Although Jack had been in practice for three years, he’d learned enough to make several things clear; patients were not statistics, he had limited control over events; and finally, hubris meets reality. Divining the future, as tempting as it was for physicians, was a fool’s game. To give in to the family’s understandable pleas to know was to gaze into a hazy crystal ball. It was a worse than useless search, a futile, and perhaps an arrogant attempt to predict an unknowable future.
In Jack’s naive days, he had intellectualized the answers to these questions. Now he found that his reaction to each situation, combined with clinical facts, was a better way of being forthright with patients and relatives.
“Tom, I’m worried about Rachel.”
“Me, too.”
“We’re exhausting our options and that’s keeping me awake at night.”
Frank statements were Jack’s best way of making Rachel’s problems real to Tom.
Cases like Rachel’s were tough for him. Decisions about care, “informed” decisions, belonged to his patients and their families. The ‘informed’ part was the problem, since how and what to present to the family would always reflect Jack’s prejudices. Early in his career, the double standard of consent troubled him; it wasn’t his to give, but, in truth, he controlled it. Today, informed bias was part of the package; part of what Jack had to offer his patients, and he refused to make excuses for it.
Jack pulled his chair to the front of the desk to sit next to Tom. “Time’s not on our side. If Rachel hadn’t been healthy to begin with, she’d be long gone by now. Even the strongest among us will eventually succumb to the ravages of persistent severe infection.”
Tom’s voice faltered as he whispered. “What are you saying, Jack? You think we should let her go?”
“Not on your life. I’m pushing on with everything we have available, but I won’t mislead you about how bad this is.”
“What will you do?” he asked softly, his eyes pleading.
“I wish that I could offer something new, but we’ve been through this with multiple consultants, including the world’s best clinicians. We’re doing everything possible.”
“What about more surgery to clear out the infection?”
“Surgery is risky. Even so, I’d go for it if we had some assurance that it had the potential to help. It doesn’t. If over time, her infection becomes localized, like an abscess; we would drain it either by surgery or some other means.”
Tom reddened. “You want to continue to do exactly what has failed all along. How does that make any sense? That’s the definition of crazy!”
“It makes sense if it’s all we have, and everything else is worse.”
Jack studied Tom for a moment. “I hate saying these things. They sound awful and I can only imagine how listening to it might affect you. It’s not my job to rob you of hope, but there are tough times ahead and pleasant or not, you’ll always have my honest opinion. With infection of this type, I’ve seen remarkable turnarounds. Everything we do from this point sets the stage for recovery, if we can sustain Rachel, and if we can just get a break.”
Jack stared at Tom. “And one more thing. You must do something about Maxine.”
“What can I do about her? She’s not going to change her personality to suit you or me.”
“Take this for what it’s worth; doctors and nurses ain’t saints. We move toward what pleases us and avoid what’s painful. Rachel’s care won’t be as good as we’d like it to be if nobody wants to go into her room and everyone wants to get out as quickly as possible to avoid Maxine.”
After the encounter with Tom, Jack sat sipping coffee with Ben Davidson in the doctors’ lounge. The room contained comfortable leather sofas and chairs, shelves filled with books and magazines, a TV hanging from the ceiling, and most importantly, the eternally full coffee urn. Ben was sixty-five, husky, and had a thick salt and pepper beard. Ben was the Chief of Internal Medicine and Jack’s mentor. Their relationship had matured over the last few years and they were more like equals now.
Jack turned to Ben. “How do you handle these frustrations, year after year? I’ve worked my ass off on Rachel’s case, and I still can’t get anywhere. I’m about to give up.”
Ben peered over his half glasses. “You’re not giving up. Most of the old-timers around here have faced similar cases, and if there’s one thing I’ve learned, you can’t surrender.”
Ben always had a morality tale for any occasion. Jack listened as Ben related his Vietnam story. Ben rarely talked about those times. “I hate the word, epiphany, Jack, but in Viet Nam, I had mine…
Pleiku, Central Highlands, Vietnam; 1968.
