Lost Cause
Hedge Mage and Medicine Book 4
SA Magnusson
Copyright © 2019 by SA Magnusson
Cover art by Covers by Christian
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Contents
Chapter 1
Chapter 2
Chapter 3
Chapter 4
Chapter 5
Chapter 6
Chapter 7
Chapter 8
Chapter 9
Chapter 10
Chapter 11
Chapter 12
Chapter 13
Chapter 14
Chapter 15
Chapter 16
Chapter 17
Chapter 18
Chapter 19
Chapter 20
Author’s Note
Also by SA Magnusson
1
I approached the exam room carefully. There were times when patient encounters were relaxing, and other times when I approached them with trepidation, when it was rarely related to something that made sense. Most the time, when patients filled me with dread it was related to behaviors rather than a medical condition. As an ER physician, I had trained for some of the most complicated patients, and I no longer feared heading into those rooms as I had when I was first training. Now I feared seeing patients only where I had to deal either with someone who had significant demands or with a difficult social situation.
This one had both.
Pausing at the door, I reached into my pocket, squeezing the coins I carried with me. I had taken to carrying spell coins with me all the time, and though most of them were mostly protective, there were a few with other purposes. I was still working on trying to create these spell coins more effectively, to use my own magic in the creation of them, but my capacity with that remained somewhat limited.
“Dr. Stone?”
“What is it?” I looked up to see one of the nurses, John—an older man with a sun-darkened face, and wrinkles around the corners of his eyes—hurrying over to me. John was new here, though apparently had decades of experience. He looked like it, and he wasn’t the typical emergency room nurse we usually had at Hennepin General Medical Center. Most of the time, we got nurses who had some experience but were younger. It was hard working in the ER. The pace was challenging, but it wasn’t just the pace that created challenges—it was also the long hours. Many of the nurses worked twelve-hour shifts, and with shifts that long, it was just difficult to maintain over time.
Then there were some nurses who craved the excitement of the ER. I understood that feeling all too well. It was what had driven me into emergency medicine, helping me to find my place within it.
“I just wanted to give you a heads up about the next patient,” John said.
“Something more than Dr. Johnson has already given me?” Eric Johnson was a second year resident, and he had proven himself to be relatively skilled. Hennepin General prided itself on its emergency medicine residency, and we had the best residents apply for our program, which allowed us to be choosy. He was like so many others who came to us.
“I don’t know if he was aware of the son who’d arrived.”
“What about him?”
“Well, he’s wanting us to do everything we can.”
I took a deep breath and nodded. I scanned the chart, looking at it again, though I had already done so when sitting at the nurses’ station before. There was nothing new on there to make it any easier for me. It was a sixty-six-year-old woman with advanced COPD from smoking. With emphysema as bad as she had it, and with her usually on oxygen, surviving illnesses such as what had brought her to the emergency room became challenging. Even more challenging was half of the family wanting her just to be made comfortable while the other half wanted everything done.
Now another son had arrived who wanted to push for aggressive care, I wondered how that would push the balance. Every family had their own dynamics. My own family was challenging enough, and after having lived most of my adult life without having any contact with my father, and minimal with my mother, I understood the challenges of such dynamics. I rarely even interacted with my brother, though he was the one I should have been close to.
“Is she still on BiPAP?”
John nodded. “We have the respiratory therapist in and adjusting the settings, but…”
BiPAP was a non-invasive ventilation. It was how we managed to treat someone before they got to the point of needing to be intubated. Most people we took care of with advanced lung disease had an opinion about intubation. Some of them had chosen never to be intubated. With bad lungs, it was difficult for people to come off of a ventilator, and some people viewed it as life-sustaining, keeping them alive in a way their god would not have intended. Others wanted everything done, and were content to have intubation if it gave them any chance of a longer life.
There were many times when it would give a longer life, and yet the question I always asked those people was what quality of life they were hoping to obtain. I found many people with lung disease didn’t consider it in the same way as cancer. How could they, when breathing was something we did without even thinking about it? Even when they started on oxygen, and even when their oxygen needs were greatly increased, many people didn’t consider their own mortality.
“Why don’t you gather supplies for intubation?” I said, looking at the patient’s blood gas. I could already tell she wasn’t going to do well with BiPAP, and if the family was going to argue about what care to provide, we were going to have to make a definitive decision. Hopefully someone had been assigned power of attorney, which would make it easier for me, but a son strolling in and raising more questions left me doubtful of an easy solution.
