I left specific orders for additional blood tests throughout the night and set parameters for the nurses for deciding when and if they should call me.
Setting guidelines for nurses reassured them, and often saved me from unnecessary calls through the night. My resident’s wise words still echoed in my mind, “Whether you think patients need them or not, write ‘as necessary’ orders for pain pills, sleeping pills, constipation, diarrhea, anxiety and anything else you can think of, or you can bet they’ll call you sometime in the middle of the night to deal with that problem.”
It was midnight when I finally finished my reevaluation of Helen Martin’s condition. She was stable for the moment.
Enough was enough, I thought. I love my work, but I was tired and anxious to get away from the hospital for home and needed sleep.
The main lobby doors had just whooshed open for me when the code blue alarm sounded, followed by the speakers blaring, “CODE BLUE FIFTH FLOOR EAST.”
Shit, I thought. I’ll never get out of this place.
Relieved the code wasn’t for an ICU patient, I rushed to the elevator bank, and fortunately, the car waited. Within fifteen seconds, it reached the fifth floor. The ward clerk standing at the elevator doors, said, “This way, Dr. Byrnes. First room on the right.”
I entered the brightly lit room jammed with people. Nurses were performing two person CPR, on an elderly, wasted man. The room reeked of death and excrement.
“What’s the story here?” I asked the charge nurse.
“Mr. Bradley Olsen, a patient of Dr. Polk’s, is an eighty-five-year-old gentleman with advanced lung cancer. He’s here for terminal care.”
Not that name again, I thought.
I stepped back, annoyed, angry, “Why are we resuscitating this patient?”
“We had no choice Dr. Byrnes. We’ve tried, but couldn’t get a DNR from Polk. We’ve been asking for one since Mr. Olsen’s admission.”
The DNR, “Do Not Resuscitate” order while not required by law, served to prevent such a travesty as this case; the resuscitation of the terminally ill. Absent a DNR order even in hopeless cases, the staff faced the likelihood that they would be prolonging suffering and senselessly extending the inevitable process of dying. These resuscitative efforts demeaned all involved, from the staff participating, to the patient, hopefully insensate. The act erasing the last remnant of his dignity.
I recalled a particularly disturbing case during my residency. In the terminal stages of AIDS, the patient’s family was overcome by grief, and refused to consider a DNR order. This refusal forced the staff into a full-blown resuscitative effort in a patient fully aware of the assault, which included electrical defibrillation. I still recoiled at the images of that patient, eyes wide open, having his chest compressed, and awaiting the next series of electrical shocks in the futile attempt to control the irregular beats of his failing heart.
There are many things a hell of a lot worse than dying, I had thought.
These obscenities threaten the sanity and the morale of nurses and physicians. They led to the creation of medical perversions such as the slow code. This code blue simulation was only a little less demeaning than the resuscitation of the terminally hopeless. Here the staff went slowly through the motions of a resuscitation, a child’s game of pretend, the sole objective being fulfillment of the requirements of law while attempting to defend the patient’s and their own last shred of self-respect.
Invariably, following these efforts, some member of the resuscitation team would utter, “If somebody ever does that to me, I’m returning from the grave to haunt all those involved.”
Some physicians were unwilling to deal with the issues of terminal care for their own set of reasons, none justifiable in my opinion. Failure to write an appropriate DNR order had consequences. Some physicians, when called in the middle of the night and informed of a CODE BLUE, would terminate it immediately. Joe Polk, I suspected, merely balked at the idea of a DNR order because it had come from the nursing staff.
The misuse and abuse of resuscitations have resulted in well-intentioned media campaigns designed first, to inform patients and families of their options, living wills and advanced directives for health care, and second, to get them signed and in place well before they’re needed. The problem with this approach is that directives, made in the abstract, when the individual is well, often did not reflect a patient’s desire when his or her life is actually in jeopardy.
