Standard of Care

By Eugene Uphoff

When Dr. Sam Wyler attends the delivery of a stillborn boy one month after his wife has died in an icy auto accident, he questions his competence to provide care in his distressed state. The subsequent malpractice suit filed against him only deepens his depression. In a story that intertwines the complex lives of his sister and children and his romantic involvement with a drug detail rep, it relentlessly drives toward the final courtroom scene. It exposes the worlds of malpractice litigation and molecular research, ultimately revealing a chain of secrets that vindicate his judgement.

• Language: English
• Publisher: Eugene Uphoff
• Release date: Dec 12, 2019
• ISBN: 9781393519881

Eugene Uphoff

A family physician with 20 years of consulting on medical malpractice claims, Dr. Uphoff draws from multiple real life cases to create an engrossing drama.

Book preview

CHAPTER 1

HE HAD REASON TO SLEEP poorly.  When the call came, the phone beside his bed on the nightstand rang barely once before his hand grabbed it from the cradle.

Dr. Wyler? the voice asked.  This is Louise, at Sacred Heart Labor and Delivery.  We have a patient of Dr. Kehoe’s here ... Mrs. Washington.  She’s a 34 year old primigravida having contractions every 3 to 4 minutes since 3:30 yesterday afternoon.

The glowing numbers of his clock radio said 1:18 am.  He’d been asleep about an hour since the last call through the answering service from a woman whose 14-month-old son was throwing up.

She’s got here about 10:30 and is now 4 to 5 centimeters dilated.  She’s getting more uncomfortable and wants to know if she can have an epidural block, the nurse said.

Sam Wyler knew Louise pretty well.  She was one of Sacred Heart’s more liberal nurses who had championed the cause of natural childbirth. Her labor and delivery classes had earned Sacred Heart Hospital its reputation as one of the most progressive maternity units in Denver.

How does the baby look? Sam asked.

Baby’s baseline heart rate is between 145 and 150 with fairly good variability and occasional accelerations.  The monitor pattern’s a little hard to track at times with the external doppler, but I’d say it looks pretty good.

Does she have any special requests other than the epidural?

I went over her birth plan when I came on shift at eleven.  She didn’t want a shave or enema and she only wants the fetal monitor on intermittantly.  She also asked that we limit vaginal exams to every two hours unless she feels like pushing.  She initially refused an IV but she understands that she’ll need to have one if she’s going to get an epidural.

That sounds all right... Who’s covering for anesthesia tonight?

Dr. Banyas.

Well, I think it’s fine to go ahead with the epidural as long as she understands it could slow down her labor.  We might end up needing pitocin if her labor pattern doesn’t stay active...  Keep me posted on her progress, okay?

You bet, Sam.

He felt vaguely uneasy about the call.  He was used to covering the deliveries for other docs in his practice.  Regardless of his own preferences, Sam honored delivery plans that patients worked out with his partners.  Although most of them came in for deliveries on their own patients, it was considered discretionary and they didn’t fault each other for opting not to.  Dr. Kehoe was one who did so about half the time, so there was no way to predict how he’d feel about having Sam deliver his patient.  An obstetrician by training, Kehoe had voiced some reservations about having family physicians deliver his patients when he first joined the medical group three years earlier.  But his misgivings gave way to acquiescence as he began to appreciate the freedom it gave him to pass his more troublesome patients on to other doctors in the clinic.  Was this one of them?

Louise’s mention of Dr. Banyas also left him unsettled. Banyas, who disliked obstetric anesthesia, made no attempt to conceal that aversion.  His primary interest lay in neurosurgical cases and viewed OB patients as generally hysterical.  That attitude was often transparent to patients he attended on labor and delivery.  Requests for a back-up anesthesiologist had occurred when a more sensitive mind was needed.

Sam was pretty sure Louise could smooth the feelings if things got tense during the delivery.  Even so, sleep returned slowly.

The next call came at 3:35.

She’s nine centimeters and feeling pushy, Louise announced,  and the baby’s baseline has flattened out at 155.  Her temp and blood pressure are up a little also.  I think you’d better come in.

That was fast, thought Sam.  It was unusual for the cervix to dilate much faster than a centimeter an hour in a primigravida, and such first deliveries were even slower at the age of thirty-four.  The epidural must have really relaxed her.

