Silent Treatment

by Michael Palmer

“You know, in spite of what everyone says about you, I always thought that.”

  Harry stripped and headed for the showers. He knew that Steve Josephson, in spite of himself, was staring at the patchwork of scars on his back. Thirty-one pieces of shrapnel, half a kidney, and a rib. The design left by their removal would have blended into the pages of a Rand McNally road atlas. Harry flashed on the incredible sensation of Evie’s breasts gliding slowly over the healed wounds in what she used to call her patriotic duty to a war hero. When was the last time? That, he acknowledged sadly, he couldn’t remember.

  He cranked up the hot water until he was enveloped in steam. Two weeks until fifty. Fifty! He had never experienced any sort of midlife crisis that he could think of. But maybe the deep funk he had been in lately was it. By now the pieces of his life should have fallen into place. Instead, the choices he had made seemed to be under almost constant attack. And crumbling.

  He thought about the day halfway through his convalescence when he had made the decision to withdraw from his residency in surgery and devote his professional life to general practice. Something had happened to him over his year and a half in Nam. He no longer had any desire to be center stage. Not that he minded the drama and intensity of the operating room. In fact, even now he truly enjoyed his time there. But in the end, he had realized, he simply wanted to be a family doc. Simply. If there was one word that was most descriptive of the life Harry had chosen for himself, simply might well be it. Get up in the morning, do what seems right, try to help a few people along the way, develop an interest or two outside of work, and sooner or later, things would make sense. Sooner or later, the big questions would be answered.

  Well, lately things weren’t making much sense at all. The big answers were just as elusive as ever. More so. His marriage was shaky. The kids he had always wanted just never happened. The financial security that he had expected would gradually develop over the years was tied to a brand of medicine he was not willing to practice. He never allowed his office to become a medical mill. He never sent a collection agency after anyone. He never refused anyone care because the patient couldn’t pay. He never moved to the suburbs. He never went back for the training that would have made him a subspecialist. The result was a car that was seven years old and a retirement fund that would last indefinitely—as long as he didn’t try to retire.

  Now, his professional stature was being hauled up on the block, his wife was facing a neurosurgeon’s scalpel, and just four weeks from the first of September in his fifty-first year, he had experienced pain in his chest.

  • • •

  The hastily called family medicine departmental meeting accomplished little. Each physician who spoke during the emotional forty-five-minute session seemed to have different information about what the findings of the Sidonis committee were going to be. In the end, no motions were passed, no actions of protest approved. Aside from presenting a unified front at the amphitheater, there was nothing to do until the specifics of the task force’s recommendations were known.

  “Harry, you didn’t say a word in there,” Steve Josephson said as they left.

  “There was nothing to say.”

  “Sidonis and his vigilantes are on a witch hunt, and you know it. Everyone’s scared. You could have calmed them down. You’re … you’re sort of the leader of the pack. The unofficial kahuna.”

  “A kind way of saying I’m older than most of the others.”

  “That’s hardly what I mean. I deliver babies. Sandy Porter strips veins and does other stuff in the OR. The Kornetsky brothers are better in the CCU than most of the cardiologists. Almost every one of us does some procedure or activity that might be taken away today. You’re about the only one who does all of them.”

  “So? Steve, what are we going to do? Challenge the specialists to a medical Olympics?”

  “Oh, this is crazy. Harry, I don’t know what’s come over you lately. I just hope it’s not permanent.”

  Harry started to respond that he didn’t know what Josephson was talking about. Instead, he mumbled an apology. He had never been a fiery orator, but over the years his directness and commonsense approach to resolving conflicts had earned him respect in the hospital. And he certainly had never backed away from a fight. He could have—should have—said something. Members of the department, especially the younger ones, were genuinely worried about their futures.

  The crisis at MMC was the direct result of the hospital being named as codefendant in three successive malpractice suits over a period of a few months. All three suits involved GPs. Harry felt the epidemic of litigation was nothing more than coincidence. In the new medical order of sue first, ask questions later, similar numbers could probably be produced to show that specialists were equally vulnerable. But the medical staff had panicked and the Committee on Non-Specialty Practice had been created. Caspar Sidonis, a charismatic, widely known cardiac surgeon, had been made its chairman.

