I descended a back staircase to the basement and came to the dimly lit corridor leading to me dissection room—and halted. I always found it oppressive walking through this passage, set apart from the busier and newer sections of the hospital. But after what happened last night, I felt my heart start to pound and my respirations quicken. “Not again,” I muttered. I’d had the same reaction going into the post early this morning but had overcome it. I stood there a moment, once more trying to slow my breathing. No way was I going to give credence to Janet’s cover story by giving in to the flutterings of panic I was beginning to feel.
I fixed my thoughts firmly on getting the X rays and meeting my residents, brought my respiration back to a respectable rate, and stepped into the corridor. To tell the truth, it was nowhere near as cramped or as old as the one at UH—the initial construction of St. Paul’s began in the late thirties—but it still pressed in on me. I had to concentrate to keep from thinking that the lights would suddenly go out or that someone was waiting for me in the darkness at the end of the passage. It didn’t help any that the tangle of pipes, conduits, and ducts just above my head seemed coated with sixty years of dust and spiderwebs. Every now and then I could hear scurrying noises from deep within this jumble, but in all the time I’d been coming down here, I’d never seen for certain what lived up there.
I passed the heavy wooden doors of the walk-in freezer where bodies were kept pending an autopsy or a pickup by a funeral home and peeked into the brightly lit room where we’d been working earlier. The empty tables, counters, and floors were gleaming from a recent cleaning, but no one was there.
The adjacent changing room was also empty, so I walked farther down the hallway toward the pathologists’ and secretaries’ offices. Len’s cubicle was one of the first in a long line of doors. I could see a light under the sill, so I knocked and let myself in. “Hi, Len, sorry to disturb—”
It wasn’t Len in the office. I immediately recognized the broad shoulders and closely cropped blond hair of Harold Miller who was standing in front of Len’s desk with his back to me. As he turned at the sound of my voice, I saw he was holding a sheet of paper with the format and familiar outlines of the human form used for our autopsy synopses. He seemed mildly surprised to see me, but returned his gaze to the document in his hand and went on reading it.
“Mr. Miller,” I said, appalled to have barged in on the last person I’d have either expected or wanted to see here, “I’m sorry, but I was looking for Dr. Gardner.”
“So was I,” Miller answered without looking up.
I felt uncomfortable just standing there.
He added, “I was here arranging the release of my mother’s body to the funeral home and wanted to know what he’d found during the post.” He still didn’t look up.
I started backing out of the office when he suddenly tossed the paper he’d been reading onto Len’s desk, looked me directly in the eye, and said, “I see you were probably right all along about there being two infections.”
“Pardon?” I asked, not immediately catching on.
His expression remained frozen, revealing neither the hurt nor the anger I’d seen in his face the morning before.
“It’s in Dr. Gardner’s preliminary report on Mother’s autopsy this morning,” he explained, gesturing with his thumb back toward Len’s desk.
“You took it from his desk?” I asked, dismayed, then quickly feeling foolish. Reading a person’s notes on his mother’s autopsy might not be too polite or appropriate, but it was a hell of a lot less an offense than sending a sick woman home from ER.
“I’m sorry about your mother’s death, Mr. Miller; I truly am,” I said, but on hearing my own words, I immediately felt overwhelmed by their inadequacy. It reminds me of a glass coffin, and you put her there, echoed in my memory. Nothing I could ever say or do would make up for what he’d lost on account of me.
He remained silent.
I turned to go.
“Once it was too late to help her, you were pretty damn on, clinically speaking,” he called after me.
I kept walking. This kind of encounter wasn’t going to end well no matter what I said. There was no way it could.
He followed after me.
“You certainly impressed me more than the others,” he continued, hurrying up and striding along beside me. “As a lab tech I get a pretty good take on a physician—who knows what to order, who follows through, who’s up-to-date—that kind of thing.”
I stopped and turned to face him. “Look, Mr. Miller, I know this must be one of the worst periods in your life. I don’t think this kind of conversation is going to help—”
“Doctor Garnet, I don’t expect any help from any conversation with you or any other doctor here. I only expect the simple courtesy of your standing there and hearing me out,” he stated.
The blank expression on his face canceled out the hurt look in his eyes that I remembered from the morning before on the stairs. Neither did he seem to be angry. I felt pity for him, and he was right about one thing; the least I could do was stand there and listen.
“Do you want to come to my office and talk?”
“No, here is fine,” he said.
I only now noticed we were standing opposite the freezer doors. I hoped he wouldn’t realize how near we were to his mother’s body.
“In fact, I may be able to help you,” he continued.
“What?”
“I’m only a lab tech. Dr. Garnet, but I keep up with the literature, especially diagnostic testing and screening procedures; this is more than a lot of physicians I work under do. Dr. Gardner’s comments in his report indicate that the staph infection hadn’t seemed to respond at all to the vancomycin you’d been astute enough to order. Rossit’s still trying to verify whether the strain was methicillin resistant, but there’s another form of resistance that nobody seems to have thought of.”
