Gary Lambert literally tripped over his own feet. The man coming toward him early that morning was Johann Gerhard. Gary had known he would be coming with the Jena delegation, but he hadn't thought to run into him the very first morning. Yet there he was. The peaked eyebrows, the balding head with its ring of shoulder-length wavy hair, just like it was in the copies of Grandpa's books. Johann Gerhard was one of the most respected Lutheran theologians of his day. Gary had a copy of an 1871 edition of one of his books and had picked up a CD of some others just before the Ring of Fire. The books were still highly regarded and had been pretty much in continuous print after he wrote them.
Since Gary was the business manager at the hospital, he'd been hoping for a chance to talk with Pastor Gerhard. Gary preferred things low key and was not comfortable being the center of attention for any reason. When he'd thought about it, the falling flat on his face part had not been included in meeting the pastor. Or should he call him Dean Gerhard?
"Here young man. Are you all right?" Johann caught the young man under the elbow to steady him.
"You're the Pastor Gerhard," Gary blurted and then blushed as he juggled an armload of papers. "I'm sorry, sir. Of course you know who you are. I didn't mean... it's just that I've just read your work since I was a kid. Your picture is in several of my books. That's how I recognized you. I've been rereading some of it when I have any spare time since the Ring of Fire. I wanted to thank you. It's been a great comfort to me," he finished with a little more dignity.
"Thank you. I have only been wandering through your fair town for an hour. With what I have already seen, I am not sure of much at the moment. It comforts me to know that some of what I believe now still holds true. May I introduce my companions? Jakob Arnold is one of the faculty in the College of Law and Christoph Burkholtz is one of my students."
"An honor to meet all of you. I'm Gary Lambert. I work at the hospital as a business manager. I was hoping to meet the pastor and ask him to autograph a copy of one of his books for me." Gary just managed to not point out that today was to be a day of rest and that they weren't supposed to be out wandering around alone yet. Evidently, these three had set out on their own first thing in the morning. It wasn't like they were being kept prisoners or anything, but he wasn't sure what he should do about this, if anything.
When he paused, apparently speechless, Johann spoke. "Perhaps we could talk a moment more unless you have to be off somewhere else? I'm sure Jakob and Christoph can look about some more on their own." Jakob and Christoph shook hands with Gary and said their goodbyes.
"You work at the hospital then? That is fortuitous. I have been looking forward to touring both Grantville and the hospital, but I understand the hospital tour is not planned until tomorrow."
"Yes, sir. I usually have breakfast in the cafeteria but I had to stop by the printer this morning first. These are some drafts I'm working on for the new hospital in Magdeburg. I could show you around a little if you'd like, buy you breakfast." Gary volunteered hesitantly. After reading so much that he had written, he realized the pastor just didn't seem like a stranger. Still, he didn't want to derail The Plan. "I'm not anybody special there and I don't know the medical stuff, but I could still show you around some of the other areas. Later, you'd see more."
"That would be most kind of you. I would like that."
A large bright yellow vehicle rumbled by, filled with children. Gary waved casually to them and headed up the street toward the hospital. Johann's gaze lingered on the children, some in American garb, some in the garb he was familiar with, all chattering or waving or bent over their studies for some last minute cramming. To be as accepting as a child. I could use some of that right now. He turned and set off with Gary, a little uneasy about what he might see but curious. He needed more information, wanted to get more of a sense of the people here in their own environment. Gary seemed like a nice tour guide. He pointed out some places he thought Johann might find interesting. The town was clearly busy and thriving, if a bit chaotic.
Fortunately, the rain held off until they got inside the hospital. He hadn't been tempted to linger knowing that he would be seeing more tomorrow. As it was, he simply admired the fact that, according to Gary, the hospital had gone up a year or so after their arrival. He noted the pride with which Gary spoke of the hospital and what had been accomplished.
"Of course, you'll be hearing more about the other plans tomorrow. There is a plan to build a hospital in Magdeburg soon. This building and the record system I set up will be prototypes. Do you think Jena will build one, too?"
"I don't think our thoughts had gotten that far." Johann sat in a large open room that Gary took him to. There were tables and chairs grouped around an area with food already prepared by the kitchen staff.
"Sure you wouldn't like something to eat as well?" Gary asked.
"Thank you, but the ale will be sufficient. I've already eaten with Christoph and Jakob before we left this morning." Johann took the opportunity to look around and observe the people in this "cafeteria" while Gary went to get food and drink. A German family had pushed two tables together to accommodate their numbers and were talking softly a short distance away. Men and women in various groupings were scattered through the cafeteria. They wore loose fitting blue shirts and pants and soft-soled shoes. Whitish jackets covered them to just above the knee and an array of books and implements he couldn't identify protruded from ample pockets. There seemed to be some sort of name placard on their left breast but he couldn't read them from where he sat without staring. Some were speaking English and some German. Their mien wasn't any different in their way than that of plowmen eating a meal on the edge of a field.
"Here's your ale." Gary slid his breakfast tray into place across from Johann and set the beer in front of him. "I can take you around as soon as we finish."
Johann Gerhard wouldn't have thought he'd be at the hospital this morning discussing Lutheran dogma and answering Gary's questions about the various schisms in Lutheranism when he got up this morning. Gary had put up the tray, waved to some of the people in the cafeteria and begun the tour. They had started with the second floor that seemed to hold office and meeting rooms as well as storage and some medical rooms. There were some areas which Gary called exam and clinic rooms. Johann was surprised to see the chapel that was located on the second floor. It was small but he could tell it was carefully tended. The third floor held more office space, a largely empty but sizable medical reference library, and a few rooms for staff to stay in if they had to sleep over during bad weather or times of short staffing. Most of the rooms for patients were on the first floor. The operating theater that was on the first floor was two stories tall so that students could observe the surgery from the second floor.
He had been impressed with the spaciousness and craftsmanship of the hospital. All those they had met on the tour had greeted them cordially as they went about their tasks. If someone they met had a moment, Johann was introduced. Otherwise, they just walked around and observed, with Gary pointing out a few features as they strolled.
The first floor of the hospital, where most of the patients were cared for, proved a different experience for Johann. What struck him most were the things Gary didn't point out. In this corner of the surgical ward a doctor and nurse spoke in hushed tones about a patient. He noticed that there was mutual respect but no subservience in the way they spoke. On the medical ward, he saw a nurse showing the doctor a chemical analysis of some kind. From what he could catch at a distance, the nurse was clearly knowledgeable and even discussing courses of treatment. Those images were repeated throughout the hospital. Gary pointed out the technology to a degree or architectural details. He showed Johann the glassed-in conservatory and introduced him to people. But he didn't even seem to notice the way the staff all worked together.
As he said goodbye to Gary at the hospital entrance, Johann had a lot to think about. He needed to speak to the others in the Jena delegation about what he had seen as well. First, he was going for another stroll through Grantville.
Ten days after returning to Grantville from Jena, Beulah ran her hand through her hair for the second time in the last half hour and looked around the conference table on the third floor of Leahy. She suspected the tangled curls were sticking up and gave her the appearance of an aggrieved rooster. This is what I hated most about academia. Curriculum meetings. Wrangling about nothing much as though the fate of the world depended on it. The things that actually are important get lost in all the noise.
"It sounds like there are some areas we agree on and some that will need further work. I'd like to summarize the areas of agreement before we adjourn this afternoon and then set some priorities for discussion tomorrow. Is everyone agreeable?"
Nods around the table. She had been careful to instruct those from the Grantville curriculum group to scatter themselves in with those from Jena. She didn't want these meetings looking like opposing forces gathering to negotiate a peace treaty. The group from Jena had spent more time looking around Grantville than they'd planned, but Beulah thought it time well spent. Nothing like an up close and personal look to make them a little more willing to consider other points of view and she'd been agreeably surprised by the things they did have in common.
"At the baccalaureate level, points in agreement are length of time to degree completion, a rigorous examination for licensure to practice after graduation, a defined scope of practice for the new nurses and some of the course content. Given the amount of science education that will be needed, it is more likely to take four years rather than three to complete the baccalaureate curricula although with year-round courses and intensive clinicals, we may be able to cut it to three years."
Mary Pat looked around at the group. "I've been asked as a representative of the military side to stress the need for medical personnel to be trained as quickly as possible. Next year, we will probably be facing more conflicts and more injuries. We're also concerned about the possible spread of diseases."
"Ann, please make a note of Mary Pat's concern in the minutes." Beulah glanced at the representatives from Jena. "I realize that it is a somewhat less pressing concern from your end, but the military is going to be using some of our students and graduates as soon as they can get them. I don't know if any of the current students are particularly interested in military medicine. But, later, I'd like to talk about a few interested students doing a residency in trauma and military medicine with some of our military staff, Mary Pat for one."
Phillip spoke up. "There are several students that I think might be interested. Werner and I can talk to them if you would like. The ones I am thinking of are particularly interested in surgery techniques such as the one you demonstrated at Jena on Viet." His smile was small but genuine. Beulah was glad to see it. Phillip looked to have relaxed somewhat in the last few weeks. He wasn't quite as confrontational. She'd been dreading that attitude in these meetings but it hadn't materialized.
"That would be very helpful. Thank you. If everyone is agreeable, I think that after the curricula are agreed on, we can put together an examination with a smaller subgroup of this committee and the staff at Leahy. For now, I think it is enough to just acknowledge the licensure issue and then move on to more pressing matters. May I see a show of hands?" Every hand rose. Beulah nodded to Ann who was taking meeting minutes. She jotted the vote down. "Where we seem to be having problems is in three areas. First, grandfathering in students and professionals from Grantville and Jena. Second, content; and third, faculty."
"There is an additional concern, Beulah," Werner corrected. "There is a difference between a trade school or guild education and a university education. What you have been proposing sounds too close to a trade school for our comfort."
"Perhaps we can discuss that when we speak about content and faculty responsibilities," suggested Johann. "After the last few days of meetings, I have a feeling Beulah has an idea about how to deal with the grandfathering issue."
"I do in general. It's some of the specifics that concern me. I think that both Grantville and Jena people who want to practice at the baccalaureate level should take the exam, even those who are already nurses here."
"Wait a minute! That's illegal!" Mara was outraged. "You can't take away our licenses! We're already nurses and should just be grandfathered in. Those from Jena can take the exam and the new students from here can take it after they graduate."
Thanks, Mara. That went over like the proverbial lead balloon with the crowd from Jena. At least the rest of our group is waiting to hear me explain before passing judgment.
"Normally, I'd agree with that and I am concerned about the precedent that could be set. The legal types will undoubtedly get involved but I think we should at least consider it for several reasons. First, we are making entry into practice at the baccalaureate level. Not all the up-time nurses have that level of training, particularly the public health content we need so badly. There are also new content and new ways of doing things that we have developed in the last two years. I believe it is important to start out clean. I don't want there to be any doubt about our nurses' qualifications by future graduates or anyone else."
Mara's mouth shut with a faint but audible click. Beulah had known that would hit home and prepared her arguments carefully. The Jenaites might not understand it, but she had no doubt that the up-timers would. The highly contentious debate within nursing about entry into practice education and licensure had raged for nearly a century in the U.S., flaring up every decade or two in ways that were not always very helpful. A classic example, Beulah had often thought, of circling the wagons and shooting inward.
