God, Sid hated this new vital sign.

Somebody, somewhere in some federal place far beyond his scope had decided pain was a new vital sign.

Sid suspected there had been some congressional hearings and outrage and coverage that got everybody’s shorts in a twist. So now there was this new mandate that the health professions include pain in the vital signs.

Sid loved the vitals. When a nurse woke him up at 3AM, he listened, then asked for the vitals. They told so much. They were vital.

There are only four, until this bullshit of making pain the fifth.

They could all be measured.

Weight. Old guy gains five pounds overnight, his heart, his organs can’t deal with it. Water is what comes and goes so quickly. Save him.

Pulse. Just how fast is that heart beating? Slow means something, and so does fast. But it all is tied to the other.

Respirations. How hard is this struggling patient trying to breathe? The diabetic in ketoacidosis breathes fast to balance the acid in their blood, not for oxygen. The COPD guy struggles always. He slows; he dies.

Blood pressure. Is the heart able to do what it should?

Sid could hear these numbers through the phone and the story the nurse was relating and form a picture. Then he would go see the patient.

Pain was often a distraction. Sometimes it was fear, sometimes real, but real would show in the vitals. So would fear. It doesn’t help to ask them. You have to go look.

But this pain got him out of his garage on a late Saturday on call. He had done the hospital rounds in the morning, seen the sick kids and worried moms in the weekend clinic, so he thought he could fix the speakers in the Hilux in this afternoon.

He’d put them in a while back, now the right side was shot.

The call came. Doctor Hawthorne, this patient has intractable headache pain, and we ask you to come in to see her. Our ER doc has done what he can.

He wasn’t too greasy. Sid washed up, changed into good clothes and went in.

As he passed through the automatic doors, he didn’t look at the waiting folks. He was not their doctor. There was an ER doc in there who would help them. Sid just had to deal with the headache.

Sid had been the ER doc. He knew such a call he had received to deal with a headache meant the problem was beyond what the ER doc could deal with. It was beyond the vitals. Beyond keeping people alive; we now try to keep people happy.

Pain is not happy.

Pain is so much else.

Sid pushed through the doors into the inner sanctum, here where we do our shit. All white in here.

He had been in a kind of head down, do your job kind of posture.

But he caught a glimpse and looked up. There was a little kid on a gurney. A wimpled mom sat small next to him. Maybe ten years old with dark hair and an open face. The big dad in pegged pants and logging boots stood on the other side. The young man looked right at Sid.

So Sid looked back at him. He had dark, piercing eyes. Before him, on a white pillow the young boy had a forearm that bent at nighty degrees right in the middle when it should have been straight. Sid knew this young man had two broken bones.

Sid stopped his trudge and looked at the little warrior who was staring at him. Does it hurt? Sid nodded toward the arm on the pillow. The young man looked at Sid, didn’t look down at his arm. Yeah, some.

Sid smiled at him. The young man smiled back.

So Sid went in to solve insolvable pain.

Insolvable?

You doctors are such wimps. You just blame the patients. You should work harder to understand their pain and alleviate it. So pain can be fear. It can be suffering. It can be other things. It can be an attempt to control a life out of control. None of these problems are solved with narcotics.

Narcotics block pain.

Sometimes we attach all these other feelings to pain. So if the pain fades, so does the attachment. Some. Some remains.

The fear, the worry, the control worry remains, though the pain has gone. This is how we medical professionals have killed so many people. We know how to treat pain. And we can legally give narcotics.

Sid came up to Kim at the nurses’ station, the ER hub.

Little trooper over there.

Yeah, we’re waiting on Ortho and the OR crew to set it. Shouldn’t be long. They’re doing a hip upstairs.

Tell me about my headache.

Kim rolled her eyes. Piece of work. Let Randy tell you.

The ER Doc for this weekend, Randy, came up with his perpetual small smile. Sid, glad you could come in.

Sid covered this ER some weekends for extra money, but Randy did it most weekdays and maybe a couple weekends a month. He lived down in Three Rivers. Sid liked him.

So what have you tried?

Sid was reading her chart and the vitals were normal. She wasn’t puking. She wanted to go out and smoke. Sid could read the orders and drugs given as Randy answered.

Her usual. We haven’t done ketamine or electroshock therapy. Or psychoanalysis. So we called you. Randy broke out into a full grin.

Randy, you want me to shrink this patient for you?

Kim laughed. Please! She needs it. I’m next.

Sid looked down at the spotless vinyl floor. His shoulders fell. He got shorter.

Come on Sid. You can do this, Randy offered. I’ve seen you.

Sid, looking down. I know this lady. She’s a hard one.

But you’re on call. I was so glad that these cycles aligned. You are who she needs.

She hates me.

Yeah, she hates me too. Randy’s smile was back to his normal. We need you, Sid.

Kim was looking at Sid with her most alluring eyes. She tried this often. And she had nice tits. They helped, Sid thought.

So he went in.

She was sitting up on the ER gurney, gown covering her beauty, but her hair and face were still there for her to use. But that was not her tack today.

Why didn’t they get my doctor? I don’t want to talk with you.

Sid still was shrugged down, slumped. He found the rolling stool and wheeled it over next to her and sat down. He looked up at her. Her scorn, her anger was there, looking down at him.

It was hard to see her beauty when she looked at him like that. But he knew it. Sid had seen her beauty so many times. It drew you in.

You are so beautiful.

Shut up! I’m calling the cops. This is sexual harassment!

Sid just looked up at this tortured face with his tired eyes and slumped shoulders. She looked to the far wall. Her profile was beautiful, angry, hurt.

Sid wanted to get up and hold her hand, caress her troubled cheek, smooth her hair, maybe even have sex on the gurney. But he just sat and waited.

She finally looked back from the blank wall. She looked down at him. So what the fuck am I supposed to do?

Sid smiled at the beauty above him.

Kim asked, how did you shrink her? We couldn’t get her to leave.

Sid was doing his documentation, so he ignored her kind of. But he did smile as he hunted and pecked.

Randy flashed by. Strong work my man. Big grin. Rare from him.

Sid looked up at Kim, still looking down at him. What the heck.

I told her I loved her.

You did?

Yeah. I love you too.

She laughed so hard.

Sid left back to the broken speaker.

She was a worried woman, and Sid was about to feel her tits.

He had felt a lot. There was the worried teenager and her mom that puzzled why one was twice the size of the other.

Let ‘em grow, had been the advice. They did. Beautifully.

There was the middle-aged saggy woman with lumps everywhere. She was worried. Sid was not. She years later got breast cancer as one in ten women do.

They are an enigma.

He knew they feared this. He knew they were baring their breasts to him for his expert examination and assessment. Not out of any attempt to seduce him. Though his mind went that way.

Sid loved breasts. Tits.

Sid called them breasts in the office with patients and professionals. But they were tits in his mind. Beautiful, welcoming, soft bags of tissue.

Sure they might sag.

This beautiful Hispanic woman bared hers to him six weeks after she’d delivered her beautiful little boy. Sid had just done the pelvic exam, but she was beyond that. Will they ever stand up again? Her dark eyes shot fire at him on his weak rolling stool beneath her.

Sid saw her as beautiful, though the fierce eyes fought off his look.

This woman here today was worried. She had found a lump. So she was in Sid’s exam room because her regular doctor was too busy. Sid always kept openings in his schedule, so he got these cases.

It’s best to consider tits as “cases”. Otherwise…

Sid heard her worry, asked the family history, the hormone history, the smoking history, the childbearing history, then gave her the cotton gown and left the room so she could disrobe. And then he would be able to go back in and look and feel and touch her tits. Breasts. Legitimately. As a doctor.

God, don’t you love them? Tits? Doctors?

So there she was on the exam table with the gown.

Some women leave the shroud open in the front, then you just open the front and do your business. Some women have the solid part to the front and you have to take it all off. Sid had pondered this.

Sid would have preferred them just naked from the waist up. It’s the tits, after all. Why are we offering the comfort of modesty? But we do.

This nervous woman had kept the opening in the back. She was bent forward and glaring at Sid, not her usual doctor, about to feel her beautiful breasts.

Some women see their breasts as powerful. And yes, they can be. Some women don’t. Sid had pondered this.

I need to take this gown off and look at your breasts.

Sid removed the cotton gown from her shoulders and laid it on her lap.

Now put your hands on your hips and bring your shoulders back.

Sid was standing in front of her, staring at the soft globes she brought out. Sid modeled the shoulders back posture and they came out more.

This was the first part, looking.

They had taught Sid this in his training. First listen, then look, before you feel. Sid loved the looking. He liked the listening too, but the silent studying gaze was his strength. He could divert distractions.

The brown areola were there, but not of interest. Browner than some pink ones, and even some almost pale ones he’d seen. He’d seen a lot. She had no hair there, maybe she had tweezed, some left it. The nipple wasn’t erect, but that didn’t really matter for this. Sid was scanning the skin.

Cancer is a crab, both in the zodiac and in our bodies. It claws the tissue around it, pulling it in. Sid had seen the wrinkle. None there on her soft, maternal, beautiful middle-aged globes.

So now he felt.

Listen, look, feel.

Medical training hadn’t been all that difficult. But the discipline was important. Don’t rush to the feel. More, don’t rush to the cut.

For that’s the last part of the training. Look, listen, feel, cut.

Sid never knew if his hands were warm or cold. He washed them. But he sometimes had a lot of coffee. One beautiful red-haired woman had shrunk from his palpation.

Your hands are cold!

Sorry, was all he could say.

Maybe he was nervous to feel the tits of a beautiful red-haired woman and his circulatory system had responded to his nerves and shut down the blood flow to his extremities. Sid pondered this.

Sid felt through the tissue, first upright. Then he had her lay back down so he could mash a bit harder. Sid felt the lump.

She was looking away, laying back, letting him do what he did.

Can you find the lump? Sid knew to use this language. Lump, tumor. Be careful.

She quickly went to what he had felt there in her left breast, over the heart.

Here.

Sid smiled.

I felt that too. It’s a very firm round lump that moves easily. I think it is a benign fibroadenoma, a fancy word we use for just a lump. I don’t think it is a cancer. It might get smaller, but it might not. I could not see it when I looked.

Can you be sure it’s not cancer?

Her gaze had fear. Sid felt her fear.

I am confident it isn’t cancer. But we could take a needle biopsy if you want. I would need to numb the skin and tissue and then push a needle into that lump and remove some tissue and send it off to a lab to look at.

And then we could be sure?

She had bared her breasts to him. And from this she wanted assurance.

Of what?

Sid knew, from the many tits and breasts he’d examined, he could not assure a woman she would not die from breast cancer. More, he knew, and they should, that they would die. Breast cancer, whatever.

Meanwhile, it’s the tits.

So would you like a biopsy?

Sid got the TruCut needle and the local and the specimen jar. He held the lump hard against her chest wall, though it wanted to squirm. He pushed the needle in, sucked back and withdrew. He squirted the little core into the specimen jar and sent it off. She got a bandage and assurance he would call.

That was a Tuesday. Sid saw 25 other patients. He wasn’t worried. He did his week of work. The weekend approached.

Friday Sid got a report.

You do this shit, cutting parts out of people, drawing their blood, or aspirating tissue out of a breast lump and then you just send it off and they give you what they give. Pathologists are remote. They don’t listen. They don’t look at the saggy or pert tits. They don’t feel. They look at the shit you send them under a microscope and render a diagnosis.

This guy called it cancer.

Who the fuck was this guy? Sid had never heard of him, though he signed the report.

Jesus.

What should we do?

It was his new nurse. Sid’s one of 15 years had fired him and moved on. This new one was good.

Sid looked over at her after he read the report, and she asked him for his judgement. She had read it. She had tits, though Sid would never see them. Women fearing their tits, while men adore them. And then we’re the judge? Go figure.

Let’s wait. It’s Friday. I’ll call her in on Monday.

She had looked away, like he was a loser. Sid remembered that.

Sid hadn’t worried about it. He’d had a decent weekend. Maybe some Tball games or swim meet or soccer shit with the kids. Maybe he’d fixed a leaky sprinkler line. It’s what we do, when we’re not thinking about tits.

Monday Sid’s email lit up.

He’d rounded on the hospital patients and just expected the usual Monday morning things, but he had an email with alert from the pathologist’s office and two new documents in his in folder.

Sid knew the woman in charge of the pathology department. He had trained up there and he trusted her. Her email to him was direct. We have reviewed the diagnosis and do not concur. I have had three other pathologists look at this tissue. We have changed the tissue report. She apologized for the mistaken report from the fill-in pathologist.

Sid went out to the station where he and his nurse worked.

Did you see the emails?

Yeah.

So we’re okay?

Yeah.

I’m going to call her with this new pathology report.

Yeah.

She turned, facing him. Her blue jacket and cotton smock covered her chest. But if I had cancer I’d want you to tell me.

Sid looked at this brave, fully clothed woman, no nakedness between them,

I would.

Sid didn’t imagine her soft small breasts under her layers right then.

Sid thought she seemed very polite and maybe a bit unnecessarily worried.

She was old, Sid thought, but then he reminded himself, he would be soon.

She was worried she would become incapacitated. And she wanted his help. Sid just listened.

She has seen her mother go through it. She described her mother as strong, wise, kind. She had seen the fading. Her mother, gardening, housekeeping, visiting had barely noticed the changes. But she had.

She said her mother would never have wanted to be like that. And she didn’t either. Could he help?

Sid understood the progression. It had happened in his downstairs. He had taken his mother nightly to the toilet and changed her diaper. Sid and his wife had made her meals, changed her sheets, and dressed her.

He studied the drugs and knew their futility. Toward the end his mother could barely speak. She had a Hemlock Society decal on her bedroom window. But she could no longer act on this.

And she wanted Sid’s help.

You don’t seem to be having any signs of dementia.

The small, maybe old hippy lady just smiled at him.

Tell me what makes you worried you are failing.

She took a deep breath. I’m getting older. I watched my mother. I don’t want that for me. Can you help?

Well I can do my best to tell you if I find any signs of dementia. But I can’t promise any decent medical treatment to reverse it. I can care for you. Sometimes people are depressed, and we can treat that. Depression in the elderly can look like dementia. But you don’t seem depressed or demented.

Would you make sure I don’t get like my mother? She was not a person when she finally died. She was a husk.

Husk.

Sid thought of his mother downstairs. He had taken the keys away years before. She had come up to him in his garage, angry that her car would not work. It was idling in the garage he had built for her. She couldn’t get it to shift. Sid followed her down the steps and got in. He stepped on the brake pedal and shifted it just fine.

It’s a safety feature, Mom. She smiled at him.

She’d gotten lost in a parking lot. Sid argued with her. He took the keys.

He put a safety knob on the doorknob when she had wandered.

Husk.

Sid looked up at the small old hippy woman from his rolling stool below her. What would you want me to do if this comes to you?

She beamed. You could make it so my family doesn’t have to be burdened with my decline.

Have you talked with your family about this?

She laughed. They think I am worried about stupid things.

Maybe I do too.

She frowned. But you know these things. You’re a doctor. If I am becoming demented, you will know.

Sid knew his mother, in the downstairs was failing. He watched her keeping lists, buying supplements, going to a lousy Neurologist in town who ordered MRI’s and prescribed useless medicines.

Soon she couldn’t talk. Then there were the diapers, the food, the bed, all the work Sid and his wife did to care for her.

Sid looked at the little old hippy lady. Why don’t you do something?

She laughed again. It was a clear, bright laugh like a mountain stream over rocks he had fished and not caught anything.

She gazed down at him on his stool. You know. When it happens, I won’t be able to. I will need somebody’s help. And you are a doctor.

Sid looked back at the clear sharp eyes, asking for his help.

Sid’s mother died downstairs. He offered her water to her parched lips. He held the glass up to her lips when she couldn’t think to bring it to her own. She choked and gagged. He put the grape she loved in her dry shriveled fingers. She looked at it and almost smiled. Then looked off vacant. She dropped it.

You need help from your family, he said to the little hippy woman. Doctors can only do so much.

Her eyes narrowed. You could help me, but you won’t.

What would you have me do?

When you see it coming, I want you to end me.

Kill you?

She laughed again, but more like tires on a wash boarded dirt road. You know where I would be going, you know the end. You could just ease all our pain and indignity. That is the help I ask of you.

Sid looked down at the industrial carpet under his rolling stool. The pattern gave him no wisdom.

Sid stood up from the little stool. He faced the intense old hippy lady. He reached out and held her bony shoulders.

I would be glad to care for you.

Her face softened, like spring snow melting on a south slope.

Thank you.

Spring on the prairie brought an annual old hippy festival. Sid’s daughters were grown, so he wandered among the booths by himself. He had sold bean burritos for the swim team in the past, but this year he was on his own. He bought some very nice wood light switch faceplates from a vendor from Montana.

The music was lilting from the stage, and Sid saw the dancers, twirling, arms out like old hippies do out in front. There she was. Happy like all the others, twirling and dipping, arms and hair flung out.

Sid looked up at the old trees over the park. The white puffy clouds held up there above. It was a beautiful day.

Martha found him and they compared their purchases. She had found some lavender eye bags. I could make these!

The music stopped, the dancers dispersed and Sid looked up from his wife to see the old hippy lady walking past. He saw her eyes a bit vacant, maybe joyless, like after a long time fishing a worthless stream.

Sid watched her go past.

Who is she? Martha asked.

No one. He smiled at her.

And then they went on.

Sid had seen all the pictures in medical school. Black and white images in books they made him buy. The book of monsters. But he’d never delivered a baby himself, like this. In this small town you can feel all on your own. But he had his training.

He had been on weekend duty in residency when that one young mom had her monster.

Sid was on his OB rotation, every other night on call and every other weekend. He’d rounded on this little woman multiple times. She’d been sent there from her small town. That was the nature of high-risk pregnancies. Try to identify them early and get them to where the care is best. The docs in her small town knew she was an insulin dependent diabetic, high risk right there. But the ultrasound images raised the alarms, so she got shipped to the center where he was training. So he cared for her.

She was young, pregnant and carrying a baby with holoprosencephaly. Sid’s training with fetal development in the monster book included lots of big names he could not always sort out. He learned, monsters don’t always have big names.

She had diabetes and also was developing preeclampsia. She was 28 weeks along. That was considered beyond the cusp, in those days for an abortion. But she didn’t, would never have wanted that. Sid didn’t know if her local docs had discussed his with her. But he knew her religious fervor. He knew her convictions.

Sid was on the team that watched her at bed rest for about two weeks. Sid looked up holoprosencephaly, though the attendings had told him on the rounds about the cyclops. This baby inside her had one central eye. It would not breathe on its own.

Sid was in charge of adjusting her insulin and blood pressure meds.

On this weekend, her blood pressure spiked, she had hyperactive reflexes, and her urine protein was 3+. The very sober attending told Sid to move her to the delivery suite and get her into labor.

So he did the work. And she started contracting, and her blood sugars and blood pressure stayed OK. And the baby’s heart rate stayed steady.

What do you do if you are trying to deliver a baby that will not survive and it shows intrauterine distress? Think about that for a moment.

It’s going to get worse.

She progressed. Sid checked her cervix. It was dilating, the baby’s head was coming down, her blood pressure and blood sugars were okay. But then it stopped.

No further progress. The attending came in. He agreed. This poor woman needed a surgery to deliver a non-viable baby. Despite the trauma, for Sid, this was exciting. He’d get to do something he’d never done. Cut open a uterus top to bottom, instead of the usual down low across cut.

The attending was a serious, South African man with a British accent and many stories to tell. He looked at Sid, shaking his head. Classical incisions greatly increase the risk for uterine rupture in future pregnancies. But that’s what we have to do.

Sid understood his torment. We would do the right thing here, to deliver this baby that would not survive, but it would give this woman future risk. She agreed to it, even if we thought it unwise. She is the boss. Not the monster.

This baby was alive inside her, kept alive by her body, her uterus, the placenta.. It would not breathe, live on its own after delivery. It was in the book of monsters. But the young woman wanted everything done to deliver the baby alive. So the attending and Sid put her future childbearing at risk and cut.

It had just the one eye in the middle of a pale, wrinkled forehead, and it didn’t breathe.

Sid learned.

But then, here he was, on his own. With her.

This young mother’s predicament didn’t make it easier. She had come into his examining room in a big overcoat in late spring. It wasn’t cold outside. She had finally decided to seek medical care for her pregnancy she had hidden for months. Sid had an opening. So here she was.

Sid tried to understand. But the young woman, bright and competent, repulsed any attempt he made to understand or generalize her predicament.

Family? Father? She forcefully shook her head and almost walked out.

Sid knew she needed care. He could see her big belly beneath the overcoat. He felt her conflict, so he backed off.

Let’s just see what we’ve got here.

She remembered her last menstrual period. She was bright. That gave Sid a ballpark idea. He asked more questions, prior pregnancies, blood transfusions. General health questions. She was a solid patient. As she answered, Sid sensed her deep pain. She had not planned or welcomed what was growing, had grown inside her. But now it was pretty big, and she was facing the coming issue.

When Sid got to her big pregnant belly and touched and measured it was way too big. It was very round. It was hard for him to feel the baby in there.

