could ask, and I seriously doubt they'd get away with asking for a demonstration!"

Doctor Gibbs laughed, "'Please demonstrate how this is accomplished'?"

I chuckled, "My response would be identical to Pulaski's — 'Not likely'. Though, had it been Crusher instead of Pulaski, I suspect she'd have happily demonstrated with Picard!"

Doctor Gibbs smirked, "'Wesley, the Prime Directive isn't the only thing I regularly violate on this ship!'"

I laughed hard, "A perfect line for the guy who goes to the planet where literally everyone gets laid and where they make love at the drop of a hat — any hat — and ends up with the death penalty for trampling flowers."

"Worf had the best straight line in that regard — 'Go to her door. Beg like a human'."

I chuckled, "And Worf's description of Klingon mating rituals sounds suspiciously like dating and marrying a Russian woman!"

"Did you warn Ghost?"

I chuckled, "No, because the benefits far outweigh the suffering! In that way, it's like surgery."

"Go heal the sick!"

I left the office and went to find Kylie so we could do shift turnover.

"Two waiting on beds in Medicine," she said. "Or, rather, waiting until the lazy Resident goes off shift. Clarissa will take them right away, I'm sure."

"Have you reported that?"

"I let Doctor Nielson know before he left this morning. This is the third time. The first time, OK, sure. The second, maybe? The third? No way. And I asked one of the nurses. There are eight open beds."

"Wonderful," I said, shaking my head. "Anyway, I may need coverage for concerts in September and October," I said.

"None this month?"

"At Taft, but it's a Friday night, so I'll gut it out. Once the new schedules hit on August 15th, I'll talk to you about September and October. Anything else?"

"No. It was a mostly quiet night."

"How's your mom?"

"Still alive and kicking, which wasn't a sure thing back when we traded shift schedules."

"That's good to hear."

"And your family?"

"Rachel will be two at the end of August, and she's asserting herself."

"Having more?"

"That's the plan!"

"You proved to my satisfaction you know how that's accomplished!"

I laughed, "Fortunately, only as practice!"

"Fortunately! I'm outta here!"

She left, and I went to the lounge to find Bob and Len.

"Up to speed on the two admissions?" I asked.

"Yes," Bob replied. "Now that it's 6:00am, I'll call upstairs and speak to Doctor Saunders and get them transferred."

"Good. Len, let's go see if there are any walk-ins."

There was actually nobody waiting, so I sent Len to have his breakfast, and I sent Bob for his once the two patients had been admitted. I picked up my first paycheck, or rather a receipt, as the money was direct deposited into my bank account, then went to the lounge.

"Morning!" I said to Ghost when he came into the lounge just before 7:00am. "How was your week off?"

"Enjoyable! Loretta said you had an interesting week."

"You could say that."

"You're going to clash with Psych for the rest of your career. I tend to agree with you, but I'm not nearly as passionate. Just be smart about it."

"Did Lor tell you I'm seeing a counselor recommended by Shelly Lindsay?"

"No. It's almost always off limits to reveal counseling, for reasons I suspect strongly you understand."

I nodded, "To avoid stigmatization, among other things. In my case, it really comes down to what happened with Angie, which sensitized me to mental health issues, something also reinforced by a friend's attempted suicide and another friend's successful suicide, along with my own battles with depression on more than one occasion."

"I've had my own struggles, though nothing compared to yours."

"Ghost? Mike?" Ellie called from the door of the lounge. "Nate says EMS is on scene of a high-speed MVA. Four victims, but no ETA due to potentially lengthy extrication. We're clearing all four trauma rooms."

"Any further details?" Ghost asked.

"No," Ellie replied. "Just Doctor Gibbs saying it's an all-hands-on-deck response."

"Thanks," Ghost said.

"This is where we need paramedics who can intubate," I observed. "Or doctors responding to the site."

"We're understaffed as it is," Ghost said. "The juggling I'm going to have to do with the schedule will be worthy of a circus!"

