by Atul Kumar
The nerve he had. I didn’t say anything else and snuck out to report back to Cindy.
There wasn’t much else we could do; he was inconsolable and unreasonable. I mentioned sedating him until his procedure. That’s what Jack would have done, but Cindy was absolutely against it, stating that there was no medical reason.
Apparently, maintaining our sanity didn’t count as a good enough reason. I figured his sedation would prevent the headaches everyone taking care of him would suffer from his attitude. But that was not a ‘medically indicated’ reason for sedation.
It was a particularly busy day in the ER, and another two emergent code whites came in before Jacob could be catheterized. He was getting increasingly agitated as the hours passed. By early afternoon he had called the nursing station over a dozen times, initially demanding updates and later cursing at the staff about their incompetence.
The charge nurse eventually paged Cindy, after the second time she was cussed out, asking for advice on how to manage Jacob’s uncivilized and now potentially threatening behavior.
Cindy gave me a quick update and I immediately thought about how Jack would handle the situation. Instead of attempting further reasoning, he’d just call risk management and notify them of the situation. That way it’d be documented and become somebody else’s problem. Thus, that’s what I mentioned as a proposed plan of action.
It was quickly vetoed.
Cindy asserted that she could ‘polite yet sternly’ inform Jacob about the delay and calm him down.
“Wouldn’t Valium or Xanax be easier and safer?” I asked.
She gently punched my arm, “You’re so cute.” I didn’t mind the flirtatious contact, but she clearly didn’t take my suggestion seriously. Thus, I pressed forward, “No, I’m serious.”
“I don’t think that’s necessary. He’s just a little hungry, apprehensive, and tired of waiting.”
“Precisely what Xanax will help with, no? Besides, he was using profanity with the staff; that’s not our responsibility to deal with. We should just notify the legal team about his inappropriate behavior. Maybe they can sue him,” I joked.
“Come on, Raj, back in the day docs dealt with all this stuff. It shouldn’t be a problem.”
I quit arguing knowing I’d lost. But I definitely saw what Jack meant about Cindy wanting to befriend patients. Perhaps she was overly eager to compensate since her initial interaction with Jacob was rather unfavorable. I just backed off and let hear lead the charge.
“Let’s go talk to him. We can go together.”
I shrugged and gowned up to talk to Jacob for the fourth time that day. Freaking twenty dollars spent on just me seeing Jacob today. This time he was more agitated—the medical way of saying ‘pissed off.’
Cindy took point, and immediately she made the fatal flaw of starting off with an apology, giving Jacob the upper ground right off the bat. “I’m sorry for the delay, but there have been a lot of emergencies today. You are next on the schedule. It shouldn’t be too long now.”
“NOW! My procedure has been delayed for over seven hours! I was scheduled for 8 a.m. It’s after 3 p.m. now. What kind of a joke are you running here? Starving me on top of everything. This is bullshit.”
“There is no reason to be angry. We have kept you updated and even changed your sheets and given you a new gown as you requested. We have been nothing but professional and your rude treatment of the staff is …”
“My rude treatment? Have you looked at your staff?? They are a bunch of fat fucks. They should be the ones dieting, not me! Why don’t you keep them NPO? They could stand to lose a few pounds. Instead you starve me so you can watch and laugh at my suffering.”
“I assure you it’s nothing like that. We are doing our best to ensure you get better. The fact that your fever is reduced and your energy improved is proof that we’re making progress.”
“Why the hell are you here, anyway? Where’s the other doc? He’s smart; he’s the one who started me on these medications. You’re just taking his credit.” I could sense that Cindy’s resolve was fading and emotions were taking over. Not a good sign, we needed to exit his room STAT.
Jacob was just trying to get a reaction, and Cindy was about to give it to him.
“Jacob, this is your last warning, I need you to calm down or I’ll …”
“Or you’ll what?” He slammed his palm into the wall for emphasis. “Nothing is what you’ll do.” Jacob was feeling empowered now, feeding off the fact that Cindy was powerless and throwing empty threats in his direction. “Just like you’ve done nothing all day. You don’t need an MD to starve people; you can just go to Somalia and stare at all the hungry people you want if that’s what gets your rocks off.”