Registered nurses or RNs could come from any one of three educational backgrounds but all took the same licensing exam. Hospital-based diploma schools were three years with minimal coursework and an emphasis on on-the-job training at a particular hospital. Those schools were largely closed in the U.S. up-time. The second group was taught in junior colleges. Although in theory it took only two years of courses to complete the degree and be eligible to sit the RN exam, Beulah had rarely seen anyone get through the program in only two years. The third group was those who attended four-year universities and obtained baccalaureate degrees. Those students had public health, teaching and administrative content as well as greater depth in other areas.
Mara was as aware of all that as any other up-timer would be. Since a license wasn't something that could legally be taken away by changing the law, nurses with different preparations would have to be grandfathered in to RN status. Grandfathering the current crop of nurses in would always leave that kernel of doubt about their knowledge and competence. Since the legal authority that had granted those licenses, namely the state of West Virginia, didn't really exist anymore, the legal types could probably make a case for not needing the grandfathering fairly easily but she really didn't want to get into that at all. Beulah hadn't mentioned the fact that it would go down well with the Jenaites to have everyone sit the same exam for licensure. She would if she had to, but Mara made no further comments beyond a quietly murmured "I hadn't thought of that." The group from Jena clearly noted her response but made no comments. Beulah appreciated their tact.
"I think we should all think about that for a few days and then revisit it after we talk more about content and faculty roles. The content difficulty seems to be between what we up-timers would call liberal arts and professional education. As I understand from what's been said, grammar, literature, rhetoric and logic are the basis for the trivium and start in what we'd call grade school. Literature includes Latin and Greek classics, and basic mathematics is part of logic. At the baccalaureate level are more of what up-timers would call liberal arts. Courses like physics, which we are all agreed should be in the curricula, are taught as part of astronomy. We up-timers find the placement of physics in astronomy a little odd. I don't know how helpful it will be to have a nurse or physician study astronomy and physics related to astronomy rather than physiology, but at least we agree that we need physics. Engineering, which we are conflicted about including, is taught under mathematics and so on as part of the quadrivium. Masters' level education is for teaching at Latin secondary schools in the arts, and doctoral education is what we'd call a professional doctorate such as a doctor of medicine or a doctorate of jurisprudence. The current doctoral level doesn't really have any liberal arts content at all. Professionals without a doctorate can get a license to practice in a particular area after they earn a baccalaureus. Professional schools such as law or medicine need a doctorate to teach. There is not a research doctorate like the doctorate of philosophy we're used to. Have I got it right so far?" Nods again from the Jena group.
"Your contention is that without the liberal arts courses such as astronomy, the students will be getting essentially a trade school education, not a university degree. Without those courses, you can't say they are graduates from Jena. Our contention is that some of those courses need to be shaped more toward practical need for the medical or nursing profession and be heavier on the sciences at the expense of some of the courses you regard as essential. We don't believe, at least initially, that there is time for courses like drama right now. We need nurses and doctors who can practice. To you, they aren't able to be fully functional without the liberal arts courses."
"You have captured it succinctly," Johann agreed. "We cannot call what we are creating here a university education without those courses. Any graduates of the program would be unable to be employed or to continue their education anywhere else. It would also bring us into conflict with the guilds and make our students appear more like barber surgeons than university graduates. The courses must be included in the curricula."
Whatever else Johann would have said was interrupted when a very pale Starr came into the conference room. "Can I talk with you a minute, Beulah?" Starr was wearing what Beulah thought of as nurse face. It was the kind of neutral, calm look that nurses used to avoid alarming patients or their families when things were going seriously wrong. Beulah felt her own face automatically assuming the same mask as she excused herself and stepped into the hallway with Starr. Once in the hallway, Starr's mask cracked and her soft brown eyes began to fill with tears.
"Oh, Beulah. There's been a battle at Wismar. Hans, Larry and Eddie have been killed in action!"
The shock of it made everything sway sickeningly in front of her for a few moments. Isolated, fragmented images and incomplete thoughts went spinning through her mind. Sharon and Hans at dinner. Larry coming into the high school infirmary banged up from something after the Ring of Fire. So many people were going to mourn the loss of those boys. They'd achieved legendary status in the Battle of the Crapper and with all they had done since. Aside from his notorious driving, Hans was well loved here, too.
"Where are Sharon and James? Veronica Richter and the others? Do they know?"
"They're being told. Sharon was there in Wismar. James is here and I'm not sure about Frau Richter. I wanted to tell you before I made a general announcement over the PA."
"That was the right thing to do." Beulah heard her own voice from a distance, making suggestions and giving instructions, slow tears falling down her cheeks. Oh, God. How will I tell Mary Pat?
"May I join you, Beulah? If it won't disturb you," Werner asked quietly. At her nod, Werner sat on a bench next to her in Leahy's conservatory. "This is a lovely spot. I can see why you start your mornings here. Especially lately."
"It's been especially comforting this last week. The memorial service yesterday was pretty intense. We're going to miss them. At least Mary Pat got to go to Magdeburg to be with Sharon for a while. Given the unrest there, having a trauma nurse on the spot might not be a bad thing. She'll be back in another week or two if things settle down there. I hear she and Philip had organized a trauma rotation for a couple of the students."
Werner gracefully accepted the change in topic. She clearly didn't want to talk too much about what had happened. He understood taking refuge in work. While he hated to push at a time like this, the needs and responsibilities that had brought him to Grantville still existed. "So I am given to understand. Philip and the students are very excited about it. We have spent a considerable amount of time in the library reading basic texts and sharing the texts we brought with us with Hayes and Stoner. I have had some very interesting conversations with Stoner. When he can be spared from his work here, and before he leaves for Italy, I should very much like to have him visit me in Jena and look over our gardens there."
"I'm sure he'd be happy to see them. You've done a great job with them."
"Thank you. As we have been reading in the library, the complexity of public health measures that are taken to prevent the spread of illness are of particular interest, especially as it will be spring soon. I was wondering if it would be possible to have a lecture given to the students and faculty on public health and the prevention of communicable diseases? I understand you have some expertise in this area."
If she was at all unhappy or angry about being in essence asked to give a lecture to the group from Jena after what happened last time, Werner saw no sign of it. Then again, she was an experienced faculty member. The circumstances were different and one incident out of a long career wasn't going to stop her. He doubted much of anything would stop this woman once she set her mind to something, and he both needed and wanted to have a better relationship with her and the other medical personnel in Grantville. But particularly with her. She was very highly regarded and involved in some way in every aspect of medical care here. It was Beulah who was the liaison with the program at the high school, who had been the Director of Nursing, who consulted with the Sanitation Committee, and on and on. While they had been here less than a month, her central role in the small medical community was clear. He and the other faculty would make sure the students stayed in line this time.
Not that he thought it would be really necessary. Kunz had had a severe talking to for some of the more rigid students. Being left behind with Grantville's treasures before them had weighed more heavily than some of the views currently being shaken. He rather thought Kunz had been surprised to find himself as an advocate for Beulah and the Grantvillers, however reluctant he had been to do it. Werner thought that the students had responded very well to the lead the faculty had taken. They had all had their eyes opened to another way of practicing, a highly effective way at that. He didn't know what they would take from the Grantville way of doing things in the long run. But, in the short run, all of them were very curious and being very observant. And polite about it, too.
"Makes sense. I'd be happy to give the lecture myself if you'd like. I'd want to pull some materials so they have a few of the basic science concepts down before I gave the lecture. We could set it for say, two weeks from today?"
"I was hoping you would agree to do it. Two weeks from today then."
Beulah paused in the ER exam room door that evening to watch Ernst, one of the Jena students, with Fritz as his assistant stitch up a small shin laceration. The patient was an up-time youngster of about eight, whose mother was watching carefully. Beulah didn't see any extra anxiety because a down-timer was working on her son. Fritz was translating Ernst's comments when he needed help with English. Nice bedside manner, reassuring and calm. A little gentle teasing to set the little one and his mom at ease and distract him. She noticed with a tiny smile that he was being very, very careful of his sterile technique.
Beulah slipped away unseen by the group in the small room. She didn't want them to feel she wasn't confident in them. The scene heartened her. This was what they were working toward. The child would have had to wait until James or one of the RNs was free to do the suturing otherwise. He'd have been in pain and the normal inflammatory response to injury would have made the wound more difficult to close. Since James was in surgery and the only RN available to cover the ER was with another patient, that wait might have been an hour or more.
They would make this work. It had taken no time at all for Phillip and two of his students to start spending every spare moment in the ER. Phillip the adrenaline junkie. Who'd have thought it?
"What happened?" Phillip asked as he hurried into Leahy's Emergency. Two of his students, Ernst and Heinrich, trailed closely after him as he more or less trotted beside Mary Pat. She'd grabbed them out of the Grand Rounds they'd been having on the Surgery Ward. Phillip, Ernst and Heinrich were doing a trauma and surgery mini-rotation. They spent every spare minute they could in the ER.
Beulah had instituted Grand Rounds as a teaching tool. The rounds gave them a chance to review cases with Beulah who did hands on teaching and explanations of actual patient conditions and their treatments for small groups of students. Much as Phillip and the other two students appreciated the floor time, they'd fallen in love with trauma and any opportunity to get in on something that got Mary Pat moving that quickly was to be pounced on with speed. Beulah had waved them on with a "Catch up in a few minutes. Go on."
"Just got a call from the ambulance. We've got a couple of casualties coming in; they're about ten minutes out now. I left Mara prepping before I came to get you and grabbed some supplies from the OR on the way. The report the EMTs called in is that there was an accident at one of the farms. The loft in a barn gave way and the two men getting hay for the cows went down with it. One of the men is in pretty good shape. Bumps, bruises, stable vital signs. He's got a possible concussion but also has a scalp laceration that's bleeding even through the pressure dressing."
As they arrived in the ER, she directed them to the side-by-side exam rooms where Mara was prepping IV fluids and setting out linen bandages. Mara worked quite a bit in the ER because she got calmer and calmer the more desperate the situation. She was sharp as the proverbial tack to boot. Mary Pat appreciated her abilities but the fact that Mara's thick drawl also got slower during a crisis drove her nuts sometimes. Mara looked up at them and waved Ernst over to a cabinet. "Great. Our master of the suture is here. Going to put all the suture practice you've had to use today Ernst. Can you get your stuff ready?"
As Ernst headed over to the supply cabinet, Philip and Heinrich looked at Mary Pat, who continued her report. "The one we're most concerned about, Harmon Manning, wasn't so lucky. Evidently, he fell directly onto the concrete floor rather than the hay, and some equipment stored in the loft fell on his chest. Looks like he's got crushing chest injuries as well as a broken arm and collarbone. May have some spinal cord injuries. They're bringing them all in on back boards just in case. Mara, any new info?"
"Vitals are going downhill on Manning. Carotid pulse is palpable, rhythm sinus tach with a rate of one-sixty, up from one-forties." Seeming to remember who else was in the room, she glanced up and then went on. "They don't have much time with someone that far out and that seriously injured. So they don't spend a lot of time on blood pressure taking. Instead, as a general rule of thumb if you have a carotid pulse, you have a systolicah that's the top number on the blood pressureof at least sixty. Sixty is the minimum amount necessary to for the brain to be perfused, although it isn't optimal. Sinus tachycardia means that the heart rhythm is regular but too fast."
