Seven Patients

by Atul Kumar

  Jack looked at us with a look of approval if I wasn’t mistaken. “Cindy, I’m the one with a rep for pissing off patients, but I think you might have just stripped me of my crown. I don’t think you did anything wrong per se, and we did had the right to search his belongings, including his phone, when he was unconscious as part of our effort to save his life. When you testify, just say you were searching the phone for an emergency contact or next of kin, not for girlfriends.

  “We still don’t officially know if he has HIV. BUT, if we put him on a psych hold, he loses his rights and we can test him that way. If he turns out to be positive, and if we can prove he knew about his disease while he was fucking around without telling his partners about it, we’ll have to get the police involved. I know just the detective to call. I’ll get on it. You guys debrief Clyde; this might even get a reaction out of him.”

  We turned to leave and Jack called out to us as a passing thought, “Guys, make sure to document the hell out of everything on this case, its serious CYA time. This is going to get messy.”

  ~~~~

  Dr. Clyde was doing a lot of silent nodding as Cindy and I filled him in on what happened in the ICU conference room. He’d occasionally ask a question here and there, but he mostly just listened. He commented after our story was finished. “Well, we obviously can’t go through his phone now. How do you know he has at least four girlfriends Raj?”

  “Well, I just went to the ‘favorites’ section on his phone and there were four female names there. So I took a picture of them with my phone, along with their phone numbers. Most people keep important numbers under that heading. You know, like ‘Home’ or ‘Mom’ and typically a few best friends.”

  “So you don’t know that they are his girlfriends per se. You just know there are four female names on his quick dial list? They could be red herrings, i.e.—he might refer to his mother or sister by their first names.”

  “Yes sir, Dr. Clyde.” In all honesty, that thought had never crossed my mind, but was very rational of Clyde to conclude.

  “Certainly we can say that going through his phone was required emergently in an effort to locate a contact that could provide further medical history critical to saving his life. Thus, looking through his phone is kosher. Also, there are two separate female nursing notes commenting on his rude and crass treatment towards them. That helps demonstrate his poor regard for both women and authority. Make sure you both document exactly what transpired this morning as well as his aggression when requested to comply with standard medical testing and care.”

  Dr. Clyde straightened up in his chair, stretched his arms, took off his glasses, rubbed his eyes, and threw his spectacles across the table. Staring hard into the distance at nothing in particular, he finally spoke, “Well, what we have here is a … how do I put it? A mess.”

  After several moments of uncomfortable silence, Cindy was the first to break it, “Well, we didn’t technically do anything wrong.” I always find it amusing when even the nicest people refer to a situation with “I” when things go well and either “we, us, or team” when something is awry. One of the easiest ways to exude humility in medicine is to always use the third person—for both good and bad.

  “No, nothing was wrong. Perhaps not handled as tactfully as possible, but we’re not in violation of any laws or hospital rules. In fact we saved his life and his recovery has been fantastic, so that’s the upside. The downside is this has become a very touchy case. He’s likely to sue us for some cockamamie reason or other, either discrimination or maltreatment or God knows what else. The other, more pressing issue is that he’s likely going to continue to infect other innocent people with HIV as soon as he gets out of here. It’s definitely a gray area. We have to report cases of HIV/AIDS, but technically we don’t have the diagnosis confirmed. The question is where to go from here?”

  More awkward silence as we all pondered his question.

  This time I broke the silence. “Why don’t we get an ethics consult?”

  “Yeah, that’s a great idea.” I was happy with Cindy’s enthusiastic support.

  “Normally I’d agree, but due to the economic downturn, that position was dissolved about a year ago.”

  So much for my brilliant idea. I figured I’d throw out another one. “Can’t we just scare him into getting tested for HIV, or strong arm him somehow?”

  “Well, from what you’ve both told me, he’s too smart for that and knows his rights. He’s demonstrated his knowledge of how to work the system in his favor. Also, fear is a poor motivator in medicine. Just look at the continued rates of smoking and obesity despite widespread public awareness of lung cancer and the risks associated with being overweight.”

  “Perhaps we can place him on a psychiatric hold and then test him?” Cindy added.

  “I was thinking about that, Dr. Lee, but what are our grounds for placing him under a 5150 hold? We can’t place him on a 5150 just because he got a little upset and ran at you two. We have patients threatening to attack staff and physicians all the time. Calling security is all a first time offense warrants unless there is any form of physical harm; in that case a patient simply goes to jail.”

  We were getting nowhere fast. Stuck in a limbo of stupid laws requiring us to heal someone who had no qualms about ruining the lives of others. That’s when I noticed an ephemeral glint in Dr. Clyde’s eyes. I knew he’d come up with something. I just didn’t know what. He’d been doing this for decades, but the current situation seemed to stump even him. His next words were a testament to his brilliance, though I didn’t realize it at the time.

  “Well, I think perhaps we should all take a step back and let Jack handle this case for a while.”

  “But Dr. Clyde, I feel quite comfortable managing AIDS, and we had plenty of tough patients in New York …”

  “Thank you, Dr. Lee. I have no reservations about your knowledge, credentials, and ability; but I think given his aggression towards you and other females, it is safer if you allow Jack to assume care over Jacob beginning immediately. I’ll be available for consultation should the team need my input; otherwise I think in Jacob’s management, less is more. Thus, we need not formally round on him any longer.”

  “But …” Cindy tried to argue, but the decision was clearly final.

  “Thank you for your time and for informing me of this situation, Drs. Raj and Lee.”

  That concluded our meeting, and completely changed the course of events in Jacob’s management.