Pushing open the door, I quickly surveyed the room. There were three men sitting on one side of the room, all of them likely in their mid-thirties to forties, and one of them looked gaunt, a hint of jaundice to his skin. Either alcohol abuse or a form of hepatitis, most likely. On the other side of the room there was a younger woman sitting next to two slightly older women.
The division seemed clear. Men versus women, brother versus sister, and at stake was their mother’s survival.
She was a gray-haired older lady, and the BiPAP mask covered most of her face, but she was thin, suggesting to me that she’d had advanced lung disease for some time. That fit with what I’d read about her, as well as her needing four liters of oxygen—though from what I had read, she didn’t always use it.
“I’m Dr. Stone,” I said, sweeping my gaze around the room. I found it was best to try to make eye contact with everybody within the room, though someone was bound to take the focus of my energy. “I’m the attending physician. Dr. Johnson has been telling me about your mother.”
“Yeah? Did he tell you we don’t want them here?” the jaundiced man asked.
“We have every right to be here, Carl,” the woman standing off to my right said. She rubbed her eyes, wiping away tears, and looked down at her hands.
“Has Dr. Johnson explained that she has a pretty significant pneumonia?”
“We’ve been through it before,” one of the other sons said. He glared across the room, over his mother, and at the others there.
“This is different. Sh
e’s not been sick this often before,” one of the daughters said.
“What has your experience with her been?” I asked.
“Why don’t you just look at the chart?” one of the sons asked.
“I can do that,” I said. I could tell why Dr. Johnson had wanted to move on to the next patient, but I wished he had been more willing to participate in this conversation. Sometimes the hardest conversations were the ones where you learned the most. I wasn’t sure what I would learn here, though I wasn’t the one who was still in my training. At least, not my medical training. There was a different training I continued to progress through, though my magical training was different to what I had gone through in residency. “It helps for me to sometimes get a sense of what you have experienced.”
“Don’t you need to examine her and start medicines?” the jaundiced son asked.
“Dr. Johnson has already started the necessary treatment.” I stepped toward the bed, touching the IV bag hanging alongside it. Antibiotics were already in, as were steroids to help with the initial inflammation that came with an exacerbation of her chronic lung disease. She had been given several breathing treatments as well, and yet she continued to decline. It was possible that with more time and more medicine she would make a comeback, but it was helpful for me to know what she wanted. “We’re seeing her struggling. At this point, the next step would be to place a breathing tube. Has she ever had that done before?”
“I told you to look at her chart,” the same son said.
I turned my attention to him. He seemed to be the spokesman, or at least he was the one speaking up the most. Sometimes, those were the people I needed to address first, to get them on board with what we were doing. In his case, I suspected he wanted to be engaged. Carl, the jaundiced one, had a certain angry sense to him, though all of them looked angry. Maybe it was anger at the situation, or maybe it was anger at their siblings, but regardless, it was the emotion which struck me most of all.
“I’ve seen that she’s been hospitalized four times this year. It looked like she was hospitalized a couple of times last year. Now, I can certainly go through each of those records, but in the emergency room, sometimes it’s a matter of just treating. But first, I want to know what her preferences regarding her treatment are.”
“She wants everything done,” he said.
“She does not,” one of the daughters said. “She was starting to sign papers—”
“Yeah, but she didn’t sign them.”
“You don’t even know what she wants,” the daughter said. “She’s been living with me, and—”
“She’s been living with you because you took her out of my home,” said another of the sons.
“Because you were stealing from her.” The daughter looked at me, a plaintive look in her eyes. “Mom has been on pain medication. They say it helps her breathing, and Donald there keeps taking her pills.”
“I don’t take her pills,” Donald said. “If you want to drug test me, I’m happy to take anything you need to prove I’m not doing it.”
“Why would I need to do that? You’re selling them anyway.”
I raised my hands, trying to silence them. “I think it would be helpful for us to keep the focus on your mother. What would she want done if she were able to tell us?”
“She told me she didn’t want anything done. She was tired of being in the hospital, and she knew her time was short,” the daughter said. “She understood the next time she came in, she might not be able to have the breathing tube removed. She wouldn’t want to live in that way.”
“She knows every time she’s been sick like this she’s gotten better,” Donald said.
“And you know how hard each time has been on her.”
“I know how hard they’ve been, but I also know she’s a fighter.” Donald turned to me. “You don’t understand. You don’t know my mother, Doc. She is a tough lady. She raised all of us, and then she raised her, too.” He said, pointing to a younger, thinner girl I hadn’t seen before. She was hanging along the far wall, but definitely on the brothers’ side. “Mom wants us to do everything we can so we can keep her alive.”