He pushed back the comforter and switched on the bedside lamp.  His eyes rested momentarily on the empty half of the bed.  He still hadn’t gotten used to the void left by Elyse’s death.  Answering the phone at night, his voice was so quiet his answering service often asked him to repeat himself.  It was his habit, begun to avoid waking her, to speak softly for nighttime calls.  Now, in the middle of the night, without her sharing the bed, there was no need to lower his voice but he did so anyway, a fact that struck him with painful irony.

Sam hung his pajamas on the closet hook and took clean underwear from his dresser.  If the delivery was delayed, he might not have time to get home again before going to the office in the morning.  Better to have a clean change of clothes to start.

He dressed rapidly, loosely knotting a tie under his collar and tying his shoes from the edge of the bed.  In the bathroom he turned on the light to check his appearance in the mirror.  Since his first contact would come amidst of the stresses of labor, he wanted to present a  reasonably professional appearance to the Washingtons. His facial stubble didn’t look too disreputable but he recognized a tiredness in his eyes that spoke more to last month’s tragedy than the interruption of this night’s sleep.  With a glance down the hall toward the children’s rooms, he descended the stairs, pulled his overcoat from the closet, and opened the back door.

The sidewalk was dry.  There hadn’t been fresh snow for a week.  Although the February sun had warmed the streets enough during the day to thaw snow from the pavement, there was still plenty to be seen on the lawns and parkings.  On his way down Colorado Boulevard he managed to get through the traffic light and turned onto East 17th Avenue.  The trip to the hospital was so familiar he could drive it half asleep.  His best time from home was eight minutes but in heavy traffic it could easily take twice as long.  Driving into the parking lot, he pulled the wallet from his back pocket and rolled down the window, presenting the card key to the control gate.  The red and white striped barricade lifted and he took a space near the doctor’s entrance.  At least there was no contention for parking spots at this time of night.

Sam hurried to the stairs near the elevator and took them, two at a time, to the second floor.  He pushed open the double doors at the entrance to Labor and Delivery.  Which room is Mrs. Washington in? he asked, throwing his coat over the back of a chair.

The nurse at the desk looked up from a crossword puzzle.  She’s in G-6.  She’s complete.  Louise is in with her.  The family got upset with Dr. Banyas.  He had a hard time getting the block in and yelled at her for moving when she had a contraction.

As he pushed open the door to G-6, Sam sensed that he was invading a very private event.  A heavy-set woman was laboring on the birthing bed.  An older man he took to be her husband and another couple stood beside her.  He looked at Louise.  Do I have time to put on a scrub suit?

Sure you do.  She’s pushing well right now for having a block but there’s still a ways for the baby to come down.

I’m Sam Wyler, he said to Mrs. Washington.  I’m one of Dr. Kehoe’s partners.  I understand this has been pretty difficult for you.

The woman blew out her breath, took another and pushed for a few seconds, then exhaled explosively.  Her husband spoke as if interpreting for her.  She’s really tired just now and not up to conversation.  Can you give us some idea how long this could take?

It depends on how easily the baby descends through the birth canal.  I understand the cervix is complete.  I’ll go change into my scrubs and be right back to check.

Would you mind looking at this tracing before you do?  Louise said, pulling a pleated stack of monitor strips from the stand.

Sam took the tracings from her and began to scan methodically through the pages from the most recent backwards.  The last pages were hard to read.  The external monitor didn’t always pick up the baby’s heartbeat.  He suspected either the baby changed position or perhaps it was because of the mother’s obesity.  In any case, it left something to be desired.  It wasn’t really worrisome, but it didn’t say much about how the baby was doing either.  As he flipped back through the pages the pattern looked better and the tracing was more consistent.  The baseline heart rate had gone up over the course of several hours but there were no decelerations that looked ominous.  It wasn’t really possible to read variability due to the intermittent nature of the recording.  He turned to the patient.

I’m not sure we can say much about what your baby thinks of these contractions.  Louise told me that you hoped for a more natural birth.  Do you have feelings about using an internal electrode to monitor the baby’s heart rate?

I’d rather not screw that thing into my baby’s head if you don’t mind.  Is it really necessary?

Martha Washington had received enough relief with the epidural that, having been relieved of her discomfort, she had regained her confidence and assertiveness.  She also seemed to harbor some residual anger from her experience with the epidural block and added, Have you ever been in labor, Doctor?