Finally, when the nurses reached Polk asleep at home, they obtained a DNR order for Mr. Olsen and stopped the Code Blue.
Chapter Eighteen
When Polk hung up the phone, his wife Marion said, “Was that about Brad Olsen?”
“Yes, I called off the resuscitation.”
“It’s a blessing. That man suffered enough. At least he’s at rest now. Why were they trying to resuscitate him in the first place? Wasn’t he terminal?”
“I wasn’t about to let those damn nurses tell me what to do. They were pushing me for a DNR order from day one of his admission. Who do they think they are, telling me when to write orders? What’s the next step? Turn over my practice to them?”
Marion listened in disbelief, “What are you talking about? You’re writing orders in rebellion against what nurses are saying, instead of what’s good for your patients?”
“You don’t understand. Nurses have to know who’s running the show in the hospital. Nurses can’t constantly second guess me, or patient care will suffer.”
The knee-jerk response, outrage at any challenge to his authority, she expected, but his logic in explaining his actions was more than faulty. It was wrongheaded, destructive, and not up to his usual high standards of deceit.
What’s going on here, she thought?
The night charge nurse, Carla Watts was surprised at three-thirty in the morning when she discovered Joe Polk pouring over Helen Martin’s chart at the nursing station. She didn’t know how he got into ICU, but she knew he had no business here.
Something’s off with this man, she thought. His dark eyes and intense stares were disquieting, the rattle of a snake as you walked through the brush.
Carla wanted to avoid confrontation, if possible. She hated to admit it, but she, like many of her nurses, found the infamous Dr. Polk intimidating. Carla was dedicated and responsible. She could not let this pass. She furtively glanced back over her shoulder, making certain she had a clear pathway for escape, then began, “Can I help you, Dr. Polk?”
He raised his head from the chart and stared directly at Carla.
I can’t turn away, she thought, starting to tremble.
“I’m reviewing Mrs. Martin’s chart. She is my patient.”
“Dr. Polk, sir, you’re not on her case, and I must ask you to return the chart to me and leave the unit.”
His response unnerved her. He turned his neck and stared upward, a questioning gesture, as if he hadn’t understood her request.
Absent a response, Carla continued, “Sir, I must ask you to leave.”
Polk startled her as he sprang up, rattling the table and throwing his chair backwards as it tumbled onto its side. His tightly drawn mouth revealed a snarl of white teeth as he stared into the distance with the face of barely controlled rage.
Without a word, he turned and left.
Carla’s heart beat rapidly. Relieved, but still rattled, she sat at the desk.
Chapter Nineteen
I succeeded in my second attempt to leave the hospital, and crawled into bed at two a.m.
When I opened my eyes, the morning sunlight was shining through my window and I gave thanks that I’d made it through the night without any calls. Answering calls all night was the downside of caring for ICU patients, so this morning I felt fortunate for the little sleep I caught. I’d been restless upon retiring, the product of stress and worry. I desperately wanted Helen Martin to get through this thing. In addition, ignoring all the other surrounding pressures was difficult. Restful sleep was the price
.
“No problemo,” I said to myself, “anyone can work with a full night’s sleep.”
After a bite, shower, and shave, I drove through the light morning fog, arriving at ICU as morning report ended. I chatted a few moments with Beth then sat with Helen’s night shift nurse and got a detailed report. The only significant development was further improvement in Helen’s awareness, though she remained confused.
Beth waited in the nurse’s lounge. I took the chart and vital signs clipboard and entered.
She smiled.
How I love that smile, I thought. I can feel the warmth surging through my body.
“Well, what do you think?”
“Think about what?” I asked, totally confused.
Beth smiled. “Helen…your work…let’s focus.”
I leaned back on the chair and replied, “She’s doing better. The major threat, the bleeding, has stopped. Her kidney function is improving, as is her mental status, though on that front she has a way to go. Although she’s less sleepy, she still doesn’t respond appropriately. We may be missing something. It’s too soon to begin chasing other explanations. We’ll wait a while longer and see how she does.”