  ~~~~

  I ran into Cindy the next morning looking through Jacob’s chart. “Hey, I thought you were off the case?”

  “I am, but that doesn’t mean I can’t still follow what’s going on. We’re all on the same team after all. Actually, Dr. Clyde didn’t say you were off the case. He just said that it was to be handled by Jack. My evaluation is shot to hell, but it doesn’t mean that you can’t still learn from Jacob. He’s an interesting case, both medically and socially, plus you have the most rapport with him.”

  Great, just what I wanted, to have more work. Don’t get me wrong, I don’t mind learning, but I also don’t mind going home earlier and having to see one less patient, especially a pain in the ass patient like Jacob. But of course I couldn’t actually say that, it would mean my evaluation going to hell, too, and other unpleasantries such as not passing the rotation, getting a good residency, fellowship, job, etc. So of course I had to seem excited by agreeing with Cindy. But I also couldn’t risk pissing off Jack or Clyde. “Sure I’d love to follow Jacob, but you heard Dr. Clyde; he’s Jack’s case now.”

  As if on cue, Jack entered the unit and bee-lined straight into Jacob’s room.

  “See that’s what I like about you Rajen, always willing to do what it takes to learn. I’ll talk to Jack and see if you can still follow Jacob. I’m sure he’ll appreciate the help, and then you can keep me posted on his status.”

  “Uhh … sure, I’d love to help out. It’s almost like a soap opera in how this is unfolding
.” Little did I know it would be more of a murder mystery soon enough.

  “Sure is, that’s why I love medicine, always interesting and unpredictable. Oh, here’s Jack coming our way. I’ll ask him if you can continue to follow this case so you don’t have to ask.”

  Before I could thank her, though that was the last thing I wanted to do, she broke off and intercepted Jack.

  “Hi, Cindy.”

  “Hey, Jack. I had a quick favor to ask of you.”

  Jack was busy scribbling in Jacob’s chart, clearly trying to avoid doing any extra work or favors. But Cindy seemed oblivious to such subtle clues as Jack turning away from her, sitting down, and continuing to write. But she just stood there and quietly waited. Eventually he responded, “What’s up?”