What am I doing at a Medical Clearing Company in the middle of the jungle? Ben thought. I’m an internist.
The distant thump, thump, thump, and then the distinctive engine roar of the approaching UH-1 Medevac helicopter ended his reverie and his fantasies of what he’d be doing if he were anywhere else but here.
Master Sergeant Carter, a sixteen-year veteran and Ben’s most experienced corpsman stared at the tent’s entrance. “Get ready.”
You never know what’s coming next, Ben thought, as the helicopter settled on the red cross painted on the arrival pad. The 150 miles per hour, blade-driven winds kicked up dust and shook the forty-foot tent that housed the Medical Clearing Company.
Ben thought that after six months in the field, he’d seen it all, destructive bullet and shrapnel wounds, Napalm burns, amputated limbs, and a variety of tropical diseases he’d only read about in textbooks. What he hated the most were the white phosphorus grenade injuries where the metallic fragments remained bubbling inside the open wound, cooking the tissues.
Ben, nurses, and corpsmen cued up at the entrance awaiting the arrival of the injured. Nurses and corpsmen would peel off with each injured soldier, moving him to their appointed work area. Each emergency treatment area contained two sawhorses, stretcher supports, placed under a bright overhead light and surrounded by open olive-drab medical cases containing virtually everything required to treat and stabilize a war-wounded soldier. Ben would move from litter to litter, making assessments, ordering treatments, and performing minor surgical procedures, more procedures than an internist would perform in an entire professional career.
Ben had stabilized two patients and then approached the next stretcher. The nurse and the corpsman were in quiet conversation. When the nurse caught Ben’s eyes, she shook her head. The message was clear—spend your time elsewhere.
The soldier could not have been more than eighteen. Ninety percent of his leg from the middle of his right thigh was gone. His ashen cadaverous body was cold to touch, and in spite the severance of the large vessels in his amputated limb, there were no signs of active bleeding.
“I can’t get a pulse or blood pressure,” Sally Bohrman, a twenty-three-year-old RN said. “Pupils are fixed and dilated.”
Ben confirmed Sally’s observations. “We’re too late. Let’s call it a day.”
Just as Sally began raising the sheet to cover the soldier, Harrison Stanley, a vascular surgeon forced his way between Sally and her corpsman. “What’s going on here?”
Experience had made it clear to Ben and the nurses that this was not merely a question, but a challenge. Ben worked with physicians of every ilk in his civilian and military life, but he’d never disliked anyone more than Harrison Stanley. Harrison’s every word, every gesture, and every action said, “Get the hell out of my way, you incompetent fools–let a real doctor in.”
Harrison should have been in the operating room working on the wounded, but he’d sometimes wander into the patient receiving area for a power fix.
Ben turned to Harrison. “He’s gone. No vital signs. His pupils are fixed and dilated.”
“Move it,” Harrison shouted as he began external cardiac massage. “Bag him,” he said to indicate that the corpsman should begin using a breathing bag to ventilate the soldier’s lungs. “Open that IV full blast and let’s get b
lood into this guy stat.”
Sally and Ben looked at each other, shocked, speechless.
The soldier’s chest expanded and contracted with every squeeze of the breathing bag in the corpsman’s strong hands. Vigorous chest compressions by Harrison sitting astride the soldier pushed his chest wall back toward the spine.
The soldier’s skin remained ashen.
“What are you doing, Harrison? This guy’s gone,” Ben said.
As he continued external massage, Harrison stared at Ben and through gritted teeth said, “You see that silver leaf on my shoulder, Doctor? Do as ordered.”
Still in shock, Ben thought, what an arrogant prick. This is a total waste of time. I have others to see.
They breathed for, massaged, and transfused the young soldier, but he still showed no signs of life.
