My office was as busy and frustrating as usual. I still fought with the HMOs, and I resumed the QA Committee’s chair.
In the past, when the sun bathed me in a light of pure joy, I dreaded the dark storm clouds I knew lurked just over the horizon. Now, I savored each sunny day, heedless of the worries that troubled me in the past. With the blackjack dealer showing a ten, I’d hit sixteen knowing I’d bust. Now, I knew that the next card would be a five or less.
When I returned home after a particularly busy afternoon in the office, Lois greeted me with a hug. “How was your day?”
“I think I saw more patients today than ever before, but it was okay.” I moved my head in a lateral arc, sniffing the air. “Leg of Lamb, honey, with Worcestershire sauce, and rosemary, right?”
Lois stared at me. “That’s amazing. All I can smell is the lamb itself.”
“It smells awesome. I can’t wait.”
“We’ve got another thirty minutes before it’s done. I’ll get you a glass of wine, brie, and crackers.”
When Lois opened the refrigerator door, a rancid stench hit me. “Something’s rotten in there, Lois.”
“I don’t smell anything.”
“You’re save leftovers in plastic bags, and then forget them. Throw them out or let’s do a search and destroy mission from time to time. Who knows, maybe we’ll find a cure for cancer.”
Lois gave me a smirk and walked away. “Go with God, my son. Enjoy your reconnaissance.”
I rummaged through the refrigerator. After removing the known and recognizable, all that remained were a half dozen Tupperware containers and one plastic-wrapped furry-white alien substance that exuded a ghastly essence. I turned my nose away, held the thing between my index finger and thumb in my outstretched arm, and extended it toward Lois.
“Eureka!”
Lois turned from reading Prevention magazine. “Very good Arnie. Feel free to do this any time.”
“Do you have any idea…?”
“None,” she interrupted.
“What about these Tupperware containers?”
“Go to it with that talented nose or toss it all.”
Afterward, I sat at the kitchen table reading the mail and sipping the icy wine. It was a Double Oak Chardonnay from our wine club. I savored the dominant buttery flavor with a hint of oak and pear. We had a glass of wine most nights. Lois purchased wine by price. Somehow, she managed to find a decent yet inexpensive wine. The only expensive wines we drank were gifts, though on occasion we’d splurge on a good bottle of Champagne.
Lois reached over to the mail. “Two of your favorite catalogues came today.”
I thumbed through the Sharper Image catalog, before scanning the Victoria’s Secret, which came six times a week. “I enjoy the artistry of their professional photography.”
“Right.”
I went to the refrigerator, filled my glass with ice water, and returned to the table. I took one sip and grimaced. “Something’s wrong with the water. It tastes terrible.”
Lois came over and took a sip. “It tastes fine to me, Arnie.”
“Something’s wrong. You’d better call the water treatment people out to check the system. It tastes like iodine, chlorine and something foul.”
“I’ll call them in the morning.”
Dinner was delicious.
“You really did it this time, Lois.”
“What do you mean, by ‘this time’?”
“No. I think it’s both of us. The lamb was succulent with a pungently sweet tang. It tasted better than it smelled.”
“You’re getting into this taste thing, Arnie.”
“Taste is complex and starts with our tongue taste buds for salty, sweet, bitter, and sour, and the new one, umami.”
“How can we have a new taste bud?”
“We don’t. The Japanese first described it a hundred years ago as the receptor for MSG in Asian food. When you combine taste bud sensation with smell, the result is what we commonly call taste. Then, when you add the satisfaction of chewing and the relief of hunger, the result is a splendid sensory symphony.”
As usual, I ate too much and nodded off in front of the television.
I felt a tug on my arm. “Play Chutes and Ladders with me, Daddy.”
I nodded and joined Amy on the floor for the next thirty minutes. She smiled then giggled in triumph over her dad.
“Can you help me with my homework?” Rebecca asked.
“Sure, sweetie, as long as it’s not math.”
“Oh Daddy, you know it’s math…I hate math.”