Personally, no.  But I’ve attended enough births to be sympathetic.  Redirecting the conversation, he said, Let’s see if we can pick up your baby well enough with the doppler for the next few minutes while I change into my scrubs and we’ll figure out what makes the most sense to do.

Louise followed him out the door of the birthing room and halfway down the hall whispered You know me well enough, Sam, to know that I’m pretty flexible when it comes to delivery plans, but I just haven’t been able to connect with these folks.  Their birth plan isn’t all that weird or anything but she’s had a chip on her shoulder since she came in on evening shift.  The only thing I got in report from Sharon, who took care of her initially, is that she wanted Dr. Kehoe to do her delivery.  But he went up skiing this weekend and said he’d induce her next week if her labor hadn’t started.

And Dr. Banyas didn’t cheer her up any, she added.  You’d better put on your charm with your scrubs.

Sam strode to the doctor’s lounge grabbing a scrub suit and shoe covers as he passed the linen closet by the door.  He opened a locker and hung his tie on a hook.  As he undressed, he wondered how to break the ice.  Even with patients who were sick or in pain to the point where they were upset, scared or angry, he usually could find a way to help them get past their fears.  Still, he accepted as fact that he didn’t always like everybody and it made sense that not everyone could be expected to like him.

He looped the waist ties into a knot and threaded the end through his wedding ring.  Except for deliveries, he never took it off his hand and then routinely tied it through the knot of the scrub suit drawstring so it was always with him.

Walking briskly down the hall toward the birthing room, he pondered how he might convince Martha Washington to allow the placement of a fetal scalp electrode.  Entering the labor room he joked, I hope I’m not too late, and crossed to the bed, smiling at the parents-to-be.  They didn’t smile back.

The tracing really doesn’t look any different, Louise pointed out as he examined the monitor pattern.  The fetal heart rate tracing dropped rapidly from 160 down to 30 and then back so quickly he felt sure it was simply missing some of the beats.  This made sense because the monitor light changed from green to yellow and then red as the rate fell, indicating that it no longer picked up the echo.  When it returned to its previous baseline he concluded that the baby was just moving out of range.  Mrs. Washington’s size didn’t make monitoring any easier.  He looked at her pelvic floor for the bulge of the head’s descent.

Performing a quick physical exam, he palpated the glands in her neck and checked her heart and lungs with a stethoscope.  Have you had a cold or anything recently? he asked.

No.  It’s always like that, she said.

As he felt for swelling at her ankles, he said, I’m sorry Dr. Kehoe can’t be here to help you with this.  I’m sure it will work out all right, though.  At the rate you’re pushing I’d expect we’ll see your baby’s head in another ten or fifteen minutes.

She shot him a doubtful glance.

When you feel the start of the next contraction take two deep breaths and with the third, hold it and bear down, pushing the baby down into your pelvis.  You’ll feel the head start to push on your rectum and it may feel as though you need to move your bowels.

Martha Washington gripped her knees, trying to pull them up toward her chest.  Her abdomen got in the way.  Her face flushed and veins in her temples bulged as she bore down with the contraction.  Her husband sponged her forehead with a wet washcloth and said nothing.

Mr. Washington, it might help your wife if you can count slowly to ten while she’s pushing.  Then she can take a deep breath again and push for another ten-count.  Most contractions last long enough to get in three good pushes.

Louise came to the bedside with two large pillows and offered,  Let me put these behind your back.  They’ll keep you more upright so gravity can help you push during the contractions.  Do you want some more ice chips?

What I’d really like is to get this thing out of my arm so I can grab my knees when I push, she retorted, glaring down at the IV tubing in her right arm.  How long do I have to keep it in?

It gives some insurance that we can get medication into a vein if there are problems.  If you were to start hemorrhaging we’d need to give you a lot of volume replacement to maintain your blood pressure.  That and pitocin to control the bleeding.

He looked at the IV site in her arm for swelling or bruises.  We prefer to avoid blood transfusions with the risks of hepatitis or AIDS, he added.

Apparently satisfied, she pushed harder thereafter.  Louise and Sam alternated as labor coach while Martha Washington’s husband, Steven, played little part in the unfolding birth process.  The baby’s head made very slow progress coming down the confines of the birth canal.