"Can you two start setting up the splints and chest tube trays?" Mary Pat headed for the oxygen cylinder set up near the wall. They didn't have oxygen piped through the walls the way an up-time hospital would have but at least they could make it and refill the cylinders from the nursing home. With the curtains open between the ER "rooms" they could all talk freely. The rooms were large so they could handle lots of people and equipment if needed. Philip, Heinrich and Ernst had spent a fair amount of time here and they'd been shown where things were located and some of the basics during the last few weeks. "A pulse at the femoral artery should indicate a pressure of at least seventy, radial at the wrist at least eighty. That they're looking at a carotid pulse and that his heart rate is that rapid is a probable indication of being in shock. The shock could be from hypovolemia, that is, too much blood loss or from cardiogenic shock from injury to the heart. That is that the heart has been hurt too badly to function well."
Mara laid out toweling and said "Okay everybody, get scrubbed up. They should be here any minute. The last report indicated that his respiratory status was bad. Supraclavicular retractions, respiratory rate is almost forty and he's cyanotic. They've been able to cut away his clothes in the ambulance to get a better look at him. They've got a flail segment. Sounds like a big one."
Philip looked from one to the other. "And the significance of that is...?"
Mary Pat looked back at them and scrubbed her hands harder. "With a flail segment, a contiguous group of ribs are broken. The person can't breathe normally because the rib cage doesn't move in a unified fashion. When the person breathes in, the flail segment sinks instead of expanding and vice versa. There isn't enough negative pressure to fill the lungs with air sufficiently if the segment is big enough. That means we're probably dealing with a pneumothorax, maybe a hemopneumothorax, which is blood as well as air building up in the chest cavity."
"Ah, like Viet."
"Worse than Viet this time, I think. Heinrich, I'd like you to handle the ambu bagging please. You'll be monitoring his respiratory status. You've done it before. You may be at it a while this time."
James came in through the double swinging doors from the OR. He pulled off the surgical gown he was wearing, dumped it in a linen bag and began scrubbing his hands. While Mara briefed him quickly, Mary Pat looked around to make sure that everything was ready and got a final report from the ambulance crew. Their patient sounded unstable as all hell. Mary Pat felt the adrenaline pumping through her system, sharpening her mind and slowing everything down with an odd crystalline clarity. They were lucky to have this much prep time but every minute that their critical patient was in the field was a minute too long. Beulah came in and caught the report while she joined James at the sink to scrub.
"Beulah," James began, "I'd like you and Heinrich to take the possible concussion. Evaluate him and get him patched up as much as you can. Give a shout if you think he's got an intracranical bleed cooking in there or anything else you think I ought to look at. The rest of us will work on the patient with the flail segment."
Two things happened as James finished speaking. The outer doors opened with the ambulance crew bringing in the stretcher with their critical patient while the LPN and nurse's aide stationed outside to wait for the ambulance helped get the second patient out. Another aide came rushing in carrying two glass bottles of blood from the blood bank. Mara had ordered them as Mary Pat had gone out earlier.
From the looks of Harmon Manning they were going to need both of them, and then some.
Phillip didn't like the way the man looked as the EMTs wheeled him in. There wasn't a great deal of bleeding apparent, but the man's skin was a grayish blue color he'd recently learned to call cyanotic. Each rapid breath was a labored, pain-filled gasp. Philip knew what death looked like and this was death before him. He exchanged glances with Ernst and Heinrich who both looked grave but still optimistic. Phillip, who had seen far more death than they, wasn't so confident. They had seen amazing things in Grantville these last weeks, true.
Ernst and Beulah headed for the second patient while Mary Pat, Mara and one of the EMTs helped move him over onto the ER gurney since it was wider. Phillip managed the IV and oxygen tubing as James leaned over to expose his chest, stethoscope in hand. Phillip had been reading about "breath sounds" and he'd been able to actually hear an asthmatic child's wheeze just that morning on rounds. He didn't think James would be happy with whatever breath sounds he heard out of this patient.
He could hear Beulah talking with the second patient, hear his slurred speech and concern about his friend. Beulah was talking quietly with him behind the drawn curtain and reassuring him that his friend was being treated. Phillip had moved a tray of instruments and gotten out of the way as the others settled Harmon and began the examination. Mara's face was the only one he had a good view of and something in her face made him edge closer to the gurney, trying to see what had occasioned that sad compassionate look.
As he got closer, he could see the look on James' face as well. James was very carefully touchingah, palpating, the word was palpatingtheir patient's chest. Phillip frowned. He thought that normally, one listened to the chest first in an assessment. That was what the book had said. He remembered the passage clearly. As James lightly touched his chest on the right front side, Phillip could hear a crackling kind of sound.
"What is that noise? His ribs?"
"Crepitus," answered Mary Pat. "That means that the ribs have probably punctured the lung and air is being forced into the skin by the building pressure. See how the area is swollen too? James is trying to get a sense of how big the flail is. An X-ray would tell us more but the patient doesn't have that kind of time."
"About twelve by sixteen centimeters." James reported grimly. He turned to Chester, the EMT. "Is the family on the way?"
"Won't be here for at least an hour."
Phillip felt it again, just as he had with Viet all those months ago. It was clear that Mara, Mary Pat and Chester knew what to make of James' question. He didn't and neither did Heinrich who was carefully using the ambu bag to help the patient breathe. Beulah stepped softly to Phillip's side. He could hear the LPN working with Ernst as they stitched up the bleeding laceration on the patient in the next bay.
"Want me to get some morphine?" she asked quietly.
James looked up at her and nodded. "Yeah. Let's make him as comfortable as we can."
Phillip walked with Beulah to the medicine cabinet at the nurse's station in the center of the room. "He is not going to live, is he?"
"No. The flail is too large and the bones are pulverized under his skin. I watched as Mary Pat took his blood pressure. I could tell she didn't get a very good pulse and when I saw the mercury pulse the first time in the glass, it was only around fifty. His heart rate is becoming not just rapid, but erratic. We'd rush him into surgery at this point if we could, giving him more blood and IV fluids to keep his pressure up as much as possible. We'd also put in at least one chest tube and so on. But we don't have any ventilators. Ventilators are machines that can breathe for the patient when the patient can't manage. With a flail chest, we'd need to do that so the bones could knit together while the machine breathed for him. We can't splint the ribs when they're broken that badly because we could drive a piece of bone into his lung. Plus, unlike limbs, which can be immobilized by casts or splints to heal, the ribs will move multiple times each minute with every breath. It would take too much strength for him to do that himself for a few weeks. With a small flail, we'd give it a try but this is just too large. The other injuries he has might kill him as well but if we can't keep him breathing, it's a moot point."
She finished drawing the morphine into a syringe and headed back to the patient. "All we can do is make him comfortable. We don't have a vent to breathe for him for weeks after the surgery. We also don't have any of the substance that could help glue the bones together. Even though we know he won't make it, we could try to keep him alive until his family gets here so they could say goodbye." She handed the syringe to Mara. "There's ten mg in the syringe. I thought you could space it out as needed."
She turned back to Philip and motioned him back from the bed. "We can't use the supplies to buy him an extra hour and give them a chance to say goodbye. We only have so many chest tubes. That blood was scheduled to be used this afternoon in surgery. We don't have all the resources we once did. Even then, we never had endless resources anywhere I worked. Which means making tough choices sometimes."
Everyone who remained was oddly hushed, their movements and aspect subdued, Philip thought. They continued to do small tasks for their patient and to clear away material, used or not. There was an air of sadness and frustration in his Grantville colleagues. He was familiar with the feeling of losing a patient. How much more difficult must it be to lose one that you might have saved, that you had the knowledge to save.
"For God's sake, Mary Pat, did you have to come armed?" Beulah hissed the aside as she looked out into the lecture room on the third floor of Leahy. They were using the future medical library for a lecture on the history of public health and infection control for the Jena students. A lecture Beulah was giving. Damned if she was going to let anyone else face them after her experience last time in Jena.
Mary Pat tenderly patted the Berretta 9mm pistol her oldest brother had given her and tried very hard to look innocent. Beulah didn't think she looked at all repentant and the sparkle in those green eyes was far from innocent. "I'm on duty. So of course I'm in my Basic Dress Uniform and carrying a side arm. Do you really think I'd shoot one of these med students for getting out of line?"
"I don't think you'd do it but they might. This is serious overkill here. Not that I don't appreciate the sentiment but even I'm more subtle than that." She looked at Mary Pat out of the corner of her eye. "That smile would reassure me and our audience a little more if it had fewer teeth in it."
"I'm on duty. I wouldn't go around shooting unarmed civilians for no good reason." She pursed her lips thoughtfully. "Like say, oh, disorderly conduct."
"We have cops to handle that. I don't buy the just happened to turn up here of all places while on duty line Lieutenant."
"Didn't think you would but it got your mind off the lecture didn't it? I'll be on my way, Officer Flanagan, always at your service."
Beulah laughed and shook her head at her. She was so relieved to see Mary Pat teasing again, she'd forgive her just about anything. "Brat. Okay, okay, it worked. Besides, I think they've already got your point. The lecture's about to start, now scoot. You're scaring my students."
Besides, she thought, I've got to be in the right mood to pull this off. These were not stupid people. In fact, some of those in that room, like Werner, had first rate minds. They also wouldn't be strangers to some of the political maneuvering she was about to try. Ah, well. Misdirection and cooptation were tried and true strategies. She just had to make sure she approached it properly so that she gave them an "invisible war" that they would be fascinated enough by not to look too closely to see what other invisible war they might be fighting. And to think I've given James such a hard time of late. Maybe I should start hanging around Mike and Balthazar more often myself.
"Good morning. For those of you I haven't already met, I'm Beulah MacDonald. Today, I'll be giving a lecture introducing some of the developments in public health as we use it in Grantville. The readings I assigned should have provided you a basis for understanding terms and concepts I'll be using. I know you've all had to learn a lot of information about statistics quickly."
In fact, that had nearly led to an interdisciplinary wrangle. There was only one basic statistics book at the high school. She knew that the students would need that content to understand simple concepts in public health, particularly in epidemiology. The medical students and faculty from Jena had set up a roster to share the book and essentially taken over the high school library for the duration. Those not studying the statistics book had been studying other material until it was their turn. Copies were being made as quickly as possible when the book wasn't actively in use. Basic statistics had lots of applications.
One of the Jena delegates was a high-ranking math faculty member. Seeing clear evidence that the math part of the university quadrivium would be needed by future nurses and doctors, he wanted the book for the math faculty and students. He was genuinely interested in the concepts and quite ready to stake a claim to the text. The school librarian had found him some other texts on probability theory to hold him off for a time, but who had the priority need for the text had been a bit sticky for a moment. The librarian was both amused and appalled. She was thrilled to have people wanting to get to a textbook but the arguing over it was a different matter. Beulah gathered that the argument had gotten quite heated. That was perhaps the most blatant conflict over up-timer books among the Jenaites but not the only one. It made Beulah a little uneasy. There were more faculty and students coming from Jena. This was getting out of control. Each group had some reason attached (not always peripherally) to why they needed access to information or books or specialists to help get the new health sciences program up and running. They seemed to have started an avalanche. Or a train wreck.
She had had the Grantville high school math teachers tutoring the students in the evenings, whenever one had a break between classes and at lunch so the group from Jena had at least a little information about statistics. Math students had joined the med school group. Fortunately, there were only a few math students here. So far at least. She'd also given them quite a bit to read in terms of foundations of public health. According to James, the med students and faculty had spent a late night at the Gardens with their notes cramming before this morning's lecture. She hoped they weren't too hung over.