“Well, I wasn’t too crazy about math myself. If I could learn it, you can, too.”
Her math book couldn’t be more than a few years old. It had a faded cover, many torn pages, and a distinct musty aroma as if it had been sitting in a damp place for decades. The first time I helped Becky with her math, it was immediately obvious that while numbers never change, math teaching did. Before I could help her, I first had to understand how they did it today.
After an awkward start, we completed her assignment.
I remained before the TV, not really watching. I gave the girls their final goodnight kisses before Lois put them to bed.
Lois collapsed at my side onto the soft couch. “I’m glad that’s over. Give me a moment to restore my energies.”
I stared at the TV, and then pushed the remote’s off button preferring silence and the moment’s intimacy.
Lois stirred then lowered her head into my lap, closed her eyes and slept. Suddenly, I felt a familiar stirring in my groin. I felt relieved that this part of my anatomy had come through encephalitis unscathed.
Twenty minutes later, I was still erect.
Lois stirred, and then did her best Mae West impersonation. “Is that a gun in your pocket, or are you just happy to see me?”
She raised her head and moved to sit astride me. “How about a lap dance, big boy?”
I lifted her into my arms and carried her to the bedroom. “Why go for fantasy, when you can have the real thing.”
Chapter Twenty-Two
Two nurses and an orderly wheeled Connie Rinaldi into the ICU and transferred her to bed five. One look at the purple-blue and unresponsive woman had the staff in crash mode. When they stuck the electrodes to her chest, the cardiac monitor showed a rapid and irregular heart rhythm.
Beth Byrnes turned to the ward clerk. “Get Jack on the phone, stat.”
The ward clerk pointed to the phone.
Beth pushed the blinking line. “Connie Rinaldi just got here and she’s ready to code.”
“Get a stat electrolyte panel and blood gases. I’m on my way.”
Jack called Jim McDonald who’d returned to his office. “If we don’t do something, she’s going to code.”
“I’m stuck in the office, Jack. Can you take over? Get Alan Morris, the pulmonary doc to see her again.”
“Okay, Jim, but when you come back this afternoon, don’t be surprised to see her intubated and on a ventilator.”
Jim hesitated. “I understand. Can you ask her nurse to get the Rinaldis’ phone number? I’ll try to explain what we’re up against and what we’re going to do.”
Jack Byrnes had the operating room on the line. “Get me an anesthesiologist right now. We need to intubate one of our patients before she codes.”
“They’re all in surgery,” said the operating room director. “I can get you somebody in about thirty minutes. Will that be okay?”
“That may be too late,” Jack said prophetically, as the ICU code blue alarm sounded.
Jack rushed to Connie’s bedside. The nurses had removed her pillows, lifted her torso, and placed a resuscitation board behind her back.
Beth lifted her stethoscope from Connie’s chest. “Her heart rate spiked to over 200 and her pressure’s down to 60 systolic. She’s not moving any air. We had no choice, but to push the button.”
The nurses were trying to breathe for Connie with an Ambu bag, but her lungs were
so stiff and the airways so filled with mucous that they were having little success.
Jack removed his lab coat and shifted position to the head of the bed. He removed the headboard. “Get me the intubation tray.”
Beth opened the tray while Jack donned green gloves.
“Extend her neck,” Jack shouted as he grabbed for the stainless steel curved laryngoscope blade and placed it atop the battery pack. As he started to insert the blade into Connie’s mouth, he shouted, “She has an upper dental plate. Get the Goddamn thing out now!”
Beth reached into Connie’s mouth and removed the denture.
Jack guided the blade back over the tongue and then, lifting the soft palate, tried to visualize her vocal cords. The laryngeal area overflowed with frothy blood and mucous.
Jack’s heart raced. His mouth was dry and he felt the first cramps of fear in his abdomen. “I can’t see a damn thing. I need suction.”
Beth handed him the vacuum wall suction catheter and he swept it rapidly through Connie’s mouth and throat.
“Take it easy, Jack,” whispered Beth. “You’ll get it.”