"Have you heard of Sergej Ignatov?" I asked.

"No."

"A Russian who's called 'The Poet of Juggling'. He often juggles seven balls and holds the world record for juggling eleven rings in the early 1970s."

"That's about what I need for the next ten months. Cutting PGY1s back to eighty hours didn't help, and means PGY2s will be on eighty hours and PGY3s on seventy-two. All Attendings are on sixty hours. And having to have a babysitter for one Attending doesn't help, either."

"For how long?"

"End of August, though ultimately it's up to Northrup. I really need those additional two Residents right now. We're busier than we've ever been, and it's only going to get worse. Patient loads are up nearly twenty percent since last year and fifty percent over five years."

"EMTALA. I've treated more people who should have been seen by a GP or a 'doc-in-a-box' than I have severe traumas."

"And it's going to get worse," Ghost replied. "Shall we go slum by the ambulance bay doors?"

We got up, grabbed gowns and gloves but didn't put them on, and went to stand with a gaggle of other ED staff by the door.

"I called for a surgical Intern and one from Medicine," Doctor Gibbs said. "The Medicine Intern will cover anything that comes in while we're on this trauma, and the surgical Intern will pitch in where we need them."

"Which one?" I asked.

"Mary Wilson. Concerns?"

"No, just curiosity."

"Somebody called for the best Intern in the hospital?" Clarissa asked, coming to join us.

"I'm already here," I chuckled.

"277, Petrovich!" she exclaimed.

"Double valedictorian!" I countered.

"And yet, I still had the highest MLE Step 2 score in the history of the medical school!"

"By one point!"

"Now, children..." Doctor Gibbs warned. "Clarissa, you'll need to cover walk-ins. Take the Third years — Len, Kim, and John — to assist. Ellie can fill you in on the patients in the exam rooms."

"What's coming in?" Clarissa asked.

"Four high-speed MVA victims."

"ETA?" Doctor Wilson asked, walking up to us with a male student in tow.

"Lengthy extrication," Doctor Gibbs said. "Send your student to help Clarissa."

"Let's go, little ducks," Clarissa said to the Third Years.

I laughed as the four students followed her towards the triage desk.

"First squad is three minutes out with two victims," Nate called out. "Other two are still being extracted."

"We'll double up," Doctor Gibbs said. "Mike, with me; Mary, with Ghost. We'll take the first two. Chuck and Naveen wait for the next squad. Send a nurse to me if you need surgical help."

Two minutes later, the first squad rolled up, and Bobby jumped out.

"First patient male, about thirty, restrained passenger; Multiple crush injuries; possible collapsed lung; tachy at 120; BP 80/50; PO₂ 92% on ten litres; GCS 6; IV saline TKO, backboard and cervical collar."

"Trauma 1 with me!" Doctor Gibbs ordered.

She, Bob, nurse Jamie, nurse Anne, Bobby, and I quickly moved the patient towards Trauma 1.

"Mike, verify the collapsed lung and get a chest tube in; Bob, EKG and monitor then Foley; Jamie, a unit of plasma; Anne, full trauma panel."

We reached the room and rolled the gurney next to the trauma table.

"Carefully, on my count!" Doctor Gibbs ordered. "One ... two ... three!"

We hoisted the backboard with the patient on it to the trauma table, and after disconnecting the oxygen bottle, Bobby left.

"Absent breath sounds on the left," I announced. "Chest tube tray to me!"

"Plasma running!" Jamie announced. "Chest tube tray to you, Mike!"

"Sinus tach!" Bob announced.

I glanced up at the monitor and confirmed his read.

"Agreed," I said.

Jamie brought the chest tube tray, and I began the procedure.

"Foley is in!" Bob announced. "Blood in the bag!"

"Flail chest, right side; possible skull fracture; crushed right arm," Doctor Gibbs announced.

The patient was, in ED parlance, a 'train wreck'.

"Rigid abdomen," Doctor Gibbs announced. "Surgical belly."