To talk so clinically about his mother’s case seemed to me an eerie kind of defense against grief.
“Three months ago,” he continued, “the CDC published an advisory to screen staph infections that failed to respond to vancomycin for evidence of decreased susceptibility to that drug as well,” he told me, his voice taking on an easy authority that I wouldn’t have normally expected from a laboratory technician, even in a less-charged setting.
The CDC is the Centers for Disease Control in Atlanta, staffed by the national experts on infectious diseases. I knew about the advisory; I’d heard the residents talking about it. It had been published in the Mortality Morbidity Bulletin, an excellent bimonthly report exposing troublesome new medical puzzles or twists in the presentation of old familiar problems that had recently killed or maimed patients somewhere in the world. I had about a year’s worth of issues piled up in my office, waiting to be read.
“What are you getting at?” I asked, intrigued.
“I’m saying the staph organism that killed my mother should also have been tested for decreased susceptibility to vancomycin. Dr. Mackie has had me update our own techs on the new protocol for such cases already. But according to my mother’s hospital chart and the autopsy synopsis I just read, that hasn’t been done here.” He studied me for a few seconds, as if waiting for my reaction to his remarkable pronouncement. When I neither said nor did anything, he added, “The test still should be ordered, for obvious public health reasons.”
As he watched me further, I felt uncomfortable again and couldn’t decipher what he was watching me for—a response to the information he’d revealed? A recognition of his knowledge and intelligence?
And then he completely disarmed me. “You see. Dr. Garnet,” he said with a sudden gentleness, “I couldn’t help her when she was still alive. But I want her death to be handled properly. I want whatever killed her identified and tracked down, by the book. If her death were to point out the need for screening to prevent the same infection from hurting anyone else, well, at least that’s something...” His words trailed off, and tears welled
up in his eyes. He spun around and walked away.
* * * *
I finished my seminar with the residents a few minutes to 4:00. I’d been so distracted after my run-in with Miller that I’d nearly left pathology without retrieving Sanders’s X rays, which was why I’d gone down there in the first place. I’d had to rush back to Len’s secretary and have her dig out the films, but the effort was worth it. Seeing those lungs nearly whited out by infection so soon after a seemingly benign initial visit had a profound impact on my protégés. That radiographic image taught them more about the perils of missing postural hypotension than hours of listening to lectures or reading textbooks ever could.
Back in my office I made a quick check with University Hospital. Locating still hadn’t heard from Michael. I left yet another message for him to phone me right away.
I put my hands behind my head and leaned back for a stretch. The bruise on my forehead had begun to throb and it hurt to move my neck, but with less than four hours sleep, only coffee for breakfast, and no lunch, I figured I should be grateful that I didn’t feel worse. Nevertheless, I groaned aloud when I stood up.
The notice for Hurst’s meeting with the hospital physicians was lying on my desk where I’d left it. Should I go? I didn’t have much stomach for politics at the moment, but in all honesty, I was increasingly too preoccupied with worry about Janet and waiting for Michael’s call to be much more use in ER. The encounter would at least be a distraction, I thought, and besides, maybe I could help give Hurst something else to think about besides dumping me as chief of ER.
Before leaving, I took a few minutes to hunt up my copies of the MMB. I was curious about the article Miller had quoted, both as to its content and as to how accurately he had interpreted it. Also, I had to admit I wanted to discover something else a lot less scientific. If the man who held my career in his hand was capable of discerning a balanced medical argument, maybe he’d give me a fair shake.
Ripping through my pile of back issues, I quickly spotted the title I was looking for—”Interim Guidelines for Prevention and Control of Staphylococcus aureus with Reduced Susceptibility to Vancomycin.” The article itself was brief, and I took it with me, stuffing it into my lab coat pocket as I hurried from my office and headed toward the auditorium.
A special meeting of Hurst and all the physicians at St. Paul’s was rare. Hurst could barely abide the interference of regular hospital committees into the way he ran St. Paul’s. And doctors were usually loath to get involved in hospital politics. They barely had time for the day-to-day issues in their own departments—scheduling, teaching, doing shifts, and the never-ending struggle to keep their clinical skills up-to-date. Speak of downsizing or budgetary restraints and their eyes would roll upward. “That’s what chiefs are for,” my own staff would say, “to protect us from having to deal with all that garbage.”
Stepping through the large oak doors at the rear of the steeply raked amphitheater, I was struck by the size of the turnout. The place was packed, every seat taken and the aisles lined with clinicians in lab coats sitting on the tiered steps. They were a vociferous lot, sounding more like a fight crowd waiting for the start of a match than a group of professionals.
The place was a great choice of venue, for the doctors. Six hundred seats in a steep curved bank towered above Hurst and his band of cronies—all of whom were bunched together on the small stage below. I could tell the man knew he had trouble from the large number of board members he’d brought with him. I recognized most of them from previous social functions, but they’d looked a lot more comfortable then than they did now sitting on folding metal chairs and peering up at the noisy ranks of white coats above them. There had even been a touch of theater in the lighting. While the stage was harshly lit, the spectators were in semidarkness. Hurst kept squinting at us while shielding his eyes, but I doubt if he could recognize a specific face. As I sat on one of the upper steps, the single word “trial” popped into my mind to describe the spectacle—the kind of trial in which the jurors render verdicts with stones.