  “I was wondering if Raj could still follow Jacob with you? After all Clyde said for me to be off the case, he never said anything about the med student. Also, Raj was the first one to see him in the ER and diagnose him. Plus he’s built some good rapport which will be very helpful …”

  “Sure, no prob, I’ll let Raj run point and I’ll assist.”

  Convincing Jack was much easier than Cindy had anticipated.

  “Hey Raj, why don’t you come here and look over these orders with me, huh? Thanks for your concern Cindy; we’ll keep you posted. See you at rounds.”

  Cindy nudged me as though we’d accomplished something great as I walked past her towards Jack. In reality all she accomplished was creating more work for me. Granted she was nice, but a bit clueless.

  Jack tossed me the chart, “Look over these orders and meet me in the cafeteria. We’ll discuss the details there. Don’t bother with a physical exam; he’s comatose.”

  I shuffled through the chart. Apparently after our little confrontation last night Jack was able to calm Jacob down enough so that he agreed to remain in the hospital and complete his treatment. Jacob also began to develop some tremors and was started on high-dose IV diazepam; that’d certainly explain why he was comatose. He also signed the consent form for his HIV testing which was drawn last night.

  I was completely confused. Just yesterday Jacob was refusing to be tested for HIV while about to attack me and Cindy and storm out of the hospital with a life threatening infection. Now, by some miracle, Jack had convinced him to remain in the hospital for his treatment as well as agree to being tested for HIV. I clearly had a lot to learn about the art of medicine. Knowledge could get you but so far, there was no substitute for human interaction, or manipulation, as I soon learned.

  “So what’d you think?” Jack asked before I could even sit down with my bagel in our secluded corner booth of the cafeteria.

  “About what?”

  “Raj, you’re not an idiot, don’t beat around the bush with me. About Jacob, who else?”

  “Oh, well, I guess after you gave him some time to calm down, you were able to reason with him and get him to agree with getting tested for HIV. I noticed you started him on IV Valium. I presume that was for alcohol withdrawal? The timing makes sense, it’s been about 72 hours or so since he was admitted to the hospital, assuming he hasn’t drank since he’s been here; this is when an alcoholic would be expected to start withdrawing. I’d say you caught the withdrawal early, potentially saving his life.”

  “And how did you put that little story together?”

  “Well, we know how he almost attacked us yesterday; security was called. He was notified that if he kept up this behavior he’d be placed on a psychiatric hold under which he would lose his rights and be tested for HIV regardless of this wishes.

  “After hearing that he must have calmed down, allowing you to talk some sense into him. Clearly logic and reason prevailed. The alcohol withdrawal was likely coincidental, but good thing you noticed it, instead of whoever was on call. Besides, it’s all consistent with his presentation; he’s a drug addict who was way drunk when he came in, so a history of alcoholism is not surprising.”

  “And you’d swear to that under oath?”

  “What are you getting at?”

  “It was a simple question.”

  “Uh … yeah, I guess. It’s the truth and all documented after all, doesn’t take a rocket scientist to figure it out.”

  “Are you pro-life or pro-choice?”

  “Pro-choice, but what does that have to do with Jacob?”

  Ignoring my question Jack continued his questioning. “Are you familiar with the trolley thought experiment?”

  “Yeah, the one where you’re in a position to pull a lever which changes the track a trolley is on? If you don’t pull the lever the trolley runs over a family of four killing them all. But if you do pull the lever only a single individual is run over and killed. Basically a question of sacrificing one to save many and the dilemma of whether the failure to make a decision is the same as being proactive?”

  “That’s the one. So, if it was you, would you pull the lever to save the family?”

  “Sure.”

  “Ok, tougher situation. What if you have nice gentleman who you’ve known professionally for some time with end stage cancer with metastasis to bone. You know that shit hurts like a mother. Say he used to be an active guy with a great family, but over the last couple years of chemo and radiation he’s pooped out and always in pain. He’s so weak that he’s essentially immobile, and not anything close to the vivacious character he used to be. In essence he’s already dead, but technically he’s alive and in constant pain, so much so that he’s unable to do anything he used to find joy in.