He reinserted the blade trying to find her vocal cords, but all he could see was the fleshy soft palate. “Somebody push down on her larynx, I can’t see shit.”
Beth placed one finger on each side of the thyroid cartilage, the part of the neck laymen call the Adam ’s apple, and pushed it down toward the back of Connie’s neck.
Immediately, the two white vocal cords appeared in Jack’s view and he pushed the endotracheal tube through. “Got it! Someone inflate the cuff before we lose it.”
Jack breathed easier as the respiratory therapist attached the ET tube to the ventilator and turned it on. He smiled as the machine provided Connie’s first good breath and her chest rose in reaction.
Jack listened to Connie’s lungs. “Suction her out then let’s begin bronchodilators. Get a stat portable film to check the tube’s position and draw a set of blood gases.”
Three hours later, Jack stood with Jim McDonald and Alan Morris. “The tube’s in the right place and her blood gasses, although poor by anyone’s standards are a hell of a lot better than they were before.”
Jim looked at Alan. “What do you think?”
“She’s safe for the moment. I don’t know how she’ll respond to more vigorous treatment, but I’ll make one prediction; it’s going to be difficult to impossible get her off the ventilator.” He hesitated a moment. “I know things happened precipitously, but in a woman with advanced lung disease, maybe we’ve done her a disservice by putting that tube in, especially if we can’t get it out.”
When Jim entered the ICU waiting room, the Rinaldis rose together, looked at him expectantly.
In muted tones, Tina asked, “How’s my baby doing?”
“She’s out of danger for the moment, but we had to insert a tube into her throat so she could breathe. This will give us and her a chance to bring this infection under control.”
Joseph, Connie’s father, pumped Jim’s hand. “Thank God, Doctor.”
Please sit for a moment. “I don’t like to bring this up, but with Connie so sick, we need to understand what she’d want if things don’t go well.”
Tina turned to Joe. “What is he talking about?”
“I’m not sure,” he responded. “I’m sorry, Doctor, but you’re not suggesting that we stop treating our daughter?”
“Absolutely not,” Jim said, and then he girded himself for what was to come. “We’ll do everything possible, but we’ll need your help. You know Connie best. You know what she’d want if she gets worse.”
“We’re still not following you, Dr. McDonald. We’ve known you for a long time and we trust you, so just say it.”
“Let me give the worst case to make the point. This is only an example. It’s not about Connie. If something were to happen to a loved one and they had extensive brain damage to the extent that they had no chance of meaningful survival, would you wish to continue treatment. Would you keep a person like that going by keeping them on a ventilator, providing them with nutrition and other treatment to keep them alive at all costs?”
“Like that young woman in Florida?” Joe asked.
Jim nodded.
“I’m Connie’s father and I love her more than life, but if we were sure that her mind was gone, that everything that made Connie, Connie, we wouldn’t try to keep just her body alive. We’re religious people, but doing that would be a disgrace to the memory of our daughter. If she dies,” he hesitated wiping a tear away, “it should be with dignity and peace.”
That’s a relief, thought Jim, but it barely touches on the complexity of keeping someone alive on a ventilator where her mind’s intact. God help us if we have to deal with that one.
Jim moved his gaze between the Rinaldis, fixing each for a moment. “Connie knew that she has a severe form of lung disease, and that she might require a ventilator. Did she ever discuss this with you?”
“No,” said Tina, “but I know my daughter. She’s a fighter. I do know one thing for sure; Connie wants to live.”
Chapter Twenty-Three
For the first time in his life, Tino Ruiz had things going his way. He’d arranged his schedule to accommodate his classes, and although the work left little free time, he’d never been happier. His fear about handling the college curriculum faded. He discovered that the classes interested him and he aced the examinations.
Tino’s training as a pharmacist’s assistant was going well. His bright mind captured the complexity of the dosing system as he read extensively about the more common prescriptions he filled. More significantly, he felt that Henry Fischer and Brian Shands no longer looked at him as if he were about to steal the silverware or rape their daughters.