He did the office doppler. Normal heart tones he and she heard. Sid even scanned around, thinking there might be another, a twin, but he couldn’t find another. Just one he could find. But her dates didn’t fit with her size. She was due to deliver in a few weeks by her dates, but the belly was bigger. Twins that he couldn’t find?

Sid didn’t want to run up the bill, but in this case, he wanted an ultrasound. You’re telling me you should be due in a few weeks, but by my examination your belly is bigger than it should be.

Sid said she needed an ultrasound. He convinced her to go across the street and get this done. All while he was fearing she would just walk away. Sid knew her fear. She was on the edge.

But she went.

The radiologist called him in about 30 minutes. That’s never good.

Hey Sid, this lady you sent over has an anencephalic. Plus she’s got big time polyhydramnios, they often go together. Or oligohydramnios. You know, when it’s a monster, the system is messed up. Do you want us to send her back to you?

Have you talked to her?

Heck no, that’s your job. He chuckled.

Please ask her to come back so I can talk to her.

Will do.

As he hung up, Sid knew this radiologist was paid three times what Sid was as a family doctor. Not only was this poor young woman about to hear some tragic news, but Sid also understood, he was in a fatally flawed health care system. But that’s for another day.

Sid looked at his morning schedule and told his nurse what was going to happen. She understood.

Sid had never had to do this before. He hadn’t practiced. No doctors are good at this. It is rare, monsters. But it does happen, and so the medical school classes, pictures, causes, prevention, all that shit, like they want to prepare you for the horrible shit you will have to do.

Sid stood in the hallway between patients and reviewed in is mind what he knew about anencephaly. It took a second for his mind to recall the enfolding process of the developing neural tube. Ectoderm, endoderm, neural tissue, developmental folding, all that shit just settled back through his young, bright brain. And of course, when it doesn’t happen like it should…Here we are.

She was beautiful. Sid thought all pregnant women were beautiful. Her curly hair and round face and tall stature sat up there on the exam table, looking down on him on his low rolling stool.

You have a baby that cannot survive birth. The brain has not developed through some twisted developmental thing. Your baby does not have a brain. It has grown inside you because it doesn’t need a brain as your body gives it safety and nourishment. But it will not live once it leaves your body.

She didn’t cry. Maybe her moist eyes were that. She just stared her sharp piercing eyes at him and asked him about what was next.

So Sid told her. We have to get you delivered. We have to get this baby out. Sooner or later.

When?

Sid looked at the industrial carpet his rolling stool slid over. It depends on your cervix. I need to see if your cervix is ripe. That means ready to let this baby out. So I need you to take off your clothes and I need to do a vaginal exam to assess the cervix.

Sid gave her a paper drape and left the room.

He saw another patient. He told his nurse what was happening. Then they went into the room for the vaginal exam.

Sid found the beautiful pregnant woman sitting on the exam table naked holding the paper drape in her hand by her side. She was actually radiant. Sid found most pregnant women were radiant, even if not naked.

Her breasts were full and warm, her skin almost glowing. Her big round belly held the infant, the monster. Her eyes sharp, met his and followed him.

Here, hold this across you while I examine you.

She blushed as he put the thin paper drape across her breasts. So I was not to take my clothes off?

You did fine. But we offer these for modesty.

She laughed. Modesty as you are going to probe my vagina?

Sid laughed too. It’s the trick of the profession. That we can keep our distance.

Distance? You’re going inside me.

She didn’t seem the shrouded unexpected young mother here. But Sid had just met her. And he had told her the news and now needed to go up inside her. And deliver this monster.

Sid felt his nurse behind him as he had this intimate conversation. This too was part of the trick of the profession. Doctors need assistance for the intimate things they do. And two sets of eyes and ears maybe give credibility.

Yes, I need to examine your cervix. If it has softened, maybe even dilated, we can induce your delivery. So lay back down and put your feet here. Sid did the hand to the shoulder, laying her back and pulling out the little shelf to hold her legs. Then he pulled out the arms that held the stirrups. He moved her warm feet there, one to one.

Sid had his male patients who decided for vasectomies put their feet in the stirrups while he operated down there between their legs on his rolling stool. Such symmetry gave him some small measure of joy.

Sid gloved and lubed his gloved fingers and found the introitus with his right hand. That’s the medical term for the vaginal opening, “introitus”. Now you know.

Sid kept his left hand above, on the fundus. That’s the medical term for the big round belly she had below her full glowing breasts. He had to go up under the false paper sheet he had offered. Her laughter at his sham echoed as he felt for the opening.

Sid knew that what he was doing was trying to squeeze this infant, this baby, this monster between his hands, to get a sense of it. But he couldn’t.

Sid only raised his own daughters. But he had delivered hundreds into this world. And this feeling the baby, the mother’s birth canal, the cervix, the position, it was what he needed to do to predict, to prepare.

He pushed his fingers in and found the cervix soft; in fact she was dilated to two cm. His trained fingers knew this. His index finger within the glove could feel the water filled membrane, right there, delicately floating. Sid pressed down with his left hand to see if he could feel the presenting part. He could not. The ultrasound had said it was head down, but there was so much fluid.

Maybe because there was so much fluid inside the membranes, maybe because there wasn’t a skull to feel. Sid could not know.

All while he was probing, feeling inside this woman, pressing on her belly, she was staring at him. Sid felt it but didn’t look at her. He had to get this monster out of her. Then she had to live her life.

Sid would also have to live his.

Sid scheduled it for the next morning. He called his mentors. They advised. Since the cervix was ripe, just needle the membranes. Maybe it will progress. Have you checked your state laws?

Sid was taken aback. What do you mean? Sid’s mentor was in another state, and Sid knew there were differences.

His kind of British accent was soft, not really British. Some states do not allow intervention to deliver a nonviable fetus.

So this might be illegal?

I don’t know. You should check.

Then what?

I don’t know. Maybe wait. She might go into labor on her own.

All that fluid? Rupture, walking around?

His South African chuckle told Sid he understood. Well, God Speed to you and this poor woman. Let me know how it goes.

Sid thought it went fine, all things considered. He was able to see the membranes, poked a 16-gauge needle in, she leaked, then gushed, then went into sweating, bearing down labor and the monster came out.

The nurses swaddled it, covering the absent skull so she could hold it, though she didn’t really want to. She kept sobbing. It was over.

And Sid never got arrested. No deputies he knew from all the coroner calls showed up in the waiting room to cuff him. No charges were filed that he ever knew about in the county courthouse. Though Sid had actually broken his states laws.

So he just kept being a small-town family doctor. He delivered babies. And he often wondered just who the monsters were.

As a family doctor you go through years of classes and training and learn a lot of shit you never see. But maybe it’s in there. Some you hope to never see. But hoping is stupid. So the Buddha says.

Sid learned about the viral hemorrhagic fevers. Marburg, Ebola, they made the news. Maybe he even heard about Hanta. But when he was watching this woman die, it’s one of the first things his weak mind thought of. Funny that, the learning thing, the memory. Us humans are so poor at remembering. Maybe AI would be better. We don’t remember the last politician who screwed us, but we kind of recognize his name, so we vote for him again.

Maybe that sort of weak memory is what Sid had, just a name, some symptoms. But when he watched her die, he really remembered.

Sid got a call from the PA working down at the urgent care clinic. She had recognized the severity of this woman’s illness and sent her to the ER. And she had called Sid. She’s really sick. I think you should go in and see her.

So Sid got on his professional clothes. He had been out trying to get the lawnmower to start and run decent. His shirt was dirty and his hands smelled of gasoline. He changed his clothes and headed in.

She wasn’t in the ER; she had already been moved up to the little hospitals ICU. So that’s where he went.

But he read what they had. Blood in her urine. Platelets low. Chest x-ray shows acute respiratory distress syndrome, lungs filling with fluid. Oxygen levels very low. Sid called the lab and asked if they could send the serum off for Hanta. Sure, it will take a couple days. Then he went upstairs.

Sid recognized her. She had yelled at his daughter on the T Ball field. Come on, make the throw!

But here she was breathing 50 breaths a minute, barely able to say a word. And her oxygen saturation in her blood, even with all her effort, was dismal. Sid knew where this was heading. He told the nurse to get ready for intubation.

Sid knew he could give oxygen. We can give you 100% oxygen in a mask over your nose and mouth. The air you breathe only has 20% oxygen. But if this isn’t enough, we can force oxygen into your lungs through a tube. It goes past your vocal cords, and a cuff is inflated down there so we can use pressure. But you hate this, you fight and gag, so we sedate and paralyze you, so you won’t fight us as we try to save your life. Sid had done this too many times. The gunshot, the motor vehicle accident, the pneumonia; all these folks needed oxygen. Or they would die. Some lived.

But this patient he knew from the ball fields was bleeding into her lungs. No pressure they applied would combat the melting of her small vessels that she relied on. The virus melts little vessels. Hemorrhagic viruses do this.

They are special. They melt our bodies essential tiny connections. But, because of biology, they do not transmit easily. A virus that kills it’s host quickly does not propagate through aerosol. A virus that kills quickly needs another path than a cough or sneeze. If so, we would all be dead and then so would they. A virulent virus doesn’t want a lot of people dead.

Our mistake is that we are thinking of this from our perspective. We are so afraid of really bad things. And we should be. Lions and tigers and bears. But it’s the slowly lethal virus or bacteria that kills the most of us. Fast is fatal. Slow can be too. And slow allows for more spread. It’s just what we all do. Strategies, functions, kill quickly or slowly, what is the end game? What is winning?

But this is all theoretical bullshit. Though it wafted through Sid’s mind as he watched this woman die.

And he had to decide when to do the forceful intervention. Once the tube is past the vocal cords, the cuff inflated and the patient sedated and paralyzed, the conversation is over.

Sid leaned into this vocal mom he knew from the ball fields. She was sitting up, breathing fast for her life. Breathing so fast she could only get one word out between breaths.

Sid told her about the intubation, the paralysis, the sedation.

She stared at him as he went through all the details.

Sid quit his litany and just looked at her as she worked to breathe. Her arms were on the rails, holding herself up with the little strength she had left. Her eyes bored into him.

Doc…am…I…going…to…die…?

Sid knew his eyes told her. But he tried to say the right words. They got her intubated and onto the helicopter, but she died before she landed on the top of the 14-floor big city medical center.

The test came back positive on the weekend. Sid saw it. Four days later the new hospital CEO called him to let him know there had been a death from Hanta virus in the hospital. Sid thanked him for the call and thought him an idiot. And Sid knew the asshole made more than twice what he did. And he didn’t take call or care for dying patients.

Sid was out in the garage again, sorting screws or cleaning up when he was crippled by the absurdity. It hit him in these moments. Maybe it was the Pearl Jam on the stereo, I wish I was the full moon shining off a Camaros hood.

Knowing and appreciating absurdity teaches us to listen.

Sid was covering the ER for extra money on the weekend. He knew the lady. He liked her, but she was here because, “I just don’t feel good.”

They can never tell you the problem. It’s his job to figure it out.

So he did the exam, ordered the tests. Her liver enzymes were out of whack.

So Sid asked some more questions. Tylenol, solvents, alcohol?

Doc, I been cleaning out a shed behind my house. I want you to test me for that Hanta virus.

Hanta?

Yeah. Lots of mouse turds out there.

Sid probably rolled his eyes. Look, if you had Hanta you’d be dead by now. And it’s going to take a couple days to get the result. But you are sick enough I think you ought to spend the night in the hospital. I’ll order the test, but I think it’s something else.

The next morning her liver enzymes were better and she felt pretty good. And the lab had improved it’s Hanta immunoglobulin turn around. She was positive for acute infection.

So Sid told her, thanked her. She went home well, to die later of something else.

And Sid learned.

She was quite attractive. But there was no blood in her urine, no evidence of a kidney stone. Her last two scans had been negative. Two IVP scans? Her regular doctor had ordered them. That’s a lot of radiation for a young person. As Sid read through the charts and labs, nobody had really diagnosed the source of the pain this patient was presenting to him.

But she was young and beautiful. Salacious Sid wondered if this was why Dr. Payne, her primary doc had started giving her Demerol injections. From the past year and a half of office records, she had been in here about twice a week. Most visits had no doctor’s note, just the nurse’s note detailing the injection.

Sid realized from the pharmacology, this was not a narcotic addiction. An IM narcotic hits the patient in about 5-15 minutes and wears off in a couple hours. Twice a week was serving some other need.

But Dr. Payne was gone on vacation. And Sid was on call. And she was here. Beautiful, but stating she had severe pain. But she didn’t look like it. Sid knew severe pain. This lady didn’t add up.

Sid had seen some shit in his early days out here in the practice of medicine. He had joined this group to have support as he thought he might learn more and get better. But some of these guys were on the edge. And it seems it made them money to satisfy these wackos.

The wackiness went both ways.

The top two producers in this group wrote more prescriptions for antibiotics for kid’s viral colds and for narcotics for unspecified pain than the bottom producers. Sid was learning that this was his job in this business of medicine; to be a “producer”. That meant making people want to come in to see you so the practice could bill their insurance and pay the overhead of the 5 folks working in billing, the other five in medical records, the seven in reception and the ten in nursing, four in lab. And after all that the doctors got a big chunk. It was a big machine. And it was all driven by making these suffering folks happy and coming back.

Sid had read the studies. Most acute ear infections got better in a week with or without antibiotics. But all these kids got antibiotics. In his first year of practice Amoxicillin was the most prescribed medicine in the US. It sure was in this clinic.

The shit was deep. There was an orthopedic surgeon in Sid’s community with fifty patients on daily outpatient IV infusions of antibiotics for his diagnosis of Lyme disease. Never mind that the bug that caused the disease didn’t exist in this part of the country. His patients loved him. They loved his care. They needed to feel cared for when they ached and were in pain. And he cared for them with the daily IV antibiotics.

Which cost us all. We all paid. Insurance.

Sid started to believe insurance, the shared risk tool, was evil. But that just started him down another rabbit hole.

Sid tried to explain to the worried moms missing work with their kid with a cold that the child didn’t need antibiotics. They argued back. And probably spoke badly about him to their friends. Sid was slowly learning this twisted world of the market of medical care.

And he was learning, too slowly, just where the pivot points were.

But Sid could not convince this beautiful young woman she did not need an injection of narcotics. She got angry. “Doctor Payne listens to me.”

Sid had looked at her carefully and done his best to examine. Her vitals, pulse, blood pressure, respirations were all normal. She was not dripping sweat or puking. In fact, she was arguing cogently and angrily and claiming unbearable pain. She wanted what she wanted: injected narcotics for extreme pain. Sid looked at her across the exam room, her clear, beautiful angry face demanding.

Sid knew the pain was just her tool. And she knew it too. She had the hammer; he was the nail.

And he saw the much bigger picture. Dr. Payne and his dependance. And hers. And he decided right then he couldn’t change the course of both of their twisted lives. So he said okay, turned and left.

As he turned, he caught the glimpse of her triumph in her face, her demeanor. Just a glimpse. That is what Sid learned in this twisted encounter.

After he ordered the injection and went in to see another patient, he happened to be in the hall as she came out of her room. She didn’t direct her beautiful gaze toward Sid, but instead looked above him, over his head. She held herself erect and proud. Then she turned and flounced down the hall as in full victory. Sid knew, maybe she did too, just how twisted this was.

The coda took time. She avoided Sid, and Sid avoided Dr. Payne. It wasn’t like he hadn’t tried to have the conversation. But rejection is painful, twisted. It’s normal this, Sid thought. And twisted what we do. If we chose to.

A year or so later Sid was earning extra money covering the ER on a weekend. The father came in. Sid had never met the man. He was the father of the beautiful young flouncing woman.

Why are you letting this happen?

What?

She’s getting her kidney cut out next week. Everybody is telling her it’s a normal kidney, but she wants it cut out. And this surgeon is going to do it.

Sid pondered this for a while.

Sid looked the father in the eye. Why are you letting it happen?

He looked down. She won’t listen to me.

Sid took a deep breath. She wouldn’t listen to me either.

Nobody listens. It’s what you do that counts. Decide what to do.

Sid got the surgeon’s operative report. Since he was the medical chief of staff now in this small hospital he could get this stuff. The surgeon detailed in his official dictation that he had described to the patient that all studies showed her kidney was normal, there was no pathology there to explain her pain. He documented that the patient insisted she wished her kidney removed, despite all the evidence. He also documented that the kidney was totally normal when he removed it. The pathologist confirmed the totally normal kidney.

Sid was just learning this twisted world. And his part in it as a Board Certified, state licensed physician.

He read about the folks who wanted a perfectly healthy limb cut off. Sid loved the word, “Apotemnophelia”, but it nauseated him when he thought of the prospect. In fact, he had probably seen such a patient. But it was before he was learning all this in real life. In the office, from the patient in front of him.

Sid heard of the guy who wanted to be taller. He died from the complications. Sid had always wanted to be taller. There are some doctors out there…

And there are some patients out there.

Maybe some right here. And maybe, Sid reflected, he might be one of them.

This different young woman wanted his help. Not the kidney, just the facial hair. She had done the research. She told Sid of a drug he didn’t know of. He did his research. Sure enough, this drug blocked the effects of testosterone. The male hormone caused facial and masculine hair, arms, chest. This plagued her.

She was a heavy, round woman of some ethnic background he had no reference to. But she wore tight clothes and tried to look like the magazines described women should look.

She wanted Sid to prescribe this medicine to make her look different.

Out in the garage that night, he couldn’t find the right little screw. 10/32 or 10/24. He hadn’t sorted them, just all of the little screws in a jar. How stupid. Just sort them he resolved, after he dumped the jar out on the counter. So he set about sorting.

It gets more twisted. Doesn’t it always.

Sid saw a colleague transition. Sid knew him as Jim, but now she was Jamie. She gave the best care. Sid had to force himself with the pronouns and name. When he messed up, Sid wondered if this meant he rejected something about this. Or maybe he was just a forgetful creature of habit. She did really good work.

Sid, an aging white man in this changing culture tried not to be reactive. Sid accepted that gender was a bit of a spectrum. He had learned of genetic men born with an absence of the receptor for testosterone. They looked totally female, physically. The advice when Sid was in medical school was to not be honest with the patient about their genetics, just assure them they would never be able to have children. Don’t confuse the issue of male/female. They considered themselves female, though their genetics disagreed. Don’t let the facts of the genes torment the patient. Sid found this accepted medical dishonesty perplexing. He never had to confront this rare condition.

But he had, in his medical school training had to watch an attending physician, very thoughtfully and gently, tell a young girl she did not have the genetic composition to have children. The town, the region, was very LDS. The mother and the child sobbed. Turner’s syndrome is rare. But it’s part of this gender spectrum some want to be simply binary. Sid knew the colors ran red to blue to green to purple. Sid knew.

Some people who came to Sid were not comfortable with their gender.

Sid felt lucky he never had someone come to him who was not comfortable with their limbs.

Sid knew many people used sex hormones illicitly to enhance their bodies. He knew competitive athletes used testosterone to improve their performance. He had seen it.

But now Sid was reading, people who had been born with the biologic ability to make more testosterone now identified as non-male, and wanted to compete in sports with women who had not had the same amount of testosterone in their development. Sid found this twisted.

When Sid first came to Paradise he wanted to play volleyball. He had played a lot in his previous life. It was an obsession. He found some guys who played but they were shitty. The local junior college had a women’s team. They were good. They could control the ball. Sid was shorter than their middle blockers. The coach invited him to join them in their workouts.

Sid was clearly a man. They were clearly women. Some of them were taller than him. But he could beat them all at the net. Sid could out jump them. Testosterone is a performance enhancing drug. He had it. They didn’t.

Some of them could serve as well as Sid. Most passed the ball as good as he did. But Sid could out jump them all.

So the coach did not have Sid play at the net against her middle blockers. Good for her. Sid would have beat them. It wouldn’t have been fair.

There were the patients. That’s where Sid learned. Sure, there was all that medical school, book shit. But in this twisted world, Sid found he just had to treat the person in front of him.

There was the young man, or so he considered himself. But he had grown breasts. His chromosomes clarified. Sid treated him as best he could. The young guy did well. It’s a long story and too much biology and genetics to bother you. Sid bothered.

There was this crazy trans guy in the wheelchair for no reason. Why can’t he/she/they walk? Sid dug through the medical records. He found nothing, except that his medical colleagues just kept letting this person bully them to prescribe or diagnose something that just wasn’t there. Sid considered the diagnosis of factitious disorder. But he never got the balls to put it in the patient’s chart.

At that point, Sid was learning the profession did not serve some higher calling, some truth, as he thought it might have when he signed on.

Sid came to appreciate the twisted nature we all have. And doctors are just people after all. Twisted too. The different needs, the struggles. So entwined.

But Sid appreciated this twisted state had given him the legal power, prescription and scalpel, to harm or heal. And he needed a sense of direction as all these twisted folks came to him. Sid had his sense of right and wrong. It was not biblical or driven by some doctrine. But Jesus did say to care to care for “the least of these”.

No.

It’s time to just listen.

Sid did his best.

After he got all the little screws sorted by size and thread, he swept them into his trash can and went back into his bedroom with a smile.

