Philanthropist

by Larry Hill

  “You’re an awesome teacher, Dr. Choudhury.”

  Fred was gurneyed in. It became clear from the history offered by his friend, the lawyer, that he wasn’t diabetic and that the patient who had just come from a poker game surrounded by six upstanding low stakes gamblers, had not been shooting narcotics or swallowing sedatives or involving himself in activities that could lead to head trauma. He couldn’t talk any better than he had earlier – unintelligible grunting only. His left hand and leg moved, even on command, but not a twitch on the right. He was awake and appeared to be aware of his surroundings, but clearly, he’d stroked. The question that had to be answered was whether the stroke was caused by an obstruction in the artery or a bleed from something like an aneurysm. The treatment and the prognosis were very different. He was whisked off to X-ray for a CT scan. Ten minutes later, he was out of the machine. There was no bleeding. The left middle cerebral artery, the vessel that supplies blood and oxygen to the part of the brain that controls movement on the right side of the body and allows for communication was obstructed, probably by a clot. No reason for even considering surgery. He was wheeled back to Emergency.

  Dr. Choudhury, shadowed by the two students, was with Fred as Jennifer, Jason, and Art came into the holding room.

  “Freddy, it’s me, Jen. Are you OK?” She leaned over to kiss him on the cheeks.

  “Ugghh. As she was on his right side, he could not move his eyes to look at her.

  “I’m Dr. Mohammed Choudhury, one of the residents on the trauma service.” He offered his hand, grasping hers sympathetically. “You are Mrs. Klein?”

  “Yes. Tell me what’s wrong.”

  Your husband can understand everything we say, I believe,” he said, looking directly at the patient. “He’s had a stroke, in fact, a very large stroke. The CT showed that he hasn’t had a bleeding aneurysm, so there’s nothing that can be done surgically. Obviously, he will have to be admitted to the hospital, to the neurology unit where they take care of stroke patients.”

  “Can’t we take him over to Cal Pacific, or even to UCSF?” asked Jennifer. “They are so much closer to home and, honestly Doctor, he hated this place.”

  “The magic number in stroke care is three hours. Anything longer than that, the newer treatments aren’t nearly as effective. If we send him to another place, and both of those are good, it’ll be well beyond the three hours since his symptoms started.”

  “All right, but let them know that we want Fred out of here as soon as possible.”

  “I will.”

  The next doctor that entered the area, almost sprinting, was no more than five foot three, black- bearded, wearing a wrinkled white coat with stethoscope, reflex hammer and other tools of his trade threatening to fall out of the pockets. A diamond stud pierced his right ear lobe. His rolled-up sleeves of his white jacket revealed a pair of tattoos of wild animals. He looked young enough to be Jen’s son, Fred’s grandson. “I’m Doctor Behrens from Neurology.” He acted as if the only person standing in the room was the ER Resident. Two students and three friends and family of the patient did not register. “What do we have here?”

  Choudhury gave a concise, logical two minute presentation of the case, including the past history of his subdural hematoma. Behrens approached the patient. “What brings you to the hospital?”

  “Ugghh.”

  He raised his voice. “WHAT BRINGS YOU TO THE HOSPITAL TONIGHT, SIR?”

  “Ugghh.”

  “Does this patient speak English?”

  “Yes, Doctor, my husband speaks English, very well.”

  The neurologist flashed a light in Klein’s eyes, pried open his mouth to look at his tongue, bent his neck back and forth, tested his limbs for spasticity, poked his feet and hands with a sharp rolling device, and banged on reflexes in his arms and legs. Knowing full well that there would be no decipherable answer, he asked questions of his patient, including the day of the week and the name of the governor of the state.

  “You know, I think I recognize this guy. Was he in here, like two years ago?”

  “Yes, that was when he was in for the subdural,” said Choudhury.

  “Yeah, I was a student on my neurosurgery rotation. I think I scrubbed in. And, isn’t he, like famous?”

  “Please, Doctor. We can talk about that another time,” said Schofield.

  “I saw the CT on my way over. Big ischemic stroke. No blood. No tumor. Usually, we’d try to break up the clot with tPA, but he’s had a bleed, that subdural last time, so he can’t get it. Nothing we can do but put him in and hope for the best – maybe some physical therapy. I’ll dictate a consult note when I have time.” He sped out of the room, returning a few seconds later to pick up the reflex hammer that he left on the bed. An attempt by Jason to get him to talk with him in the hall produced the same response as the attempt to get a second cup of coffee in a busy eatery.

  Jason returned and asked Choudhury to speak to him, in a spot where his father couldn’t hear. The linebacker and the blond followed silently.

  “What a jerk! Is that guy always that awful?” Jason asked.

  “I don’t know. I’d never seen him with a patient before. They say he’s a good neurologist.”

  “If that’s how a good neurologist works, I’d hate to see one that wasn’t any good. So, tell me what we learned, please.”

