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 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."