These cases can haunt you.

“Cases”. Don’t you know, as a person wheeling into a medical setting, maybe in an emergency, maybe sitting in the waiting room, that you are a “case”? Sid loved the good cases. Then he started to look for the story. Maybe that was the problem.

Sid was just a medical student in training. He has lucky to be at a level I Trauma Center, not in Pittsburgh.

This is where all the shit rolls down to. The street drunks with AOB (AOB= Alcohol on Breath. The anagram abbreviations are legion.) head lacs (lacerations), the suicidal teen, the total body burn victims all roll in here. Some come from the streets of the metropolis; some are flown in from distant states. And the young medical students like Sid are trained to deal with it. We want this trauma. It teaches us. Something.

So he learned. Sid loved learning and he learned fast. But he learned the rush, the joy of the save can be an illusion.

This trauma he remembered. Saving people.

Watch out. Some shouldn’t be.

It was right after morning coffee and free donuts from the drug reps selling what they sold. Sid didn’t understand this then, but he did later. The drug companies wanted to influence. Donuts were a cheap lever. But this was in his naïve days when he couldn’t afford donuts.

The case came in at a convenient time.

Sid wondered if this old soon to be dead guy always tried to be convenient. He was at least thoughtful. And brave.

He wasn’t that old.

Sid stood in the circle of blue scrubs against the wall as the residents and senior residents and even Chief Resident stood by the gurney holding him. Sid heard the story told from the EMT’s as they left and then repeated by his lesser colleagues as they murmured around him.

The old guy was helping his son with a truck flat tire on one of these steep hills of this big town. The jack slipped. There were grandkids in the front seat. The truck started to roll. Old guy ran up to steer or brake but fell and got under the wheels. His rolled over body steered the truck to the curb, saving the kids, paralyzing him. He was transported as a quadriplegic. His neck had been broken from the truck rolling over him as he tried to save his grandkids.

The blue wave of residents and caring doctors in training ordered things Sid heard, and remembered as he stood in the background, as medical students do in this part of their training. But the story goes on.

C5 level of paralysis, barely breathing.

IV access, vitals down. Next steps?

Intubate? Risk injuring the spinal cord more.

Sid watched as the higher ups deliberated the sequence. Neurosurgery chief resident and another show up. The cross table and AP films have been taken. They are put up on the viewing screen. The upper-level guys study and Sid listens in.

C4-5 subluxation, don’t see a facet fracture. We’ll try to reduce.

Sid steps back. This strong, now paralyzed old man is at our mercy. Somebody smarter than Sid has a plan.

A couple Ortho residents had mingled and looked in. He’s got a deep laceration over his left patella. Once you guys are done, we’ll take him to the OR and clean it out.

The neurosurgical guys are in control. They bring in a medieval set of tools. Sid is just up against the wall. He watches.

They apply the tongs to the old man’s skull, careful and arguing about placement. The fulcrum is attached to the gurney with clamps and weight is applied. The lower status resident goes down to his feet and holds on. More weight. They pause. They are fighting the old man’s neck muscles. He is strong. His injury has not made them flaccid, like his arms and legs are. He couldn’t resist them if it was a femur or humerus fracture. But his nerves can still talk to his neck muscles. And they scream against this traction. Who wouldn’t. We drop the condemned off a trap door and stretch their necks quickly. Their muscles cannot resist. But when you try to help someone carefully, thoughtfully, resistance is normal.

They put more weight on. Sid has no idea what tells them is enough. He knows, he would never want to do this.

Maybe the old man relaxed. Maybe he was tired and just gave up. The neurosurgical residents seemed pleased. The follow up x-rays gave them joy. They got congrats from the surgical residents and the ER chief resident. Sid stood there against the wall and watched.

The old man got wheeled down to the OR. There were no signs of neurological recovery. He was still a quadriplegic.

Sid was having his second drug rep donut when he heard himself paged overhead. He was here on a surgery rotation, and medical students never got paged overhead. He answered. You need to go to the ICU and check out bed 4.

What is it?

Just go. You will never see this again.

Sid had just gotten an overhead page from his supervising resident, an R1. All the people he had watched yesterday with the old man were R2’s to R5’s even maybe some R7’s.

But you did what you were told. Sid went up there.

He’d been here before. It is a house of horrors. It’s where our medical profession turns on all the technology and human effort we can to save a life. The drips flowing in, the pressures applied, the drugs tried, the devices applied, the effort. Full court press to save a life.

Sid looked for bed four.

The ICU was up on the tenth floor. It was an old hospital with worn linoleum floors, but it had windows up here. The grey light came in, filtered by the low, always clouds. His short medical student white coat gave him admittance.

Sid walked past the huddled family listening to some attending telling them what might come next. Sid brushed past a busy nurse wanting something.

He found bed four. There were no nurses here. The old guy laid on his ICU bed, covered with a sheet, intubated, ventilated. Sid knew the face. He never knew his name. He looked up at a vial taped to the wall above him. There were no words, just the red at the bottom as it should be, but the serum above was pink, not clear.

So this is what Sid needed to see. Hemolysis. Bad.

Sid pulled the sheet up off the feet. He felt the tense skin. It crinkled, crumpled under his pressure. He moved up. The thighs were twice the size expected and Sid’s pressure against them told him of gas in the tissue. Further up, the scrotum was inflated to the size of a softball. The old man’s abdomen was still flat and muscular, but Sid could feel the soft crepitus in the skin underneath.

The next morning, after his second drug rep donut, Sid’s short little R1 got in his face. Did you see it? He was almost gleeful. Did you see the tube I taped up on the wall?

Sid chewed and swallowed. Yeah. Hemolysis.

Yeah. Incredible. Gas gangrene man. The brutal killer. And you got to see it. He almost hugged himself.

Yeah, thanks. Sid finished the donut.

You going to rounds? You should man. This is all they’ll talk about.

Um, Okay.

At rounds that next morning there was a lot of discussion about gas gangrene. How painful it can be. The treatments, the prevention. There was significant criticism of the ortho guys who had cleaned out his deep knee wound. They had closed the wound with just a couple stitches. This was widely criticized.

The ortho chief resident wondered about the patient’s immunization status, if that had been explored. The room looked at him. Tetanus? Well, it is related. Clostridium tetani which causes tetanus and clostridium perfringens which causes gas gangrene are related. Shouldn’t that have provided some protection?

The two different bacteria create very different toxins, as does clostridium dificile, known for its GI disease and clostridium botulinum, for its food borne paralytic poisoning. The toxins are all different. The immunization is against the toxin, not the bacteria. The toxin is what kills you. We eat, breathe the bacteria daily. Sid learned this in his second year, maybe in premed.

The conversation continued and Sid went on his rounds.

Sid knew the old guy didn’t feel it. He was numb from the neck down. The pain of gas from a bacterial toxin separating his flesh as it migrated toward his uninfected body didn’t register. He was numb. It’s just what such an organism does. And the old guy was the host.

It would have been excruciating. But he didn’t feel it. Then he died.

Sid had seen the saves.

The 19-year-old Australian visiting our fair city, stabbed in the heart, dying, saved in the blue wave ER by a brave senior surgical resident who split his chest and over-sewed a punctured right ventricle. Chest bumps. The victim walked out seven days later, a saved man.

There were saves.

The 15-year-old who self-immolated with a can of gas had 80% total body burns. He got saved. Sid saw him up on the burn unit months later after all the grafts, now pretty much a stuffy from all the drugs to treat his pain. Saved.

But the old guy had his way.

Not taking this. Not buying what you are selling. I’m in charge here. I’m going out my own way, despite all you assholes. And he did.

Sid learned a lot in this tower of tortures.

He learned about chest tubes and IV access and central lines and intubation and ventilation. These are all important things to know when you need to save a life. And Sid went on to save lives.

Sid had always wondered about saving lives.

So he decided it was really about suffering. Lives are saved or lost. But suffering can be changed.

How are you going to make a living at that?

He didn’t know.

This kid came in with baggage. We all have it. Sometimes it has what you need.

The ambulance from up on the prairie radioed they had a five-year-old and his dad. The radio described a stable little kid with a head injury. Talking, bleeding, vitals stable.

Sid got ready down in the canyon. He was doing another weekend shift to pay off the med school loans. And to gain experience. He liked doing the work down here. It could be stressful. But he felt he could manage it. His wife was so generous to let him do these shifts. She carried the home burden. Little kids can be a real pain.

Sid would now get a little kid with a head injury. No CT scanner here. Sid started thinking about the transport option, how long it would take, the helicopter time. Find an attending to accept him. The hospital had a helipad just outside those big windows looking down on the river. He’d called them many times.

He’d walked out to the chopper beside the gurney with the heart attack, the gunshot, the pregnant lady bleeding. It was his last resort, but you had to handle what came through the door, unless you couldn’t and then you made the call.

Sally was his ER nurse today. It was late on a Friday summer evening. Sid had just gotten there, changed into the scrubs they let him wear, and had a late dinner. The cooks always sent him up a tray. The nurses had to bring their own food, or order pizza. But he, the doc, was special.

Sally had done this a lot, and she knew most the folks that came in, though not all. If she didn’t know them, she had probably heard of them. This was a very small, very remote place, the canyon. The folks up on the prairie were often referred to with a sideways glance by the folks down here. Isn’t that true everywhere?

They radioed in again before they dropped down the grade. Said everything was fine. We wouldn’t hear from them again until they were just right out of town.

Sid imagined what would be happening if these volunteers weren’t there to drive the EMS rig down the grade.

He had seen that once. It was at a different little hospital on a different little prairie in this place with rivers and canyons and prairies and mountains.

The dad had come through the doors with his 12-year-old daughter almost dead in his arms. He’d driven her all the way from their remote homestead. No cell service, no land line, so when she started having trouble breathing, he’d scooped her up, laid her on the bench seat of the pickup and drove like hell. He said he kept shaking her as she faded in and out. Then scooped her out of the seat and brought her through our doors to us. We saved her. Sid had never seen such anaphylaxis. Her nose, her mouth, her eyes dripping mucous. She was barely passing air.

But he’d read about the steps, the treatment. No helicopter, just his wits and steady hand. And the dad who took the steps, driving like hell. She survived.

These things taught him. He cherished them.

Sally was bustling in the ER bay. Sid loved the familiar grey green tiles up to the ceiling. Like when they built it, they knew they’d be flushing down blood spatter.

These people up on the prairie, Sally tsked, like she knew who they were.

Do you know this family?

No, but I can imagine. Letting their child get hurt like this.

Sid went to the coffee room and brewed his first cup of the weekend.

Ten minutes later he could see the twirling lights through the big windows of the family room, down across the river. The few June chinook left were past here by now. The downriver dams had decimated them. It was hard to get by here unless you got a government job. The salmon couldn’t get home around the government concrete walls.

Sid watched the red circling lights turn onto the bridge and then head his way. He sipped the strong coffee. There was no rush. He had learned this. Take your time. They still got to come through town and climb up to the hospital on this bench. He didn’t have to be there right now. He gazed at the light reflections on the still full river, flowing strong as the snow melted. It would run down river for another forty miles until it met the slack water of the uppermost dam. It carried barges and irrigated fields and generated kilowatts but blocked the fish. You can only get so much energy out of a system. You can’t have it all.

The white ambulance climbed the hill below him and the red lights lit up the pine needles like fancy Christmas tinsel. But it was June, and the sun had dropped down below the ridge. It was darkening here, but the sky would be light blue for another couple hours. The colors were transcendent.

Sid and Sally were there as they came in. Just two prairie EMS folks wheeling the gurney with the little guy, his head wrapped in a big white bundle. The kid was dirty. So was his dad.

But the kid wasn’t screaming. Sid liked that. Little kids can be tough. The dad was glaring. Sid didn’t like that.

The dad had on bib overalls with a t-shirt under. He had a big, long auburn beard beneath his darkly tanned creased face. Mind you, this was way before these big beards became fashionable for the in-your-face right wingers and holy rollers. Maybe this guy was a trend setter, back before you could be an influencer. The ponytail he hung told Sid something, as does the shaved head of today’s bearded brethren. Styles tell us something.

Hello, I’m Doctor Hawthorn. Are you this boy’s father?

Just a nervous nod.

Can you tell me what happened? I will look at his injury in just a minute. Sid heard Sally scooting the alert little boy across to the ER gurney behind him.

The overalls kind of melted here. The glare fell away and he teared up a bit. We were feeding the sheep. He got too close to the mule. She kicked him.

Did you see it?

No. But my daughter told me she saw it. I just picked him up.

Was he unconscious when you picked him up?

Here the overalls looked at Sid intently. Like he needed to figure something out.

Yeah, maybe. He was kinda limp. God, I feared he was dead. Here Overalls did start to cry.

Sid touched his shoulder. Is this where compassion crosses over to self-interest? Sid needed some information about the incident to decide about the helicopter.

How long do you think your son was limp like that?

Overalls was still sobbing and hadn’t heard.

Sid took a couple deep calming breaths right in front of the guy. He tried again.

Sir, if there is a head injury, the length of unconsciousness can tell us how much injury the brain received. So that’s why I’m asking.

Overalls was coming around. So Sid prompted. Do you think he was limp for a long time? Say a minute?

Oh no. He shook his head. It felt like an hour I was so scared, but it was probably just a couple seconds after I picked him up. He started yowling and I hushed him.

So he knew who you were right away?

Overalls smiled at Sid. Yeah, he knew his Poppa was telling him to hush. He hushed.

Sid liked the guy. Didn’t know his name or what he was about, but he liked him. I’m going to go examine your boy now. I’ll let you know what I find.

The head-wrapped kid was sitting on the gurney, looking around. Hey, what’s your name. You can call me Sid. I’m Doctor Hawthorne.

The grubby boy looked at Sid under the big bundle of gauze and Kerlix wrapped around his head, half covering the left eye. Sid could see the dark dried blood down his neck, onto his chest and staining his light green t-shirt. It was a significant stain.

I’m Isaiah. Sid smiled. Short and sweet.

So you are a prophet. How old are you Mr. Isaiah?

I’m five. His dark eyes pierced Sid.

I need to look at you since you got injured and figure out what we need to do. Can you remember what happened?

I didn’t like riding in that truck. Sid looked at the EMT’s bundling out and they both of them, looked down at the floor and smiled, almost laughed.

Yeah, that’s no fun. But I’m asking about this. Sid softly touched the bandaged head. Do you remember how your head got hurt?

Here the little guy looked away. Like he’d done something wrong. He barely shook his head.

Do you remember your dad picking you up?

Here the Prophet stared at his overalled father and said softly, He told me to hush.

Sid stood there in his blue cotton scrubs. He took a deep breath. Well, I need to look at you carefully, then I’m going to take this bandage off your head and look at that.

Sid did the stethoscope thing, heart and lungs, knowing this was a formality to gain trust and look competent. He even felt the kid’s belly and legs and arms, being a thorough, patient doc. The otoscope came out and Isaiah was not fearful, just solid. Sid lifted the bandage to look in both ears. All good.

Show me your tongue. He did. Teeth OK, no blood back there.

Let’s unwrap this. Isaiah sat quietly as Sid wound off the white webbing over the big pad of gauze 4x4’s.

With the last wrap Sid could see the edges of the cut beyond the 4” pads. Let’s have you lie down for this part. Sally had been watching closely and put a chucks pad on the pillow. She was expecting blood. So was Sid.

The EMT’s had probably put this dressing on 45 minutes ago, so the blood would be congealed to the gauze. When Sid pulled it off, the natural glue would lose its effect, and the blood would flow again.

Sid was careful, peeling it off from the cheek toward the scalp. There was some oozing, but no big gush.

There on the side of Isaiah’s left head, from just above his left eyebrow to the top of his scalp and back down to behind the left ear, was a perfect dirty maroon half circle laceration. It was wrinkled and the edges oozed just enough to make Sid worried about what was underneath.

Sid looked at the EMT’s who were still standing there. Good bandage. You got the flap back up where it needs to be. The woman smiled. The old guy nodded.

Sid got a new pack of 4x4 gauze and pressed it onto Isaiah’s head. Hold this he told Sally. She did. As she applied pressure to the flap, Sid pressed his gloved fingers around the edges, feeling for grating, crepitus. If the skull was fractured, it was time to call the helicopter. Sid knew this sort of check was not what they would do in the big city. The kid would be in a CT scanner before…anything. He pressed slowly and carefully. Isaiah let him.

Sid turned to the overalls Dad who was glaring intently from the north wall. I’m not worried about a serious head injury. I mean, he did get knocked out, but just for a bit. But I will need to clean this wound very carefully. The risk for infection is big. There could be a lot more bleeding, and the scar might be significant. I could get him shipped off to a plastic surgeon; they would do this repair in the OR. What do you want me to do?

Overalls was staring at Sid. For a while. We got no money, no health insurance. Can you fix him doc?

It was what Sid expected. Sid didn’t really want to sew up a 15 cm laceration on a little kid’s head with all the dirt and risks. But what the hell. He knew he could. Maybe not as good as the best, but as good as most.

Here walked in the Madonna. Mom with three more kids, one at her breast and the oldest going straight to Isaiah. She looked at Overalls. They talked a bit, Sid standing there, then she looked at Sid with wolverine eyes. You fix him up.

So he set about doing it.

Local anesthesia. It hurts going in. You hurt a five-year-old when you have told him you will help him, it can piss them off.

I’m going to use a combination of lidocaine and Marcaine, because this could take a while, Sid said to Sally. Do you guys have Marcaine down here? Or do we need to call pharmacy? She nodded and found the vials in a drawer.

See if you can get his skin kinda clean before I inject, he told Sally. Isaiah, we’re going to wash you off there where you got kicked.

He just nodded. Little trooper. Then I need to get the area numb, so you won’t feel what we’re doing. The numbing medicine stings a bit if I go too fast, so I will need you to tell me if I’m going too fast. Sid said all this while he was opening up the big suture tray on the stand by the gurney. He unpeeled come dexon and ethilon sutures. Madonna had moved over next to Isaiah. She still had the babe at her breast, but it was sleeping. Sally washed, scrubbed the kids grubby face and up into the scalp. It was a big flap.

Sid knew the anatomy. He knew what was under there. And he expected it to be pretty dirty. So he kept up the banter.

After this wash of the outside we’ll get you numb so you can’t feel anything. Then we need to wash out the cut, so you don’t get an infection. That’s when germs grow in your body where they shouldn’t. Germs aren’t bad, they just need to be in places where our body can deal with them. Our skin keeps them out pretty well, but your skin got cut, so there could be germs down under your skin.

Sid got out the sterile gloves and dropped them onto the tray. It was all set. He drew up the two syringes of local anesthetic. He turned to the patient.

Let’s get you comfortable. Sid fluffed the pillow and had Isaiah lie on his side so he could look at his mom. She was staring at the plastered down flap. Sally had the skin pretty clean. Sid hoped what was underneath wouldn’t be too bad. But a mule hoof is not clean.

Sid slowly injected the local. Isaiah only complained a couple times when Sid rushed it, but dad told him to hush, and mom patted his arm and he calmed down. Sid had done this on so many screaming kids whose parents were just as afraid as they were. This kid was great. It took Sid about fifteen minutes to get it all injected.

Sally, can you get me some sterile saline to wash this out?

Sid lifted the flap.

There it was, the pulsing temporal artery. Sid knew it hadn’t been cut. The dressing would have been soaked, inadequate. There were little bleeders here and there that he could sponge. And there was dirt.

This little kid had a flap bigger than his hand on the side of his face and scalp from a mule kick, and he would live to tell about it.

Sid looked up at the Madonna. It’s not too bad. We’ll clean it up and close it.

She frowned at Sid. Will he have a scar?

Oh yes. One he can be quite proud of. Impress the girls. He smiled at her, there holding the sleeping babe. She was still worried and looked over her shoulder to the overalls. Then she calmed.

Sid spent twenty minutes irrigating, picking out debris, cleaning the wound. Isaiah actually fell asleep. Then Sid closed it. He put just a couple deep sutures to hold the skin down, then a lot of nylon sutures around the edge. He needed three packs of 4-0 ethilon. Then the dressing, almost the same as the EMT’s had applied.

You can take him home. Take the dressing off tomorrow to look at it but then put it back on until Monday. Come back in a week or so for us to take out the stitches.

They loaded out. The prophet was asleep on his dad’s shoulder.

Sally was bustling, cleaning up. Sid removed all the needles from the tray. Five suture sets had gone into that, and the two 5cc syringes of local.

Sally tsked. A mule. They let their boy near a mule. I can’t imagine.

The windows were clear and Sid could see the river, He thought of the big chinook coming up to spawn, the few that could get past the dams. He thought of the reds, where they went to lay their eggs, The streams off the sides, up in the canyons where the clear water flows.

Sally came in. We got another kid with an earache. Sid smiled.

Hey Sally, you ever been kicked by a mule?

She laughed. Naw, Doc, I know better. You?

Sid paused. Not a mule, but a horse. Knocked me down.

Sally shook her head. That little boy was lucky.

Yeah, he had something on his side.

They went to the ER together.

