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An Invisible War (Conclusion)

Written by Danita Lee Ewing

Chapter Five

September, 1633

1

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."

2

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.

Chapter Six

October, 1633

1

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?

2

"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."

3

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?

Chapter Seven

October, 1633

1

"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 systolic—ah that's the top number on the blood pressure—of 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.

2

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 touching—ah, palpating, the word was palpating—their 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.

3

"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.

4

"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 ...