Someone in the second row stood and made his way toward the podium. Even before he stepped into the spotlight, his frizzy red hair and large physique gave him away. “I’d like to call this meeting to order,” said Sean into the microphone, igniting a round of applause, cheers, and whistles. Some of the board members clutched their briefcases to their chests and looked nervously at one another. Hurst, his face always a pale shade of gray, scowled disapprovingly at us and looked positively ill under the overhead lights. His forehead had an unhealthy sheen in the glare.
More than a decade ago a heart attack had brought an end to his surgical career, but since then he had found his niche in administration. During my tenure as chief over the last eight and a half years I’d watched him become more and more obsessed with his pursuit of absolute authority over the hospital. He was ruthless in cutting budgets and trimming deficits, and in a world where hospitals were subject to hostile takeovers and closure, the board loved him for it — called him dedicated. Clinicians had other names for his management style and either feared him, submitting to his decrees, or held him at bay, challenging him whenever he risked patients’ lives in his drive to get them out of hospital quicker and sicker—to save a buck.
The enthusiastic clapping became rhythmic, and a few voices took up the chant “No! No! No!” They were joined by more and more until the entire room was booming with the defiant shout.
Hurst sat back in his chair, made a pyramid of his fingers, and tapped his lips, seemingly keeping time with the protest all around him. His eyes were fixed on the floor and he remained motionless, but I knew that pose from previous encounters; he was livid.
The other board members were shifting uneasily in their chairs, whispering to each other, and shuffling their feet, all the while looking repeatedly at Hurst and then back out at the crowd in front of them. They seemed as astonished by his immobility as by our raucous behavior. Finally Sean held up his hands and spoke again into the microphone, “Okay everyone, come to order now, settle down...”
The room gradually grew quiet.
“Fine,” said Sean brightly. “Let’s get right to the point. We, the clinicians of St. Paul’s hospital, are here to issue an ultimatum to you. Dr. Hurst,” he said, turning and gesturing toward the stony-faced former surgeon, “and to the members of the board,” he added, opening his arm farther to include their part of the stage, “who, I may say, I’m glad to see have joined us and have turned out in such numbers.”
Sean was smiling and speaking as pleasantly as if he were honoring the visitors. Some were obviously confused by such effusive politeness in a hostile encounter and returned his smile, then checked themselves and retained the same severe expression Hurst had adopted.
“As far as we are concerned, there will be no merger of our clinical departments with UH. This whole operation has been engineered by accountants and managerial gurus, with all the decisions coming from above. That approach may make sense in companies,” opined Sean, again turning toward the board members, most of whom were CEOs of their own corporations and industries in Buffalo. “It would even be a sensible way to amalgamate the administrations of our two hospitals, which, by the way, the majority of us here would support.”
I wasn’t sure, but I thought I saw Hurst flinch at the mention of merging his control of St. Paul’s with the CEO of another institution.
“But clinical departments aren’t like companies. Academically and professionally each of us is his or her own CEO when it comes to taking care of a patient. We have the ultimate responsibility for that life; we cannot and will not surrender that autonomy. Neither will we allow our departments to be reorganized by anyone but ourselves. We’re the ones with the competence to assess how our clinical units best work to deliver safe and timely care, not some time-and-motion expert. And we will not accept that our departmental leadership be parceled out to another institution. That’s a formula to guarantee a department won’t make i
ts needs heard at the budget table. Shutting us up isn’t going to save money, Dr. Hurst; it’s only going to lead to misinformed decisions, misspent funds, and a patient clientele denied the equipment and resources it really needs. Do whatever you want with the other services in the two hospitals—laundry, catering, distribution, and supply—they seem perfect things to merge; But our clinical departments must retain fall thickness.”
There were immediate murmurs of approval from everyone in the audience. Hurst suddenly flushed. The board members looked puzzled, clearly not familiar with the term that had caused such a buzz around the room.
“Full thickness” was a surgical expression known to all the doctors in the amphitheater, including Hurst. It referred to a skin graft that restored all levels of tissue. Sean meant that our clinical departments and departmental leadership would remain completely intact, chiefs included, or there would be no deal.
“I needn’t remind you,” concluded Sean, “you can merge and amalgamate all you want, but you need physicians if you want to have a hospital.” With that comment he walked from the podium and took his seat.
The applause from his colleagues this time was long and loud, though decorous, as befitted the seriousness of what we were faced with. Sean had lifted our opposition to the plan from petty worries over turf to the vital connection between saving lives and solid medical representation at the level of financial planning. Some of the board members were whispering to one another and nodding. A few reached into their briefcases, pulled out notebooks, and were busily writing. Hurst hadn’t budged, and he was no longer tapping his lips with his fingers. But his eyes looked molten with rage.
Death Rounds Page 11