It was still light when Sid headed home on the Sunday evening. The drunks, the crying babies, the sad whiners he left behind. He drove down the canyon, as the river flowed next to him. He thought of the big salmon coming up. They had a place to go to. As did Sid. Then they would die.

Not Sid.

Not yet.

Sid was doing another shift down here in the canyon. He had the license, and he had the time and his wife let him go do the work for the money. Maybe they could buy a house, maybe have a home for the kids.

He drove the Hilux down the canyon in the fading light of a Friday evening. He started at 8pm on a Friday and left at 8PM on Sunday. Forty-eight hours.

Sid loved the experience the canyon gave. And the extra money.

The Hilux told him the gas was low. Get it now or Sunday night on the way back? Sid was a get it now kind of guy. Why wait? The little river town had a gas station right across the bridge. The ten gallons wouldn’t make him late. He rolled up to the pump and went in to pay. He noticed the couple at the dark corner, toward the river. When he came back out one was coming his way. Hey, you got change? Sid looked at her sunken cheeks and straight black hair. She was looking down, not at him. She didn’t look well. No, I got nothing. She shuffled off and he pumped his gas.

A raven landed on the asphalt between him and the river. The couple must have been off in the shadows. The raven strutted, as they do. It kept looking off in directions, never toward him. Like he wasn’t there.

He got his ten gallons and went off to work.

He brought his own coffee. Theirs was shit. A local doc had commented on his choice. He told Sid about how he bought raw beans and roasted them himself in a cast iron skillet. His excitement was infectious. But Sid only tried it once. He found the store roasted beans suited him just fine.

Medical training is so arcane. Sid thought about this as he could see the river through the family room windows. A jet boat went upriver. Sid listened to old, experienced docs. Some were full of shit. Some were wise. He tried to sort.

Mainly he tried to learn the tricks. When to do a cut down. How to do a cut down. When to intubate. How to intubate. This medical thing required a lot of when and how after all the books and tests. And it took some experience, some real time in the saddle doing to get the sense. He swirled his good coffee and wondered about the steelhead down below. He had no thought of the panhandler at the gas station, or the raven.

There were a few interesting things through the day, but not much. Sid read some journals about Jacob Creutzfeld disease and wondered about prion diseases, but then they brought him dinner. The three or four old guys or ladies got their trays and then they brought Sid his. It was good.

About 8pm he wandered the halls again, checking with the nurses. He wore blue cotton scrubs. So did they. He was making twice what they did, and he was reading journals, not caring for patients. But Sid didn’t consider much of this. He had a full tank of gas and just another 24 hours to do.

He went up to the nurse’s station. So I guess I’ll lay down before we get the late calls. Patty smiled at him. She was beautiful. She had done the ER work today and would be heading home soon.

You get your rest. I’ll be here all night. Sandy called in sick so I’m doing a double.

The other nurse laughed. I’m gone. It’s been quiet.

Patty scowled. Never say that.

She woke him at 1AM. Ambulance from upriver with a man with bad vitals.

Sid sat up. Like what?

Pulse 150, BP 100. Barely conscious.

Anything else?

58-year-old vomiting and shitting blood.

Okay.

Sid woke up easily. It was a gift. Like going to sleep easily was. He didn’t question his gifts. But he did this thing, medicine, to look for things. Things to learn. What to do when. When to be quiet. When to speak up. When to cut, when to sew. He sat up on the little bed and put his head in order.

Call in Lab he said to Patty before she left. Sid knew he would need help on this. First you needed to know what help you needed, then you had to figure out the problem.

It went like this. He was learning to sort. That was all the help he could imagine right now.

So he moved on. Fifty-eight years old meant he wasn’t at the end. Something else must have brought on this total failure. Shitting and puking blood meant bad things.

Sid had his scrubs on. He washed his face in the little porcelain sink and went to get bad coffee. As he was pouring, he heard the ambulance come up the drive.

So he went to work.

The crew rolled him in. Long stringy hair and balding was the first Sid saw. The skinny arms and hollowed cheeks were in view as they did the transfer. One, two, three, over. The EMT’s bustled to grab their stuff and Sid and Patty were now in charge.

Did you guys start an IV?

The young woman flipping the straps over spoke. We couldn’t access. Tried antecubital but he was too flat.

Sid moved down to the arms as Patty put on the leads and O2 sat monitor. Sid knew this guy would need blood, fluids at least. And he had to find a place to put it in. IV access is the ER skill to die for.

As he continued his survey down the pale, hyperventilating, not dead, but near dead body, Sid saw the black shit up and down his legs. Black is the color of shit-out blood. Red in the movies from a gunshot or knife, from veins or arteries, but when you bleed into your gut, the intestinal bugs deal with blood; they reduce the iron, removing the oxygen and it is black as you shit it out. This skinny, barely alive guy had black streaks all down his legs. He’d been bleeding into his gut for a while.

They said he was 58 but Sid thought he was death approximated. Hey, can you hear me? Sid yelled at the side of the balding, long haired head. He breathed so fast Sid doubted he could speak, if he could hear. Sid thought, He’s dying.

And he was. Very close.

Can you get an IV? he asked Patty.

I’ll try.

Sid kept doing the survey. Looking at this near-death man for why and for what to do. He needs fluids, probably blood, he said to the room. He’s probably anemic and low volume from the vomiting and diarrhea.

Patty was not listening as she studied the skinny guy’s arm for IV access. Sid looked at the monitor. Pulse now 160. He’d felt the thrill of the struggling heart under his bony chest. There was not black shit up there.

Sid thought about the residents joke he had heard in training. Guaiac was the test done you had in the ER to check for blood in body fluids. Mainly “stool”= shit. You got just one point for a positive guaiac on rectal exam. You got five points for guaiac positive under the fingernails.

This guy’s would have gotten him five points. But Sid had never gone for points. Let’s just keep him alive.

Here’s a red top for lab and I have access. Patty was a trooper.

Send it off for CBC and CMP. Give him LR wide open. If he comes back at all, we will need to type and cross. The lab tech Tran was there, grabbed the vial and ran down the stairs. Sid hadn’t written any orders, signed anything, but things were getting done.

Sid kept looking at the skinny 58-year-old. There was so little else he could do. He knew he was here so the local docs could sleep in their beds and be real. And he knew he was here because he wanted the money and his wife put up with his being gone. And he knew this meth head was here because he had abused his body and ignored so many signs, signals. And Sid wondered.

The phone rang.

Tran was panting. Hematocrit 7.

Sid knew what the numbers should be. No, that’s his hemoglobin.

The ratio is about 3:1. These are measurements of how many red blood cells are in the blood circulating in your body in ratio to the serum, the liquid around them. Hematocrit should be above 40. Hemoglobin above 7.5.

Are you sure?

Yes. Hematocrit 7. Hemoglobin 2.3.

Jesus, Sid thought. This has taken a while to get here. A lot of things came into focus.

Acute blood loss doesn’t change the concentration of blood cells. You lose half the blood in your body with a stab wound; your hematocrit will still be close to normal. You might be dying from the blood loss, but the ratio of blood to serum is what it was before all that blood left your body. You lose blood slowly, chronically, and your body can’t keep up with the slow drain, this ratio drops.

Skinny guy had been losing blood for weeks, months. And here he was.

Can you type and cross from that red top?

I’ll try but see if you can get a lavender.

Two units.

Sid turned to Patty. How’s his IV?

Sid had treated patients who had died. It didn’t burden him, their death. What he pondered and fretted was the question of what he did. Had he done the right things? Had he missed something, made some bad choice?

This meth head was going to die from weeks or months of blood loss and he was going to die in Sid’s ER. Dammit, he was going to do what he could.

The raven didn’t look at him.

Sid looked at Patty and she looked back. If you can get a lavender top, we need to transfuse this guy.

She went to her work and Sid went to his.

It kept going, almost through the whole Saturday night. The IV blew and Sid did a cut down on the skinny guy’s saphenous vein down near his ankle. Both were white, the vein and the nerve he exposed with a simple cut. He used a clamp to figure it out. Clamp the nerve of a hyperventilating, non-responsive meth head and he let Sid know. A unit of blood brought the vitals closer to stable. And the meth head even began talking to us.

Sid got him shipped down river.

Then, late he went to sleep.

There was a little kid before breakfast with an earache. Sid liked little kids. Their parents could be the problem,

Coffee looking out toward the river.

Sid saw the crows, maybe ravens, pretty far off. They clustered above the boat ramp in wheeling and spinning circles. The jet boats were set to launch. The birds knew. What?

He did the Sunday. Before he drove off, he called the down river hospital to see what had happened with the skinny guy. Oh, he left AMA. Against Medical Advice.

So he was Okay?

I guess. She just answered the phone. Sid left with his tank of gas as the sun was darkening the canyon.

On a tight curve he saw a dead crow or raven on the asphalt. He swerved and missed it. But ahead he pulled over, maybe to piss, maybe. The log trucks shot past as he looked across the downstream current.

The far slopes still had sun. His eye caught the motion. A big bird in the water was working toward the shallows. Its white head bobbed. Sid knew its talons were embedded in a bigger fish than it could bring up. Sid turned away. He had to get home.

Sid had his coffee and breakfast, so he knew, now he could deal with whatever came into the ER. He was doing another 48-hour weekend shift in his early days. He loved the money and what he could learn.

The fog laid down in the canyon so he couldn’t see the river from the family room. Sid couldn’t see the jet boats or drifters fishing steelhead. He hoped to be down there some day.

There was a group down on the other end with the old pale person in the hospital gown. Some little kids ran around, but the adults conversed as Sid looked out windows into the gray.

He had made some of his own coffee. The hospital stuff ate up his gut.

Raven walked in. She was a beautiful person, and in fact, the nurse covering the ER with him for the next twelve hours. She had explained the hippy parents when Sid had asked about her name. Her long glistening black hair, down to the top of her round butt made him wonder about native genetics. Likely, everybody in town knew, but Sid didn’t.

“There’s a patient in the ER for you.”

Sid was in his cotton scrubs. The kids running around and the folks talking with the old person didn’t seem to know he was a doctor. That suited him just fine.

Sid followed Raven. She had a nice walk. Sid had an empty coffee cup in his hand.

The tiles of the ER bay were maybe green, maybe gray. They softened the light.

There was a youngish woman on the gurney covered with a blanket. Sid thought she seemed small. But these things are hard to tell when they are laying down.

There was a guy in a chair. Beyond the beard, he seemed big.

Maybe it was all the kids he had treated, but Sid had long ago learned to address the patient. Small or big, the patient with the “chief complaint” is who deserves the doctor’s attention. The simpering wife or the domineering parent might try to interject. But ignore them until you have addressed the patient.

I am Doctor Hawthorne. How can I help you today?

The silence from the patient and the guy in the chair told him something. The fear in her eyes told him something too. But Sid waited. Give her room.

I’m having pain down there. Such a small voice with such conviction. She moved her thin strong hand over her lower abdomen under the blanket.

When did this pain start?

Here, she looked to the big beard, almost as if to apologize. It’s been a while.

This shit pissed Sid off. But somehow, he looked away and saw Raven, standing there against the grey green tiles. Her face was looking down, not at him, but at something. It was glowing, radiant. What the fuck does that mean, he wondered.

Sid shook it off. So has it been a few weeks, a month?

Why can’t they just tell the story of their illness? If they could just tell the story, Sid could do his job to interpret. But they always seemed to not want to tell a story.

The small woman was now looking at the tiled wall. Sid could see a glistening in her small bright blue eyes. Sid felt her pain.

It’s been for quite a while.

More shit. Sid took a deep breath. He looked up. The ceiling was not tiled. Maybe plaster, since this place was old. He felt the big, bearded guy shift.

Sid went back to work. Have you had children?

The big guy snorted and shifted.

Sid stayed still. The patient looked back at him. Oh yes, four. She was almost happy even with her pain.

When was your last menstrual period?

Sid thought if he could just get the right information out of these folks, he could solve their problems. But instead, they would just give him shit.

Raven was at his elbow. Can I get you some coffee?

Sure. Raven asked them both if they wanted anything in her clear soft voice. They both wanted tea.

Where were we? Sid asked the patient who now seemed amused. And the big guy relaxed.

She described having babies and breast feeding and she did so with almost glee. The bleeding wasn’t anything regular she had learned. Four babies, then pregnant again and now this pain. Here she looked at him. Like she had known something, and now she didn’t. And this guy in cotton scrubs was supposed to.

Sid hated this. He wanted them to know.

Raven came in with a small tray. She was not glowing, just business. She took the tea to the patient and then to the big, bearded guy, then Sid. Here’s a fresh cup.

When Sid took the cup, he felt the warmth. He looked down into the dark liquid. For a while, that’s just where he was, looking down at a hot liquid in a ceramic hospital mug. Then he looked up at the patient and the guy, and raised his cup, almost toasting them. He slurped the hot bitter liquid. They raised theirs and blew on it.

Then, he went back to work. So you haven’t had regular menstrual bleeding for a while now?

It was like the two, the small woman and the big man had changed. Sid felt like he knew them. Maybe some fear had left the room. The story leaked out. Not like Sid wanted it told, but they did their best.

They lived up on the prairie. It was a small cabin with no electricity. They had a stream for water. He cut and sold firewood. She raised the kids and managed the garden and sheep. The babies had been born there, in the cabin. A friend, a neighbor had midwifed for the births. This helpful neighbor had told the patient this problem needed to be attended to by a doctor. So that’s why they were here. To the weekend ER doctor in a small rural hospital and Sid didn’t think he had the patience for this.

Sid sipped the bitter stuff again as she paused. The big guy sipped his tea too.

The youngest, Isaiah, is two now and I’ve pretty much stopped breast feeding him. But I keep bleeding. Not a lot. Not like I used to, after the babies, just always bleeding a little.

So you have persistent vaginal bleeding?

Just a little. Every day. And then a lot after we have relations.

The big guy spoke up. His voice was smaller than Sid expected. And it hurts.

The patient looked off to the grey green tiles and nodded.

Sexual intercourse hurts?

He nodded, looking at Sid, and she did too, looking at the tiles.

Sid thought that now he had heard the story they could tell. So he said he needed to examine the patient. That’s how he tried to do it. Get the story, as best he could, then look for findings. Then, provide treatment.

He announced his turn and asked Raven to prepare the woman for the exam. Doctors do this. Command the room, command the next steps. Sid had never liked this command thing, but he had learned that leadership was his duty.

Sid and the big guy left the small ER room as Raven undressed and gowned the woman.

Sid was not tall. The big guy was. Sid’s coffee was gone, but he gestured with the cup as he made small talk. So what brought you up to the prairie?

The big guy shuffled. It was her, really. She sees the end coming. She thought we could make it best up here.

Sid looked at him, while he looked down. The end coming?

The big guy sighed. It’s all there in Revelations. We study it and understand it. Most people don’t. Most think we’re crazy. But we know the next things. The evil angels, disguised as the government will come for us. We have filed an affidavit with the courthouse. We know what is coming. We are prepared. You probably think we are crazy too.

Here, he looked at Sid. His eyes were soft, almost pleading. But Sid knew, this was not the patient.

I’m going to examine your wife. I don’t think you are crazy. Let me try to find out what’s wrong.

Raven was not beaming. She was almost invisible up against the tiled wall. The patient was on the gurney, under a white sheet. Sid thought she looked almost death like, stretched out there. He stood at her side.

I know your pain is down there, but I examine all of the patient. He used the otoscope to look in the ears and the tongue blade to check the mouth. Some bad teeth, but not remarkable. He felt the glands of her neck and armpits. He listened to her heart and lungs. Her flattened breasts had no masses. He had pulled down the sheet, then lifted the gown to get to these parts. He pulled the sheet down farther now to check the abdomen. He pulled the gown down over her breasts. Sid could feel her tension, her fear.

Her pale abdomen was scaphoid, thin. Sid had pulled the sheet down to just above the mons pubis, the clump of pubic hair above her genitals. He saw the deformity but did not skip palpating the upper abdomen. He had learned a while back not to rush to the object. His mind might take him there, but the thoroughness of a complete exam can give both reassurance and credibility. It was just the discipline he had come to.

Above the white sheet that laid in a line below her pelvic bones and above her pubic hair, where she had circled her hands in the first conversation was an irregular lump. Sid saw it and knew. But he put his hands there. He felt the irregularity with his fingers and watched her face, as he had been with every touch. The eyes, the face will tell you more than your fingers can feel.

It was hard and lumpy, and she turned toward the wall as he touched. Sid knew. He figured she did too. Though she couldn’t tell him the story in weeks and months, he knew she had lived with this growing within her. And she knew.

And she was afraid.

It was his job now to move her on.

Sid turned to Raven. We need to do a pelvic exam. Raven turned away to get the stuff. Sid looked at the thin blond, blue eyed woman. First, I’m going to do a vaginal exam with just my fingers inside and a hand on the abdomen. Then I’m going to use a speculum to open the vagina so I can look up inside. Her pale blue eyes were locked on his. Have you had this done before? She nodded. It shouldn’t hurt. I need to see and feel what I can.

Then, Sid thought, I can tell you the dismal future. But he knew he had to do the rest. So he did.

There was an irregular mass where her firm round button of a cervix should be. It did not move like it should, and the lumps on her lower belly moved with it and she felt pain. When he looked up inside in the green, gray tiled room with an old light goose necked down, Sid looked cervical cancer in the face.

The big guy now stood by his wife, though Sid doubted they had ever asked for government approval of their union. Raven was behind him.

Sid addressed the patient, though he felt the husband and Raven right there. Her blue eyes seemed to drill into his. He hadn’t written this speech out. Maybe he should have.

From what I can tell from my examination, I believe you have cervical cancer that has grown into your surrounding pelvic organs.

She clutched his hand. They looked at each other.

Sid saw Raven, over there not glowing, not looking away, just looking at him with an open, bland face like she was asking something. What?

The big beard bent down and was kissing the sobbing small woman. Their hands were entwined.

Raven here lifted her finger. An admonishment. Like Sid had been yelled at by attendings in his training, but she was silent and almost smiling. What?

They cried some more.

Sid didn’t know what to do.

There was this big open space here inside these small, tiled walls as the couple cried and he, the doctor with his limited knowledge of this history and examination had told them what he considered a diagnosis. He knew there was so much more out there.

Raven’s finger had dropped. She smiled clearly at him, like she knew.

So Sid went up to the top of the gurney where they were hugging and sobbing, and he put his arm around the big guy’s strong shoulders and he put his hand on the small woman’s shoulder and he cried with them.

Sid came to enjoy delivering babies. It hadn’t started easy.

He had watched his wife deliver their first child in his first year of medical school. He had never seen anything like it. The doctor, who Sid had followed through his clinic, kept turning to him and kind of explaining things, like Sid might understand. But Sid kept looking up to his wife’s face, her sweat, her effort, and the products of conception that issued forth, the watery slime, some blood, then the wrinkled skin and then the baby. But Sid only recognized the tiny bent and soft arms and legs as a hallmark. The rest was just wrinkled goo. He missed all the details of what to do.

But he hadn’t passed out. Later, when he did the deliveries, he paid attention to the color in the dad’s face, standing there, and warned the nurse she might have to catch him. Hate to have to stich up the dad’s head after stitching up his wife’s vagina.

He had training in medical school. He remembered a nurse bringing him in to check for dilation. He gloved and lubricated as the woman panted. He thrust his fingers, hand up inside, feeling for the rim of the cervix deep up at the end of the vagina. It held the baby in its home for these months, up in the uterus. But now, with labor, it was softening and opening. It forecast the progress of the birth.

Sid told her what he guessed. Seven centimeters. “No, she’s only six. You are overestimating. You have to be accurate.” The babies come out.

That was not always for sure, he had learned.

But this lady was for sure going to have a baby.

Sid covered the local ER almost every other weekend. It paid a flat hourly rate, and he had medical school debt. Sure, the 48 hours tired him out for his Monday morning patients and he missed the kids and his wife. But debt drove him. And he saw patients and learned.

Sid had slowly and painfully learned the messy business of bringing babies into this world.

He would always remember the attending teacher who had given him a delivery in residency. When the slimy infant shot out Sid had almost dropped the wet projectile into the bucket there to catch the liquids. The attending noted and brought Sid back to the delivery room afterward with a doll. He had showed Sid where to place his hands, thumb and forefingers as the caput passed to grasp the neck. “Now do it.” Sid did it. “Do it again.” Sid did it again. “It needs to be muscle memory, like shooting a free throw.” Sid got it. He never dropped one.

And he learned to know when the baby wouldn’t come out.

Sid learned to understand the pelvis of a laboring mother. Her bones might not be able to let this infant come. Or the position, the presentation. He almost accepted it was an art. Almost.

One woman in his residency had not gotten prenatal care. This was not uncommon, but she was white and employed and educated. But she was fat. And Sid guessed, ashamed. So she was on the delivery floor, pushing, working with them, agreeable and it seemed things were progressing. But all that was coming through her fully dilated cervix was the soft forward part of the infant’s head. The infant was really not coming down. She was so big. But her pelvis wasn’t.

So he learned how to operate to bring the baby out abdominally. And he watched the doctors make these decisions. Some were just for convenience. And Sid learned how he might make these decisions.

But this lady who happened into a Sunday night ER was going to have a baby.