"The public health situation has been frightening and in some ways, shocking, to us. Public health measures for us have been so interwoven into our lives that we no longer noticed many of them. We took for granted that our water would be safe to drink, our air clean to breathe and that our food wouldn't make us sick. Children are taught the basics of handwashing when they are toilet trained. No one has to specify that the reason for washing your hands after going to the bathroom is to avoid spreading certain diseases. It's part of the knowledge we absorb as small children, unquestioned and just there. It's considered rude to sneeze or cough without covering one's mouth and nose. The reason isn't openly stated, that the person who sneezes or coughs without covering their mouth and nose could spread airborne diseases to other people. It's automatic, part of everyday life. Then, suddenly, we've found ourselves fighting an invisible war, a war we thought largely won, against communicable diseases. That is, diseases like measles and smallpox that can be spread among a population. Many of those diseases were controlled or eradicated in our time. Vaccination had been around for several centuries. School children were required to be vaccinated before entering school. Before the measles vaccine was developed in 1963, there were millions of cases every year in the U.S. By the time children were six, more than half had had the measles and ninety percent had the measles by the time they were fifteen. After the vaccination programs began, the number of cases dropped by ninety-eight percent. What was once a common disease became rare. While many of the public health supports that we took for granted are gone now, much of the knowledge remains and we are putting those supports back into place just as quickly as we can. I'd like to talk with you today about how public health developed, how we got to where we were and where we are moving toward in the future. As you learn about these measures, you could become soldiers in an invisible war against diseases that have been the scourge of humankind from time immemorial.
"Public health efforts focus on measures that prevent illness or injury, track disease outbreaks, and promote life and maximum functionality in groups of people. I'd like to talk with you today about historic developments in public health history and how those have led to changes in public health practice. I'll be focusing on three areas primarily: epidemiology, public health measures and vaccination. Obviously, this will be a brief introduction to what can be a very complex subject.
"Epidemiology is a cornerstone of public health. Epidemiology gives us a way to study how factors which affect health and illness are distributed in a given community or population. Epidemiology is really a form of research and uses many of the same methods as research. The epidemiologist collects a variety of data from many sources in order to identify at risk populations and to prevent or ameliorate the spread of disease and illness and promote health."
So far no one looked lost. She turned on the computer she'd borrowed from Hayes and pulled up the first slide. "Hippocrates was the first known epidemiologist. In fact, Hippocrates was far more accurate in his perceptions about public health and the spread of communicable diseases than about his medical treatments. He developed a number of principles of epidemiology that are still important. Hippocrates gave very accurate descriptions of diseases in his practice. He also wrote about natural factors such as water supplies that are important to consider in public health. He stressed that clinicians should be observant and should consider lifestyle factors such as activity in treating illnesses. He noticed that certain disease occurred at certain places or times of year. We'll talk more about some of these things as class progresses today."
Beulah paused for a sip of water and let the students catch up a bit on their notes. She hoped that hearing a familiar name and that he had contributed relevant, accurate information to public health would reassure her audience that all they knew didn't have to be relearned. Some but not all of it had later been proven inaccurate. Hayes had found copies of Hippocrates' Epidemics I and Epidemics II that were being translated. She planned to use some of it in the developing curriculum. Not only was some of it still relevant, but use of some "classics" added legitimacy to the things they were teaching and were still relevant. She was acutely aware that in the long term, there was more involved here than just the university at Jena. She also wanted to make the point that they all stood as it were, "on the shoulders of giants." Knowledge had been created, lost, accepted, ignored and tested in various ways, moving forward in fits and starts. Such was the nature of scientific advances.
"Did you all have a chance to attend the sanitation committee meetings?"
Most of those present nodded. James had commented that there hadn't been so many people at the committee meeting last week for over a year. We take the risk of infection too lightly. We're too used to antibiotics and clean streets and an immunized population. So we don't pay attention to them. Despite all the preparation we've been trying to do, most of our people still have, at most, an intellectual understanding of an epidemic. Even the oldest of us, who ought to remember our younger years, aren't immune to that attitude. She shared the fears of James and the others. It was only a matter of time until they were hit here in Grantville. How bad it would be depended in part on how prepared their neighbors were. There's never enough time to get everything done. There are too few of us, spread too thin. We should be having programs like this all over the USE. At least this is being videotaped. I've got to talk with James and the others on the sanitation committee about spreading this information out. We need to put together a basic primer and recommendations for prompt action.
She'd given lectures like this so many times that part of her had gone on autopilot while she talked about how to identify potential problems or disease outbreaks. The classic example she'd given was John Snow's work identifying the cholera epidemic in 1850s London. The initial outbreak in the early 1830s had caused at least sixty thousand deaths in Great Britain. Snow's investigations of the 1849 and 1854 epidemics had occurred years after the first outbreak. She saw the way the students' attention sharpened when she pointed out that the epidemiological approach he'd taken to identify geographic clusters of outbreaks had helped identify the water source as a culprit before the cholera germ was identified. She emphasized his use of epidemiological data such as mortality rates, too. He'd spotted the crucial fact that, among other things, the source of drinking water had changed but the population had stayed the same. Those with the better water source were twenty times less likely to die from cholera. He'd done door-to-door validation of water source to get an accurate rate, a typical public health approach to collecting data. The result was that they were able to take appropriate public health measures and control the contaminated drinking water sources. She thought that the students leaning forward a bit in their chairs got the point that you needed knowledge, not just technology to address these problems. Public health and spreading knowledge were two types of invisible war. They weren't fought in the open but the effects could be profound and even more lasting. Kunz and Willi were both nodding thoughtfully in separate parts of the room. Kunz had a particularly intense look on his face. And if they thought that example was pointed, wait till I bring up Florence Nightingale.
With an effort she pulled herself back to the matter at hand and went on to talk about the work of Koch and Pasteur in discovering microorganisms and how to set criteria to determine the role of the microorganism in a given outbreak. "In order to transmit an infectious disease, you need three things: a vulnerable host, an agent and an environment that can result in an infection. I'd like to take each one at a time. Host factors may be things that can be changed or things that indicate the public health professional should pay particular attention to that group in certain situations."
Beulah moved onto a discussion of passive and active immunity and immunization. Active immunity to a particular disease was acquired through immunization or a previous infection with the microorganism that caused the disease. Passive immunity was a bit more difficult to explain. Maternal antibodies and gamma-globulin prophylaxis weren't as easy to understand but she thought they were getting it. She noted another student perk up when she talked about the idea of herd immunity. If at least eighty percent of a community was vaccinated, it was more difficult for communicable diseases to find a vulnerable host. The example she used was of the development of smallpox vaccine using cowpox by Jenner. She was careful to point out how long some form of vaccination had actually been around and what Jenner had done that was different and why what he did was so effective. The drops in death rate were impressive statistics.
From there, it was a fairly easy step to talk about personal hygiene and cleanliness before she moved onto the agent of disease part of the lecture. "Are you all familiar with childbed fever? During the 1840s, many women died of childbed fever. Often, the child became ill and died as well. A doctor named Semmelweis conducted a classic epidemiological study of what caused the fevers. He noticed that in the two clinics he was director of, one had higher rates of death than the other. The mothers were ill during the birth or up to thirty-six hours later and then quickly died in the clinic with the high mortality rates. He observed that the problem seemed to start during the examination of the mother during dilation." She went on to discuss the data he'd collected and analyzed and the controlled experiments he'd conducted to try to determine the cause of the deaths.
"He realized that the deaths were caused when the medical students came to the hospital from the death house after performing autopsies and conducted pelvic examinations on the laboring mothers. The doctors' hands carried germs from the dead bodies to the mothers because they didn't wash their hands. The traditional Hippocratic view of disease was still held and, initially, his findings weren't accepted. He was successful however in instituting handwashing by every nurse or doctor entering the ward. At first, he thought it would be enough just when entering the ward. Later he realized that it was necessary to wash between each examination. Something as simple as consistent handwashing dropped the mortality rate by ninety percent in just six years. I know you've seen how often we wash our hands in the hospital and clinics here. It is a very simple but very effective way to stop the spread of infection. It's quick, cheap and anyone can learn to do it.
"The presence of infectious agents is another concern I'd like to touch on. One of your handouts gave common infectious agents, which we also call pathogens, that are found on or in the body and that are found in the USE."
One of the students waved his hand. "Yes?"
"Excuse me, Frau Professorin, but if these pathogens are in and on the body and all around us, why aren't we all sick all the time?"
Beulah beamed at him. "An excellent question Mr...?"
"Georg Holtz." His voice sounded a little more confident.
"Well, Mr. Holtz, you've raised a very important issue about pathogens. That has to do with part of the agent, namely the vector, as well as how strong the pathogen is. The vector is the way the pathogen gets to the person in a way to do harm. The vector may be biological, such as a person or animal that has the disease, or it can be mechanical. A mechanical vector can be something like a contaminated surgical instrument or piece of clothing." She very carefully didn't notice them stiffening. She remembered how she and all the students she'd met had reacted when they came face to face with some of this. As she recalled, she hadn't been the only one who'd suddenly wanted a shower with lots of hot water and soap. A truly evil thought encroached. Well, it's all for the greater good. It certainly made an impression on other students and it's fairly easy to do. The lab is going to love this one.
"As a matter of fact, if you're interested, I'll talk to the lab folks for you. They can show you how to culture some of those organisms we live with all the time on our hair, skin, clothing and so on. Most of the time, we call those organisms benign. Even benign microorganisms can be nasty under the right circumstances. Let me give you an example you've probably seen in practice. A person with a wound has an open area that the germs that normally are on your skin, such as the staphylococcal class, can get into. If the person had an intact skin, the microorganism couldn't get into them to cause an infection. The host was vulnerable, the microbe was there and it had a way to get in."
She finished what she had to say about agents of disease and went on to control measures such as quarantines. The students seemed surprised that the practice of quarantines had begun in the fourteenth century and that she still considered it a relevant measure of infection control.
When she talked about the role of disasters such as floods or war in creating conditions that promoted the spread of disease, she saw that they were fitting what she was saying into their own experiences. War as a topic led her to Florence Nightingale and the Crimean war. She talked about how Florence had used epidemiology and statistics as well as astute political and other lobbying to improve conditions and reduce mortality and morbidity of the soldiers and later, of people in England. Making the point that when she'd arrived in 1854 in the Crimea, she'd immediately worked to improve the conditions for the ill soldiers by organizing measures such as kitchens, laundries and a central supply department. The end result was that in ten days, the death rate dropped from thirty-eight percent to two percent. Mentioning that she was a nurse near the end didn't hurt either. Beulah fully intended to discuss Clara Barton, the U.S. Civil War and the founding of the Red Cross later in her lecture.
"The methods Nightingale and others have used rely on incidence, prevalence and relative risk ratios." She went to the board and put the formulas up with discussions of each, how it was calculated and what it meant. That naturally led her to a brief mention of statistics such as infant mortality that gave important clues to a population's health.
"But that is really beyond the scope of our talk today. I'd like to talk some more about modes of transmission of disease and then we'll talk about ways to break that chain of environment, agent and host determinates leading to infection. Biological modes of transmission are physical contact such as spitting or touching, sexual contact such as intercourse, and airborne contact such as dust or droplet nuclei. Those modes of transmission are direct or airborne. Indirect transmission results from mechanical transmission. Books, coins, toilets, soiled dressings, food and many other things can be a reservoir for an infectious agent. For the last hour today, I'd like to talk about ways to interrupt the transmission vector, to strengthen potential hosts and to reduce risks from the environment."