  “Understand that his family still takes excellent care of him, but he’s gone from being breadwinner and head of household to completely dependent and occasionally incontinent. He’s told you in complete lucid candor on more than one occasion that he wishes to die. He’s at peace with himself and has led a good life. What do you do?”

  “Well I’d offer hospice or palliative care options, either in home or at a skilled care facility.”

  “Raj, do I look like a dung beetle? Cause you’re feeding me a lot of shit. Do you help this nice gentleman commit suicide or not? He’s not going to a home or anything else; he has a great family. He feels like a burden on them and you know for a fact that he’s only going to get worse with time.”

  “Then in a word, yes, I’d help him.” I instantly thought of Duane Little.

  “You know that committing suicide, or assisting one to commit suicide, is a criminal offense?”

  Finally I saw where Jack was going with all this … he wanted to feel me out before he let me in on some kind of secret. I bet it had to do with Jacob.

  I have to admit he piqued my curiosity and I wanted to know more, so I played along.

  “Well, two things then, there’s the issue of getting caught, which can easily be avoided, and the second is whether it is actually assisting in one’s suicide,” I said, my turn to be vague.

  “What do you mean about actually assisting in suicide?”

  “Well, suppose the aforementioned gentleman has signed a DNR form; that clearly means that if he stops breathing our hands are tied per his request. That document is perfectly legal. Now suppose his pain is so severe that very high doses of narcotic medications are required for alleviation of his pain. Such high doses, in fact, that his breathing is arrested before his pain is controlled. That way he legally gets what he wants.”

  “But if it’s still you giving the medication, aren’t you technically a murderer then?”

  “Fine, put him on a PCA pump and let him push the button to keep increasing his medication dose until he is either comfortable or stops breathing. That way both the choice and action is his, and we are only carrying out his wish for no resuscitation.”

  “BINGO! That’s thinking outside the box! More importantly, it’s perfectly legal. Not bad for a third year med student.”

  “I get the feeling this was some type of test?”

  “Let’s just say you passed.”

  I stared at Jack quizzically. He continued, “Ra
j, there are good doctors and nice doctors. You’re destined to be a great doctor. You’ve shown that you can make the tough decisions and stick to your guns. Your answers are definitive and your thinking is both clear and logical.”

  Jack continued, “I know you like Cindy, but she’s the proverbial ‘nice’ doctor. Meaning she’s warm and fuzzy and patients are going to like her personality. She’s more interested in where a patient went for vacation and how their family is doing, rather than making the tough decisions specialists are paid to make.

  “Don’t get me wrong, she’s a great person and very competent, but she’s definitely the primary care type. She gets too emotionally attached to patients and takes things too personally.

  “You have to remember that patients are not your friends! Nor is your goal to befriend them. Patients are simply not meant to be your friends. You are a professional and they are seeking your services, expertise, and opinion in a time of need—nothing more.”

  I just nodded until Jack was done, and then asked, “That’s fine and all, but how does this all relate to Jacob?”

  “Always cutting to the chase, another sign of a specialist. That’s where I was headed with all this. Clyde basically put me in charge of Jacob’s care because it’s a sticky situation with no easy answer or way out. He needs somebody who is not afraid to do what needs to be done to get some results. Consider this case your initiation into one of the unspoken realms of medicine, except I’ll openly discuss it with you. Of course if you mention it to anyone else, I’ll deny it.”

  I wasn’t sure if I liked what I was hearing, but I was definitely fascinated about yet another subculture of medicine. It felt like politics, where what is stated is not necessarily what was actually said.

  Jack continued, “So what actually happened last night was that Jacob was acting completely immature and hostile. Annoying maybe, but nothing for which we could have actually placed him on a 5150 hold. Our threats to do so were empty and unfounded.