Her partner or her driver brought her through the ER doors in a wheelchair. It was a slow late Sunday night, and Sid hadn’t laid down to try to sleep yet.

They both looked native. Sid never figured out if she was from the tribe down south or the northern one. It hadn’t mattered. It just mattered why she was here.

She was panting. “She don’t feel good.” The other had said. Sid and the ER nurse could see the belly.

Doppler, Sid muttered to the nurse as they moved to help her onto the gurney. She was a big woman. Tall and strong. She did most of the work between her fits of panting and writhing.

“When are you due?”

Between her panting and writhing she grunted or snarled at Sid. “I don’t fucking know. You tell me.”

Sid smiled at her. “It looks to me like you are in labor, like your baby is coming. If we have an idea of your expected delivery date, we can plan for the baby’s needs.”

She was up on the ER gurney and Sid could see another contraction coming. Her eyes lost focus and her panting became rhythmic. These were coming fast.

The other guy was no help. “I just told her I would give her a ride. Then she started acting funny, so I pulled in here.”

The nurse helped Sid strip down her pants and underwear as the mother panted and writhed on the gurney. They both knew where he needed to go. To the opening.

Sid put on the glove and pushed the laboring woman’s knees aside. She complied. Sid never got over how women allowed this. Or that he should ask permission. He just did as he had been taught.

There, deep inside her vaginal vault, he felt for her cervix. When women are not pregnant it was firm, hard, forbidding. But in this woman whose name he did not know, it was soft and open, sliding out to let the infant’s head come down. And the head was coming down.

She’s 8 cm and plus 2. Do we deliver here or upstairs?

Let’s get her upstairs. The calls were made and the gurney rolled.

Sid liked the delivery suite in his small-town hospital. He knew the nurses and he appreciated their skills. But this, an unexpected delivery from the ER would challenge them. Most of the time things were expected.

Sid rolled up with her.

What is your name? Sid asked in the elevator. The round sweaty face looked at him.

“What is yours?”

The nurse interjected. “This is Doctor Hawthorne.”

Sid muttered. “Call me Sid.”

The sweating lady laughed. Then a contraction came on, and he didn’t get her name.

The OB nurses had roused from their post-partum cares and met the elevator. They had the room ready and moved her onto the delivery bed. The baby resuscitation stand was plugged in and lit. Sid and the two nurses, OB and ER moved the patient onto the birthing bed, although in fact, she did the work herself. She was strong and able between the contractions. When they came, she became possessed.

The ER nurse excused herself gladly and Sid just had Sally, the veteran OB nurse now to help. But she was good. Sid thought, this was going to be Okay.

“Do you want an IV?” Sally asked. The laboring mother had come up from the ER with no IV access. Sid thought about it. Maybe he just went to a mind palace place where the risks and the need could be balanced, like when you place your bet before the roulette wheel spins. Like making art, or gambling, or loving another. It’s so messy. And beautiful.

We’ll be OK.

Sally worked to put the monitor straps on the big belly between her painful contractions. And this is when the mother had time and less distraction so she could cuss at us. Sally knew this well.

“What the fuck?”

“Just lean forward and we’ll get these on so we can listen to the baby’s heartbeat.”

Pretty soon Sid could look at the monitor, watching the contractions and fetal heart beats, much like a normal delivery like he had done hundreds of times. Maybe Sally just did the monitor things to make him feel better. It’s best if we can all feel good when something is about to happen. Or so Sid thought.

He watched her through another contraction. She was now dripping sweat and said she had to puke. Sally brought up the basin and the lady filled it. The fetal heart rate dropped as she wretched and vomited but then came back as the contraction eased. Sally brought a wet washcloth and wiped her mouth, forehead and the lady leaned into the comfort. She breathed deeply and regained strength.

Sid took in her beauty. She was not a beauty, but he saw something. This pause, this reflection, this absent appreciation of the moment, and this woman before him took time. And he knew what he had to do. But another contraction was coming fast.

It’s coming time for you to start pushing. I need to see if the cervix is fully dilated so you can push. And he plunged his hand in as she started panting and became possessed.

As he felt that the rim of her cervix was past the edge of the descending head he felt a blow to his chest. It staggered him back. When he went inside a woman with his hand he usually looked off, not wanting to make eye contact. But when he felt the chest thump, he snapped into focus. Her possessed eyes were glaring at him, and her right foot and leg had made the agile movement to push him back. Forcefully.

It was a precise blow. The possessed woman’s heel met Sid’s sternal notch and her right foot pads landed right over his heart. Sid appreciated the precision and limited force. He knew a little harder, or all her force, she could have killed him.

But then his hand was up in there where the baby is coming.

This is the intimacy of doctor, birth, life.

Sid watched the contraction lose it’s hold on her. Her eyes focused on him.

It’s time for you to push. You can help this baby come out. But you do that again, kick me, and I’m out of here. You’re on your own.

She looked away, at the pale walls, breathing, knowing what was coming.

And she had a baby.

Sid only learned her name from the chart.

The baby was beautiful.

They were gone the next day.

Sid was hauling the concrete chunks into his backyard. It sloped down and he wanted it level. And he thought he could do it himself. The kids were upstairs or off somewhere and his wife was minding them. He’d told the demolition folks he would take their sidewalk concrete scraps. They dumped them on the street and Sid got out the wheelbarrow. Just simple work.

****

She came to him as a patient. She had no complaints of pain. She was just bothered that she couldn’t get to the mailbox anymore. Are you short of breath?

Sid sat on his stool before the thin elderly woman. He tried to run through the possibilities.

No, Doc, I’m fine.

Have you had chest pain or palpitations when your heart beats funny?

No doc. She looked at Sid like he was simple.

So what stops you from going on to the mailbox?

She sort of laughed, like his question didn’t make sense. And that’s what she said. Well, I don’t really know. That’s why I came to you.

Sid felt the slap. He was just told to do his job by an older woman with more years than he could expect.

****

The flipping of the concrete slabs into the wheelbarrow wasn’t hard. Then trundling them down and tipping them out was the other side of the equation. The pile up there and then pile them up down here.

Maybe the tenth or the twentieth load he might have felt tired. But that didn’t register. The pile on the street, the wall to build defined it for Sid. Do the job.

****

Sid listened to her heart. That’s where he thought the problem was. But doctors need to be open to things beyond their presumptions. Sid tried to be.

Her heart was strong. The pulses good. Even with the things he tried, he couldn’t get the old pump to act up.

Her lungs were good.

She was old. She had good strength. But she couldn’t get to the mailbox. And Sid needed to figure out why.

****

Maybe it was the twentieth or thirtieth load of concrete blocks. Sid had broken some with his maul when he thought he couldn’t handle them. The wall was now up a couple layers. But here you want the big blocks.

So he tipped the big one in and got it up so he could wheel it down to the wall he was building.

****

Okay, let’s see you walk. Let’s get you to walk like you would to the mailbox. How far is the mailbox?

Oh just out on the street.

So how many steps off the porch. Sid was seeing an old farmhouse with a nice south facing porch, but he had never been there. He was here in the office and so was she.

She stood up as he asked on the little pullout step the exam table had, and Sid offered his hand to steady her.

He saw the problem right away.

****

He couldn’t tip this one out. He needed to place it on the wall as it had grown. The wall was growing, as he wanted. So he needed to pick this big one up out of the wheelbarrow and place it. He thought he could do it.

****

Sid walked next to her as she managed the flat hallway out to the entrance and back. Sid saw her knee was at a very unnatural angle. Sid saw her dip and compensate. He saw her pain, though she never grimaced or complained. Sid just knew. It’s what some do. Pain can tire you out or stop you from doing what you want. And if you don’t say the word “pain” or “hurt” to the doctor, sometimes, they don’t understand.

****

As he lifted and turned, he felt the click, maybe a crunch in his right leg. He set the big concrete chunk where he wanted it. And he went and got more.

****

Okay Darling. There’s nothing wrong with your heart or lungs. Your bones have failed. You need a new knee. We can fix this.

He did the referral. She got a new knee.

****

Maybe a year later at a softball game when he hit it to the outfield and rounded first to get to second, he held up. It wasn’t a big deal, just a swim team game. Sid came back to his wife from where he was stranded on second.

You are limping.

What?

Yeah, you were limping going to second.

No I wasn’t.

****

And so it goes.

In residency Sid learned he could get licensed in the next state after just a year of training. And then he could work weekend shifts in small town ERs and make extra money. So he did.

He loved it. He managed the kid with diabetic keto acidosis with just one lab tech and a nurse on call. He carried the screaming logger in from his pickup. He set the little kid’s broken arm. The gunshot wounds, the little boy half scalped by a horse kick, all the things he cared for and learned from.

He was in training in the big city hospitals. The experienced attendings shared their wisdom. But down in this little river town with a tiny hospital and miles to go for help, he had to figure it out with what he knew and the resources he had. He loved it. And they paid him.

The call came from upriver. The ambulance had a “75-year-old man barely responsive with a slow heart rate and low blood pressure”.

The nurse relayed this to Sid as he was watching a late-night movie in the doctor’s room next to the ER. It had a sink, a shower and a bed.

Did you get numbers? What was the pulse? Regular? And what was the pressure?

We lose signal as they go into the canyon. They’ll be here in twenty.

Eleven o’clock on a Saturday night. Sid has to decide who to call in. Call lab and x-ray, he says. They’ll need to be here when he comes in.

No point going back to the movie. Sid got out his well-worn handbooks to refresh and got a cup of coffee. It was burned and bitter. He didn’t have time to make a fresh pot. He thumbed through bradycardia drugs and protocols, though he found he knew them.

He went down to the nurses’ station. Sid knew them both. April was younger and would stay with the floor patients. Sally would help in the ER as she had Friday night. She must have the weekend.

We’re going to need an EKG soon as he rolls in. Maybe the crash cart too.

Sally was charting but nodded like he was a slight bother, but tolerable. Nurses taught Sid a lot. She sensed his excitement and was telling him, as she scribbled her notes no one would read, that this was going to be okay, if you can just keep your cool. Or not. And then it would be okay too.

For Sid remembered the teen with the .22 gunshot to his abdomen down here on the river. White as a sheet when he rolled in and no IV. Pulse at 150, BP 60, dying. Sid did all the things he knew…and so he got nervous at times. But he could calm down with help. Sally was helping.

Sid went out to the overlook. Only the streetlights shone through the glass walls, but the big river was down below in the dark, quietly moving. The salmon were coming up, just a few still. Not like before. The bitter coffee in the porcelain coated his tongue. The room with chairs for visitors was empty, so his anxiety was amplified. But that big river down there, he couldn’t see it, but he knew right where it was.

Sid saw the circling red lights coming up the canyon through the trees from his stance in the glassed room. He did not feel afraid or weak or scared or strong. He just felt fine.

He swirled the dark burnt coffee and headed back.

Sally was on the radio with the ambulance. Pulse regular at 40, pressure 90/60, patient unresponsive. Sid and Sally went to the grey tiled ER to await the EMT transfer.

These small-town volunteers do a good job, Sid knew, though some are pretty weird. These rural EMTs get up from bed or out of the field to go to the ambulance shed and drive to some place and pick up something. They are volunteers that hold a community together. The hurt person is not a package, but a neighbor, sometimes a friend, sometimes an enemy. But they bundle them up, doing their job, and bring them to Sid. Most of the time they do it very well.

Sid remembered a different call. The ambulance called from up on the prairie. Ten-year-old with a gunshot to the abdomen was the radio message. Sid told the nurse to ask for vitals. Had they started an IV? There was laughter and chatter on the other end and then they lost the signal.

They were right to laugh. It was a bb gun wound. His older brother had popped his younger tormenter. Turned out the little brat indeed had a bb in his right upper abdomen. In fact, it had penetrated his liver. Sid sent him down river to a surgeon who snorted and sent the kid home.

The EMTs do their jobs well. And then Sid was supposed to do his. With the little he knew and the short experience he had gained. It’s a frail web down here on the river.

The upriver EMTs rolled the patient in with the monitor beeping a slow monotonous steady tap. Sid saw the dark creased face with the blanket up to his chin. The long straight grayed hair was in long braids that lay on the front of the button up shirt Sid found under the blanket.

You guys start an IV?

We tried but couldn’t.

Does he take any meds?

They shook their heads silently as the transfer to the hospital gurney was accomplished. Sid thought the man substantial as he lifted.

Sid rubbed the old man’s sternum. Sir, can you hear me?

What’s his name? Sid asked the EMT next to him.

This is Ellis.

His breaths were slow but regular. Sid did not smell any alcohol or ketones. He listened to the strong, very slow, very regular heartbeat. He had unbuttoned the clean worn shirt. The chest was strong. No murmur. The skin was firm and warm. Sid thought he could help Ellis.

Sid turned to Sally. Take the EKG first, then get an IV started. She glared at him.

OK, I’ll start the IV, you do the EKG. He looked and Tran, the lab tech was hanging back by the door. Tran, draw the cardiac panel with troponin. Also CBC and chem panel.

The trio set to work and the EMT’s kind of faded back toward the walls. Meanwhile, the 40 beats per minute beep was the steady, strong, slow pace they heard.

Sid was taping up the 18 gauge on the old guy’s knobby hand when Sally brought over the EKG.

Yeah. Third degree block. No ST signs. See if Tran has the troponin done.

Negative. Jeez, Sid thought, that was fast.

We could hit him with atropine but that won’t work. I won’t hurt him any, but we could try it. Sid was thinking out loud and looking at Sally who was just looking back at him for some direction.

Do we have a pacer? Sally motioned to the crash cart.

No central line pacer? She shook her head. Give him a milligram of Atropine IV. I’ll read up on this pacer set up. Sid realized he had an audience of EMT’s that were learning just how incompetent he was.

The defibrillator was like he had used in the big city. Same set up, same settings. Sid hadn’t had to code anybody here, but the external pacer settings were familiar.

Atropine in.

Sid heard the steady 40 beats per minute. He wondered if he should sedate him. External pacing can be pretty uncomfortable. Shocking a dead heart made the person’s chest muscles contract violently. But they were dead. Ellis was alive and Sid would need to send some electricity through his chest to get his heart going faster. It would hurt some.

Fuck it, he thought. Let’s get this going.

Sid stuck the sticky pacer pads to his leathery brown skin where the wrappers told him to. He plugged in the leads to the unit and turned the dial to “external pacing”. The read out asked him synchronous or asynchronous. Sid set the milliamps at the lowest and the rate at the lowest and pushed the button.

Sid didn’t notice the three EMTs watching him. He did see Sally standing by the gurney. She was holding the old man’s hand.

You might not want to be touching him right now. Sid saw the chest muscles under the stuck-on pads quiver regularly at 60 beats a minute.

What?

We’re shocking his heart with this electricity. Only touch him through his clothes. I don’t want you to get any jolts.

Okay. She rubbed his thigh.

Sid turned up the amps one notch. The monitor kept the 40 metronome. Another notch. The chest muscles bounced more but still no capture. Third try was a charm. The beep perked up to 60/ minute. Staying alive, staying alive. Ha, ha, ha ha, staying alive.

Ellis blinked his eyes and took a breath. He sat up violently with a great inhalation of all the air his lungs could hold and gave out a big, violent “Aghh”.

Sid wondered. Did this mean something in his language. Sid had his hands on the dials of the defibrillator, but came over to Ellis, sitting up there on the gurney.

What is it. Ellis, are you Okay?

The old man looked about the room and extended his hands out in front of him. He looked at the young white doctor next to him asking him questions in a loud voice and dropped his extended hands down to his legs. Ellis looked at the young white doctor and said, “My legs! My legs.” Then he laid back down with his jerking chest muscles and 60 beats per minute.

Sid leaned over the old man with the long braids. Do your legs hurt?

No, Ellis murmured. They are fine.

Are you in pain?

Ellis took a deep breath and turned his head back and forth. He looked at the grey tiled walls and the EMTS standing back there observing. His chest muscles jerked, but he laid still. No, I am fine.

Sid looked at the settings, the rate, the blood pressure.

This guy needs a pacer, probably a permanent. He needs to go downriver. Will you guys take him? Sid looked at the EMT’s.

The older guy with the fu Manchu said, Usually the locals take him, and we go back to station. Sally nodded.

Well get me a transport then. I’ll call Three Rivers and let them know he’s coming.

Sid looked at the EMTs from upriver, but they were holding their gear and getting out the door. He didn’t thank them, though later he thought he should have. They filed out the door back to their rig. Sid told Sally to give Ellis some morphine and get the transport here. Then he went through the ER door go out to the little room where he would call Three Rivers to tell them what he was sending.

But the place between the grey tiled ER and Sid’s little room with the shower and sink and bed and telephone was the ER waiting room. And it was now full. Sid was surprised. The upriver EMTS had gone out the doors to the parking lot, but here in the waiting room were fifteen, twenty people. The mom with the infant, the older men, the women, some young children, they all looked at him. He did not know them. He did not even know Ellis. But they looked at him like they thought he did. They looked at Sid like they knew he knew something. And that Sid should share this with them.

And he did. Sid did not ask each person their relationship. Sid did not couch his words or soft pedal. He told them, all of them, the whole room what had happened and what he thought would happen. And that he thought Ellis was going to be okay.

Sid spent some time with April, the younger nurse who would go with Ellis and the local EMTs on the trip down river. Something like this takes up everybody’s life in a small town of volunteers. Sid explained the issue of capture and rate and how the external pacer could be adjusted based on his symptoms. He told her how to assess the responses. And that maybe, should he be uncomfortable, he might need some more morphine. Sid specified the doses. April paid good attention and seemed up for it. The local crew bundled him off and headed down the river. By then, the waiting room had almost cleared out.

There was a young man with the long dark hair. It was shiny as it draped across his sweatshirt, his back to Sid as he bent. He was helping an old woman get up. She looked small. Older than Ellis and frail. She stood and the young man turned with her, helping her out. Neither of them looked at the young white doctor, standing there in his blue scrubs, about to go off out of their life. They went on out the door to their world.

And Sid went off to his.

And the canyon held the river. And it went on.

Julie was beautiful. But she didn’t know it.

Sid thought she should. But he was her doctor. And doctors don’t tell beautiful young women they are. Or at least so Sid thought.

“So, doc, I keep getting this rash.”

Can you show it to me?

“Sure, it’s right here on my butt.”

She hopped down and dropped trou and pushed her white round buttock toward Sid’s face. The pattern of vesicles and erythema were familiar. They traced downward. He thought of having her bend over farther, maybe getting a look, but it wasn’t necessary. Why did he get such thoughts?

Does it tingle or burn before the blisters show up?

She’s pulling up the cotton panties and pants. “Yeah” and frowns like Sid might know some secret.

And he did.

Doctors know secrets. They learn them in school, and they learn them from the steady flow of patients, morning to night. Some docs pay attention and learn this shit, some don’t. Sid was always trying to learn the secrets.

But he only wanted to hear them directly. No gossip. The secrets patients shared were powerful. Gossip just sucked you in.

He then had to decide.

Should these secrets be shared? And how?

Sid didn’t know all the secrets, just some.

He was telling his nurse about how the episode with the angry mother with her teen son a week back had been illuminated by his wife over dinner last night.

The angry mom had brought the kid in with his vague stomach complaints after he’d missed a day of school. The young man struck Sid as depressed and that fit with this stage in life. His exam was normal, and he was appropriately nonforthcoming. He did a lot of shrugging and looking at his mom.

Sid did as he had been trained and broadened the investigation. “Is there anything else going on I should know about?” He asked the room. The kid did more shifting and glancing at mom who barked at Sid.

“What do you mean by that?”

“Sometimes there’s family conflict that can affect our health.”

The mom blushed and then raged. “We don’t need this!” and drug her kid out of the room.

Sid had gotten home late from hospital rounds and missed the family table. But he shared Martha’s meal as she sat with him. He mentioned the angry mom from a week past. “Oh yes, I heard they are getting divorced.”

Sid tried to tell this to Nancy, his nurse as briefly as possible, because the charts were coming up. He shook his head. “I just don’t like to gossip. Maybe I should.”

Nancy smiled. “Yeah, you never talked about Dr. Stout and Melanie.”

Sid startled. “What?”

Nancy blanched. A chart came up. “Oh nothing.”

She roomed the patient.

Sid had beautiful Julie sit down on the exam table above him and he did his best to tell the story she needed to hear.

Herpes is a mysterious and magical viral affliction. It gets into our body and causes its problems, usually a severe rash, pain, sometimes fever with the initial infection. Then our body fights it off and the virus hides in a nerve.

Julie was tearing up at the severe rash part, but Sid knew the herpes thing was the trigger. Right up there with cancer.

Sid paused to let her catch up. Telling people, they have herpes often takes more than the scheduled 15 minutes. He had made the mistake of rushing it too many times.

Julie wiped the tears back and muttered, “That asshole.”

Sid decided to skip ahead to the transmission and recurrence part of the lecture. He wished he had a handout. She was not going to remember a word he said. But he tried to re-engage this beauty. Should he hold her hand?

The initial infection is very hard to be sure of. The symptoms you have now are of a recurrence. Your body has beat the virus into hiding, but it has decided to come out now for some reason. You were most likely infected years ago, not by your current partner.