During the next hour, she covered everything from adequate sewage disposal to handwashing. The work of Joseph Lister and the use of antiseptic techniques and carbolic acid solution fit in here. She also brought up Thomas Syndenham, who was only nine years old at the present time. She made an effort not to stress too much that he used observation and other techniques to diagnose different diseases and avoided Galen's approaches. Syndenham's work classifying fevers in London during the 1660s and 1670s and how he treated the different classifications went against the Hippocratic and Galenic approaches. For which he took considerable flak. His treatments were effective, however, even if he hadn't understood what was causing the fevers. She also made a point of talking about the criticism and threats he endured. He persevered despite that and influenced an up and coming generation of physicians with his use of empirical techniques.
She gave them additional resources to read on all the areas she'd introduced and hoped it would be enough to get them started. Hopefully, they'd take the ideas back to Jena. "If any of you have specific areas of interest in public health, please see me. I'll try to set up an experience for you so that you can learn more in a clinical setting and I can probably point you to more references. Thank you for your attention today. Do you have any other questions before we adjourn?"
"May we join you, Frau Professorin?" Georg sounded a little hesitant but eager.
"The Leahy garden is always better for company. Please Georg, Kunz, have a seat."
"We wanted to thank you for showing us around the lab and setting up the culturing experience after the lecture yesterday." Kunz sat next to her on a bench and grinned at her. "We really enjoyed it. Georg and I are very interested in aspects of public health and would like to talk with you more about books to study and a clinical experience in public health."
"With you if we can," Georg blurted and then blushed right up to his straw-olored hair. "I'm particularly interested in microbiology."
"While I am interested in the methods of disease surveillance you spoke of," said Kunz. "We were on our way to check on the microbial growth but when we saw you here, we thought we'd take the opportunity to ask."
The smile she gave them both was slightly blinding. "I'd love to. I'll make up a list of materials for you. I can even lend you my personal texts if you'd like in some cases. Most of them have been copied already. I'll check and see what's at the printers right now."
"You're all certainly keeping the printers in Jena busy." Kunz grinned back at her. She couldn't help but contrast that with the attitude a few months ago and took heart.
"Please excuse me, Frau Professorin, but in the lab, they said that there would be growth within a day. I'd like to go check the petri dishes before things get too busy there."
"Have fun. Kunz and I will set up a time to meet and talk some more."
She and Kunz grinned after the tall young man as he dove for the door.
"What are you doing here?"
Georg nodded politely. "I am one of the medical students from Jena. My name is Geo-"
"I know you're one of the Jena students. I asked what you're doing here in the lab?"
Georg straightened to his full height. "I have permission to be here. I was checking the growth of the cultures we took yesterday."
Mara stared at the young man standing a few feet away. She couldn't believe he was arguing with her this way. Little know-nothing. "There won't really be anything to see if you just took the cultures yesterday. I don't know why anyone is letting you do cultures in here anyway. It's a waste of our resources to be using materials that way."
"Frau Professorin MacDonald didn't think so. She called it a good learning experience. I and the other students found it most interesting."
"We only have so many supplies. They should be used for patients or for our students." Mara heard the belligerence in her tone but didn't care. She was sick of everyone trying to make them happy. She'd already figured out she wasn't going to be one of those asked to be in the MD program at Jena. She should be. God knew she'd earned it and she was certainly smart enough. She'd even volunteered for the education committee. It was all going to be people's pets who got in, especially Beulah's pets. She'd heard someone talking with Mary Pat in the hall yesterday, asking if she was going to apply to the MD program. The other nurse thought Mary Pat would be great. Mary Pat had laughed and said she wasn't interested, she liked nursing too much. Hearing one of Beulah's pets dismiss what she herself wanted had just frosted the cake. She should be in that program. She should be getting special attention. But no. Beulah was sponsoring Fritz and now it looked like she was going to have one of the Jena students, too.
"I am one of the students," Georg replied in evident confusion.
That was more than she needed to hear. All thoughts of running a pregnancy test before her shift started and anyone else was around went flying out of her head. The injustice of it, the slights were more than her temper could stand. "Well, you are sort of a student. Not that any of you'll be worth much for a long time. We'll have to spend a lot of time and effort just getting you up to speed on things any junior high student would know. Some people may think you'll be useful teaching assistants but I'm not one of them. We'd be much better off starting from scratch with our own people."
Georg's attempt to interrupt went unheeded. "You're nothing but a bunch of parasites. You'll take and take but you sure won't give much back. You don't know enough. Your ideas about everything are from the dark ages. There's no way you'll be able to catch up on hundreds of years of knowledge in a few years, much less a matter of weeks."
"How dare you say such a thing!" Georg's voice was rising toward a yell and echoed oddly in the lab. "We are not parasites. The others would not be spending so much time with us if they didn't think we could learn. More than that, we are not some sort of ignorant fools who..."
Even Mara knew she'd gone too far. With an effort that left tears in her eyes, she stopped herself from saying any more. She spun away from him and slammed out of the lab.
"Hi Kunz, Georg. Are you all right Georg?" Beulah asked in concern. Georg and Kunz had just come into the conservatory as she was about to leave, and looked upset.
"Fraulein Beulah. No, I do not think I am but I will be fine."
Beulah tried again. She thought she had an idea of what was wrong. Young people had tender egos about such things, sometimes, so she proceeded rather obliquely. "Did you just come from the lab?"
"Yes. I had permission to be there." His tone was both defensive and angry. He looked pale. "I was just checking the samples."
"An excellent idea. Did somebody say you couldn't be in the lab or look at the samples?"
"Not exactly."
"What did happen? Exactly." Beulah noticed that Kunz was getting red blotches in his face and clenching his fists. Something was really off here.
"I can handle it."
"I have no doubt of that but since I was the one who suggested the lab experiment, I feel a little responsible. Humor me, okay? What happened?"
"One of the nurses felt that I should not be in the lab."
Kunz jumped in. "She did far more than just tell him that he shouldn't be in the lab. She also felt that our presence was a waste of time and told him that in the rudest way. There is no excuse for such behavior."
Beulah was adding one and one and coming up with... Mara. She had a pretty good idea what Mara had been doing in the lab since she was the one who'd told Mara to have a pregnancy test. Beulah had seen lots and lots of pregnant women in her career and Mara definitely had the look. She'd like to be able to blame Mara's behavior on hormones but the hormones had probably just made her less subtle in her attack methods. "Let me guess. About this tall?" She help up her hand to around five feet and a bit. "Strawberry blonde, big blue eyes, tanned, looks harmless?"
At Georg's nod she gritted her teeth and said one word. "Mara." This certainly put her in an interesting position. Starr and Mara were sisters-in-law. She needed to go to Starr about the behavior of one of her staff. It was going be awkward for Starr but she would handle it. In the meantime, Beulah got damage control duty. Lovely. "Help me up please, Georg. We'll all get something from the cafeteria and then go to my office to talk. I'm upset at Mara, not at you. I just want a little privacy."
Georg and Kunz were largely silent after that except for an offer by Georg to carry her coffee mug. She hated being glad of that offer. The cold weather wasn't doing her joints any good and she'd had to cut back on the willow bark tea. The tea and stress was turning her stomach sour and she was starting to get bruises at the slightest touch. She'd been able to hide them with long-sleeved sweaters or shirts and since she almost never wore dresses, no one had noticed the bruises. Delayed blood clotting times were one of the side effects of the tea. So, less tea. Which didn't leave her much for the pain unless she wanted her mental state interfered with by some of Stoner's crops of marijuana or poppy. She couldn't afford that right now. A break in the tea would give her body a chance to recover. It would be weeks though before her clotting times were close to normal again. She was also trying more stress management techniques. So far so good. Except for the pain.
Beulah nodded toward the small table in her office. She used it for meetings sometimes or when she needed to spread her work out. She didn't want to be sitting behind the desk with Georg in front of it like an errant schoolboy. The walk had helped her calm down a little and given her some space to think. "Can you tell me what happened, please?"
By the time Georg had finished the description of what had just happened downstairs, Beulah was ready to do Mara a mischief in a dark alley. Kunz would probably help by holding Mara still for it. The description rang too true to some of the things she'd seen Mara do, but she'd never gone this far over the line before. She'd been tripping over little bits of poison strewn by Mara and a few others over the last month. This was the last straw. I don't care if it is her hormones, we do not need this kind of crap. Specifically, she didn't need to be doing more damage control right now. Now, how did she avoid undermining one of the few senior nurses they had but support Georg while one of the Jena faculty was watching and not looking at all friendly? She had no doubt that this would spread among the Jenaites at the speed only good gossip can obtain. Einstein should have made gossip an exception to the travel at the speed of light stuff.
"What do you intend to do about this woman?" demanded Kunz.
"I'll speak with Starr first. Mara is one of her staff. Second, I'll speak with Mara personally. I know I'm not the DON anymore but Georg is one of our students and that should give me a say in how this is handled. It won't happen again if I have anything to say about it. I'm really sorry Georg. If Mara had pulled anything like this in an up-time hospital, she'd have been out the door so fast she'd have left skid marks on the linoleum." Beulah sighed. "As it is, because we don't have enough staff, we can't do what I'd like which is fire her. Between Starr and me, we'll come up with something... suitable. One thing for sure. This won't happen again to you or any of the other students. If you or any of the other students get so much as one whiff of attitude from anyone, come right to me."
Just wait till I get my hands on little Miss Twit. Maybe I'd better watch some WWF reruns first.
Beulah peeked into Garnet's hospital room. Garnet was sitting up in bed, awake. Beulah didn't like the way she looked or was breathing at all. This is what happened when people pushed themselves this hard for so long. She'd just got the call after Kunz and Georg left her office. Garnet had just been admitted to the medical ward. She hadn't been able to get to see Garnet for another few hours, which was probably just as well. She had other things to take care of including meeting with Starr, finding the treat she'd brought and that didn't even touch what she had to get through before today had started going downhill. The meeting with Mara at the end of the shift today was just going to finish up a lousy day with a lousy mess. Garnet, however, didn't need to know or see any of that. She needed to get well.
"Come on in. I'm not contagious. It's just pneumonia."
"There isn't any just to pneumonia anymore and you know it." Beulah came in and set the small package she was carrying on Garnet's nightstand. Bringing flowers to someone with pneumonia was out so she had brought some of the lemon candy Garnet loved. It would help soothe her throat, too.
"I shouldn't even be in here. I can lie around in bed at home."
Beulah settled herself in a chair by Garnet's bed and said pleasantly. "You even try to get out of that bed and I'll personally put you in four-point leathers and abscond with the key."
"We don't have leather restraints here."
"There are plenty of people around here who could make up a set real quick. Besides, it'd do wonders for my reputation."
Garnet gave a choking laugh that started a coughing fit. Beulah helped her sit up and handed her a handkerchief. She poured Garnet a glass of water when the fit was over.
"Don't make me laugh, okay?"
"Sorry. I'll be sober as a judge. Promise. I'm just glad Stoner's got some more antibiotics on hand. I've seen your micro report. What we've got will cover you so you should be able to go home within a few days and be back at a limited work schedule in a few weeks."
"We've got classes going. I have to teach..."
"Class material that you aren't teaching will either be taught by someone else if we can find them, or not get taught till you're better. The students won't mind a break, especially before the holidays. We'll think of something, maybe more clinical time. They can always use more of that. You just concentrate on getting better, okay?"
"Okay. But I could probably..." She broke off at Beulah's frown and firm head shake. "I thought it was just the flu."