Sam donned a sterile glove to check the position of the head.  It was a little hard to be sure about the position since he was feeling the baby’s head through the layer of fetal membranes.  As he felt the scalp for positioning, he could feel the suture lines – spaces between the bones of the skull – which pointed toward each of the fontanels.  Four from the front and three from the back.  He thought there were three sutures felt high up under the arch of Martha’s pubic bone.  That was reassuring.  With the crown of the head anterior, the fit with the pelvis would be better and the delivery easier.  He reached deep behind the head to feel how much room there was for the head to descend into the birth canal.  This, too, seemed adequate, although she complained about the pressure of his exam despite the numbing effect of the epidural.

Could you listen to the heart rate again? he asked Louise as he slowly withdrew his hand and removed the glove.

Louise repositioned the ultrasound low on Martha’s abdomen and tilted it several times trying to pick up the familiar ka-toosh, ka-toosh, ka-toosh sound of the fetal heart.  She found it briefly at 32 and then 166 beats per minute.  It held there for perhaps ten seconds before it was lost again.  Sam took it to be a sign of stability and allowed Louise to set the probe aside.

He spoke to the Washingtons,  I’d like to know how you feel about rupturing membranes at this point.  I think it makes sense for two reasons.  First, it will let your baby’s head descend further into the pelvis and second, we’ll get a look at the fluid to see if there’s any meconium in it.  Meconium usually means your baby has moved his bowels – a stress sign for a baby and it might push us to intervene.

As soon as he’d said it, he knew he’d used the wrong words.

Martha grunted,  Let’s wait and see if he can do it on his own.

The next thirty minutes crept by.  The intermittent monitoring picked up enough of the heart tones to let Sam relax.  He tried to lighten the mood of the room by engaging Steven Washington in conversation.  At one point he said to Martha, I know this is taking a long time but at least you won’t have to do it again tomorrow.  No one laughed.

When she had been fully dilated and pushing for an hour and a half, Sam repeated her vaginal exam and found the head just under the pubic arch.  She would have to force the head under the pubic bone so it could turn upward as it crowned.  He asked Louise to turn down the epidural block to allow more of Martha’s sensation to return.  Maybe if her reflex urge to push returned she might avoid a Cesarean section.  He palpated her uterus again for size.  The baby didn’t seem particularly large and it bothered him that her labor wasn’t progressing more quickly.

Finally, as the two-hour mark passed, he approached the head of the bed.

I have to tell you, he said,  that it’s unusual for a second stage of labor to last longer than two hours when everything is going well.  I think we should rupture the membranes and see if that will help expedite the delivery.  If necessary, we can even use a vacuum cup to help you with your pushing.  There can be some risks in doing so but I think waiting could be worse.

Martha and Steven looked at each other.  They were both tired and didn’t understand what was taking so long.  Childbirth classes hadn’t prepared them for the duration of this ordeal.  The films in their class always showed a rapid and joyful delivery — not a labor marathon.

Will it hurt?  Martha asked.

Not more than a vaginal exam.

Well, go ahead and get it over with, she sighed, frayed from the pain now that most of the epidural’s effect had worn off.

Sam turned to the nurse and said,  Let’s set up for delivery before we do this and get a vacuum extractor in case we need it.

Louise swung into action like a pro.  She raised the bed; broke away the bottom end revealing two leg rests and adjusted them to cradle Martha’s legs with her bottom at the end of the bed.  She adjusted the spot light and quickly cleansed her patient’s perineum with iodine solution and blotted it dry.  She rolled the instrument table into position where Sam could easily reach it from the stool and then stepped out to get the vacuum cup.  Sam, meanwhile, scrubbed his hands and gowned and gloved –  as much for his safety as for the patient’s.

As he sat down and separated Martha’s labia with his left hand he saw that the head looked dark.  Dark hair, he guessed.  Then he realized that he hadn’t felt enough thickness through the membranes on previous exams to account for that much hair.

Oh, shit! he thought,  Meconium.  This kid’s been in trouble and we’ve just been sitting on our butts!

Meconium! he said to Louise.

She punched the call button, We need Cynthia from the nursery right away in  G-6.  She flipped on the warmer over the baby crib and then squirted extra gel on the doppler  transducer and pressed it down on Martha’s lower abdomen looking at the fetal monitor for reassurance.  There was none.