Ben took his turn doing chest compressions, and after ten minutes said, “That’s enough, I can’t waste any more of my time. We have others who need our help.”
With hatred and disgust on his face, Harrison pointed a long finger at Ben. “You’ll stop when I tell you to. Keep pumping.”
Knowing and frustrated looks passed among Ben, Sally, and the corpsmen as they continued the pointless resuscitation.
Suddenly, the absorbent pad over the amputation stump turned bright red and when Ben removed the dressing, red blood, arterial blood under pressure, squirted across the room. Ben reached for a hemostat and clamped the bleeding artery.
My God, Ben thought, he’s alive–I can’t believe it.
Ben’s mind raced. I could have killed him. How many others have I let go when I thought they were dead? Who’s the arrogant prick now?...
“That was a harsh lesson, Jack. One I’ll never forget.”
Chapter Two
Circumstances couldn’t be much better, thought Harmony Lane as she signed the last sheet of the eight-page form. She’d applied to the staff at Brier Hospital in the ultra liberal, anything-goes Berkeley community, and one of the best hospitals in the San Francisco area.
She’d come to accept, and even enjoy, the name her hippie parents found inspiring at her birth, though she sometimes thought there was an element of whimsy or altered brain chemistry in their choice.
Thank God, they rejected their first choice, Penny Lane.
Harmony (Harm to those who knew her well) had grown up with several friends whose parents felt that as they named their children, they were acting in faith to the ideology of their generation. They were the ageless hippies who’d never progressed beyond their ‘60s experience, keeping it alive in the names of their blameless children.
Anyway, Harmony Lane, M.D. sounded good enough for her.
She laughed when her parents sat with their ‘60s and ‘70s scrapbooks reminiscing over how their generation had changed the world and all the insight they’d obtained from the funny-smelling cigarettes or those LSD laced sugar cubes. With the benefit of time and experience, Arnold and Elizabeth Lane had become their own worst nightmares. They’d evolved or devolved into prototypical suburban parents, almost, but not quite Republican, yet the invisible ties that bound them to the past still shaped their lives.
Harmony was the most stable and mature member of her family. At fifteen, she was fortunate to be self-motivated and disciplined. She’d continued to resist all their well-intended seductions. “Study later Harmony. Let’s party tonight. Why not take a year off and study in India?”
She read extensively. At first, it was the typical teenage fare, some classics, and then primarily science fiction and fantasy, especially story books that extrapolated today’s scientific principles into the future, such as those of Douglas Adams and Arthur C. Clarke.
School was easy for Harmony; straight A’s. She had many girlfriends, played the clarinet in the school band, and in her junior year served as editor of the school newspaper. Tall, blonde, and gangly she looked like Twiggy, the rail-thin fashion icon of the ‘60s, and endured the unending gibes about her pectoral inadequacies.
She yearned for the Three-Letter-Men, but attracted the nerds.
A 3.97 GPA, an SAT score of 1480, activities, and recommendations galore, earned Harmony a full academic scholarship to USC in Los Angeles.
Harmony roomed with Sally Hayes, a blonde valley girl, smart as hell. Sally majored in communications and minored in the pursuit of pleasure and thrill.
On the day Harmony dragged her suitcases into their room and introduced herself, Sally walked a circle around her new roommate and checked her out. “I really have my hands full with you, honey.”
Sally’s magic, clothes, makeup, and attitude, made a remarkable metamorphosis. Harmony, pleasant looking at best, was suddenly a knockout.
Still serious at heart, Harmony struggled with her newly found popularity. Life was easier, people were more accommodating and more attentive, and her phone rang constantly for dates.
Harmony’s one serious relationship with a junior pre-med student ended badly—well, she thought, at least I’ve lost my virginity.
After scoring high on the Medical College Admission Test (MCAT), they accepted her at two medical schools in California and one in Illinois. The allure of the University of Illinois, far away from San Francisco, and her mother made Chicago irresistible.