"That's been going around. I've been working with our outbreak tracking team all week. Looks like the flu is all it is and we've got it pretty well contained so far. I don't think we're looking at a major outbreak. Flu isn't anything to mess with, though. I'm going to be showing Kunz and some of the others how the tracking team works later and how we're responding to this. It should be a good small-scale object lesson." She switched the conversation briefly to the interest Georg and Kunz had shown in public health and then left after making sure Garnet had plenty of handkerchiefs and cold water. She didn't want to tire her out.
As she left, she was mentally trying to rearrange the teaching schedule. She needed to talk with Courtney or Marcia as soon as she could get in touch with them. There was going to have to be some shuffling but they'd work it out. The sooner Garnet had a definite solution, the sooner she'd be able to relax a little and focus on getting well again. Beulah would stop by again as soon as she had things worked out with the other teachers at the votech program. The EMT and LPN courses would be most affected. She'd have to contact Starr again today and talk about what that would do to staffing projections, especially with some of the staff being pulled as students at Jena in two months. Starr is going to start running when she sees me coming after today.
"Please come in and sit down, Mara." Beulah kept her voice even and pleasant with an effort. This was a professional conversation. She wasn't going to stoop to name calling, ranting or even incivility. Well, probably not.
"I wasn't exactly surprised to get a summons to your office at the end of the day. Don't you think using your authority to protect one of your pets is stretching it a bit? Especially since you aren't the DON anymore. Starr is."
Mara had evidently decided she didn't have much to lose and that there wasn't much Beulah could do about what had happened. Wrong move, Mara. The best defense isn't always a good offense. "I'm not talking to you as the DON. I'm talking to you as the dean of the Health Sciences School and the chair of the Health Education Committee. Of which, at the moment, you are a member." A brief pause to let that sink in; then, "I'm here to talk about your unprofessional behavior and the fallout from it. Mr. Holtz told me what you said to him in the lab this morning."
Mara crossed her arms over her chest and glared at Beulah. "And is what I said so wrong? Okay, calling them parasites went a little far but the truth is that they are parasites. They don't have what we need to do this and by the time they get it, we could have trained our own people to the level we need. We give; they take. That's parasitism."
"And how many of our own people could we train, Mara? How many of us are there available for health care? How many of us have any significant time to teach the math and science that we need taught or the"
"But they don't have what we need taught, so why do we want them teaching any of it? They don't understand the scientific method. They don't understand being skeptical and observing and testing what they see. For them, knowledge flows from the authority. They've just figured out that we're now the authority. You want that attitude passed on to students? And that doesn't even get into content. They don't know the basics of virtually anything."
"You're exaggerating. Just the experience of having to look at what has changed historically, how and why is already leading them to question their knowledge and how it was generated. They've made a lot of progress and we've got a plan in place to move them forward. The seeds of the scientific method are already present. Autopsies and other ways of observational learning are already going on and have been for a while. See one, do one, teach one has worked for a long time. We still use it in our time. They do have content we need and some of their knowledge is valid. They do have skills we need. Yes, some of what they know will have to be unlearned. Yes, they'll have to make changes in their world view. But they're smart and motivated and I think they can do it."
"In two more months?" sneered Mara. "Yeah, right. Meanwhile, we'll be splitting our resources and wasting our time on them. Just splitting the campus so that some of us are here and some in Jena is a waste of time and resources we don't have. You aren't the only one who knows what we're facing. I tried to tell you this months ago, but you wouldn't listen. If I said it, it had to be wrong, didn't it?"
Beulah took a firm grip on her slipping temper. "Have you ever heard the old saying about putting all your eggs in one basket? Right now, all our eggs are in Grantville's basket. What happens if we have one nasty epidemic wipe out most of our medical staff? You and I both know that in epidemics and plagues, the healer death rate is sky high. If we have some of our people and knowledge in Jena, they may be far enough away to have some of it survive. Not to mention that the time issue is really a wash. Yes, splitting the campus takes more time but it also means that we can have students, the students you don't think know anything, teaching basic anatomy lab and skills like how to dissect, how to suture. We don't have the people or the time to do everything that needs doing."
"Most of our people may lack those skills but they've still got more basic science knowledge and they've got the mentality, the world view that the Jenaites don't." Mara leaned forward, fists clenched on Beulah's desk. "Why won't you see that?"
"I do see it," Beulah returned angrily. "I just don't see it as an insurmountable barrier. These are smart people and they've very motivated. They can get it and they will."
"As fast as we need it? Have you thought about the fact that your little jaunt to Jena has already meant the word about our medical care is spreading even faster? Most people will think it's a fairy story and dismiss it but not everyone and not for long. We can't take care of our own people and now you're spreading this around. We've got more people coming in. What if one of us gets sick? They can't take care of us but we can take care of them. You can damn well bet that if my kids or husband are ill, I'm not going to want the medicine or care my family needs going to someone else. And I'm not the only one who feels this way."
"The only way to change that is to train more people and make more resources. Does that mean there will be a bottleneck, for a while? Yes. Does that mean that we're vulnerable right now and will be for a while? I know that better than you ever will. That means we have to look beyond ourselves for both teachers and students. There. Are. Not. Enough. Up-timers. Why won't you see that? Or is it just that you don't want to hear anything I have to say? You talk about content but do you know how to judge the potency of herbs from a particular place? And how to grow and collect and administer them safely and effectively? They do. They may not know all the whys and wherefores but together we can figure that part out. That's just one example. We can help each other and that's symbiosis not parasitism." Forget professionalism. She'd had enough of Mara and her attitude.
"So what are we supposed to do? All turn into little Jenaites? You've been in those meetings. They're still trying to hang onto the quadrivium and the trivium even when it doesn't make sense. We need people who can think and practice nursing and medicine. We don't need nurses and doctors who can debate how many angels dance on the head of a pin because they've had years of theology as part of their basic education. That's bull and you know it. But you won't call them on it. They're fighting for things that aren't what we need, things that don't matter. That doesn't sound to me like they're getting it at all. They have their definition of knowledge and what makes a university and it isn't anything like ours and never will be."
The truth of some of what she was saying stung Beulah. But she's skewing things, twisting them. How much of it does she really believe and how much is to fight me? Beulah suddenly felt exhausted. Rage had given her a temporary burst of energy but she couldn't sustain it. "They're trying to hang onto what they, and others here, believe a university education to be. It's difficult but we're working it out." Even to Beulah's ears, that sounded pretty lame. She was getting so mad that she couldn't think too clearly. This meeting had gone way far afield. Maybe Mara's strategy hadn't been so off target after all. "Debating what is going on with Jena isn't the reason you're here. I'm relieving you of your position on the education committee. Unless I see changes in your behavior, you won't act as preceptor for any students, whether from here or from Jena. Starr will talk with you about your behavior as a staff nurse tomorrow. Dismissed."
After Mara left, Beulah stood shaking in her office. She hadn't been this mad in a long time. Or this scared. Mara's comments went round and round in her head. They argued for a very different course of action. But there were other voices, too. The voices of the dead and of those who would die if they didn't succeed. She had worked in poor areas of West Virginia. She had a pretty realistic idea of what could happen if they didn't get modern public health and other methods in place. The specter of epidemic was real but not as visible as the other threat, war. She'd seen so many die in Korea. Now, war was taking children from her town, people she knew. And it was going to get worse, not better. At least for a time.
No. They'd chosen the best path. None of the choices were without risk. Certainly none were ideal. Mara was just being spiteful. Even as she tried to rationalize it, Beulah knew she couldn't just dismiss all that Mara had said.
The pain hit suddenly. Something with lots of dull teeth was trying to gnaw through her stomach from front to back. A cold sweat broke out on her skin as she lurched for the bathroom just down the hall. A few very unpleasant minutes later, she looked down into the toilet bowl. Blood.
There wasn't that much really. Probably only a few ounces. And it didn't look that bright a red. If the bleed was arterial, she'd be in a world of trouble already. She got shakily to her feet after flushing the toilet, thankful that most people were gone from the second floor for the day. The blood wasn't a big surprise, given her symptoms. After washing her face and rinsing her mouth, she wobbled down the hall to her office, sank down into a chair and reviewed the 1633 available options for a bleeding ulcer.
She'd already changed her diet although she'd have to add more greens and liver to up her iron intake and correct for the blood loss. She could start a baking soda slurry to help reduce the acid. Not too much, she didn't need metabolic alkalosis on top of everything else. Instead of cutting the willow bark dosage, she'd have to stop it entirely. She didn't have anything else for the pain. She wasn't going to try to deal with these problems stoned. She'd just have to tough it out.
They didn't have the equipment to do a scope and see what was down there and then cauterize any bleeders. Surgery for something that might not be so bad, just to see what was there, was too risky in this time. If it came to that, the surgery would be both exploratory and repair work. There wasn't time for surgery. Things were at a crucial juncture with the Jena project. They were already behind where they needed to be and events like this morning didn't help.
She'd have to hide this from Mary Pat, which wouldn't be that hard as busy as they both were. She could tell her that she had had her tea before Mary Pat left on her run each morning. There would even be a hot tea kettle there. Getting the variety of calendula and licorice she needed wouldn't be hard. Ray wouldn't ask what she needed it for. He'd just assume she was helping out with a patient or working with the Jena students. The calendula would help with the bleeding as well as the healing. She could possibly use some sucralfate but that was expensive and time-consuming to make. They didn't have much in stock and she couldn't get that without rousing some suspicions. If she had to, she'd get some but that would mean going to James. She'd set a little more time aside for the stress reduction exercises. Just a few minutes here and there could make a difference. The exercises would also help with the pain.
There were options. She'd take them. There wasn't any point in adding to anyone else's worry, especially Mary Pat so soon after the death of Hans and Larry. There really wasn't anything else anyone could do, either. She'd make the changes, take the meds and monitor her condition. If things got much worse, she'd talk to James.
The stress didn't abate over the next two weeks. If anything, it was getting worse. The meetings with the Jenaites weren't going as well as Beulah had hoped. Mara's words came back to nibble at her more often than she'd have liked. Garnet was back on light duty starting today. If Garnet had gotten ill just a week earlier, there wouldn't have been any antibiotics to treat her pneumonia. They'd sent them all to the siege areas. She might have survived the pneumonia but the odds were much worse without antibiotics. Garnet wasn't just a colleague. She was a friend. She knew her so well. Garnet the gun nut who loved to debate for hours on caliber and range and anything else gun or hunting related. Garnet who was positively phobic when it came to spiders and who loved the color yellow. They'd already lost so many people they couldn't treat. Beulah firmly believed in the moral stand they were taking and the pragmatic logic that also went with it. But there were consequences. Always consequences.
They were still arguing with the Jena faculty about things like astronomy, for Pete's sake. Great, you've got an observatory. We're happy for you. What does being able to find Venus have to do with diagnosing and treating a patient? Beulah's patience wasn't endless and they were running out of time. It wasn't just the January start date she was thinking about. It was almost Thanksgiving. The Jenaites would be leaving the first part of December and they still hadn't been able to iron out some basics in the curriculum. Every time she thought they'd gotten ahead there was another stumbling block. She also wanted to get some more knowledge squeezed out of them. Just yesterday, Werner came up with a botanical treatment none of them had heard of for a patient that they'd been trying to treat without success for weeks.