“Why don’t you fill these,” said Brian one afternoon. He handed Tino a stack of prescription forms. “I’ll deal with the refills.” The pharmacy was bustling with prescriptions, their normal heavy load, plus those written because of the influenza epidemic.
Tino worked closely with Brian and had learned much, but something about the man made him uneasy. In his gang days, Tino learned to respect first impressions about people. It saved his ass several times. Brian was secretive about his activities and spent hours alone in the air-controlled clean room. Since airborne particles can carry bacteria and viruses, the clean room eliminated them, a critical step in making up IV fluids, and other injectables. Once, when Tino tried to enter to get medication, he found the door locked. Suddenly, Brian opened the door and shouted, “When the door’s closed, it means don’t disturb me, comprende amigo?”
“Of course. I needed to get sterile water from storage.”
In addition, Tino noted that Brian lied. A few were the-check’s-in-the-mail lies, small deceits to explain their failure to supply medications or fill prescriptions when promised. Others were senseless lies over trivialities, and several were major-league, like failing to log in supplies received, and falsifying records subject to examination by the state’s division of pharmacy inspectors.
Was this business as usual, Tino wondered, or was something else going on?
I looked at the wall clock that showed we had ten minutes left for the QA meeting. Anything else, Cindy?”
“Yes, Arnie. We have mostly minor stuff to deal with, but we can deal with it after the meeting. We do have another request, an unusual one. The pharmacy committee is on a rampage to reduce cost. In their review, they noticed an unusual drug usage pattern, a costly one.”
“What is it, and what do they want us to do?”
“One of the most expensive items in our formulary is EPO, a powerful stimulator of blood production. In the past, we used it primarily to treat anemia in patients with kidney diseases, but now they’re dispensing it for AIDS, a variety of cancers, and to boost a patient’s blood count before surgery to avoid transfusion and its risks.”
“It’s a revolutionary drug,” I said, “and a real advance in treating a difficult problem.�
��
Cindy passed out a spreadsheet. “Take a look. The pharmacy’s budget for EPO has gone up nearly 100 percent. They want us to find out why.”
I scanned the data. “The hospital lives and dies by Medicare, Medicaid, and private insurers’ reimbursement formulas for this drug. The current usage pattern makes the economics of this drug a break-even or a losing proposition. Simply, they’re asking us to look into the reasons behind this increased usage.”
“Since we use the drug is more widely now, are they sure they have a problem, Arnie?” asked Jim McDonald.
Cindy Hines shook her head. “They’ve looked at its use in all these groups and it’s an overall increase in per patient usage and not an increase in a particular new patient group. They can’t figure it out.”
“Cindy and I will meet with specialists who prescribe EPO the most and look at its usage in a systematic manner. I’ll bring the evaluation criteria back to you next meeting for discussion before we begin the study.”
When Cindy first received the request about EPO usage, it drew her attention at once…
Cindy divided her life between job and work with the Special Olympics. She’d been engaged to Mike Kelly, a husky, athletic Berkeley cop who’d been shot in the abdomen during a drug raid seven months earlier. She’d been through the wringer with Mike during the horrendous first stages of his injuries. He’d undergone multiple surgeries and was near death several times until his condition finally stabilized. She loved Mike, and continued at his side into rehabilitation.
Cindy had been Mike’s guardian and protector throughout. Experience told her that even in a good hospital like Brier, mistakes were inevitable. She’d questioned everything, berated physicians, nurses, technicians, and virtually anyone interacting with Mike. Incredibly, she performed her watchdog function with grace, good humor, and kept on good terms with everyone.
After five weeks in rehabilitation, Mike became depressed and withdrawn.
“It’ll pass,” Cindy told him. “Be easy on yourself. Look at what you’ve been through.”
“Look at me,” he replied as he gazed down over his flat abdomen, disfigured with multiple healing scars and two foul smelling yellow rubber drains. “I weigh 120 pounds. Half of what I was before being shot. These infections will never heal.”
The Sixth Sense (Brier Hospital Series Book 3) Page 10