The first two years of medical school were a blur. Months passed without seeing the sun. The third and fourth clinical years were a revelation. For the first time, Harmony knew that she’d be a physician.
She loved working with patients, exercising her skill and knowledge to their benefit. Once committed to her patients, Harmony’s maternal and protective disposition made her rage against her limitations as a physician and the frustrating medical bureaucracy.
She rebelled against the seduction of specialization, opting instead for the residency program in Family Practice in Santa Rosa, California, where her one-woman crusade continued against the realities of medical practice. Harmony refused to accept futility in the care of her sickest patients. Her refusal to give up, brought her behavior to the attention of the program’s director, Alice Hoffman.
Alice had managed to live multiple lives in her forty-five years. She had two of her three children in college, and the third in medical school. Thanks to her husband Ronnie, and in spite of all the difficulties posed, they’d made it work. They were fortunate that Ronnie, a gifted software system designer, worked for a Silicon Valley company that was more interested in results than a time card.
Alice was in her third year of a Radiology fellowship when one morning she broke the news. “I don’t think Radiology is for me, Ronnie.”
“It’s a little late, don’t you think?”
“As long as I’m living, it’s never too late.”
“You know I’ve been totally supportive of your training, but in truth, I’m looking for some respite in our busy schedules. Are you sure you want to change now?”
“I’m only sure that I can’t see myself doing Radiology for my entire professional life. The only part of it that I love is the few minutes of direct patient contact I get. I know I need more. I’m thinking of applying to the Santa Rosa family practice program. What do you think?”
“You’re not going to become a surgeon or a psychiatrist or a cowgirl after that, are you?” he said smiling.
She smiled and embraced her husband. “No promises honey. You’re the best.”
Alice was able to get credit for her previous training and completed the Family Practice program in two years. She stayed on as faculty, and five years later, became program director.
“Have a seat, Harmony. We need to talk.”
“What’s up, Alice?”
Alice sat behind her glass table with the gleaming mahogany antique roll-top desk behind. Large framed pictures of Alice, her husband and their kids hung on the wall. She put on her reading glasses then picked up and opened Harmony’s personnel folder. “You’re one of our very best residents, Harmony...”
“I’m waiting for the ‘but’...”
“Nobody doubts your skill and dedication, but you don’t know when to stop; when to let go. Every mature physician eventually learns that we have limitations. As much as we want to help everybody, often we can’t. We share that frustration, but you’ve let your emotional involvement in the care of your patients send you searching the fringes of medicine for some solution, some panacea.”
What is she saying? I can’t believe what she’s saying.
Harmony stared across the table. “You’re accusing me of inappropriate treatment of my patients. I’m trying so hard. Shouldn’t I go the limit?”
“If you like, we can get into the details, but hear me out first. You’re in a teaching program. We supervise and scrutinize your work. You are not yet a free agent. Nurses, attendings, and several of your fellow physicians have said that in struggling to save your patients, you lose all perspective, pushing way beyond what’s appropriate and ignoring the consequences. We’re also concerned with unorthodox prescribing. None of this is so extreme that we’ve had to intervene, but it resulted, at least once, in complications. All of us do ‘off label’ prescribing, but, it seems, you’ll try anything.”
“I can’t believe you’re saying these things to me, Alice. If anything, people around here give up too soon. They’re frightened. They refuse to approach a patient’s problems aggressively, and won’t try therapies, which, if they can’t harm, might help. Everyone is practicing as if a trial lawyer were looking over their shoulders, and I think it’s changing medicine for the worse.”
“Look, much of what you say is true, Harmony. We could spend all day discussing these issues, but in my opinion, and in the view of others that I respect, you have a problem. I want it resolved before we lose you from our program. Do I make myself clear?”
Harmony stood facing Alice. “Yes, Alice. I’ll try to curb my enthusiasm.”
Alice started to say something, but stopped.
The Plague Within (Brier Hospital Series) Page 2