She was able to hide the bleeding for those two weeks, even from Mary Pat although she was beginning to watch Beulah pretty closely. At first, the measures Beulah tried seemed to be helping enough. The bleeding stopped for a while but the pain was worsening over the last few days. She was debating whether or not to see James in the morning when the decision was taken out of her hands that night.
"Beulah?" Mary Pat shrugged out of her coat and shook the rain drops off as she stood by the front door. She put the coat onto the coat rack and headed for the kitchen. Dinner preparations were partway made and the light was on, but no Beulah. Mary Pat had stepped out of the kitchen and headed down the short hall to the stairs when she heard the sound of vomiting. The flu was going around but it was more respiratory this year than GI.
She quickly headed up the stairs and opened the door, calling Beulah's name. What she saw wasn't what she expected. She had caught a whiff of the blood as she approached the door but it hadn't had time to register. Beulah had almost made it to the toilet before she was sick. Despite all Mary Pat's experience, the sight of Beulah half lying amid reddish black blood, deathly pale and shaking hit her hard. For a heartbeat, then another, she couldn't move, couldn't think. Then training kicked in and her nursing skills came flooding back. She touched Beulah gently on the shoulder, then the neck, doing an at a glance assessment. The feebleness of her pulse, her pallor and the moisture on her skin worried Mary Pat. Beulah was going into shock.
"I'm here. I'm going to call an ambulance and be right back." She didn't remember later whether her feet even touched the steps on the way down the stairs. The phone was in her hand and she cursed under her breath. Why couldn't Beulah have a touch-tone phone instead of the slow black rotary phone? The second it took after dialing 9 in 911 would have been all the time she needed to punch in 911.
"EMS, Walter Allen. What is the nature of your emergency?"
"Walt, it's Mary Pat. I just got home and Beulah's throwing up a lot of blood." She gave him a concise assessment, not that there'd been time to gather more information. She didn't hear anything from upstairs. Had Beulah passed out?
"Chester and I are on our way. Be there in a few minutes. I'll notify the ER staff on the way. They'll gear up for her."
Mary Pat was relieved that Walt and Chester were on duty. Both were experienced EMTs in their fifties. "I'll have the door open for you." She hung up and rushed back up the stairs, praying all the way. Please, please God, help her. And, more selfishly, don't take her from me yet.
James sat on the edge of her hospital bed and glared at her. "Don't think we aren't going to have a long talk about you hiding this the last few weeks just as soon as you're up to it."
"Mary Pat..."
"I'll see she's taken care of. Right now she looks like hell. I'm going to send her home with something to help her sleep."
"She won't take it."
"Then I'll come up with another plan. You're going to rest if I have to hogtie you to that bed. I heard about you threatening Garnet with leathers. I'll have a pair made up for you."
"Haven't worn leather in years. Don't have the body for it anymore." As comebacks went, it was a little weak, but James' lips twitched just a little. She couldn't be that bad if she could still come up with a joke.
"We'll see about that. You can bet that everyone who walks into this room is going to be on your case if you overdo. And we all know you well enough to watch you like a hawk. In the meantime, I'm giving you four mg of morphine. It'll help with the pain and let you get some sleep."
He stayed with her for a few minutes waiting for the medicine to take effect and then got up. He had an idea of how to handle this before he faced the crowd outside. And he had no doubt there would be a crowd, even this late.
Mary Pat was at the desk talking with the nurse who'd be caring for Beulah tonight. James' gaze lit on Fritz and he relaxed a little. "Fritz, come over here a minute."
A very concerned Fritz walked out of the group of others hovering near the door. Hospital staff and EMTs, off duty or not, a couple of Jenaites even. Word had spread fast even though it was after ten at night. Garnet was there too. He'd have to see she got back to bed as well. Dammit, didn't anybody know how to get some rest around here?
"I'd like you to special Beulah tonight. It'll let Mary Pat get some rest and her bearings. Then she can help me deal with Beulah tomorrow. Can you do it?"
"Of course. I was planning to study for another few hours anyway. Now that Fraulein Garnet is back, we are catching up on our studies for the LPN courses. I was off tomorrow anyway. Just let me get my books." As Mary Pat approached, the crowd moved in a little closer. Fritz patted her on the shoulder a little awkwardly before moving off. "She's going to be well soon. She is very strong and we'll take good care of her."
"How is she?" asked Mary Pat anxiously.
"Sleeping. I gave her some MS for the pain. I've got a couple of patients I'm keeping a close eye on, so I'll stay here tonight. Fritz was going to be up studying anyway, so I've asked him to sit with her." Anticipating her protest, James continued firmly, "I'd like you to go home and get some sleep tonight, Mary Pat. You get some rest so you can help me sit on her tomorrow."
"I'd rather stay. Not that I don't appreciate Fritz being willing to stay."
"I just gave her four of morphine. She's out like a light. She needs the rest and so do you. When she wakes up tomorrow morning, we're going to have a stubborn patient on our hands." James looked past her to see Hayes coming down the hall with Gary and a stack of papers. Hayes lived not that far from Beulah and Mary Pat. "Hi Gary, Hayes. Hayes, could I ask a favor? If you're leaving, could you walk Mary Pat home? We just admitted Beulah and Mary Pat's a little shaky."
"Wait a minute. I haven't even said I'm leaving. Besides, Hayes, I don't want to bother you."
"No bother. Beulah going to be okay?"
"Bleeding ulcer." Mary Pat steadied her voice with an obvious effort. "If she gets some rest and with treatment she should be okay. James is hoping not to have to operate. She's getting blood and pain meds and she's stable right now. I found her when I got home."
"We'll call you if anything changes with her. I promise. Please get some rest. You know she's going to want to get out of that bed tomorrow and take on the world again."
"I'll be glad to walk you home," said Hayes. "Sorry to hear about Beulah. I'll come in for a visit tomorrow if she's up to it." He nodded to James. "Please tell her I told her to get some rest and hope she gets better soon. Let's go, Mary Pat. I'll see you tomorrow, Gary. Night everybody."
His tone may have been a little abrupt but he looked at Mary Pat with concern and crooked an elbow in an old fashioned gesture that brought a brief, wan smile to her face. "How about I make you something to eat? I'm a great cook and I need to eat anyway."
An hour later, Mary Pat was sitting on the couch in the 1633 equivalent of comfy sweats. The scent of old blood still lingered and it was too cold out to open up the house to air it out. She shivered anyway. Beulah's blood. She'd cleaned up the mess in the bathroom and was now staring at the phone. It was stupid to be staring at an inanimate object this way. She'd kept finding excuses to come stare at it while she was cleaning. And changing her clothes, too. Which was also stupid. It wasn't like she could will Beulah to get better and the phone not to ring. Hayes' knock on the door came as a relief.
"Hi. Look, I really appreciate you going to so much trouble."
"No trouble. Always nicer to eat with company, especially yours. Where do you want me to set it down? Hope you like pasta. I've got a standing arrangement with Senior Nasi to have some of the special flour I need and good olive oil brought up with the coffee. Took some doing but it's worth it to have the right ingredients. And pasta dough doesn't take long to whip up. I put up some really great sauce before we went to Jena this summer. I can't wait til we get some tomatoes going but a white sauce will do for now. I've made up the tortellinis so if we can get some water boiling, we'll be ready in a few minutes. There's salad, dressing and bread and some wine to go with it."
"This way to the kitchen, master chef. That sounds perfect and very impressive. Especially the wine. A glass of that would be very welcome right now."
Dinner and the clean up afterward were surprisingly pleasant. The phone didn't ring and Hayes kindly didn't say anything about how many times she stared at it. He just kept up a light conversation to help distract her. Partway through the second glass of wine, sometime before 1:00 A.M., she fell asleep curled up in a corner of the couch. She didn't stir when Hayes covered her with the brightly colored crocheted afghan from the back of the couch, then opened the work he'd brought with him. He'd be there for her. Just in case the phone did ring.
It was a conspiracy and they were all in on it. Two days after she'd been admitted, Beulah was convinced of it. The old saying about even paranoids having enemies had a corollary. Your friends can make you paranoid in the first place. It wasn't that she didn't appreciate the attention. She was touched. Really.
"But if I don't get out of this room soon, Mary Pat, I'm going to scream."
"You've been out of this room. Hanna caught you trying to sneak up to your office last night. At this rate, we're going to have to post guards outside your door to keep you in this room. I know a couple of Marines who'd love to volunteer."
"I just wanted to look at a little paperwork."
Mary Pat grinned. "Now I know it's bad. You're eager to do paperwork. And you're still not getting out of this room. I know all the arguments about what you have to do and how much you have to get done. That still won't get you out of here any faster. The only thing that is going to get you out of here is no more signs of bleeding and no more pain. That won't be for a few days. Deal with it."
She reached into her satchel and pulled out a stack of letters. "These are from home over the last few days. I'm not letting you at anything official that comes into the hospital. I'll be back later tonight. Hayes is bringing over something special for you for supper. He's been consulting medical books and me about what you can have to eat."
"Anything is better than just sitting here. And I'll be sure and tell Hayes thanks when he brings supper. One of the great mysteries of the universe is how otherwise normal food becomes the dreaded Hospital Food the moment it clears the hospital doors. The phenomena wouldn't dare affect anything Hayes fixes."
Much as she hated to admit they were right, having some time to rest and think was precious. She really needed it. She'd had a couple of days to do nothing but think about the current situation with Jena and the need for more modern medical education. The ideas simmering in her brain would mean changing their approach pretty radically.
If Mary Pat had known what was in those letters, she'd have kept them away from Beulah at all costs. She probably thought they were ordinary correspondence since they came to the house. There were two letters that concerned Beulah. The first letter was from a man named Johannes Schultes or Scultetus in the Latinate version of his name. She knew about him actually because of his work in obstetrics. The Scultetus bandage was still in use. His publications were famous and sometimes infamous, as was the case for his book illustrating a Caesarean section surgery, then rarely performed. He was writing to her from Ulm.
She'd had some letters from physicians, mainly over the last year or so. Usually they were asking for specific advice and often wanted to correspond with James or one of the other doctors rather than with her. A few had been willing and able to come to Grantville but they hadn't been willing to do what Balthazar or the Jena faculty had done, learn or relearn what they thought they already knew. This letter was different. Schultes was brilliant, comparatively local and his letter reeked of Desperately Want to Learn, Ego Checked at City Limits. She'd hoped that they'd have the courses at least sketched out before outside physicians started coming to them. By now, she shouldn't be surprised that as usual, they were a step behind the need. It had been that way ever since the Ring of Fire.
Looking at the second letter, she thought, make that a step behind in multiple directions. The letter from Debbie Leek contained a not so simple request. Magdeburg was growing at an incredible rate. There was a great need for a more modern medical system. Debbie wanted to be sure that the hospital that they wanted to add had the ability to use or add on up-timer medical technology. That made perfect sense to Beulah. Part of the letter was asking questions about which technology could be incorporated into the new hospital now and which would have to wait another five to ten years for their tech base to get to that point. Beulah could ask some of the people here and have them pull the information together for Debbie.
The second part of the letter was about the need for trained personnel to work in the hospital. Which would be built in the next eighteen months or so. The first part was easy enough to answer. The second, far more problematic. Quite understandably, the Jenaites were already making polite noises about upgrading their facilities in Jena. It would benefit them and the students. Which was true. So they'd need even more staff. There had to be a better way of doing this project.