The tears drippled down. She shook her head. “So, it was some other asshole.”

Probably.

Julie laughed as she shook the beautiful blonde hair and let the tears shed. “So, what do I do now, Doc?”

Before lunch, after reviewing the phone messages Sid cornered Nancy. “What about Dr. Stout and Melanie?” Melanie was an ER nurse at the hospital that had left over a year ago.

Nancy shrugged. “Yeah, you never talked about their affair.”

Sid did the blanching. “Affair?”

“Yeah, that’s why she left. She got pregnant by him.”

Too much to take in right then. He just looked down at the industrial carpet and shook his head. The rooms were full, and he was behind.

Julie was back to her beautiful self as Sid sent the prescription off. “This will not cure your infection, but it can control the outbreaks.” She smiled at him like he was some sort of savior. Sid knew better. And he had now gotten behind on the morning patients. And he hadn’t even held her hand; just looked at her blistered butt.

After the half sandwich and walking the circuit, he dropped into Dr. Pearl’s office. He was doing his morning dictations, catching up. “Jim, did you know about Dr. Stout and Melanie?”

Dr. Pearl smiled softly, like Sid was just catching up. And indeed, he was.

“Yeah, poor John. This has really hit him hard.”

Sid thought back to the last years business meetings when partner Dr. John Stout had only been partially present. Sid wrote it off to his busy practice, all those patients that wanted to see him, all those deliveries. Sid didn’t know the secret to being so popular.

Dr. Pearl shook his head. “Yeah, and the history of that’s why he came to this town makes it even harder.”

“What do you mean?”

“John had to leave his group in Red Lodge for the same reason. He got a patient pregnant there and the docs fired him.”

Sid felt the room spinning. “A patient?”

Jim Pearl smiled softly and looked down, saying softly, “Yeah.”

Sid grasped for something. “Well, at least Melanie wasn’t a patient.”

Here Jim frowned. He gave a long pause, like Sid’s ignorance of such details was a burden he should not have to bear. “In fact, she was.”

Sid flipped his shit. “What?”

Jim came back to the knowing soft smile. “Yeah, she was seeing him as a patient.” Jim gave a big sigh and offered, “Yeah this has been really hard for him and his family.”

Sid looked Jim in the eye. “Are we going to do anything about this?”

Blank look. “What do you mean?”

“So, we partners of this guy think it’s okay for him to be impregnating his patients?”

Jim fussed a bit, uncomfortable. “He’s had to suffer. His wife has too.”

Sid left and went to his office. He needed to learn some things. And the afternoon patients were piling up.

Sid finished and looked around. The place was emptying out. He found Melanie’s chart and looked at it in the file room. Sure enough, Dr. Stout had been seeing her regularly as a patient. His last note described the missed periods, so he did a bimanual exam, fingers up her vagina and hand on her belly to confirm she was about 12 weeks along. His note said he would refer her for care of her pregnancy.

Sid had done this so many times, two gloved, lubricated fingers up inside a woman’s labia, into the vagina, feeling the cervix, then with pressure from the left hand on the belly to press the uterus down to feel this orb between his fingers and the woman’s tissues. It’s done to estimate the size. Also, to feel for other abnormalities. If you are lucky, you can feel the ovaries on both sides, but you have to twist your elbow and wrist around to get both. Sid just tried to do his best.

How does one deal with secrets? Keep them, share them? It really comes down to the burden. Sid felt very burdened. He thought there might be some help from his profession. He called the State Medical Association. “Um, yeah, do you have anybody who can talk to me about the laws about medical practice?”

The phone answerer sent him to the person the state medical profession’s association had on staff.

Sid didn’t always pay his dues to the State Association. He wasn’t always sure they worked for him. But here he was, asking them for help. He thought maybe he’d pay his dues this year.

The nice man introduced himself and asked if he could help. Sid hadn’t prepared his questions. Mistake. Don’t fumble now. “So, I am just wondering if it is illegal for a doctor to have sex with his patient.” That didn’t come out right.

The nice man didn’t give any ominous pause of titter, he just launched right in quite professionally. “As a matter of fact, there are no Idaho laws regarding this. The counsellors have a statute we have been looking at. And this has been a discussion about legislation we have considered.”

“So, it’s not illegal?” Sid was learning his privileged position. As just some doctor in this state he could call this professional association, and somebody would talk to him. Sid doubted they had checked if he had paid his yearly dues. What a privilege. Sid hated privilege.

“No, not in statute. But the AMA has a paper about the ethics of this. Would you like me to send it?”

The guy seemed to know a lot. Sid wondered what statutes were. Small statues? Maybe big ones.

“Um, sure.”

“And where should I send this?”

Uh oh. Hang up now? Give his name? Hell, Sid wasn’t guilty of anything. Why did he feel so guilty? He gave his name and address.

“And do you have a number I could call if I get more information?” What the hell, in for a pound. Sid gave the clinic number.

The days rolled by. The information arrived neatly folded. The AMA ethics paper was so much weaselly hand waving Sid was glad he hadn’t joined that self-serving bunch. If you have a sense of right and wrong, you know where the line is. The piece was obviously written by committee.

But there was also the Idaho law (statute) with little numbers by it indicating its location in the trove.

Statutes were hard for Sid to read. He’d done the pathology texts, the embryology, the immunology and gotten to where that language fit into his skull. But statutes, laws, written to tell us the rules we are supposed to follow took him much longer to sort out.

It turns out the counsellors clearly couldn’t screw their patients. It was against the law. But not so for doctors, Sid learned. Statutes.

More days, more patients, more nights on call. Then a call over the intercom between patients. Sid went to his office to pick up line 5.

“This is Sid Hawthorne.”

“Yes Dr. Hawthorne, I am just calling back to see if you got my printed information and if you had any more questions about your situation.”

My situation? Sid feels slapped as he realizes this guy thinks Sid is fucking his patients. Sid took a deep breath. “No, your information was helpful.”

“Is there anything further you wish to discuss?”

Yeah, that’s what he thinks. “No. I’m good.”

Sid feels the burden. His professional organization will wring their hands and waggle their fingers about doctors fucking their patients. And the state laws will only reflect what the professional organization supports. So, he’s just going to have to accept this. It made him wonder, what’s the problem here? Sid often wondered if he was the problem.

More days of patients, more nights and weekends of call.

Julie called him late one weekday, right before bedtime. “Hey Doc, they need the coroner on east Second Street.” She was a county dispatcher. He thought of her soft round buttock with the blistery rash and her beautiful blond hair.

“Address?”

She gave it.

Sid rolled up in his rusty Hilux. It was dark and only a couple Paradise cop cars in the cul de sac. It hadn’t gotten too cold yet, but winter was coming.

“So, what have we got?” Sid asked the detective.

Detective James hooked his thumbs in his utility belt and said, “This is complicated.”

There was a pickup camper back in the dark with a dead body. It looked like a cook stove had exploded and that’s why the dead body. The name of the guy clicked a faint trigger in Sid’s name abhorrent brain.

“This guy is living here in his camper?”

This gets into the complication. It seems the property belonged to Mrs. Jones, a widow. And she let the dead guy camp here if he performed services for Mrs. Jones. Here the detective bobbed his eyebrows and gave a bit of a smile. He repeated “services”.

“So dead guy was fucking Mrs. Jones?”

She did suggest that to us, the detective offered.

“What’s the question?”

Well, her son was seen in the area this evening. Detective names the son and Sid does remember this guy. Real in your face bully. He’d tried to bully Sid into prescribing narcotics and Sid had walked him out.

“So, you think the son might have had something to do with this? Was he pissed that his mom was getting these services?”

We have him downtown now giving us a statement.

“Anything else I need to know?”

Here the detective looked sideways and tightened his lips. The son is a CI for our department. He is helping us find drug dealers in the community.

Sid thought this bully could be playing both sides. “Does he get special treatment from you because of that?”

No sir.

“Let’s go look.”

The whole rear of the camper had blown off, so the body was easy to see. It was splayed back, arms out, the face and front blackened. The remains of a charred Coleman stove were on the floor and ruptured parts of a propane bottle were still attached.

Jeez, Sid offered, I’ll be more careful with mine. I didn’t know they could do that.

The detective agreed.

Autopsy showed trauma from explosion as cause of death and positive for THC and meth.

Were there more secrets here?

Probably.

Weeks later Sid got a chance to talk to his partner, Dr. Pearl again, He was the president of their partnership. “I’m having a hard time with this Stout- Melanie thing.”

Jim stopped his dictation and leaned back in his chair. “Yeah. It’s been hard for everybody.”

Sid had learned that silence and attention were the fertile ground for secrets. “Everybody?”

Here Jim laughed and couldn’t stop himself. “You heard about the sweaters?”

“No.”

“Didn’t you see them at the hospital Christmas dinner?”

“No, I was on call and in the ER that night, I didn’t go.”

Jim was now guffawing. “Yeah, well, Melanie came, I guess she’s still doing some shifts here, and Stout shows up with his wife and it turns out he’s bought the same sweaters for his wife and Melanie. They are both wearing the same Christmas sweaters. Caused quite the buzz.” Jim laughs with his belly.

Buzz? So, everybody knew, except Sid.

Secrets.

Sid wondered if his state medical licensing board had any clue. They must know the secrets. And they were empowered to grant licenses to practice, or not. Their job was to insure that the doctors they licensed were good doctors. Do they care if the doctor is diddling his patients?

Sid found his own records there on the website. Pretty bland. Dr. Pearl’s were too. As were Dr. Stout’s. No little note about him impregnating his patients. Sid figured no complaint had been filed. For that’s what must drive the Board, complaints. If it’s kept a secret, what’s the problem?

Sid kept searching. Dr. France, another partner, nothing of interest.

But Dr. Payne, another partner had a stipulation. That means there was a problem. Click on the records icon and read the long documents. Dr. Payne had been dumped out of the military for alleged, never prosecuted claims of sexual misconduct. The state board had required he only see female patients with a supervising physician in the room. Sid had to read all the legal mumbo jumbo, but it seemed the stipulation had been dropped a year after Sid had joined this group.

Sid had joined a group of physicians, one who was impregnating his patients, and another who had had a restricted license for patient sexual abuse allegations.

Dinner is over and the girls are going to bed. He finishes the dishes as Martha herds them upstairs. Then he goes out to the cold as a wedge garage. The toaster is broken.

Screws loosened. Take it apart. Shake all the crumbs out. Look for burned up connections, burned out elements. God, Sid was so happy to have something to fix.

But he couldn’t stop thinking of Dr. Stout and Melanie. What the hell did it mean? It brought back an episode in the ER. This was about when Sid was deciding to open up the thermocouple on the toaster. He went for it.

Sid was bending over a kid’s laceration, injecting the lidocaine, and trying to get him to calm down. Melanie was behind him and leaning over, looking over his shoulder. Sid was wearing the cotton scrubs, and so was she. He was working down the cut, poking in the needle, injecting slowly. He could feel her breath on the back of his ear as she looked. And he could feel the weight of her breasts on his back. The nipples firmly traced on his scapulae. They stayed there a while until Sid finished. As he straightened, Melanie stepped back and looked right into him. She grinned. “Thanks for letting me watch.”

Everything in the toaster was fine, it just needed the crumbs shook out. A good cleaning and it toasted again. Sometimes things work out. But Sid was happy he had taken apart the thermocouple. They can go bad.

It was a winter weekend of being on call for the group.

Sid started early Saturday morning in the hospital. He would round on patients in the hospital then he needed to cover the Saturday clinic from 830 to 1:00 in the afternoon.

The hospital inpatient load from his partners was light, so Sid started in the hospital at about 7 AM. It was still dark on this deep winter, just after New Year’s Saturday. That means Sid was covering another holiday weekend. That’s how it goes for the new guy.

He first saw the two other patients he was covering for his partners. Read the chart, check the history, review the notes left by his partners, then talk with and examine the patient.

Sid’s third hospital patient was Mrs. Smith. He knew her since he had just become her doctor.

She was an elderly woman who had come to the hospital two days before. She was brought to the emergency room by worried children who were responding to her complaints of chest pain. On examination and questioning it seemed Mrs. Smith had experienced a heart attack in the day or two prior. She said she felt fine now and didn't see the need to be in the hospital. Her daughters were worried. Sid had been called as the doctor on call for “unattended patients”. The hospital kept a schedule for the community primary care doctors to admit folks from the ER who didn’t have a local doctor. This woman did not go to doctors. She was Sid’s kind of patient.

He had reviewed the tests and listened to her story that Thursday afternoon. He explained to her that we usually hospitalize people after a heart attack to observe them and treat any irregular heart rhythms or medical problems. Sid understood her wanting to return to the comfort of her home, but he felt it would be prudent to be in the hospital for a day or two.

"By the way Mrs. Smith, who is your regular doctor?" Sid always wanted people to have their preferred provider.

"Well, I guess you are now, honey." She grinned at him. She was almost cute.

"I'll be glad to do that. Do you have any questions about me?"

"Oh no, you look like a fine young man." She patted his hand and looked at her worried daughter with almost a giggle. Jeez, Sid thought, a live one.

She had no serious problems from her heart attack so far. In fact, Sid was sure her heart injury had occurred at least a day before and we just needed to care for her should any complications arise. It turned out she had diabetes but wasn't taking any medicine nor hadn't for quite a while. It just wasn't something that worried her much. Her daughters rolled their eyes and shook their heads (tsk tsk) when Sid asked them.

"Oh, Mom doesn't like doctors. She took medicine for a while I think, but then just stopped. She didn't want to come to the hospital with this chest pain even. She sure did take to you though," they both smiled.

"Well, we'll see how she feels in a day or two when I bug her to take her medicine."

"Oh, I'm sure she'll listen to you."

Sid smiled. No sense arguing. We'll just wait-and-see.

On her second hospital day Sid had come by to see Mrs. Smith in the evening. She was her usual chipper self but a little bit more tired than the first day. Her pulse was a little weaker, but steady, and her blood pressure down a bit, but not short of breath nor with any swollen ankles. Her weight was stable. So, it seemed like her heart attack had weakened her heart but not seriously at this point. Still, Sid needed to know some things from her.

"Good evening Mrs. Smith. How do you feel tonight?"

"Oh, just fine. A little tired."

"Have you had any chest pain?"

"Know, I've felt just fine."

"Did you walk at all today?"

"Just to the bathroom."

"Did that tire you out?"

"No"

"Did you feel short of breath?"

"No"

"Good."

Sid was feeling her pulse as they talked. Steady. Regular, but a bit weak. Still, it was the end of the day.

"Mrs. Smith, all the tests confirm you have had a heart attack, but you seem to be doing OK. I expect you to go home in a day or two. At least by Monday if all goes well."

"Oh, I hope so."

"You live alone, don't you?"

"Yes. My daughter's visit a lot. My husband died six years ago."

"You like living at home, don't you?"

"Oh yes. I love my little house and my yard."

"Mrs. Smith, I don't want to alarm you, but I need to ask you some questions. When you are here in the hospital we can do things to you in many ways, some things that you may or may not want done. We do our best to respect your wishes. Sometimes things happen and people can't talk to us. But we could do things to treat them that may revive them or not. For instance, if your heart were to stop beating, we have ways to treat it that many restart it. It has to do with shocking the heart with electricity. Further, if you were to stop breathing, we can put a tube down into your throat and breathe for you with a machine. Now, are these things you would want us to do? Have you ever thought about this before?"

"Honey, you just do what you think is best."

"I'd really like to do what you want. It's very hard for me to know what you would like. We've only just met. I'd like you to think about this. If you like I could talk with you and your daughters about it."

She looked fairly peaceful about the whole discussion. "That would be all right."

"Why don't we visit tomorrow morning. Do you think one of your daughters could be here Saturday morning?"

"I'll ask her. I'll call her tonight on the phone."

"Well, tell her I'll be here around 8:00 if she can make it. Otherwise, I'll just talk with you. Sleep well. Tell the nurses if you have any pain or feel short of breath. Goodnight."

So, Sid had cleared the decks and now this sunny January Saturday morning he hoped to discuss Mrs. Smith's wishes with her and at least one of her daughters.

Federal law requires that all patients entering the hospital be asked if they want resuscitation. (Advance Directives is the government- speak term). But most of the time the admitting clerk just checks the box "patient unable to discuss" and fulfills the obligation. Mrs. Smith had now been in the hospital for three days with a heart attack and no one knew her wishes. Truthfully, she probably didn't know what she wanted. She didn't even know the possibilities. Doctors and nurses who shock hearts and pump on chests almost always check the Do Not Resuscitate box. They know the futility, the violence. But patients and family often think such treatment is care. Who wouldn’t want care?

It was a very pleasant and comfortable talk. One of Mrs. Smith's daughters was there. Mrs. Smith had decided that if her heart stopped or she stopped breathing she wanted nothing done. "Mr. Smith has been gone for six years now and I've thought for a while now it was my time to join him." Her daughter was blinking back tears.

"Mrs. Smith, I appreciate what you want, and we will respect your wishes, but honestly, I'm not sure this is your time to die. You have had a heart attack, but I think you'll make a full recovery. Still, it is best to know what you want should anything unexpected happen."

She just smiled at Sid warmly and patted her daughter’s hand in comfort.

Sid had not checked her pulse or examined her in an attempt to use all his time with the discussion about her "Advanced Directives." As he left the room he glanced at her bedside chart: blood pressure even lower and some weight gain; pulse still regular but a little higher. A little troubling.

Sid checked with Mrs. Smith’s nurse on his way out. She too frowned at the vital signs, concerned. Sid told her of the discussion, ordered a new medication and went to the morning clinic. Sid made sure he had written an order for "No Code" in her chart and told this to the nurse. Then he went across the street to see the morning patients.

Busy clinic as usual. At 11:00 there was a knock on the exam room door of the 10th little kid with a cold that day. Nancy said through the crack of the door "Sheriff's office, line one". That was her code for a coroner's call.

"I'll be right out." Sid offered and did his best to comfort the worried mom about her kid with a cold.

The Sherriff's dispatcher asked that he go to a rural Cemetery in the south of the county for a suicide. Sid decided he had to leave and disappoint the last 15 people with colds. He wouldn't be able to cure them today. Or even comfort them. But he knew they would all get better.

The directions were very good, but Sid was still nervous.

About getting lost.

He always seemed to get lost when looking for these out of the way deaths. And everybody acts like you know the same country they do. "Oh, you know, right past Mrs. Kannikiberg's old house, where that divorcee is now living, and she has all those boyfriends". Trying to pin down the dispatcher to right and left, miles, yards, color of houses, etc. is painful. They act like he’s an idiot. Sid feels that way often.

Suicide in a cemetery. Reminded Sid of the 80-year-old guy who parked in front of the funeral home and shot himself, trying to be considerate, save the undertakers the trip. He even left a note on the windshield. “I shot myself” to dispel any question of foul play. Still, the funeral home had to have the blood and brain bit soiled pickup towed.

Sid bet this guy wasn't being considerate. But the story wasn’t told yet.

He looked across the winter landscape. Not much snow, sunny, with a chill blustery wind out of the west. Sid figured the dead guy went up on Cemetery Hill last night to look into the wind out of the west and eternity. That’s what he would have done.

There was very little traffic and no ice on the road. Sid had a pleasant drive. As he wandered through the small town heading east, he saw the cemetery hill with the sheriff's patrol cars on it. A couple well-established trees signified it wasn't just another hilltop. He couldn't see the headstones from this distance, but it had to be his objective, since there are only so many hills with sheriff’s patrol cars on them. The hill had a view over the little town and valley. Maybe it was a comfort to the people attending funerals. Probably give a sense of perspective and peace. Something we all need.

Although Sid could see the top of the hill, finding the drive to get him up there took a while. After his first circle around it on dirt farm roads, he took the first driveway that he had initially passed up. It was right by a trailer house, and he hadn't seen the sharp left and the gate right afterwards.

As he crested the top of the hill, entering the cemetery, Sid noticed how the one deputy’s rig was running, a trail of steam out of the tailpipe torn to the east by the wind. They were seeking a warm refuge in the bitter breeze of the hilltop. He doubted they were contemplating the peaceful perspective, with their motor running, the radio conversations with dispatch and parked next to a cold car with a dead teenager in it.

As he parked, he saw the victim's car. It was painted half black, half primer, a 1970s Pontiac with a peeling vinyl top. From here he could see the windows misted over and the back window frosted pink.

"So, Doc, you get some clues in your first sweep around the hill?" Both deputy’s grin. People always love it when other's look dumb.

Sid didn't answer.

"Yeah, we watched you from up here. If you went around again, we were going to come down for you."

Sid still didn't want to rise to their taunts. "So, what have you got?" he asked.

"19-year-old male, at least we think he is. Caretaker found him this morning. Opened up at 9 AM and drove up here. The car was running. He looked in the window and saw him dead and went down and called dispatch. He said he locked up the gate the night before at 8 like usual but didn't come up here so he figured the kid must have drove up before that and then got locked in. Says he didn't hear anything. He lives down in that trailer at the bottom that you went by. They let him stay there for cheap for minding the cemetery."

"Who is he?" Sid nods at the dark car.