“The phone in ICU rang all night with inquiries about Helen,” Beth said. “She sure has a following at Brier. People are upset, and it’s no surprise that they are raising questions about her care.”
I put my head down on the table and said, “I feel as if I’m in a fish bowl with everyone looking over my shoulder. This much pressure won’t do me or Helen any good.”
“I hear Sixty Minutes wants to meet with you today to discuss Helen’s case,” Beth said with a straight face.
I lifted my head from the table with a smile, and said, “I wouldn’t be a bit surprised. That would be better than The National Inquirer.”
“Ease up. You’re doing the right things, and Helen’s getting better.”
“I know, but this is like taking care of a doctor or his family. With all the best of intentions, something often turns to shit.”
I grabbed the phone, called Chuck Martin, and described Helen’s condition in less rosy terms than I’d used with Beth. I didn’t like to ‘drape crepe’, the term docs used defensively by presenting a loved one’s condition as worse than it was. I knew from experience that we could avoid trouble by portraying the prognosis as guarded until I was certain the patient would make it. Death or severe complications that came when the family’s expectations were at their highest, was the worst possible scenario.
I turned back to Beth. “The formula for being sued is simple; surprise plus bad outcome equals a visit to a malpractice attorney. I understand it, but it’s troubling. With radio, TV, newspapers and magazines, and now the Internet, we have no shortage of medical tragedy, yet individuals and families are still shocked when it happens to them. It can’t be that we don’t relate to what we see. Look at the public’s reaction to disasters. The truth is, we just don’t think it can happen to us.
“Worse still, is the propaganda from the medical establishment and media, which has succeeded, beyond their greatest hope, in making people believe every medical problem has its solution either with high tech procedures or wonder drugs. The truth is much simpler; in most cases, there’s no substitute for a caring, skilled, and attentive physician doing his best with a patient who is plain lucky.”
Beth was off for the day I leaned over to kiss her. We would meet for dinner.
Chapter Twenty
Arnie Roth asked me to consult on an ICU patient. Francisco Carino was seventy-two, and had developed persistent diarrhea with dehydration and mild kidney failure following a total knee replacement. It had been rough going because of the difficulty in treating the illness and the extreme anxiety of the family, especially Maria Carino, his wife. I’d done my usual, handing her my card with phone and pager numbers. For the first time in a while, I regretted saying, “Call me any time.”
Maria obliged, calling me five or six times a day and paging me at all hours. The calls were anxiety driven, but my best attempts, with detailed explanations and optimistic predictions, did little to stem her misgivings. In addition, she’d managed to infect other members of her family with the virus of apprehension.
“Francisco’s going to do well,” I tried again. “We’re getting the diarrhea under control and his kidneys should get better soon.”
“He’s gonna die!” she screamed. “He can’t live without kidneys, even I know that.”
“He’s not going to die, Mrs. Carino. Everything’s under control.”
“Give me a moment, Doctor,” she said, moving across the dimmed waiting room to confer with her family in the far corner, especially her oldest son Bruno.
Moments later Maria and her son returned. Bruno was a burly longshoreman and approached, standing a few inches from my face.
I recognized this is an act of intimidation, and thought, why does he think it’s necessary?
“We appreciate all you’ve done for Papa,” Bruno said, “but we think it’s time for another opinion.”
“No problem,” I said. “We have some excellent internists and gastrointestinal specialists at Brier. Would you like me to call someone?”
“We’ve been asking around, talking to friends and family. What do you think about asking Dr. Polk to help with Papa’s case?”
Oh, my God. I must have heard that wrong, I thought.
“Excuse me, I didn’t get the name,” I said, hoping I’d been dreaming.
“Dr. Joseph Polk, you know him, don’t you?”
“Of course. Dr. Polk has been practicing here for many years, but he may not be the right consultant for your dad.”