Sam ruptured the membranes with an Allis clamp and found meconium mixed with the fluid in the forewaters.  The head was still dark and he wiped the meconium from the small patch of scalp he could see.  It was still dark.  Lack of oxygen.  He seized the vacuum and hurriedly applied it on the top of the head.

Give me some suction, he said to Louise as Cynthia burst through the door.

He spoke to his patients for the first time about this looming crisis.

We’re going to have to really hurry on this one.  I’ll need all the pushing you can give me.  I’ll help you with the Mity-vac.  I think your baby’s in trouble and we need to get him out now!

The delivery went easily.  The pushes Martha gave in response to his telegraphic urging were balanced by the traction of the vacuum. On the next contraction he cut a generous episiotomy in her pelvic floor with a scissors to remove the last resistance to the delivery.  Her sensation restored, she screamed as he did so.  The head appeared and was dark.  The baby wasn’t moving.  Sam hastily suctioned the nose and mouth with a DeLee and then felt the neck, checking for a tangled umbilical cord.  He found a nuchal cord but it was loose and slipped easily over the head.  He couldn’t detect pulses in the cord.

Call Dr. Banyas.  I need him here now!  Sam barked as he pulled the flaccid body of the male infant from its mother.  He clamped and cut the cord and rushed the baby to the warmer where he inspected the mouth and larynx with a laryngoscope.  To his surprise, there was no meconium below the vocal cords.  He pushed an endotracheal tube into the baby’s airway and together he and Louise and Cynthia began the resuscitation — the grisly task of trying to breathe life back into this lifeless child.

They were still ventilating and had already given the intracardiac epinephrine when Dr. Banyas arrived.  He took over the resuscitation and Sam fell back against the wall.  His mouth was dry — drier than he ever remembered it.  He felt warm and flushed, faint and reeling with the devastation of this deadly catastrophe.  He looked over to see the parents’ horrified faces.

HE AWOKE WITH A START; jerked upright in bed and felt a dry burning in his mouth and throat.  He was sweating profusely and realized that the summer night was surprisingly humid for Denver.

He went into the bathroom for a drink of water and was suddenly sick.  As he knelt by the toilet he could still visualize the stunned faces of Martha and Steven Washington.  The recollection of the event numbed his neck and arms with a heavy chill.  When would these nighttime visitations cease?

He wiped his face with a cold washcloth and went down to the living room.  His heart pounded and he knew he wouldn’t be able to go back to sleep.  He collapsed into the corner of the sofa and reached to his right for the light.  The soft patterned light through the shade of the lamp did little to lift his distress.  His hand found a stack of journals on the table beside the couch.  Absently he brought an issue of Journal of Obstetrics and Gynecology to his lap and gazed at the list of articles on the cover, then set it aside.  He couldn’t concentrate on reading.

Against his will, his thoughts returned to the details of the delivery.  The baby’s heart had stopped but he couldn’t picture when it had happened.  Why hadn’t there been more warning?  How had he missed the clues?

The subsequent malpractice suit characterized him as a careless, inept practitioner, the exact opposite of his self-image.  If anything, he was overly compassionate and accomodating.  It was not to be reconciled.

The noise of a closing door came down the stairs followed shortly by the appearance of his son, Bradley, tiptoeing down the carpeted steps.

Hi, Dad, Brad offered.  Couldn’t sleep again, huh?

You got that right...  How come you’re up?

Brad was eight.  He shared his father’s seriousness much of the time, more so since Elyse died.  His lighter hair resembled his mother’s but it stuck up in the back like Sam’s.  Sam unconsciously smoothed it down with his left hand.

I heard you flush the toilet, Brad said.  At first I thought it was Mom but then I remembered.

Do you think it woke Amy?  Sam asked.

Be serious, Dad.  She sleeps like a rock.

Tell you what.  Let’s go up and I’ll lie down with you till you get back to sleep. Okay?

Brad stood up and took his father’s hand.  Together they climbed the stairs to Brad’s bedroom where they stretched out on top of the covers.  The open window allowed a light current of warm air to pass over them.  Brad fell asleep quickly but Sam’s mind tossed in a maelstrom for nearly an hour.

CHAPTER 2

AMY, RUN UP AND CALL those brothers of ours again, Margaret Wyler charged her niece,  or the waffles will be too soggy to eat.