“That’s not what she was telling me,” the daughter said.
“What do the papers say?” Donald said.
“You know as well as I do the papers aren’t up to date. She was looking to get them updated.”
Donald shook his head. “She hasn’t updated them because she didn’t want to. She still wants me to be involved.”
“Then why did she move out? You know why she did, Donnie, and you know the truth.” The daughter turned her head down and started sobbing again.
“She has an advanced directive?”
“She does, and it says she wants us to do everything,” Donnie said. “I’m the power of attorney, and I am saying I want everything to be done.”
“She was changing that,” one of the daughters said, reaching into her purse. “I have the papers here.”
“Unsigned papers,” Carl said.
“That doesn’t change anything.”
I squeezed my eyes shut for a moment. Unfortunately, unsigned papers did mean something. It meant I couldn’t follow them as the power of attorney. I had to follow the ones we had signed, and they would reflect the wishes we had from a legal standpoint, but that didn’t change the ethical issues at play here. If she was in the process of changing her advanced directive, along with changing who her power of attorney would be, it made for a far more complicated situation. But then, why would I expect anything else? “I’m going to need to see her advanced directive,” I said.
“You have it on file,” Donnie said. “We made sure they had them the last time she came in because we went through this then.”
I glanced at the monitor, looking to see what the settings were for the patient. Her oxygen saturations were still on the lower side, and she was taking shallower breaths, and her upper chest seemed to be retracting more. Even with the BiPAP on, it was still not taking away enough of her work of breathing. Eventually, we would have to make a more definitive decision, and from what I could tell from the siblings gathered around here, the definitive decision was going to be to intubate her. I didn’t like it, and I didn’t think the sisters liked it either, but it might be better for us to intubate and then work through the decision later. “Has she ever been intubated before?”
“I told you, Doc—”
I turned to Donnie, focusing on him for a moment. “Yes or no. Has she been intubated before?”
“The last three times she’s been in the hospital.”
Well, bumblefuck. If she’d been intubated every time she’d been hospitalized, then it suggested she did want to be intubated.
“I’m going to need you to step out into the waiting room and someone will come get you when we are finished.”
Donnie flashed a triumphant grin at the others, and it tore at me. I hated the idea that this family was arguing like this, but I hated more that they had dragged me into it—and worse, I didn’t know what my role needed to be.
They shuffled out, and the younger woman who had been on the sisters’ side came over to me. “I just wanted to let you know she’s been staying with us. That’s my mom, Teresa,” she said, pointing to the woman who claimed the patient had been staying with her. “And Nana was living with Donnie, but with Donnie’s drinking and with the concern about him taking her pills, she asked to move in with Mom. She’s been with us for about a month. She’s done this before, though. She’ll stay with us for a little while, but then Donnie promises to clean things up, and she goes back to live with him.”
“Why does she go back if he doesn’t treat her well?”
“I think part of it has to do with him being the oldest. She thinks she needs to stay with him because of that, but she always forgets what it’s like, and the way he treated her before, and she goes away for a couple months and then comes back. But every time she comes back to my mom, she ends up sick.”
�
�She ends up sick with your mom?”
“No. She’s sick because she’s been with Donnie. You see, he still smokes, and…”
God. What had I got myself into? The advantage in the ER was that this wasn’t a situation I was going to have to manage in its entirety, but it still stunk. I hated being caught in the middle of this family drama, but hated them putting their mother in the center of this family drama even more. She didn’t deserve that. She was suffering, her illness claiming her, and what she needed was an opportunity to find peace.
I could offer her that peace, but it would take a palliative care conference to help her more. It might even require an ethics committee consultation, though that wasn’t going to be my role.
The granddaughter left the room, leaving me alone with Mrs. Reynolds. I approached the bed and touched her on the shoulder. “Mrs. Reynolds. I’m Dr. Stone, and I’m working with your family to try to take care of you as best I can.” She blinked open her eyes, and in that moment, I had a swell of hope that maybe I might be able to talk to her, and I might be able to use her alertness. If I could, then it was possible I could have her make the decision. “Do you want a breathing tube placed?”
Her eyes drifted back closed again. She wasn’t going to be able to help, and I didn’t know why I would ever have expected her to be able to help. Instead, we would have to follow her advanced directive, regardless of whether or not I agreed with what it said.
Stepping back into the hallway, I found Eric Johnson, and pulled him off to the side. “She’s going to need to be intubated. Either you can do it or you can call anesthesia down, and they’ll take care of it.”
“They’re going to intubate her?”
Lost Cause Page 1