"Well, we haven't ID him, because we're waiting for you, but the car is registered to David Rich. His mom called the sheriff's office this morning saying he didn't come in last night and an officer went to her home. We haven't told her yet because we're not sure he's dead. (He grinned at Sid. Coroner call comedy.) We thought we'd wait for you to declare him dead. Then we can check his pockets."

"Mom say he was depressed? She worried about him?"

"Well, she says he just broke up with a girl. But the girl didn't see him last night, the mom says anyway. But she must be kinda suspicious since she's called all over this morning looking for him. He's just moved back in with his mom. He had some troubles recently, I guess. Lost his job. Didn't graduate from high school last year and his girlfriend is just 16 so that actually is illegal if they are having sex, you know." (Another grin)

"He shoot himself?"

"Boy did he."

Sid and the deputy have walked up to the driver side window now. The car is parked facing west, into the biting wind. It is a big 1970s two door muscle car.

The wind draws tears to his eyes and drops from his nose. Sid feels all alone up here.

He can see him through the window. Not much of his face left. Top of the head gone and the face split, folded sideways. He's got a jacket on. It is remarkably clean, unlike the rest of the car. Splatter goes along the line of force.

A rifle, looks like a knock off AK 47 with a banana clip, is between his legs now with the muzzle on his chest. One hand is on the rifle and the other lying by his left side.

"Look here Doc, we think he may have got off a second round. There are two dents in the roof back here from bullets. That's a semi-automatic and sometimes they jerk enough with the first shot to discharge a second round."

Two small pimples protrude the roofs peeling vinyl. Sid considered this must have occupied their conversation for a while before he became a more available distraction.

"Could be," I said. "Is the door locked?"

"Don't know. Caretaker said he heard the radio when he came up here, but the car wasn’t running. So, the car’s died sometime during the night, you know, after he’s shot hisself, and we don’t hear no radio now, so the battery’s gotta be dead. Here Doc. I'll clear that gun for you."

Sid stands back and the deputy opens the big door. It creaks loudly. "Bet he had a hard time sneaking in at night with that door" Sid offers.

"I'm not sure he had to Doc. His mom is a real case. We know her pretty well. She's out all the time. We think she's into meth but haven't pinned anything on her. I bet she wasn't even home last night to know if he was home or not."

The deputy is removing the rifle. It has a bit of spatter on it, but it’s now frozen. The boy’s arm is stiff on the stock. Sid can see the majority of the mess is in the back seat and on the headliner. Blood pooled on the floor of the back and brain bits; skull bits sprayed all over. Front seat pretty clean except for his premorbid mess; the empty cigarette packs and candy wrappers and old cassette tapes.

As they were manipulating the stiff, near-frozen body to get to the wallet they saw the note in the front seat next to him. Just a little blood is on it. Block print. Miss-spelled words. He says sorry to his girlfriend. Not a word to Mom. His wallet is bloody and the deputy with the latex gloves gets the driver's license out.

"Yup, that's him. See Doc, the key’s still on. Musta run out of gas and the battery finally went dead like we said. When you think he did this?"

"Oh, last night I guess, before midnight. Car cooled down fast in this wind. Probably got down below 20 last night. He's pretty cold and stiff already." Lots of Sid’s job is just being observant.

His beeper goes off. It is the phone number for the hospital. "Well, I got to go. Call the funeral home to come get him".

"Autopsy?" The deputy asks. Sid cringes. Why do they always want an autopsy?

"Nope. You guys going to talk to the mom? Somebody gonna talk to the girlfriend?"

"We'll take care of it, Doc."

Sid drives down the hill. The caretaker is on his trailer porch watching as he goes through the gate. He's frowning at Sid, maybe glowering. Could be just the sun and cold wind. Then again, he could think Sid, the coroner, assigned by our laws to investigate deaths, is a real loser too and worthy of his contempt. Death seems to bring out judgments in people.

As he’s heading down the hill and into the little town, Sid bets to himself the beep he got at the cemetery is about a lab test result on Mrs. Smith. Or maybe she's having problems. He worries a bit. The drive back is not as relaxed. For some reason, Sid gets a bit more worried when he gets the second beep, just 10 minutes later.

He speeds up but there's only so much you can do in an old Toyota pickup. As he crests the hill and coasts down toward town doing the legal 55 miles an hour, Sid sees an old green Datsun 210 coming up the hill toward him doing his 55. As he watches, it starts to drift into his lane just 100 yards ahead.

Sid slows and eases to the right, even putting his right tire onto the shoulder. He’s gripping the wheel tighter, ready for a sharp swerve. This has happened in a second. At 50 yards he sees the driver is bent over doing something, not watching the road. The Datsun drifts all the way to the right shoulder, heading straight for Sid, then finally corrects back into his lane just 10 yards from Sid’s now barely moving Hilux.

Sid has stopped as it passes. This casual little green bullet of death speeds on oblivious.

Sid felt the nausea of fear, though the threat was passed and only the wind whistled.

He was glad to be stopped, idling on the shoulder, still alive. This moment physically expanded Sid’s perspective of death this sunny January Saturday, more than the dead body in the cemetery had.

Then, he put the little truck in gear and the perspective contracted suddenly on that clear sunny lonely highway of the New Year.

When Sid got to the hospital, they told him Mrs. Smith died about noon. They had coded her, doing CPR for 10 minutes until the nurse Sid spoke to this morning called from the nurses break room where she was having her lunch that Mrs. Smith was a "no code". They found his note in the chart and stopped pressing on her chest after the futile ten minutes of trauma, the indignity Sid had tried to save her from. The family was in the room with her now.

"Were they here with her when she coded?"

"No, they had gone out to lunch."

Cause of death: gunshot wound to the head.

Manner of death: suicide

Cause of death: myocardial infarction

Manner of death: natural

Pain

Sid couldn’t help but notice the pert nipples under the thin faded t-shirt above him.

He always sat on his rolling stool as the patient sat on the exam table above and relayed their message. He had thought this helped him listen, but those nipples were like someone cutting him off on the freeway. He did his best to not want to bite them.

She was so sad, though those nipples weren’t. This lady had pain, she said. The nipples didn’t say that, but she did. He could hear her voice and see the sad face above the little erections. And her tone was sad, he had noted that.

It was her neck; she did all that cleaning and it hurt so much she had to skip work. “Can’t you help me?” The plea coincided with a softening of the protuberances.

Sid rose to examine her. He turned his back and washed his hands in the little sink.

Her neck was tight, and she flinched a lot. She had no worrisome signs, no Spartle’s, no Wernicke’s, no grating. And sure enough, she had a positive Waddell’s sign. When he got her to relax, she had excellent range of motion.

Sid always considered the patient’s willingness to be examined as an offering. They wanted something, so they gave of themselves. He did his best to not think sexual thoughts in the exam room. But it could be hard.

He looked her in the eye, though his peripheral vision was excellent. “I think your pain is mostly musculoskeletal. Exercise, maybe some anti-inflammatory meds, regular stretching would help.”

She scowled. “I’ve tried all that doc. I thought you could help me out. Jared said you was a good doc.”

Jared?

Sid deeply regretted not remembering names. He in fact, could not now recall Nipples’ name. But so, she would be in his mind forever, her story, her symptoms, her exam and for what was to come. But not her name. Even if she were dead.

She blurted. “You gave him hydros for his knee, why can’t I get hydros for my neck?” And she started into the sobbing thing. The hands went up to her temples, the sides of her face and the small, pert breasts bobbed with no erect points on which he could focus.

Now this.

Hydros for Jared? Knee? Was he the guy with the staple in his kneecap from an errant trim stapler on the job? And yes, pain meds. Here we are.

He glanced at the chart to use her name, though she would forever be Nipples in his memory. “Ma’am, I do not prescribe narcotics for this type of pain. I’m sure it’s limiting your function,” as the hands went up and swiveling, bobbed the globes in front of him, “but the effects of …” And she got up.

Sid was standing.

She was standing on the little pull-out step for the exam table, so she was about eight inches above him with her arms at her head. She raised them, eyes locked and shimmied a little. “Go ahead.” They bobbed right there a bit below his face. Her gaze took him in faster than Sid could permutate. Though, his mind tried.

It’s just the two of us here. I fondle, I bite. She screams. Shit storm. She goes out and tells the front I bit those nipples. Bigger shitstorm. I give her the hydros and she’s back next week for more. Persistent shit storm. I give her hydros and she…” But as all this ran through his soft head, he knew, she knew, faster than he knew.

She took his measure, dropped hands, and looked down. “I guess you can’t help me.” And she left with the tears on her cheeks. She may have saved him. Or he her?

Sid had ten more to see before lunch.

That helping people thing had not been why Sid chose medicine. He really just wanted to fix things. But in a seminal moment in his residency training a pert psychologist with curly hair had confronted him after watching a video interaction. “You need to be careful.” Sid was alert.

“Yeah?”

“You want to fix people.”

“Yeah?” Isn’t that my job? I could have been a hay baler mechanic, but I’m here with people, isn’t it just a different machine? I know lots of shit about how they are put together. What’s the deal?

“That can cause a lot of problems. You aren’t here to fix people.”

Sid thought about that for a long time. He still thought about it.

And now he was seeing people in pain every day. And most wanted their pain fixed. And they thought he had some secret key to the locked box solution. Sid knew the folly of this thinking. He just couldn’t share it.

This failure caused him pain.

So, he went out to his cold garage at night and tried to fix things. The old toaster just needed cleaning and the contacts bent a little.

Another lesson that was hard to learn was that this patient, right here before you, is not the same as the one before. Especially when that last one hurt.

Sid might have had some strong feelings about the perky breasts and narcotics, but now we have Mrs. Smith.

She walked in bent over and tired looking. But Sid found her sharper than his Zebra pen.

Moved here after her husband died to be with her kids and grandkids. Had surgeries on her spine down south, probably not warranted, but now, crippled and on narcotics, and needed them refilled. And she got in to see him. Sid wondered, who is running this place?

Sid knew all the questions and asked them. He got her to tell a story. He could not now tell you her name, but he remembered this story.

She had taken a trip with her kids to Europe. She thought she didn’t need her meds, the hydros, she only took them intermittently, “when she needed them”. So, she just took with her the ones she had. But in Rome, she’d run out. “And those were the worst three days of my life. I never want that to happen again.”

Sid explained withdrawal, dependence, tolerance, the neuropathways, but it was all gobbledygook, he knew that. He knew the complicated bullshit of how she set herself up for this failure, but it wasn’t clear he could teach this to her in his fifteen minutes. She was a patient, not here to be fixed. He had to treat her.

So, Sid found himself prescribing chronic narcotics for a 76-year-old’s chronic pain, something he thought he would never do. He hadn’t bitten anybody’s nipples in the office, but here was this line he had crossed.

It caused him pain.

Sid struggled with managing pain.

He had his own.

The litany, it is so long. All the patients he tried to fix.

Sid tried to fix their addictions.

What the hell is an addiction anyway?

He slowly came to understand. Maybe it was most clear when he saw it in himself. But that is a different story.

Over time, Sid realized, slowly, he could not and could never fix their pain.

Pain is essential. Our bodies have made it so.

Michael Jackson got IV infusions of propofol to manage his pain from some doctor so licensed and empowered by that state. Mister Jackson felt no pain whatsoever when he stopped breathing and died. That’s how narcotic overdoses kill.

People talk about the heart stopping but that’s just bullshit, Sid knew. He knew the pathology, the physiology, the pharmacology.

When drugs block all pain, they also block the drive to breathe. Overdose deaths are from suffocation.

No pain, no breath; that’s how we are wired. Pain is essential.

Breath is what keeps us alive, as long as our heart beats.

We don’t breathe if we feel no pain.

This had not been in a medical school physiology class, or maybe it had, and he had forgotten it, but the years of coroner calls and overdose deaths, the ODs in the ER’s he’d revived, the post op somnolent patients not breathing enough who he’d perked back up, hell, junkies knew this truth. Shoot up too much shit, you don’t breathe.

You don’t breathe, you die.

Pain is intimate with breath.

Our bodies, may be evolution, has made it so.

But Sid was seeing patients.

And the dead.

Sid knew about the patch. Fentanyl, a powerful synthetic narcotic was formulated to be delivered at a controlled rate through a transdermal membrane. It was the rage amongst his colleagues and the pharmaceutical reps who bought free lunches. Constant narcotic dose, patch replaced every three days, no addiction they said.

Just stick it on and they feel no pain for three days. Make sure you titrate the effective dose.

This coroner call took Sid to a very dismal suburb to Paradise. The guy who had built it made fifty plots for single-wides and a “community center” with a ping pong table that was now leaking and threatening collapse. The builder might have had noble motives. Maybe he was trying to solve the low-income housing problem. But he hadn’t maintained the sewage treatment, and he was broke, as were the tenants. Shit spilled into our creek. Good intentions meet market forces.

This guy died fast. But Sid knew the sequence.

Sid was called from a morning clinic. It was a dreary overcast fall day. He entered the park and wandered on the crumbling asphalt in his rusty HiLux until he saw the sheriff’s cars. He approached and they met him before the steps.

“What have you got?”

“Overdose, we think.”

“Let’s look.”

Sid follows them up the 2x6 rickety steps and in. Dead guy is in the back bathroom. It’s tight. They let Sid go forward.

Dead guy’s a biggish middle-aged guy, head into the wall across from the toilet he is sitting on. Shitting, or just here to fix? There in the crook of his left arm is a syringe, still hanging out, dangling.

Sid wants to see more so he pushes the heavy, cold dead body back onto the toilet and asks the following deputy to hold him there. The needle stays in the stiff arm.

He’s got his pants on, and the toilet seat is down, so he’s not shitting, Sid decides. There on the top of the toilet tank is a box of the patches, the transderm fentanyl. It’s the prescription rage. There’s one cut off on the corner and a small coffee cup.

Sid looks at the deputies.

“He shot up that shit.”

Absorbed at a fixed rate through the skin, as the medicine was designed, it might only slowly block the pain and breathing nerves. And the pharmaceutical companies had made sure about the dose and breathing response. But in a vein, straight in, it did the work fast. And he’d stopped breathing as his consciousness left him. Neither returned. His heart probably kept beating for another few minutes until the oxygen dropped and the carbon dioxide built up and the blood turned to acid. But he was in narcotic land with his head against the flimsy wall across from his throne.

“Yeah, it’s an overdose. Are you guys seeing much of this?”

The deputies shuffle, the one holding him up doesn’t respond. It’s the guy back in the hall who says, “Not much yet doc. We’ll pass this along.”

And Sid got back to the rest of his patients. This coroner report would be easy.

Most of the time, patients were easy too. But not always. Mark was tough. Sid knew this because he remembered his name.

This lawyer guy who claimed Sid as a friend brought Mark to him. “You’re going to help this guy.” He’d smiled from his knowing stance.

Okay, Sid thought. A new patient. I’ll get to work.

First visit he did the history and exam. Mark got debilitating back pain when he stepped down off a ladder. His exam showed a fit guy with a lot of anxiety. His back muscles were strong, but tight and there were no worrisome signs. Sid wanted to review the records. Mark wanted something for the pain.

Like with Mrs. Smith, Sid gave the tolerance, dependency lecture. But in the middle, he thought this guy might stick. “Okay, I’ll prescribe the narcotics you have been taking. But you need to take them…” He continued his spiel. “I need to see you back in a month after I have reviewed your records and you have followed my instructions.”

Sid always prescribed daily exercise, walking, in a graduated fashion. No good days/ bad days oscillation. That always made the pain worse. Stick to the schedule.

Mark’s records showed up. Sid read through the thick volume one morning before the 15 patients before lunch. All the expensive tests had been done. No pathology had been found. That just means no surgeon wanted to operate. And none had.

This guy was lucky, so far.

But oddly, that’s what Mark wanted. He’d told Sid that at the first visit. “If you can get me to some surgeon who could fix me, I’ll be golden.” He’d said with a grin.

Sid no longer believed in the fix.

Mark came back. Sid reviewed the exercise, the walking, the pain, the meds. He repeated the lecture on tolerance “the narcotics stop working when used for a long time, your body adjusts”.

“That’s why I need more.”

Sid spent a long time explaining how this is a vicious cycle. He thought he might lose him.

But Mark came back.

For years.

Sid prescribed the drugs.

And physical therapy

And exercise

And antidepressants

And kept lecturing.

And Mark still had his pain and disability. But at his last visit, three years in, he grinned at Sid. “I ain’t taking them anymore.”

Sid had worked him down to a very low dose, and Mark explained he’d flushed the last half bottle.

These successes were few for Sid. Treating pain was Sid’s biggest pain. It was a heavy burden. He suspected it was for his colleagues too. But they never talked about it.

The pain of carrying an elk quarter up out of a dog hair hole didn’t burden SId.

The pain of his children’s suffering was not a burden.

The distance from his wife weighed, burdened, but did not hurt.

Sid still could not let go of his need to fix people.

Helping was so much harder.

And that really hurt.

Sid developed quite a few speeches over the years.

There was the sandbox parable.

“Little kid plays in the sandbox. Scratches his finger. Keeps playing. Sees blood. Screams. Runs to Mom. My finger! Blood!

Oh, does your finger hurt? Let me fix that. Bandaid.

Kid felt something, screamed. Pain? Or fear? Mom labeled pain, hurt.

We can confuse our deepest feelings with how we label them.

And doctors can confuse their treatments when the words are so clear.”

The tolerance/dependence speech needed a lot of revising. Eyes kept glazing over.

Sid pronounced the deaths. Accidental overdoses on physician prescribed narcotics. Overdoses from purloined pills. Overdoses from the mixtures of the drugs and alcohol. Sid did a lot of this. It caused him some pain.

Sid watched his colleagues struggle with this. He came to his own understanding. It was the greatest sadness, the greatest pain he felt, that they, his fellow doctors could not discuss this and come to some understanding amongst themselves. Sid carried this sadness, was it pain?

He spent a lot of time with this in his cold garage, looking for something broken to fix.

There she was before him in the same faded t shirt. She was happy and bouncing down the sidewalk. He didn’t know her name. But she was alive.

Sid kept walking. Afternoon patients awaited.

Sid and his partners sat around the conference table upstairs from the clinic. They met monthly at 6:30 AM so they could dispense with the clinic business and go off to hospital rounds and then get back to clinic by 7:30. Patient care is always first. Go to the grind.

Paul, their manager was sharing bad news.

The practice had accepted the burden that they needed a manager. So, they hired him and paid him almost as much as they made. In fact, the manager made more than Sid since he was a low producer.

That’s how this group of Sid’s had decided each should be paid. The more money you brought in for the clinic, the more you got to take home. It made some sense to Sid. If you killed the mastodon, you should have first go at the good bits. Sid was a hunter.

Sid looked around the table as Paul was preparing his bad news. Doctor Jones, older than Sid by a good ten years and probably just as cynical as Sid would be in ten years had his system. He ordered a ton of labs (done by the clinic lab, thus generated revenue) and added two diagnoses to the problem list with every visit. This allowed him to charge for a complicated visit, when it took only 15 minutes, like most of Sid’s. Jonesie had figured out how to get a good share of the meat.

Whenever Sid saw one of Dr. Jones’s patients, he did his best to clean up the duplicate diagnoses off the problem list, since it was all so much gobbledy gook. Three diagnoses of heart failure with different modifiers didn’t help Sid understand this poor creature. But such custodial work didn’t add to Sid’s income, there was no code for cleaning up partner’s messes, so he pretty much just shrugged and gave up.

Then there was Doctor Payne who could truly see 40 patients a day. It didn’t seem his name drove folks away. Maybe it drew them?

Sid had watched him. He was amazing. One-line notes in the chart, always a prescription, often a narcotic, but he got them in and out. Lots of ways to bring down the beast.

All the calls for narcotic refills that came in when Dr. Payne was off were a burden, for sure, but again, Sid kind of shrugged. He so appreciated hunting with this tribe. Figuring out why the 70-year-old needed 90 hydrocodone a month wasn’t billable for Sid, so, shrug. He just needed to pay attention to the hunt.

But now Paul needed Sid’s attention.

Paul had been a worthwhile investment for the group, Sid had decided. Paul had hired another billing clerk, they were up to four now, and they worked upstairs and were out of sight. But they sure seemed happy on their lunch hours. The clinic was seeing some increased income, so maybe all was good. Sid accepted that you had to spend some to make some. It takes effort to bring down big game.

Sid knew not all clinics paid their doctors this way. But this was pretty much the pervasive medical culture, though Sid smiled to himself, maybe it was Neanderthal. If you “do more”, that is charge more to Medicare, Medicaid, and the better paying insurances, you make more. If you deliver Medicaid babies it would pay about half what Blue Cross paid. But delivering a Medicaid baby paid at least a thousand bucks, 20 times more than one office visit. And you got to do it in the middle of the night so you could still “produce” in the office hours.

Maybe that’s why Doctor Smith was sleepy now, nodding off almost as Paul was starting his news. Was he really sleeping? He did more deliveries than any doc in town, even the Ob Gyns. And he got lots of the good bits.