Oh boy, this was not a good situation.
Cindy was turning red with anger. That was my signal to get the hell out of there. I grabbed her arm and dragged her out of the room. I pantomimed a phone and mouthed ‘risk management’ to the charge nurse. She took my hint and began to dial.
A small group had gathered as we stormed over to the central work area. Cindy ripped off her mask and threw it down. “Can you believe him?! I was just trying to reassure him and explain … and he cussed me out and told me to go to Somalia! The nerve.”
“Hon, you don’t need to be dealing with that,” one of the nurses said. “You’re a professional not a punching bag. Just let him go home and have his MI there while he’s too strung out to call 911.” Nods and mumblings of approval followed.
“Sir, you cannot be here, please shut that door immediately!” We all turned to see a respiratory therapist rushing over to where Jacob was walking out of the second door of his isolation pod and entering the common area.
This is where Cindy and I vastly differed.
I grabbed the nearest phone and dialed security.
She rushed over to try and confront Jacob.
“Jacob, please return to your room, now!” She shouted as she rushed over.
Time seemed to slow down for what happened next.
Jacob grabbed his IV pole and slammed it to the ground. Next he ripped out the large IV going into his hand and flung it to the side. A huge gush of blood escaped forming a large arc of deadly red droplets in front of Jacob. The problem was Cindy was in the center of the arc and it splashed across her face, in both her eyes, and into her open mouth as she screamed in response to the incoming blood. She fell to the ground in an effort to duck, but it was too late. The blood had already made contact.
I suddenly had a flashback to Dr. Dan from the ER when we admitted Jacob. I made a mental note to notify him of Jacob’s HIV status. But I recall he was well covered and shouldn’t have gotten any splatter on his actual person like Cindy just did.
Thank God, I still had on my mask with eye shield. I rushed over to Cindy’s side and pulled her back to the work station. Jacob stood there with blood dripping from his hand as everybody backed away.
He was a walking biological weapon that could erupt again at any moment.
The scene was surreal, like a showdown in the Wild West. But instead of a gun there was a stream of blood dripping from his hand. Before he had a chance to draw and splatter anyone else with a stream of blood, security and risk management burst into the unit.
It was the first time I’d seen a firearm drawn and pointed towards a patient. Only, it wasn’t a firearm, it was a Taser, and there was no hesitation like you see in the movies. The officer didn’t ask him to raise his arms or get on his knees; he just took in the scene and shouted for everybody to get back … then he fired.
Two small metal darts with wire tails buried themselves in Jacob’s chest. He looked down, but before he could comprehend what was happening, I heard the sizzle of electric current which instantly caused all of Jacob’s muscles to contract simultaneously. His eyes rolled up in his head and he fell forward, hitting the ground with a dull thud.
Once the threat was neutralized, everybody rushed over to Cindy to ensure she was OK.
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She wasn’t.
Cindy was a mess the rest of the day between emotional duress and the myriad of testing performed by employee health services. It’s no surprise she didn’t come to work the next day.
I hazarded a phone call to her despite Jack’s advice to let her recover; he’d heard that she wasn’t taking anyone’s calls.
She took my call and I consoled her for 45 minutes through several episodes of sobs and silence. I did my best to reassure her. But she was extremely distraught over how she got a mouth and both eyes full of highly contagious HIV infected blood. Which makes sense; I’d certainly be unhappy about it too.
We both knew the risk of infection was somewhere in the range of about 1/100, or less, that she actually contracted the virus. But the disquieting thing was that his viral load was so high. Thus, even a tiny amount of his blood would harbor many more infectious and virulent HIV particles than somebody who was well treated. Therefore, we estimated her risk to be somewhere about 10%, worst case scenario. Unfortunately, a medical literature search revealed that HIV infection through infected fluid-eye contact had been reported to cause infection in previously HIV negative individuals.