  Sidonis and Harry had never hit it off, although Harry never really understood why. Now they were on opposite sides of the table, playing a high-stakes game for a pot that was of value only to the GPs. And Sidonis held all the cards.

  “Steve, I’m sorry,” Harry said again as they turned down the passageway that cut through the emergency room, “I guess I have been down lately. And I really don’t know why. Male menopause or something. I feel like maybe I need—I don’t know, some sort of windmill to charge.”

  The corridor, a shortcut from the room where their meeting was held to the amphitheater, was closed to the public but not to hospital staff. Today, the ER was humming. The rooms to either side of them were all occupied. Major surgery, minor surgery, orthopedics, ENT, pediatrics, minor medical, major medical, cardiac.

  “Each one a story,” Harry said as they walked through.

  “Yeah,” Steve mumbled. “Well, after today we better get used to having to read the Cliffs Notes.”

  A nurse rushed past them from behind and into one of the two cardiac rooms.

  “Give him another three of morphine,” they heard a resident say as they neared the room.

  “How much Lasix has he gotten?”

  “Eighty, Doctor …”

  “This is V. tach. I’m almost certain of it.”

  “His pressure’s dropping, Doctor.”

  “Dammit! Someone was supposed to have called cardiology.”

  “I put a page in for them. They haven’t answered.”

  The two GPs stopped at the doorway. The patient, a husky black man, probably in his early seventies, was in extremis, sitting nearly upright on the litter, gasping for breath. Loud gurgling welling up from within his chest accompanied each inhalation. His heart rate was nearly one hundred and seventy. The young resident managing the case was a decent enough doctor, but he had developed a reputation for losing his cool in difficult situations.

  “What is his pressure?” he asked.

  “Maybe seventy, Doctor. It’s quite hard to hear.”

  There was undisguised urgency in the nurse’s voice. Her repeated use of the resident’s title was a demand that he do something.

  “We can’t wait for cardiology,” he said. “Get ready to shock him. Someone please page cardiology again. Janice, I want three hundred joules.”

  Steve Josephson, his eyes wide, looked over at Harry.

  “Pulmonary edema,” Josephson said.

  “Right you are,” Harry replied.

  “But that’s not V. tach on the monitor.”

  “I agree. Plain old garden variety sinus tachycardia, I would say. Due to the stress of the situation.”

  “We can’t let him shock that.”

  Harry hesitated for just a moment, then nodded. The two of them moved to the bedside.

  “Sam, that’s sinus tach.” Harry whispered softly enough so that no one but the resident could hear. “Try to shock that and you might kill him.”

  The resident looked first at the monitor and then at the nurses and technicians surrounding his pati
ent. In seconds his expression went from confusion to anger to embarrassment, and finally to relief.

  “You want to take over?” he asked suddenly. “Please, go ahead.”

  Without answering, Harry picked up a towel and dried the perspiration that was pouring off the patient’s brow. He glanced at the plastic identification bracelet.

  “Mr. Miller, I’m Dr. Corbett. Squeeze my hand if you understand. Good. You’re going to be okay, but you’ve got to try and breathe slower. I know it’s hard and I know you’re frightened right now, but you can do it. We’re going to help you. EKG, Steve?”

  “Maybe a small anterior MI,” Josephson said. “He’s beating too fast to tell for sure.”

  “Hematocrit?”

  “Fifty percent. If he’s not a smoker, his blood is concentrated big time.”

  They looked over at the resident, who shook his head.

  “Lifetime nonsmoker,” he said. “But what’s his red blood cell concentration got to do with all this?”

  Harry’s exam disclosed no ankle swelling and no other signs of excessive fluid. Heart failure, from whatever cause, was producing back pressure throughout the pulmonary circulation. Serum, the noncellular part of blood, was being forced through the blood vessel walls and into the man’s lungs. As a result of the serum shift, the red blood cells, too large to pass through the vessel walls, were becoming sludge. Harry checked the man’s pupils for the constriction that would signal marked narcotic effect. The pupils were small, but not yet pinpoint.