Sid was always a low charger. What the doctor charges is submitted in the code and then the billing ladies sent the code off for payment. It might be what you do, or it could be what you code. Either the mastodon died, or it didn’t. Sid wished for the good old days. Instead of this mish mash why couldn’t it just be simple hunting on the prairie?

The doctor’s coding was what Paul was talking about now, what they had charged, what they had coded.

Medicare had come in and audited all of their Medicare charges. A doctor’s charge to Medicare must be reflected in the notes of the visit. Medicare is the big government health insurance for the elderly. They have the right, because they are the government, to come in and audit your books. It seemed the clinic’s numbers didn’t add up.

“So, their findings, when they looked at a sample from the last six months, they found we had miscoded 23% of our visits. They then extrapolated that to the last five years, and they say we owe the federal government $1.3M. But…”

There were too many expletives for Paul to finish his sentence. Sid watched Paul’s small smile as his colleagues blustered their umbrage for five minutes. Sid knew he had two hospital patients to see and 30 minutes of records to review before his first patient an hour from now. He interrupted his senior partner’s rant. “Can we get to the chase?”

Paul smiled at Sid. “Yes. These are the usual findings from an audit such as this. Actually, 23% of coding mistakes is a bit below average. We will have further conversations with them. I expect the final reconciliation to be in the low five figures, maybe less.”

The umbrage started to boil up again.

Sid nipped it. “Do you need anything from us at this point?”

Paul smiled again. “I have decided to implement a coding improvement process with all of you. Should this happen again, having such a process in place will greatly improve our standing.”

The questions bubbled up.

“We will pull ten of your appointments from the prior month and have them reviewed by a professional coder. You will get their recommendations. We hope this will improve our performance.”

Sid left the meeting with quite a few questions unasked. But he had never had a beer with Paul. The smiling gnome seemed to understand the system. Sid was just beginning to.

As he walked across the wet street to the hospital, he wondered, if the clinic was already below the average for bad coding, just how much could they improve? But Sid was perplexed by statistics and quality improvement processes. This was totally foreign to the practice of medicine he had learned.

Sid opened the door to the hospital and went up the stairs.

Everything a doctor does is coded. Doctors are paid based on what they code. Can’t you see the problem? Sid screamed this to himself before the first landing.

If surgeries pay more than office visits, won’t more doctors want to be surgeons? And what we need are good family docs helping patient avoid chronic problems. But those codes pay shit.

And if surgery codes pay 100 times what spending 30 minutes telling a patient this surgery probably won’t help you, what do you think the surgeon will say?

Sid went into the ward fuming. He did the visits, talked with the nurses, then wrote his orders. As he did, he considered another coding folly.

Codes submitted by hospitals, though they may be for the same exact service as done in a clinic, were paid 50% more by insurers. It was the “institutional fee” thing. When Sid had learned this, he had first blown a gasket, then rolled his eyes. He was learning the absurdity of the game he was playing. Oh, to be hunting mastodons.

It was like his small band had discovered a weak mastodon, trailing the herd, but another, larger band of hunters had shown up on the plain. Who would get this meat? Who would live? Sid wished it was like the good old days.

As he went back down the stairs, he had calmed down. He knew there were other models. The Mayo Clinic paid docs a flat salary. No incentives to do more. But that wouldn’t fly here. He’d tried it. We still hunt. And we eat what we kill. Mastodon meat can keep you alive.

A month later Sid got his coding report from Paul. Three of his ten reviewed visits were miscoded. Two were coded too low, and one should have had a surgical code included.

Paul was in his office.

“So, what do you think I should do with this?” Sid dropped the two-page report on Paul’s desk.

Paul was again smiling. “It looks like you should code higher and remember to include any surgical procedures.”

Sid looked down at the bland carpet. “Does under coding come up in Medicare audits?”

Paul capped his pen and leaned back in his Office Depot chair. “Of course. Any code not justified is flagged.”

“So how many of those audited visits were under coded?”

Paul was not smiling now. “They don’t share that information. They just tell us our accuracy.”

Sid stared at Paul. The no longer smiling gnome continued. “They assess the accuracy of coding and assign a fine based on the percentage of mistakes.”

Sid did not smile. “So, if most of those mistakes were where we should have charged more, but mistakenly didn’t, we still get fined?”

Now Paul gave a slight smile. It was like he felt some comfort to be discussing the details of a Medicare audit with someone who cared. “That’s why they negotiate. We’ve got it down to about $9K now, so you know.” Paul put his hands behind his tilted back head. He was gloating.

Sid knew the next patient was waiting. He just looked at Paul, so proud of himself. He wondered about just what he was doing. If it was about harvesting meat, he understood the purpose. But this? He thought of his tirade in a millisecond.

I learned the origins and insertions and innervations of all the muscles in the human body. I learned the bones, they were easy, and I learned the sensory dermatomes. I know all the foramen of the skull and what goes through those holes. I learned the embryology of the gut rotation and how the testes descended from the kidneys. I know the doses of hundreds of pharmaceuticals, and what the drug companies claim they do. I’ve read their weak double blind crossover randomized trials. I know the side effects of most of these drugs I am expected to prescribe, and I pay attention for them in my patients. I know the value of the blood tests and radiology tests available, and I order them based on their value for the condition of my patient. And now I am expected to know how to communicate this for my reimbursement. Through codes? Through the seven branches of decisions with 3-5 variables at each branch on a little laminated card?

So, I order lots of tests and the reimbursement code is higher. Does that make me a better doctor? Does that make my patients healthier?

Do I freeze off the benign skin tags and get paid more? Are they healthier?

Maybe it makes me, and you richer.

Sid felt his internal millisecond rant winding down with the slow blink of his eyes. He looked up at Paul, leaning back before him.

“I got to go.” Sid went off to the next waiting patient.

And Sid saw patients. All morning he saw patients. He finished his recording halfway through his lunch hour, so he trotted across the street to the hospital cafeteria. A saran wrapped half sandwich was a buck fifty, and he could eat it and walk. So, he did.

He saw the new billing lady smoking her cigarette as he went out. He’d already unwrapped the ham and cheese, so he moved in her direction and thumbed the plastic wrap into the garbage can next to her. She exhaled a big puff.

“Well, you caught me!”

Sid knew that voice. He vaguely remembered a couple round scars on her cervix from previous biopsies that had turned out benign. But not her name.

“Caught?”

She had a winning smile and good posture. The past intimate revelations were lost. “Rhoda” She said her name, with a winning grin, like she knew Sid didn’t.

“Yes,” Sid didn’t fumble. “Are you the new coder?”

Rhoda flicked an ash. “That’s me.”

Sid took a big bite of the little sandwich and chewed fast. He had some food in his mouth when he said. “We should talk about coding sometime.”

Her laugh was so brassy it echoed from the bricks behind them. She took another puff, exhaled, and said, “That’s the weirdest pick-up line I’ve ever heard.”

Sid was surprised. Pickup? “No, really, I’m trying to figure out this coding thing. You’re the expert. I figured you could help me out.”

Rhoda tossed her butt into the landscaped garbage can where it might melt Sid’s saran wrap. She shook her head. “I’m the newbie. I can’t help you with coding. I just do what they tell me.” She looked him in the eye. “If that’s what you’re looking for you’ll have to go somewhere else.” And she strode across the street. Sid finished the ham and cheese and did his four block loop that took just fifteen minutes.

It's embarrassing when you don’t know what you’re looking for. Hunting mastodons, you look for their brown fuzzy hump above the rise and you slow down and check the wind. But coding? Increased income? Improved quality? It’s such a mess. He kept seeing patients.

But a week or so later he had gotten a coroner call and there was Rhoda, in the alley, smoking again. He could have sprinted across to the Hilux, but he turned as she exhaled and flicked ash. “I really do want to talk to you.”

She smiled. “That’s better.”

Sid ran across and did the dead body. When he came back there was no Rhoda in the alley, just ten more patients to see and code to end his day.

He did some research. It seems the coding part of medical care was a big deal. There were software programs that would up code for you, and there were companies who would code for you and there were venture capital companies buying up doctor’s practices to increase their profitability. He doubted any of this would come to small town Paradise. But he also came across a study of the “coding experts” like Paul had contracted to send their charts to for review. The study found only 60% agreement between them when they looked at identical chart notes. So much for experts.

Maybe this mess was all based on the American medical system’s commitment to paying medical services only for what they did. This had been long embraced by doctors. The socialist concept of paying doctors a flat salary for their services had been fought by the AMA. No, doctors were not fungible. And since we have successfully kept our services dear, we should be funging the payments. Sid felt the skepticism growing in him. He knew family docs like him were on the low end of the IV pole. Code payments were driven by Medicare, and specialists drove these negotiations. And the AMA was complicit. Sid knew that family docs, generalists got paid less because there were 60 specialties on the committee and only 5 primary care representatives. He was getting an idea about the US Senate.

Sid felt some pride that he hadn’t paid any dues to the AMA for years. Then a niggling thought came, shouldn’t he try to change this bullshit? Shouldn’t he get on the inside? Shouldn’t he go to work to slay the monster instead of hanging back and carrying the spears for the others? But this game was so big. It was so big, and he was so small.

Sid finished with his patients and did the dictation, the charting, the document reviews, the prior authorization forms, and he headed out to his family.

Rhoda was ahead of him in the hall. “Hey Rhoda.”

Sid gave her a ride home. It was a dismal duplex over where he’d lived when he and Martha had first come to town. Rhoda’s car was at the shop. “Thanks doc. Maybe next time.” Her brassy laugh didn’t echo off anything. He saw her profile as she turned. He didn’t remember his cursory examination of her young breasts for cancer, like there might be any. At least that’s what he had coded for when he saw her as a patient back when. Sid didn’t remember such. He had trained his mind to put everything, all the naughty bits at least, into little Tupperware containers in his mind, only to be brought out when the right guest was in the room. But she was pretty.

Sid drove home feeling lost. He didn’t know if there was any help. This coding thing was driving him crazy. But there was the family.

The next day a young man seemed to be very interested in the new electronic medical record Sid was still trying to figure out. The young man did not have chlamydia, though Sid wasn’t sure the nerd had ever had sex. He wouldn’t share his sexual history, just his worry about a “discharge”. Sid suspected a nocturnal emission was mistaken for an STI symptom that the guy had Googled. Sid tried to explain that a good history could save a lot of money and testing, but the nerd would have none of it. So, Sid swabbed and ordered the test.

“Does that program code for you?”

Sid stared at him as he removed the gloves. “No, it doesn’t. We didn’t want that feature.”

The nerd’s head bobbed. “So how long till I get the results?”

“Can you wait 15 minutes?”

“So, you guys do PCR?” Sid was wondering just who the hell this guy was. A “mystery patient” from some insurance company? Or just a really truly health care tech nerd. “You can wait in here or out in the waiting room. Your choice.”

“I’m fine here.” Sid carefully logged out and locked the screen.

He got through two more 99212’s (simple visit codes) before the test results came back. He told the young man the negative results as he sat absently in the chair.

“So hey, if you guys want help with the programming or a patch for coding, I think I could make you some money. I know the language these guys use.” He nodded at the dark computer terminal.

Sid walked him out.

But a chance meeting in the hall with Paul, the highly paid administrator occurred. “This guy said he could augment our program and add in coding, make us some money.”

Paul looked downward, like Sid had offered to sell him his first born. “Sorry, we’ll have to do it the legit way, through the contractor.”

Sid shrugged. Paul sighed with no smile. “If we hack in now, we’ll be on our own. They’ve got us by the balls. We buy their package, so we have to stick with what we got. There’re a million hackers out there who can do this. I get their emails every day. The next Medicare audit would be a nightmare.” Paul shuffled off. Sid had gotten a glimpse. It wasn’t big mammals they were hunting. But it was big money, at least from this small-town perspective. He really didn’t think it should all be his. But just some of it, what he deserved.

Sid felt pretty good about his afternoon patients. He might have helped a couple and hadn’t really pissed any off, so that’s good. And he got out in time to pick the kids up from swim practice and have a family dinner.

“How was your day, Dad?” His youngest asked. She was nearing middle school, but not there yet, maybe fourth grade?

“Just fine.”

She dipped her soup and mumbled toward the table. “How the hell can a person go to work in the morning and come home in the evening and have nothing to say.”

“What?”

She looked at him. “It’s just a John Prine song.” And she smiled.

And Sid was devastated.

This shit was just too much. He finished and went out to the garage.

There was just a mess on the tool bench. Nothing to fix, no project waiting, just a mess to clean up. And it was cold.

He threw some odd screws in the trash and wiped off the table saw. Maybe the problem wasn’t the coding. Maybe he just didn’t like being a doctor. But he’d enjoyed his time with patients that afternoon. He loved it when he could help folks, maybe make a difference in their lives. Why couldn’t he share that at the table? He had come home in the evening with nothing to say.

What was weighing him down? Should he just go fix hay balers, his alternate career path? But he was pretty comfortable. He just knew it could be better. He looked around his cluttered garage and knew it could be better too. Maybe he should change the oil in the old motorcycle.

He had learned to awake quickly when the beeper buzzed, or the bedside phone rang. He could get the call go in and do the delivery, come back, and Martha wouldn’t even know in the morning. So, he picked up the receiver and said softly, “This is Doctor Hawthorne.”

The brassy voice was unmistakable. “Doc, I need your help. Can you bring gloves?”

Martha hadn’t noticed. She slept soundly. Sid was up and having breakfast as the kids scrambled about. Martha guided them and the middle schoolers got in his Hilux and the littler ones headed down the hill. He dropped the older two off three blocks from the school so no one would see the rusty shame. He looked carefully for footprints or trampled cars, but all was in order. Then he headed south into his daily grind.

“Hey Doc, I owe you.” She had said as he left. He’d skinned the gloves into the kitchen garbage can. “Do you want me to up code your visits this month?”

Sid looked at her in the loose robe. The boyfriend was in the bedroom. They had the lube, but he’d brought the gloves. It hadn’t been easy, the retrieval. But the years of delivering babies had taught him the importance of positioning. He hadn’t once thought about how this could be coded.

“No, you don’t need to do that.”

The brassy laugh burst out. “Hey doc, you deserve it. You can’t code for what you just did.”

Sid laughed too. And he left.

The dark street led to the Hilux but for some reason he looked up. He saw furry backs moving beyond the treetops. They were headed south toward the hospital and his clinic. But they just moved quietly above the dark leaves. He heard no cracks or crushed things as the massive bodies moved. They were silent, but really big.

After he dropped off the kids and turned south, he started to look for footprints or signs of the moving herd. He saw none. Traffic was light. He worked his way down to the doctors parking lot where his rusty Hilux was notable. Sid smiled as he thought of his stain on this herd of shiny high dollar cars.

He could have turned down Sixth, but there was a light at the bottom, so he cut across Monroe to drop right down to the doctor’s lot. In the middle of the street on the steep side hill has a mound. He knew the Hilux wouldn’t clear it and he could put one wheel on it, but maybe it was too solid, so he stopped. Sid set the brake and got out. He checked and the little rusty Toyota didn’t roll so he trusted it.

The mound was still steaming. He touched it with his work shoes. It was bigger than his spare tire. Shit on the way to work. Big shit.

He drove over it and headed down to the lot. Work to do.

Sid saw the new patient on his schedule and was just a bit excited. So many old folks with so many familiar complaints. Maybe this was something new. Sid needed something new.

And the computer showed this was a young man.

Would this be another asking for Viagra when all they had was performance anxiety? He had so many times explained how fear destroyed erections, the sympathetic nervous system overriding the parasympathetic. Why didn’t they seem to understand or believe him? He had to come up with a better schtick. He had tried the image of holding a gun to their head and demanding an erection. Maybe he needed to have a real gun. Unloaded of course.

They just wanted the blue pill. Sid wouldn’t prescribe it and then his online reviews were shit and the wimps would just get what they wanted off the internet. Sid knew he couldn’t win.

Maybe it would be different with this guy.

Sid came in and introduced himself, as always. The guy was fit and trim and articulate, but with wavy dark hair to the middle of his neck. Sid washed his hands and asked his opening gambit. “How can I help you?”

The response from this guy was pointed. He had a specific concern. He would do his 20 or 30 miles, even 120, on his road bike and toward the end he would have these vague feelings, like his brain wasn’t right.

“Can you describe that for me?”

The young man kept in the vague mode. Vague always aroused Sid’s suspicions. Drug seeking, secondary gain, liability? But he tried to push that all back and listen. The guy said it was a sort of spongy feeling, like he couldn’t make good connections.

“Is there something you are worried about?”

Sure, doc. He looked Sid in the eyes. I am worried I have a brain tumor.

Sid thought he knew this fear. He had seen it so many times from the back end. Patients with niggling fears have gotten referred to specialists. Surgeries, scans, injections done, pains not alleviated, then referred back to the family doc, Sid. He got their shit. And then he had to convince them, despite their surgery, despite the fancy specialist’s high fees and fancy office falderol, that their pain, their condition would just need their attention and care, not more surgeries and expensive medications and tests. Sid’s head was exploding with this pattern of healthcare disfunction.

Sid thought, maybe, right here with this young man, he could nip this horrible pattern in the bud.

“Well, let me examine you.” And Sid did his exam.

After, he washed his hands again and said. “I can find nothing wrong. But I appreciate your worry.” As he dried his hands on paper towels he asked, for a reason he did not know. “What test do you want?”

The strong young man smiled. “Just something to tell me everything is okay.” The vague warning lights flashed.

Sid looked down to not see the red lights or hear the warning beeps. He knew the young man had Googled this. “Like an MRI?”

The weak shrug should have confirmed to Sid he had an insurgent here, not a patient. But Sid was too worried about his own problems. He was trying to fix all the patients later on his schedule, not this young terrorist in the room with him that he had failed to recognize. Sid didn’t see the weapon the young man held.

Sid foolishly thought he could heal people. He was so naïve.

“Do you know what a brain MRI costs?”

Sid unknowingly, was just getting his armor in place.

The young man again feigned ignorance with a slight smile. No weapon was brandished.

“If it costs $5000, would that be worth it to you?”

The young man nodded happily. Of course, but he had just gotten health insurance, and they would cover these costs.

Sid knew now, it was not just the young insurgent and him in the room, discussing this plot. There was a third party. And they would not be in any fight, just in the background, sending supplies, or not. Bringing up more legions for support, or not. Sid often felt very alone in this battle.

“So, I’m telling you I think nothing is wrong, but you’d be willing to spend $5000 to answer your worry?”

The young man nodded, again eager. He seemed sincere. Sid decided, this was not an enemy. This was somebody he could help.

But Sid sensed a danger. He thought of the frontal attack, what medicine should be fighting. This kid could become the most expensive hypochondriac in the county. Sid had seen the 28-year-old woman with five abdominal surgeries and fifteen CT scans in the last three years for her vague and persistent complaints. Her hypochondriasis had not been addressed by good primary care. She had bounced from surgeon to specialist to emergency room. Maybe this had served her in some twisted way. It had sure enriched some surgeons and hospitals.

Was this young man headed down this road? Sid resolved he would meet this threat early and steer it another way. That had always been his goal in primary care. A good primary care doctor can save the wasteful, expensive US health care system. Or so he believed.

Sid looked up from the floor where the bland carpet had been a background for his swirling thoughts.

“So, you want an expensive test that you think insurance will pay for to address your worries. I can find nothing that indicates to me on physical exam that you might have a brain tumor. But I will order this test that somebody, not you directly, must pay for. But my goal is to convince you to learn not to worry. You have a strong and healthy body. You should not be wasting our money on these tests.”

The young warrior looked back at him with a slight smile. He was confident. Sid’s confidence was not as strong. But he stuck with it.

Sid went on. “I will need you to come back to me and discuss these findings. I don’t want to do this over the phone or through the nurse. I need to see you in person. It is not uncommon to find minor abnormalities in these fancy tests. I don’t want that to be a worry for you, or an excuse for you to not see yourself as a healthy young man.”

He bobbed, happy. Sure doc.

The MRI was totally normal. Sid got the report. No benign tumors, no hemangiomas, no tortuous blood vessels. Clean as a whistle. Sid felt a bit sheepish for ordering the expensive but normal test. But he thought his motive was sincere. He thought this was a frontal attack. If he could convince a budding hypochondriac to trust more, maybe we would all be better off. Less health care costs, less waste, healthier people. That had always been his goal. But the insurgency was changing things. Maybe, he thought, this was the right strategy. He didn’t feel the weight of the armor he wore.

The young man was there on Sid’s schedule.

Sid had the printed report, but the young man seemed disinterested. Like he had moved on and Immediately Sid sensed there was a flank attack coming.

“You realize, don’t you the cost of this?”

The insurgent shrugged. Insurance pays. And the whole system is corrupt. He looked Sid in the eye. You know that.

He tossed his medium long hair in dismissal of Sid’s armor. Sid felt no centurions around him. His shield, his short blade was just something to cling to.

The young man smiled at the doctor in his weak armor.

Sid felt the blade in his hand. Now he saw the insurgent’s spear.

So, doc, what about this pain in my knee?

Sid ordered his phalanx to retreat. As he retreated, he wondered, just who stood next to him. Who is fighting with him? And just who is the enemy?

Sid knew this battle would end poorly.