What affected her most was that she would not know if she was positive or not for a full 6-8 weeks and would have to take prophylactic HAART medications during that time of uncertainty.
The Chief of the hospital and CEO granted her as much time off as she needed without any penalty of being held back. It was a small consolation. Or at least I thought of it that way—Cindy not so much.
Jack came up to me later in the afternoon, “Where were you? You called Cindy, huh? She answer? What’s going on?”
I filled him in and he nodded in silence. Then he looked up as though he had an epiphany, “Oh, I almost forgot to tell you, all of Jacob’s ‘girlfriends’ showed up to their appointments and got tested for HIV. They were pissed at why we were testing them out of the blue; supposedly they were all in a monogamous relationship with him … fucking jerk.”
“Do we know the results yet?”
“I put them in as routine, so as not to arouse suspicion with STAT requests. Results will be in tomorrow, though I talked to Drs. Donner and Blake, they both said the girls were already starting to point fingers at Jacob. They all know of his hospitalization and are very upset at why he hasn’t been returning their calls. Naturally they assume he has something to hide. And being called in for testing of infectious diseases only heightened their suspicions.”
“We should just tell them about Jacob.”
“OH we will,” Jack confided in me as he put his arm around my neck and walked me out of the ICU. “You want to continue to help me in Jacob’s management?” He whispered once we were outside and halfway down the long hallway.
I figured his statement had multiple meanings, but I wanted nothing good to happen to Jacob, and didn’t mind being involved if I could help retaliate for what he did to Cindy. “I’m in.”
“My boy! You realize what I’m talking about right?”
“Uhh … I guess we still have to treat the jerk and get him out of here ASAP.”
“You are right on both accounts, we must treat him and get him out … but there is nobody to dictate how we treat him. And last I checked ‘mistreat’ contains the word ‘treat.’ And when you say get him out; I hear any way possible, including the ninth floor.”
The ninth floor was a joke among medical professionals here because the hospital only had eight actual floors. Thus, the ninth floor came to mean discharge to the powers that be, resulting in the body being taken to the morgue in the basement.
I admit I should have been appalled, but I liked where Jack was going. Technically, he was also right. We’d still treat Jacob and get him out of the ICU, just not in the conventional way of thinking.
“So, what’s our new treatment plan?”
“Well, it’s complicated, but I already got the ball rolling. His recent culture results show MRSA bacteremia. Bad, but I went down to the lab and had his sample re-evaluated; there was also a gram negative bug that showed up. Strange how that happened, the microbiologist was sure it wasn’t there before, but added an addendum to his report. Translation, Jacob needs another antibiotic.”
“Gentamicin?”
“Bingo, you’re good at this game. So yeah, we add that to his regimen. Now he’s on three highly nephrotoxic drugs: Gentamycin, Vancomycin, and Amphotericin B, but needs them all to survive. The Gentamicin will also make him deaf if it’s not dosed right.”
“But the pharmacy doses his meds; they’re super anal about peak and trough levels.”
“True, but they don’t personally draw the blood with which levels are calculated. All we do is start drawing the blood ourselves. It’s easy; we draw from his PICC line when the infusion fluid is going in full tilt.”
“Clever. The specimen is already diluted and we can still document it was drawn through the same line as all his other specimens.”
“Nobody has to know that the fluid infusion was not shut off at the time of the lab draw. Besides, it’s just assumed that it was done,” Jacob winked.
“Even if his kidneys are shot in a matter of one or two days, that’s not a big deal is it? Won’t they just put him on dialysis? And isn’t toxicity from Amphotericin B pretty easy to notice?”
“I think I saw him twitch again; bet his alcohol withdrawal is coming back. We gotta put him on high dose Valium again. His stupor and somnolence will hide most of the acute toxicities.”
I still wasn’t in love with the plan and voiced my concerns, “Worst case scenario he ends up deaf and on dialysis. Now he’s a huge drain on society, but can still live for years on end. Though I doubt he’ll get a kidney transplant given his history of drug abuse.” I wasn’t convinced Jack’s plan was a good one.