Beulah swung her feet over the side of the bed and used the rail to help pull herself up. She was still pretty woozy even with all the blood and IV fluids she'd been given. She still had an IV line but was otherwise unencumbered. Poking around in the bedside stand yielded not a scrap of paper or even the stub of a pencil. Mary Pat had been thorough but Beulah wasn't ready to give up yet. It was an hour before the aides would be bringing lunch trays. Most of the staff would be busy in patient rooms right about now. If she could just sneak out to the nurses' station, she could find pen and paper and get started on the list for Debbie. She had another idea, too. The fight with Mara may have had something good come out of it. They weren't just putting all their personnel eggs in one basket, they had all their tech eggs in one basket as well. Leahy. Maybe it was time to change that, although that could lead to one heck of a wrangle. She'd have to think a lot about that and sound out a few people before she brought it up.
She stuffed her feet into her slippers and slid quietly out of bed. There was no dignity in these hospital gowns, or in a woman her age skulking about. But if they caught her, she'd be back in bed with nothing to do but count ceiling tiles. At least the IV pole rolled well. The hospital's floors didn't have carpeting.
She'd made it a few feet past her door when she heard the sound of a fretting child coming from a few doors down. Kid sounded congested. From crying or something else? She changed direction and headed down the hall toward the sound. She almost made it.
"Ahem."
Beulah wasn't sure if the polite throat clearing was from Dean Johann Gerhardt or from Dean Werner Rolfinck. Judging by the folded arms and the frown on Werner's face, it had probably been Johann. Either way, she was busted. Again.
"I'm going to have to sign up for some special ops training in order to learn proper sneaking technique. I was just going for a little walk when I heard the crying."
"I'll check on the child. Johann, if you'd escort the Professorin back to her room, please?"
"Thanks, both of you. By way of the nurses' station if you don't mind. I was just thinking about you two and needed some pen and paper to jot a few things down."
"I'll get the pen and paper after I see you to your room." Johann gestured courteously but firmly toward her room.
"Beulah, you have got to be nuts!" Mary Pat snapped, hands gripping the arms of the kitchen chair she'd brought into Beulah's living room for this informal meeting.
Beulah looked from Mary Pat to James. He and Johann were in the room's two arm chairs. Werner shared the worn floral pattern couch with her. Mary Pat wasn't through holding forth on Beulah's temporary insanity by a long shot.
"You just got out of hospital a few days ago. Now you want to move to Jena?" Her attention was caught as James stood up and retrieved a leather wallet from his back pocket. He pulled a yankee dollar from it and handed it across to Beulah. "What's going on?"
"I do so admire a man who pays his gambling debts promptly." Beulah graciously acknowledged James before turning back to a confused Mary Pat. "James bet you would wait to hear what I had to say before you freaked about me going to Jena."
Werner chuckled. "And what would he have won if she hadn't, ah, freaked?"
"My Top Secret Family Christmas Ham recipe."
"You must have been sure I'd freak if you were willing to bet that. Okay, you two have gotten my attention. Unveil the great plan." Mary Pat sat back in her chair.
"I've spent the last week with nothing to do really but think. I've thought about what we're trying to do and the things that have happened in the last six months. It was pretty clear that we were going to have to make some changes in our plans. I'm not proposing going to Jena for another few weeks. I really can use the rest and it will give me time to figure out what I want to take with me."
Johann nodded. "It would also give me time to catch up with my students in Jena and for Werner and the others to catch up with their patients."
"Yes and no," Beulah replied. "I'd like Phillip and half the students to remain here in Grantville. Or maybe go back to Jena for a few weeks and then be here the first of the year. I don't know what other plans they have. Phillip, Ernst, and Heinrich are working on trauma and surgery. Mary Pat, you're our trauma and military medical expert. You're the one who can best prepare them for that. They can even accompany you on deployments to see battlefield conditions and our MASH system if you can get clearance for it. They can also keep learning more surgical techniques from James. Phillip and all the students here can have intensive clinicals and class time for, say, three months."
"And the rest of us?" Werner asked.
"You, Willi, Kunz and I will start work on the curriculum in Jena. I can also do more teaching of public health content to those like Kunz and Georg who are interested. We can still have Grand Rounds in the clinic in Jena. We can also coordinate with the other deans and faculty about some of the courses we'll need from them."
"I still don't like the idea of you being the one to go. If you had any problems, you'd be pretty far from Leahy." Mary Pat looked uneasy but Beulah could tell she was thinking now, not just reacting protectively.
"That's part of the reason I'm not proposing leaving right away. I'll be here for several weeks and I'll rest up." Seeing the varying degrees of open skepticism on the faces off the other four, she decided to change the topic. "I know it isn't what we'd planned but if we delay opening the revised programs, I think the downside is offset by a couple of things. For one, we all get some of the pressure taken off. We also get more time to prepare and we'll be more ready if we have the curriculum set up and the faculty and med students have a chance to get more up to speed."
"If we switch the students and faculty between here and Jena say, the end of March, that would give us the summer to polish up the curriculum." Werner said thoughtfully.
"We should be able to take in more students than we'd originally planned." Beulah said. "That should help offset the delay. I'm also concerned that right now, all of our medical personnel are pretty much here in Grantville. Granted, we have a few elsewhere but not many."
James followed her train of thought immediately. "We aren't at risk of too many battles in the near future here in Grantville but if there is an epidemic, we could be in trouble."
There was silence except for the crackling of the fire for a few moments while everyone thought about the implications of the changes she was proposing. Beulah looked contentedly at the fire. She loved a nice fire on a cold, snowy day like today.
"There's another thing I've been thinking about. We have a very diverse student body, to use the up-time phrase." Beulah took a sip of her coffee, savoring the taste. Although it was very weak, this was the first cup they'd let her have. All her protestations that coffee could be considered a clear liquid too had gotten her precisely nowhere in the hospital. "Let me give you a couple of examples. Fritz is literate and by the time the classes start, he'll have completed the LPN training and have a little experience at that level. His formal education before coming to Grantville was fairly minimal though because his family needed him in the bakery."
"Ah. The reverse will be an issue as well for the up-timers," Johann chimed in. "While they have stronger math and science backgrounds than any of us, they will need preparation for our type of university education."
Mary Pat nodded. "We've also got a wide array of experience and education for those who'll be going into the MD and RN programs, not just the fact that some will be up-timers and some down-timers."
Werner nodded as well. "For the medical students and faculty, most of us will need fairly standardized content. We all need to know similar basics. For the incoming students it will be different. If we can get them better prepared now, on, what is the phrase, a more even playing field, then things should go more smoothly and the students will be better able to learn."
"I think this is the best idea I've had in a long time. This will solve a lot of problems. Granted, it isn't what we'd originally planned but this way, we'll be able to enroll a lot more students in the fall and be able to teach them better too."
"Here, let me get that." Mary Pat took the sweater from Beulah's hands and folded it herself. "Are you sure this is a good idea? You've only been out of the hospital for a month now. Why don't you sit down a minute?"
Beulah obediently sat on the edge of her bed. Mary Pat was still not too sure about Beulah moving to Jena for months on end away from Leahy and James' eagle eye. And hers, of course. If sitting on the bed for a few minutes and letting her help pack eased her mind a bit, Beulah was willing to let her do it.
Mary Pat made one final, rather weak attempt. "I still don't think you should be the one to go. I could go instead. Or maybe Balthazar could go. It's slow season for spies, isn't it?"
"Actually, I think it's heavy duty plotting season for spies. I'll be counting on you, Balthazar, Starr and James to get the ones staying here ready, including your three trauma junkies."
Mary Pat reached into Beulah's closet for another sweater to fold and pack. The bright yellow thing was a going away gift from Garnet. Beulah had no idea where she'd found thread dyed that vivid a shade to knit the sweater and matching mittens. Much less the time.
"I have to admit, I was pretty surprise by Dean Gerhardt's idea about the high school classes. I wouldn't have thought they'd have gone for something like that," Mary Pat said.
It had been Johann's suggestion that selected faculty and students from the other schools plus half the med school students and Phillip take the basic science and math classes at the high school with the high school students. Beulah hadn't been too sure about shifting their problem onto the already busy high school teachers but they'd kept it down enough that there were only three or four more students in each class. Some of them were taking junior high classes too. They were still hitting the books at night in some adult education style classes. Between that and the clinical time, there was barely time for the Jenaites to sleep but it didn't seem to faze them a bit.
They'd figured out who would be enrolled for MD or RN school in the fall and were designing specific plans for each of them to help them prepare. All the texts were going to be translated into English or German. Skipping the Latin had been a compromise for the Jenaites. In exchange, the students would be getting enough astronomy to squeak through any discussion with outsiders but most of the physics would be health related.
"Johann's a very practical sort. I'm looking forward to staying with him and his family in Jena."
"I'd rather you were staying with Werner, Willi or Kunz."
"So they can keep a better eye on me? Don't worry. I'd imagine there isn't anyone in Jena by now who doesn't have Watch Beulah duty. I probably won't even be able to lift a textbook off a shelf by myself." Beulah carefully didn't share her suspicion that Johann might have an ulterior motive for having her stay with them. After all, it had also been Johann who had suggested that Gary Lambert come show them all how to set up a medical records system for the clinic and model public health department. Johann had taken a strong liking to Gary. The fact that he had an unattached daughter about Gary's age had nothing to do with it. Yeah right.
"I'll be seeing Werner, Kunz and Willi almost every day while we work on the curricula and the public health project. I have no doubt that between the three of them and the students, they'll hover just as much as even you could want."
The public health project had come out of her discussions with Werner, Kunz, Georg and Balthazar. They were going to have people from Magdeburg and other towns come as well to see them set up a more modern public health system in Jena. Jena would be the model for other places in the USE, which pleased the Jenaites enormously. In addition to helping disseminate infection control and sanitation methods, it would be teaching the students. She'd spoken to the mayor of Jena last week. He was thrilled with the idea. It was going a long way to repair some of the damage done by the last visit. He was also happy to be getting most of the town's medical community back at last. The town should be seeing an influx of more university students soon, which didn't hurt a bit either. Jena's economic picture was continuing to improve and the mayor and town fathers were happy campers again.
"I'd like you to do a couple of other things while I'm gone." At Mary Pat's curious look and nod, she went on. "Keep an eye of Fritz for me. He loves what he's doing and is too apt to study and work without sleeping or eating. With all the pressure he's feeling as the first member of his family to go to university and being one of the down-timers admitted to the RN program, he may go a little overboard."
"Ah. In other words, make sure he doesn't follow in his role model's footsteps and wind up collapsed and rushed to the hospital."
"You're never going to let me live that down, are you? But, yes, that's basically it. Also, I want you to keep an eye on Hayes. I've asked him to drop by with the occasional meal using the excuse that I don't want you to be lonely with me gone."
"You're worried about him, too."
"He isn't looking too good. I hate to go behind his back like this but if he thinks he's helping you out, he may actually slow down a bit and take better care of himself."
"Gotcha. It certainly won't be hard to put up with the man's cooking. He's got a real gift there. I'll be happy to look out for both of them for you."
The sad part, Beulah thought, was that she didn't feel one bit guilty for playing matchmaker. Mary Pat needed a nice, reliable, smart guy. Hayes fit the bill beautifully. Besides, Mary Pat was, at best, a mediocre cook. At least they wouldn't starve if they got together.
"There's still a lot to do to get ready for fall, but I think we're going to be able, not just to pull something together, but to do it really well. I think that's everything I need. Let's get these bags downstairs. I can't wait to get started." A recharged Beulah reached for the smallest bag, already wondering what she'd find in Jena this time.