October 5, 1997

Dr. Monica Quartermaine emerged from the pool at the Port Charles Fitness Club after getting her morning laps in. She quickly picked Allison and Kirk out of the figurative sea of young swimmers in the lanes reserved for swim team and then headed into the women's locker room for a quick shower before she headed to the hospital. She needed to place a central line in the ICU and then she needed to round efficiently so she could get home in time for breakfast and church.

She was crossing through the lobby on her way to the parking lot when she saw a familiar face. "Scott," she called with more trepidation than she wanted.

Her brother stopped a few paces from her and shoved his hands into the pocket of his sweat pants uncomfortably. "I couldn't really sleep," he said.

Monica couldn't really imagine so she just reached out and pulled her older brother into a hug. When they separated said, "I'm sorry. I know this is a mess but Serena is safe with us. I guess maybe we just have to trust in our justice system to work this out."

"Maybe it would be easier for me to trust that if I hadn't spent three years working as a prosecutor in the same office that is prosecuting me now," Scott said.

Monica sensed there was more of a story there, but she also sensed it wasn't one she really wanted to hear at five AM, or in the lobby of the fitness club. Perhaps Scott sensed that as well.

"You probably need to get to the hospital. I just want you to know I appreciate what you're doing for Serena," Scott said and then he started off in the direction of the gym.

XXXXXXXX

Dr. Lois Cerullo scrolled through the Head CT on the PAX system in the ED at Weill Cornell Medical Center in Manhattan. She took a deep breath and then turned to face the EM attending peering over her shoulder. "I don't see a bleed, or an infarct for that matter. Why don't you go ahead and start the Nicardipine Drip and then, if we can get the blood pressure controlled, we can push TPA," she said.

"Don't you need to run that by an attending or something?" Dr. Matthew Palmer asked.

Lois fought the urge to roll her eyes. It wouldn't get her, or more importantly the patient, anywhere. "I spoke with Dr. Ryan while the PAX was down. He was in agreement with TPA providing we can get the blood pressure controlled. I need to go check on a patient in Neuro ICU, I'll be back in fifteen minutes and I'll make the final decision about TPA then," she said.

As she trudged up to the ICU, Lois reflected on the interaction with Dr. Palmer. To be fair, she was only a third-year neurology resident, and thrombolytic therapy was not without real risks; she supposed it was reasonable to make sure that her attending was on board. If any other attending had asked the same question, she would have presumed exactly that. Of course, she had once known Dr. Palmer as just Matt back when he had been the best friend of her fiancé, Dr. Jeremy Kinder. Technically, they probably still were best friends but Jeremy had stopped being her fiancé the second time he had hit her. She had many regrets, about her delay in leaving. Enough regrets that her parents and Sonny both believed that the second time had been the only time.

XXXXXXXX

In the Cardiac Critical Care Unit at Port Charles General Hospital, Dr. Monica Quartermaine passed the guidewire through the introducer needle and into the Subclavian Vein which ran beneath the clavicle. Fortunately, the wire fed easily, so she removed the needle and reached for the scalpel and dilator.

"I take it back, Dr. Quartermaine, you can put lines in at shift change if they will always go so smoothly," Betsy Chilson said when she came back into the room as Monica was suturing the line in place.

"I appreciate that, I guess the other option would be come back and do this after I round. My resident this month was on call yesterday so I need to get her through rounds and let her leave as early as possible," Monica offered as she cut the final suture and then started collecting the sharps from her sterile field.

"Betsy, when you give report, make sure your replacement understands that we need to continue monitoring CVP from the line and those readings need to be called to me not to the resident on call," Monica said.

"I will certainly reiterate that. Unfortunately, I believe that Amy Vining is replacing me and, just so you know, she considers your orders mere suggestions."

Monica just shook her head. She knew that all too well.