  “Three more of morphine,” he said. “Please get me a phlebotomy bag. We’re going to take some blood off him. Get ready to intubate him if we have to.” He toweled the man off again. “Mr. Miller, you’re doing great. Try to slow it down just a little bit more.”

  “Excuse me,” the resident whispered, astonished, “but you’re going to take blood off him?”

  “We are.”

  “But … but nobody does that anymore.”

  “You’re doing better and better, Mr. Miller,” Harry said. He turned to the resident. “No one does this anymore, huh? Well, we do, Sam,” he said. “Especially when someone’s hematocrit is as elevated as this man’s. Just because a method’s not high-tech doesn’t mean it’s useless. Trying to get fluid off him with diuretics often isn’t as effective as what we’re about to do. And in someone whose blood is already this concentrated, diuretics are quite a bit more dangerous. Any fluid you get off with diuretics will just concentrate his red cells even more. If those red cells get thick enough, sooner or later a vessel could clot off. Pressure, please?”

  “Holding at eighty. Easier to hear,” the nurse said.

  Harry nodded to Steve Josephson, who inserted the large phlebotomy needle into a vein with a dexterity belied by his thick fingers. Instantly, a column of blood glided down the tubing and began to fill the plastic collection bottle.

  The reversal of Clayton Miller’s pulmonary edema was spectacular.

  “I … I’m breathing … a … little … better …,” he managed after just a minute or so.

  “What do you think, Steve? Another hundred cc’s?”

  “If his pressure stays up, I would say maybe even two hundred.”

  Harry adjusted the needle slightly, and the flow of blood increased. For another minute, there was only silence.

  “Oh my God,” Miller said suddenly, filling his lungs with a long, grateful swallow. “Oh my God, I’m better … much better.”

  He was still breathless, but much less so. The cardiac pattern on the monitor had slowed to one hundred. The shape of the complexes now appeared quite normal. Two nurses exchanged looks of exuberant relief. The resident stepped between the two GPs.

  “This is incredible,” he said. “I don’t know what to say. Mr. Miller, Dr. Corbett and Dr. Josephson really came through for you—for me, too.”

  The older man managed a weak thumbs up.

  “Listen,” the resident went on, “I heard about that committee they formed to alter your privileges. If you need me to write them about what went on here this morning, I’ll be happy to.”

  “It may be a little late for that,” Harry said, “but why don’t you drop Dr. Sidonis a note just the same. He might actually read it, as long as it starts with the greeting ‘Your Grace.’”

  There was a soft noise behind them. The three of them looked toward the doorway just as a stony-faced Caspar Sidonis turned and stalked off toward the amphitheater.

  CHAPTER 2

  “Green Dolphin Street.” The Wes Montgomery arrangement. The tune started up in Harry’s head almost as soon as he had settled into a seat in the last row of the amphitheater. “Green Dolphin Street.” Harry tapped out a riff with his fingers on the metal armrest. He loved music of all kinds, but he was a fanatic for jazz. He had played bass since junior high school and still sat in with a combo when he had the time. Over the years, he had come to appreciate that “Green Dolphin Street” tended to pop into his head when he was keyed up—tense, but ready for action. He had hummed it heading into organic chemistry exams, and later on throughout his family practice boards. And of course, during the war, it seemed he was always listening to it either on tape or in his imagination. Now, for the first time in a hell of a while, it was back.

  “Full house, Harry,” Doug Atwater said, gesturing toward the rapidly filling amphitheater. “You’d think they were giving away free stethoscopes.”

  MMC was the largest of the three hospitals contracting with the Manhattan Health Cooperative. As the vice president responsible for marketing and development of the rapidly expanding HMO, Atwater had an office at each of them. He had come to the company six or seven years before from someplace in the Midwest. There were many, including Harry, who believed that without Atwater’s creative energy and business sense, the Cooperative and its hospitals might well have gone under some time ago. Instead, Manhattan Health had captured a decent share of the market and become a real force in the business. Like Harry, Atwater was a devoted jazz fan, although he didn’t play himself. The two of them managed to hit a club every three or four months. And from time to time Doug would stop by C.C.’s Cellar when Harry was sitting in with the combo that regularly played there.