"Let me finish the chest tube, and I'll confirm," I replied. "Anne, I need the ultrasound cart."

"I'll get it and give the blood to a student to run to the lab."

I finished the tube and auscultated the patient's lungs.

"Weak bilateral breath sounds," I said. "PO₂ hasn't come up. He needs a vent before I confirm the belly. Intubation tray to Bob!"

I supervised Bob putting in the endotracheal tube, and once he'd hooked up the vent, I verified bilateral breath sounds.

"Good bilateral breath sounds," I said.

The monitor blared, and Doctor Gibbs called out, "V-fib! Charge to 200!"

"Paddles to you," Jamie said to Doctor Gibbs, moving the defibrillator to her.

I grabbed two pads and slapped them on the patient's chest just as the machine pinged.

"CLEAR!" Doctor Gibbs ordered.

We all raised our hands, I disconnected the vent, and Doctor Gibbs applied the shock as Anne returned to the room with the ultrasound.

"Sinus tach," I said, then reattached the vent tube and auscultated. "Weak heart sounds. Suspect tamponade or effusion. I need a pericardiocentesis tray!"

Anne grabbed one, removed the cover and set it on the stand next to me, replacing the chest tube tray. Before I could begin, the monitor blared again.

"V-fib!" Bob called out.

"Charge to 200!" Doctor Gibbs ordered.

Before the machine was ready, I heard the continuous monotone from the monitor and looked up.

"Asystole!" I announced. "Beginning compressions!"

"Anne, 1 meg of epi, IV push!" Doctor Gibbs ordered as I began performing CPR.

"Bob, take over compressions," Doctor Gibbs said. "Mike, resolve that tamponade!"

Bob took my place, and as quickly as I could, I performed a blind pericardiocentesis.

"Blood in the syringe," I announced, knowing what that meant.

"Bob, stop compressions!" Doctor Gibbs ordered.

She listened for his heart and shook her head.

"Bob, resume compressions; Anne, another meg of epi!" she ordered.

Two minutes later, nothing had changed and after checking pulse, pupils, and cornea, Doctor Gibbs shook her head.

"Time of death: 07:13."

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

"Mike, let's see if anyone needs help."

Ghost's patient hadn't made it, but the other two were still alive, so we pitched in to help and sent one upstairs with Mary for emergency surgery while the other continued to be treated in the ED.

"Mike, see what Clarissa has and relieve her," Doctor Gibbs said.

"Right away!" I acknowledged.

I found her in Exam 3 and asked her to step out.

"How'd it go?" she asked.

"Two didn't make it; one needed emergency surgery; they're still working on the other one, but she should make it. What do you have?"

"Two needing sutures, which Len and Kim are doing, and John is splinting a broken finger."

"Doctor Gibbs said to relieve you; Bob and I will take over."

"Then I'm off!"

"That's for sure!" I teased.

"277, PetroviChapter 277."

"Go back to pushing pills, Lissa!"

She stuck her tongue out at me, winked, then headed for the stairs.

"I take it you two have an extensive history?" Bob asked.

"Partners in crime since Freshman year at Taft. We agreed to go to medical school together, serve our Residencies together, and practice together."

"But you couldn't marry?"

"Clarissa's girlfriend might have something to say about that."

"Oops. Sorry."

"Nothing to apologize for. She doesn't advertise, but she also doesn't hide it. Check on our suturing ducklings, please."

"Can I have you sign my procedure book for the intubation?"

I took his book, signed it, then added a notation he was cleared for unsupervised intubation.

"You think so?"

"I didn't have to guide you, and you got it right, with time to spare. The chances you'll need to do one unsupervised are slim, but you can let any Resident or Attending know you're completely cleared. Good job on the EKG as well."

"I should have called out 'Asystole'."

"I beat you to it because it's basically a reflex for me from Fourth Year. I should have let you do it. Would you supervise Len and Kim, please? I'll check on John and his splint."