  “What Dr. Behrens said was that your father had a major stroke caused by an obstruction of one of the major arteries in the brain, the right middle cerebral artery. The artery was blocked, probably by a clot from the heart or from the carotid artery in the neck – you know, the one you feel when you check for somebody’s pulse.”

  “What did he say about treatment – that there is none?”

  “Sometimes, neurologists use a drug called tPA – they use it for heart attacks too – a chemical that dissolves clots rapidly. It helps sometimes, although it’s not a magic cure. At least half of the patients don’t see any improvement and many of the ones that do would probably get better on their own. But still, it’s used. Problem is that a person who has had any kind of bleeding in his head, at any time in his life is not a candidate for it.”

  “Why?”

  “There’s a chance, in fact a fairly large chance, that he’d bleed again, in the same area as the last time. Even people who haven’t had previous bleeding in their brains get it in the area of the stroke. The arteries in the area of the stroke are already weakened by the event and can rupture making the problem all that much worse.”

  “So, what do we do if he can’t get that stuff?”

  “There’s not much. We have to treat him with physical therapy, blood pressure control and other things to prevent yet another stroke, and hope for the best.”

  “Do you think he’ll get back to normal?”

  “I’m no neurologist, but I’d have to guess that the chance of that is pretty small. His weakness is profound and, as you can obviously see, his ability to communicate is terribly limited. He’s not a young man and he’s had previous problems with his brain. The next week or two will be an important time – if he’s not showing at least some improvement by then, the prognosis is not good.”

  “Is he going to die? I mean, is he likely to die soon?”

  “I don’t know. When I was a child, the answer to that question would be Inshallah. God willing, he will be alive and be well.”

  “I know what that means. Thanks. Now, is there any good reason to keep my father here? I know he’d prefer to be at CPMC; it’s a whole lot closer and, just between you and me, it’s a lot nicer environment.”

  “I really see no reason that he needs to stay here. Let me talk to the Chief Resident and see if we can’t make the transfer.”

  The ultrathin blond med student approached Chowdhury after Jason had returned to his father’s bedside. “Not only are you a very good teacher, you are an awesome doctor. I hope I can be half as good.”

  It took four hours to transfer Fred from General to California Paci
fic Medical Center, near to his Pacific Heights home. His condition on transfer was no better, no worse. Monitored on the way and in the intensive care unit when he arrived, his pacemaker worked liked a Timex and his blood pressure returned to a more acceptable 140/85. The neuro team responded like a firefighting squad, efficient and speedy. They agreed with Dr. Behrens in immediately ruling out a surgical approach. One aggressive neurologist opined that he would have taken the chance with tPA as it had been many months since his subdural hematoma. It had, however, been much more than the magic three hours between symptom onset and his second evaluation; tPA treatment was no longer an option.

  The following day produced no demonstrable improvement. Nor the day after that or the following one or the next. Physical therapy and speech therapy were initiated in the ICU, and intensified when, after ten days, he was moved to a regular room in the Neurology Unit. His range of motion on the right was full, as long as somebody else did the moving. His index finger twitched a millimeter or two on command. The rest of the hand, arm, leg, and foot were paralyzed. Nothing. The left side moved well. He comprehended commands and squeezed, bent, straightened and wiggled as the therapist ordered. Fred showed no signs of improvement in his speech. “Ugghh.” On day three, he strung two grunts together: “Ugghh, eehh, “he said while pointing with his left hand at a glass of water on his bedside table. Jen put the straw in his mouth, held the right side of his mouth shut and he took a swallow. All meals involved spoon feeding by family or staff. His appetite was good.

  The San Francisco Chronicle reported the stroke on the first page of the Bay Area section on Sunday, the day before potential jurors were to assemble at the court house for selection.

  FRED KLEIN HAS MAJOR STROKE

  TRIAL ON HOLD

  Jennifer Klein spent at least four hours at her stricken husband’s bedside every day. Jason, the twins, and Art Schofield visited daily, sometimes alone, sometimes with wives and children. Rebecca Grodzinsky was heroic in her willingness to help. His room, at least for the first two weeks of his six week stay, was festooned with flowers, stuffed animals, and get well cards for the man who surely would not get well.

  After a month and a half of barely discernible improvement, the hospital decided, against the desires of family and with reluctant consent of the treating doctors, to transfer Mr. Klein to a skilled nursing facility noted for rehabilitation. There he stayed for three months. By the end of the rehab, he could help in his transfer from hospital bed to reclining chair. His left arm became strong enough that he could pull himself up in bed, one handedly, using a steel bar suspended from a longer steel bar by a steel chain. Initially, he could not play a role in his getting on a bedpan. Later he could help in stationing himself on a bedside portable toilet. His ability to swallow improved. There was little fear that he’d choke on his pureed breakfasts, lunches and dinners. Staff did not trust him to chew the foods he loved. His daily diet was high in protein, low in fat and cholesterol; Dr. Jameson approved. He watched a lot of TV.