XXXXXXXX

Dr. Karen Baldwin-Cates coiled her stethoscope back into the pocket of her long white coat as she exited her patient's room on 6 North. She had arranged to meet her attending of the month, Dr. Monica Quartermaine, to round at 6:15. She had to be in the Housestaff Lounge by seven o'clock to give changeover to Jake, Eve, and Chris but Dr. Quartermaine had suggested she could just leave a few minutes before seven, she would see some patients on her own and then Karen could join her when she was done. Chris had made a crack about how it must be nice to have your attending of the month also be your Aunt Monica. Joe had pointed out that Dr. Quartermaine had also rounded early for him so he could go home post call. Most of the rest of their group had likely moved on then, but Karen had a feeling Chris still believed that she had some kind of inside track. Karen hadn't had the heart to explain that she had only learned she was a Baldwin her second year in medical school when her mother slipped up and revealed too much after getting drunk on "Christmas Sherry".

"Good Morning, Karen, I ended up having to come in for a STEMI last night around 8:30 so I think I saw all of the new patients after I got done in the cardiac catheterization lab," Monica said as she arrived on the floor.

"You could have paged me, I saw that you started Heparin on Ms. Fisher and transferred her into the stepdown unit. I discussed that admission with Dr. Devlin last night and he felt the patient was really low risk," Karen said. She started to regret the words once they were out though. She didn't want her attending, or her aunt, to think she was trying to blame her mistakes on one of her colleagues.

"I think that Dr. Devlin was more focused on her risks for ischemic coronary disease, which I agree are lower. I was more concerned about a Pulmonary Embolus so I started the Heparin Drip and ordered a VQ Scan for this morning."

"So, I can understand, why are you worried about a PE?"

"The clinical picture from pleuritic chest pain with dyspnea, mild hypoxia, and tachycardia is a pretty classic PE picture in absence of other explanations and I can't find any. If you're taking your boards her EKG also shows the most common finding associated with Pulmonary Embolus."

Karen tried to pull her medical school cardiology lessons back to the forefront of her brain. She remembered an EKG pattern with PE something about S1Q3T3 but honestly, she wasn't sure she had ever seen that before and she really hoped she hadn't missed it the night before. When Dr. Quartermaine or Dr. Rothstein were on call they always preferred the ED physician fax them a copy of the EKG at night so they could review it. Dr. Ford didn't do that but Joe said when he had asked if he could Dr. Ford had said he didn't have a fax but he would just come back in and see the EKG. He had complained about it the next day but at least no one had missed a heart attack so Karen figured it hadn't really been so bad even if Chris had insisted it had basically been career suicide. It was just unfortunate when Dr. Devlin was on call because he would never come in and Karen had a feeling he didn't listen very closely.

"Uh, can you show me that because I don't think I have ever actually seen it before," Karen asked.

Monica smiled and opened a chart from the stack Karen had piled. "Ok, so first you have to remember that the most common PE EKG finding is just sinus tachycardia. Now, if you're thinking about Cor Pulmonale, which can be seen in other cases besides PE, like this patient with Pulmonary Hypertension, then it is S1Q3T3. So, you want a deep S wave in lead 1 like this and then in lead 3 you have a significant Q and then an inverted t-wave," Monica said as she pointed to the different parts of the EKG.

"Ok, I guess it is fortunate I'm not taking my step 3 exam until February. It is also really fortunate that you came in and saw the patient. I'm sorry I missed so much."

"That is why you do residency, Karen. You aren't supposed to know it all coming out of medical school. I know some of your colleagues are convinced they do, but they don't. Even Dr. Devlin and I sometimes need to take a second look at things. Why don't we see the patients on this floor and then you can go meet your colleagues for changeover and I will go on to the stepdown unit and you can join me when you're done. I'm supposed to pick up Kurt and Allison from swim practice at 7:30 so ideally we will be done by then."

Silently Karen took another deep breath and followed her aunt and attending into Priscilla Longsworth's room.