  “Did Sidonis or anyone on his committee speak to you about all this?” Atwater asked.

  “Of course. Dan Twersky, the psychiatrist, got assigned to interview me. You know him? He couldn’t have been more pompous or condescending if he had tried. He wanted to know how Marv Lorello could have sewn up that guy’s thumb so badly. I told him that as far as I could tell, Marv didn’t sew up anything badly. Twersky asked why Lorello didn’t call in a hand surgeon. I told him that all anyone could do was clean up the gash and suture it closed. The most skillful hand surgeon in the world might easily have gotten the same unfortunate result Marv did. Sometimes circulation to a wound isn’t all it should be, and there is some tissue loss. He said I sounded a bit defensive of GPs. I told him that a thousand times out of a thousand I would choose to repair that cut without calling in a hand surgeon, and that nine hundred and ninety nine of those times the two halves would heal perfectly. Twersky just sat there and smiled. It was an Anything you say, Doc, as long as you don’t count on ever fixin’ my thumb kind of smile.”

  Atwater reached over to give him a supportive pat on the shoulder.

  “Harry, you’re a hell of a doctor,” he said. “And nothing Sidonis or his committee can do is going to change that.”

  Steve Josephson maneuvered down the row, nodded a greeting to Atwater, and settled into the seat next to Harry.

  “They just took Clayton Miller up to the unit,” he said. “The man’s doing great. A save of the highest order. After you left, once his breathing was back near normal, he started talking baseball nonstop. He was a pro—a teammate of Satchel Paige in the Negro baseball leagues. And get this: apparently his son works for the Yankees. He says that any time you or I want tickets, we’ve got ’em.”

  “My kind of patient,” Harry said
.

  “What gives?” Atwater asked.

  Harry deferred to Josephson, who detailed the event with all the drama of a fighter pilot recounting a dogfight. Atwater listened, enthralled.

  “Too bad Sidonis doesn’t know what you did,” he said.

  “He does. I don’t think he’s impressed enough to call off the vigilantes, though. In fact, I don’t think he’s impressed at all.”

  “Well, just the same, you guys are really something. I listen to you and I honestly wish I could be on the front lines instead of sitting up there pushing pencils. Say, Harry, what’s the story with Evie?”

  “She’s coming in later this week. Probably the day after tomorrow.”

  Atwater pulled out a black memo book and wrote down Evie’s name and Flowers.

  “She’s a hell of a gal,” he said. “I know she’ll do great.”

  Evie’s headaches, which she had first attributed to allergies, then to stress from her job, and finally to stress from Harry, had proven to be caused by something far more structural and virulent. Harry spent several frustrating weeks trying to convince her to see a doctor and get a CT scan. Finally, she ended up on the neuro ward, with thick speech and a weak right arm. The tests revealed a large berry aneurysm on her anterior cerebral artery, which had bled and then sealed over. Evie was lucky. Rapidly, her neurologic symptoms had resolved. A period of rest coupled with serial CTs was her neurosurgeon’s recommendation. Now, it was time for the bulge in the vessel wall to be repaired.

  “Harry,” Atwater said, “be sure and let me know if there’s anything Anneke or I can do to help the two of you out.”

  “Anneke?”

  Doug’s smile was mischievous. When he and Harry went out to hear music, he invariably showed up with a date—always a different one, and each, it seemed, younger and more attractive than the last.

  “She’s half Swedish and half German,” he explained. He thought for a moment, and then added, “I guess it’s the top half that’s Swedish.”

  “Hail, Caesar, we who are about to die salute you,” Steve Josephson said, gesturing toward the small stage at the lower end of the amphitheater. Caspar Sidonis had just taken his place at the microphoned table in the center of his six-member committee.