"Right away, Doc. Thanks for the faith."

"Keep doing what you're doing."

We cleared the three patients, along with two more walk-ins, before another EMS run for a rule-out MI, who we admitted to cardiology with uncontrolled A-fib. I had lunch, and we had a steady flow of patients during the afternoon. I joined Kris, Rachel, and Clarissa for dinner in the cafeteria.

"Mr. Burge said it's very unlikely the government will agree to do the interviews at the hospital, but he'll ask. He strongly suggested not trying to change the date because the usual response is for the government to put it off for months and then to be difficult about it."

"OK," I replied. "Doctor Gibbs said if I bring a copy of the subpoena, I can have the time off, and the hospital will find someone to cover the hours."

"Subpoena?" Clarissa asked.

"That's how INS summons you for a citizenship interview," I replied. "And they put you under oath, too."

"All to decide if the marriage is real?"

"Pretty much," I replied. "You remember the idiocy when we returned from Europe, right?"

"Of course."

"That was when they questioned your marriage to Elizaveta, right?"

"Yes, though that was because she was sixteen. They weren't the only ones who looked askance, but Ohio law permitted the marriage. The Federal law they might have tried to apply — The Mann Act — expressly does not apply to married couples, and marriage is a state function, not a Federal one, just as driver's licenses, medical licenses, and other licenses are."

"You know it makes no sense to me that you can be a doctor only in Ohio," Kris observed.

"I realize, but occupational licenses, with a few exceptions such as pilots and ship captains, are all issued by the states. That said, it would be simple and straightforward to obtain a medical license in another state, so long as my license in Ohio is in good standing. Of course, I have to get it first."

"What about now?"

"So long as a hospital hires me, the Chief Attending, or whoever is supervising me, needs a license. I don't."

"So you have more freedom now than when you're licensed?"

"In the sense of government control? Yes. But, transferring Residency programs is not easy to do because slots are limited, especially the further on you go. There simply aren't that many that are open because someone would have to drop out, transfer, or die, and that just doesn't happen very often. So, while I have some freedom to change, I don't really have the opportunity. Granted, I could switch to an unfilled PGY1 slot in another specialty, but that's not a real option."

"But don't you think everything should be consistent across the country?"

I shook my head, "No. In fact, the system was expressly designed to prevent that. People in Ohio do not want people in California or New York telling them what to do and how to live any more than people in New York or California want people in Ohio telling them how to live. That's the entire point of the US Senate, which is meant to represent the states and ensure that simple majorities cobbled together from the largest states cannot overwhelm the small states. Without what was called the Connecticut Compromise, the Union wouldn't exist, which is why the Constitution forbids removing equal representation among the states via the amendment process unless it's on a unanimous vote of every state legislature."

"I remember that," Kris said. "I just don't agree."

"And so long as you only disagree via rhetoric, we're fine. Heck, you can even wave your red and black banner! You just have to promise not to have ever advocated violent overthrow of the government!"

"But that's what your Founders did!" Kris countered.

I chuckled, "Do as I say, not as I do. But the second Civil War ended that."

"Second?" Kris asked.

"Petrovich is just being himself!" Clarissa interjected. "He's going to point out that the Revolutionary War was actually a civil war for independence from Great Britain. Well, either that or that it was British subjects fighting for traditional British rights against a German king and his German mercenaries."

"You know me too well, Lissa!" I chuckled. "But both those statements are accurate."

"Mr. Black must have been a fun teacher."

"The best!"

"Who's that?" Kris asked.

"I've mentioned him before — he taught English and Current Events and was a font of all manner of interesting trivia, and he had a quirky take on history, including the comment about the German King."

"The Germans are always causing trouble!" Kris declared.

"Including founding France," I teased.

"How have you put up with him for so long, Clarissa?" Kris asked playfully.

"I ask myself that question almost every day!" Clarissa teased.

"At least ONE woman here appreciates me, right Rachel? Love Rachel!"