“You’re right, so that’s where we come in … this next part is a bit shady, and I need your word that you won’t tell anyone.”
I didn’t like where this was going. I think Jack was making the transition from more passive to active infringement on Jacob’s life. On the other hand, Jacob actively decided that the girls he infected were not deserving of a full and disease-free life. That thought, along with Cindy sobbing on the phone, triggered my decision to join Jack to the end. “I’m in, I promise.”
“You’re a rare find, Raj. Ok, here’s how it goes down. We’re both on call tomorrow. We tank him up with all his meds today and tonight, and then draw the diluted blood specimens for the lab ourselves. Tomorrow, when we’re on call, we push a shitload of steroids into his system. That, in addition to his other anti-infective medications, will cause his potassium levels to plummet, sending him into cardiac arrhythmia.”
I sighed, “But a code team will respond immediately, identify the problem, and resuscitate him.”
“Who’s the leader on the code team tomorrow night?”
I finally got it; Jack was brilliant. “You are.”
“Bingo.”
“You’re scary. Even if they do an autopsy, they’d expect to find steroids and all the drugs in his body anyhow. Checking levels for most drugs will be useless given all the medications pumped into him during his Code Blue. It’ll be an open and closed case, his cause of death will simply be reported as due to AIDS related complications and cardiac arrest.”
“Not to mention his history of drug use. Just another junkie biting the dust. He should have never fucked with us. Just should have been a good patient and allowed us to fix him up. But he’s getting what he deserves, just without the hassle of a judge and jury.”
“We’re essentially saving the taxpayers hundreds of thousands of dollars.”
And so I rationalized the demise of Jacob. To us he was getting what he deserved. He knowingly put the lives of five girls at risk of AIDS and likely countless others who we just didn’t know about. He had no remorse or guilt over what he did. Why should we think twice about our plan? Yet, I thought over it several times and feared my actions tomorro
w would haunt me for years to come.
I wanted to say that it was difficult and highly risky to carry out Jack’s plan, but the reality was that it was a piece of cake. Everybody in the ICU wanted Jacob dead, and we were just carrying out their unstated wishes.
That day both Jack and I stayed late and made sure we overdosed him on all his medications as we’d planned. We drew the labs ourselves. Just as we thought, the pharmacist was concerned that the levels were way too low and increased his doses. About midnight his labs were due again after the dose increases. We just happened to still be around the hospital and were nice enough to allow the nurse taking care of him to take a break while we kindly drew his labs while checking up on him.
Jacob was more than happy to comply. He was so sedated on Valium that he could barely open his eyes, much less respond to our questions.
An astute pharmacist would have noticed the medication levels were way too low at about 4 a.m. when we were home, but we prevented this by writing so many ‘pharmacy to dose’ orders on our other ICU patients that the pharmacist was overwhelmed and unable to check levels until we arrived at the hospital at 5:30 a.m.
The covering resident was relieved to run into Jack, “Oh wow, you’re here early.”
Jack said, “I couldn’t sleep and thought I’d round before breakfast; everything ok?”
“Not really, your isolation patient’s Vancomycin and Gentamicin levels are sub-theraputic despite high doses.”
“Really? That’s strange. I’ll take it from here and look into it.”
“Thanks, man, nothing else overnight.”
I sighed, not realizing I’d been holding my breath. This was too easy; nobody was even suspicious of anything. Only I seemed to think this strange. Jack seemed totally relaxed, like he’d done this many times before.
We walked into Jacob’s room and Jack yelled out, “Hey DUMBFUCK, you still with us you piece of shit?!”
No response.
Jack turned to me, “Well, I guess he’s still a bit sedated from treatment for his alcohol withdrawal.”
I looked at Jacob’s urinary catheter; the fluid was dark brown and there was almost no urine production overnight. Jack saw me looking and commented, “Yep, his kidney’s are shot. I doubt they are working but five percent of what they should; he’s gotten enough drugs to shut down the kidneys of three people.”