  Four months after the stroke, Klein was home. One of the bedrooms had been converted into an upscale rehabilitation space. Aside from rare wheelchair-aided trips to doctors’ offices (Jameson made twice monthly home visits) and a weekly ride around the area in the minivan purchased from a dealer who was thrilled to get the Prius in trade, he was to spend the rest of his life in his home, as if he was under house arrest.

  The criminal case of The City and County of San Francisco vs Frederick Klein was dropped after Dr. Roger Stern reported to Judge Dadekian that Klein would never regain the ability to aid in his own defense.

  At the advice of Personal Injury Defense Lawyer Gladstone, the civil case of Mark Spencer vs. Frederick Klein was settled for twenty-five million dollars. The insurance company paid about half of the settlement. Jennifer sold a chunk of their equity holdings to cover the remainder. The chunk was not large enough to make a major dent in their net worth. With the acceptance of her stepsons, plans for the Frederick and Jennifer Klein Institute for Aging Research were drawn up, to be established at the University of San Francisco.

  Judge Louis Gasparini resigned from the bench and joined a local law firm specializing in criminal defense. Charges against him in his driving and drinking case led to a three month suspended sentence and loss of his driver’s license. His wife, no longer stressed by the presence of a female passenger in his car at the time of his arrest, drove when they went out.

  The DA never ran for higher office.

  Six months after his divorce was finalized, Jason Klein married Rebecca Grodzinski in a small ceremony at Temple Emanuel, coincidentally, in the same room where his father had fainted. Jason’s eldest child with Emily would end up a highly regarded Foreign Service Officer, fluent in Mandarin and Korean. The younger one spent much of his teens and early twenties in rehab.

  The same week that Jason remarried, Mark Spencer and Mitzi Li said vows in a lavish event at the Mark Hopkins Hotel. Meagan, a top performer in her highly regarded preschool, was the flower girl. Carmen Contreras continued her employment in the Spencer home, with no evidence of a significant other.

  Margarita and Ernesto Contreras had a baby boy, Hector. Hector was born at California Pacific Medical Center. He was entitled to two passports, American and Venezuelan. Carmen attended the baptism and first communion. Jennifer did not.

  For all intents and purposes, Art Schofield lost his best friend. He visited often, at least early on, knowing that Fred knew that he was there. It took him a longer time than it should have to tell the poker buddies that it was time to find another regular. The chair was eventually taken by Sheldon Epstein, a local electronics importer and philanthropist. Epstein was 81.

  Jennifer Klein was abstemious as long as her husband lived.

  Fred Klein, beneficiary of the best of American medical care, lived for a long time. He observed and understood great changes in his world, his city, his family and himself. He was never again able to utter an intelligible word, phrase, or sentence. He was not able to say, “I’m sorry.”

  ABOUT THE AUTHOR:

  Larry Hill, MD, is a graduate of the University of California, San Francisco, School of Medicine. He spent eighteen years in private practice of internal medicine and oncology in Eureka, CA. He then joined the US State Department where he served sixteen years as a Regional Medical Officer in Mali, Bangladesh, the Philippines, Washington, DC, South Africa, and China. He presently lives with his wife, Terry, in San Francisco, where he is a volunteer teacher of medical students at his alma mater.

  Philanthropist is his first published novel.

  THANKS to all of the fellow doctors, nurses, administrators, lab and X-ray techs, professors, instructors, and especially patients, who have allowed me to understand the human body and the massive infrastructure that is required to reassure lots, cure some, alleviate the pains of others and all too often allow me to lend meager support at the end of life.

  Thanks to Dr. Roger Lauer who gave me a much greater understanding of mental health, including the fundamentals of forensic psychiatry.

  To the several readers, including Hedi Saraf, Sheila Gordon, Edith Bennett, Steve Spellman, George Gmelch, Sharon Gmelch, Michael McNulty, Lee Gordon (one of the world’s great nonagenarian poker mavens) and others, who enabled me to turn a hodgepodge into something that enabled me to get over the fear of pushing the “Publish” button on Amazon Kindle.

  Undying thanks to my writing teacher, Joan Mininger. She took a retired doctor who, in the past, had attempted to write fiction with amazing lack of skill, and turned him into a scribe with at least a modicum of self-confidence. Many times along the way I had reached the “chuck it – nobody would want to read this stuff” stage and each time she brought me back from the abyss.

  And, to my wife Terry, editor par excellence, who has accompanied me around the world, invariably finding something of consequence to occupy her time as I learned a trade, improved my skills in residency, practiced in two rural California communit
ies and rubbed elbows with world leaders and diplomats in Africa and Asia. Were I to get assigned to be the resident physician on the Moon, she’d be there with me reveling in the lunar wonders.

  Larry Hill, San Francisco, September 2014