Bruno pursed his lips and squinted his eyes. “It’s not that we don’t trust you or appreciate all you’ve done, it’s just that we’d like someone to see Papa who has been in practice for more than a few months. Dr. Polk sure fills that bill.”
What could I say? Polk was the last physician on earth that Francisco Carino needed.
Bruno stared at me then threw up his hands in frustration. “I don’t know what the big deal is all about, Doctor. We just want another opinion, that’s our right isn’t it?”
“Look, Mr. Carino, it’s not merely that Dr. Polk isn’t the right consultant for your dad’s case, but he and I don’t get along. That’s not likely to be helpful in the care of your dad. I’ll do what you wish, but you’re entitled to understand what you’re getting into.”
“Maybe it’s time for you to leave Papa’s case, Doctor?”
“That’s your choice,” I said, equally annoyed. “Say the word, and I’m out of here.”
Maria, now more anxious than ever, said, “Let’s not rush anything, Bruno.”
Before Bruno could answer, I had a possible out. “I do have a suggestion.”
“What is it?” Bruno snarled.
“Too many physicians caring for a patient can create problems. Orders get confused or tests are duplicated. Someone needs to be in charge. I’ll ask Dr. Polk to consult, but only if you will agree with my terms.”
I shouldn’t have said the word terms. Too provocative.
“What now?” Bruno said, glaring.
“I’ll ask Dr. Polk to review your dad’s chart and his treatment. We’ll consider any suggestion that can help your dad, but under no circumstances is he to write orders or take control of your dad’s case.”
Bruno reddened. “Who the hell do you think…?”
“Enough,” Maria shouted.
As Bruno frowned and turned to go back across the room to consult with the family, I said, “If you don’t agree with this suggestion, you’ll have my notice that I’m unable to continue treating your dad. Talk it over with your family and with Dr. Roth.”
Bruno glared at me, turned, and walked away.
Later that day, Arnie Roth called, “You sure stirred up a hornet’s nest, Jack.”
“What could I do? Polk on this case, writing orders, ordering tests. That would be an u
nmitigated disaster. You’re the boss, Arnie. I’m just a consultant. Tell me what you want me to do.”
“I told the Carinos that I agreed with you, and they’d be making a big mistake if you were no longer caring for Francisco. They were disgruntled, but agreed to your terms. Don’t take any of this personally, Jack. They’re a demanding group, accustomed to getting their own way.”
“Okay, Arnie. You’re the boss. Give Polk a call.”
“No, you go ahead, Jack.”
“No, you’re the primary. You’re the one who calls in consultants.”
“No, Jack. You know what’s going on. You’re running the case.”
“Arnie.”
“Jack.”
Shit, I thought, and then I began to smile at the absurdity of the whole thing.
I dreaded the next step, calling Joe Polk. I tried to analyze my revulsion. It wasn’t ego. I’d worked with all types through medical school and in training, often in a subordinate role— never a problem. The answer was obvious; I didn’t respect or trust the man.
My hand hesitated over the phone, paralyzed fingers unable to dial Polk’s number. Finally, I forced the issue. “This is Dr. Byrnes, is Dr. Polk available?”
The office manager’s hostility oozed through the phone line. “Dr. Polk is busy. Can I tell him what this is about?”
A reprieve.
“Tell Dr. Polk that the family of our ICU patient, Francisco Carino, would like him to consult on the case.”
“I’ll give Doctor the message.”
At five p.m., during afternoon rounds in ICU, Joe Polk swaggered in smiling, his dream come true. He grabbed Francisco’s chart and sat at the nurses’ station across from me.
You’re bigger than this, Jack, I told myself.
“I see your asses are in trouble on this case. Not to worry,” said Polk, reveling in the situation. “Maybe you’re not so smart after all?”
First, Do No Harm (Brier Hospital Series Book 1) Page 14