Amy skidded her chair against the wall of the dining alcove and thumped to the foot of the stairs.  Meg says for you guys to get down here now or forget having anything decent for breakfast, she editorialized.

Having moved into her brother’s house after his wife died, Meg Wyler was beginning to feel a little like The Mom in the household.  She liked the feeling.  Meg was four years older than Sam and took easily to mothering him since he had always been the baby of the family when they were growing up in Minneapolis.  She had left the English department at Carleton College three years ear;ier to move to Colorado for a teaching position at the University of Denver.  She hadn’t talked with Sam about her relocation until two months before she moved. 

The woman she had partnered with for four years had summarily ended their relationship and staying on in Northfield became untenable.  Though Meg didn’t consider herself secretive about that relationship, she had never talked more than casually with either Sam or her older brother, Richard, about it.  Above all she wanted to spare Brad and Amy the confusion that had plagued her when she was an adolescent.  They had enough to deal with since Elyse’s death.

Amy came back to her chair.  Do you have a class tonight?

Meg sensed a familiar anxiety in Amy’s voice – the fear that another adult in her life might not return.

Nope.  Want to do something?

I don’t know . . . Amy’s voice trailed off.  Do you think we could watch a movie or something?

Seeing as how it’s Friday, I don’t see why not.  Got any special requests?

No.  Just as long as it’s not some dumb space adventure or something like that.  Brad got to pick one last time.

Brad rounded the corner.  What did I do last time?

You got to pick the last movie, some stupid space thing.

Meg interrupted the fight before it got roaring,  How about if I pick something?  That way you can blame me if it’s too weird.

Just pass up the kissing.  Brad grunted.

Oh, Bradley, you’re so-oo charming, taunted Amy.

Sam entered the kitchen on the heels of Amy’s gibe.  Is there some bone of contention that we should all chew on?

Grab a chair, Samuel, and I’ll throw a waffle on your plate, Meg said.  She noticed that his cheek still bore the impressions of a wrinkle from the bedsheet pressed into his face.  He had been deeply asleep when she called him.

Thanks for making breakfast.  I didn't sleep much last night.  Brad and I finally crashed on his bed.  Fortunately, I don’t have to be at the clinic until one-thirty.  Stan’s covering call this weekend so I’ll probably catch up on sleep tomorrow.

She watched him pull his chair up next to Amy and Brad.  The waffles were quickly consumed by the kids but Sam finished barely half his before pushing his plate away and reaching for the coffee carafe.  He poured a second cup and added cream.  Meg studied his drawn face trying to decide of it was caused by a loss of weight or just his shortage of sleep.  Her protective impulse as the older sister sustained a grudge against lawyers who, she imagined, wished him harm.

In the three months since the lawsuit was filed she had watched him go through a slow involution of character.  She couldn’t distinguish how much of it was due to the lawsuit and how much understandable following Elyse’s death in January.  At her suggestion, after the suit was filed, he started taking a sedative at night to help him sleep.  That had worked for a time but no longer seemed to do the job.  Perhaps he’d stopped using them.

Jennifer’s mom’s taking us to Cherry Creek, Amy announced.  We’re going to see the mime show before swimming lessons start.  We’ll be back about five o’clock.

She gathered her dishes and placed them in the sink.  Having gotten halfway to the hall, Bradley noticed and returned to the table to follow her example.

Sam had started in on his third cup of coffee when his children headed out the door to Jennifer’s waiting car.  Meg asked,  I don’t remember you drinking your coffee with cream.  When did you start?

It’s been a few weeks now.  Elyse always did and I guess it makes me think of her to do the same.

Sam looked down at the cup and tilted it to one side,  I miss her you know. . . She was always around to talk with.  I liked it when she listened.  I haven’t had anyone to talk to since....

He stopped in mid sentence and looked up, embarrassed to have ignored Meg's obvious support.

I know what you mean, she said.

What I mean is, that I've never had that kind of intimacy with anyone else.  It’s hard to replace overnight.  And I worry about Amy and Brad.  They see me moping around the house.  Seriously, when Brad got up last night, he came downstairs to comfort me.  That’s not right – I should be the one comforting him.

I can’t offer you anything very profound, but I think you should try letting others help, Samuel.  You, of all people, should know the impact of stress.  You keep it inside and you’ll end up with an ulcer or something worse.

She paused and wondered to herself – Who am I to talk when I’ve never told