by L Jan Eira
“Not fair. I asked you first,” protested Jack.
“Not sure what the answer is,” said Taylor. He was a tall and thin young man with a severe case of premature graying. This made him appear much older than his early twenties. He was in the do-not-like-cardiology-much camp with Christopher and sure was glad he was assigned to the cardiology rotations with Pete, who was likely to help him through what could be a painful couple of months.
“Peter or Christopher, let’s play poll the audience. What’s wrong with this picture?” continued Jack facing the new medical students.
“Well, with a known ischemic cardiomyopathy, low ejection fraction, previous MI and history of congestive heart failure, this patient should have been on—,” Peter proudly piped in, before being interrupted.
“Okay, I got it now. Sorry. She should be on a beta blocker and ACE inhibitor,” interrupted Taylor.
“Don’t forget aspirin, Plavix, and a statin,” added George.
“And what else?” asked Jack, looking at the audience in the room.
Dr. Mary Taylor, the on call intern, said, “Aldosterone antagonist. What do you make of her being on Lasix without potassium or magnesium supplementation?”
“Yes, I noticed that too. What were her admission electrolytes?” asked Jack.
“Very low. Potassium, 3.1 and magnesium, 1.5,” answered George, picking up and reading from his piles of notes on the case.
“So, what’s wrong with this picture?” reiterated Jack. No one answered. After a moment of silence, Jack continued.
“Bad doctor syndrome. This woman is lucky to be alive. Who’s the attending on the case?”
“Dr. Skinner, the best cardiologist in Evansville,” replied Mary, in a mocking voice recalling what a patient had said of Dr. Joel Skinner a few days earlier.
Dr. Skinner was a pleasant and calm man in his early fifties with graying temples, whom his patients absolutely adored. He would hold their hand at the bedside and listen to their many complaints. Unfortunately, like so many busy doctors in private practice, there was no time to keep up with the literature. Often his patients would not be on the appropriate, evidence-based medicines. He was treating them based on what he learned decades earlier in medical school. He bragged that he went to school at Yale, a great medical institution. Unfortunately, he never learned to teach himself. He had many patients and they all seemingly loved him. Because of insufficient medical therapy, his patients would have repeated admissions for the same problems. They were not appropriately referred to other specialists, as demanded by recent guidelines and management protocols. The only salvation these patients had was when they arrived in the emergency department late in the evening. The great Dr. Skinner would, in those circumstances, allow the hospital staff to manage the patient until he could make rounds the next day.
The young doctors would have to work fast. They would discuss the case in detail, formulate an appropriate plan and write their collective opinions in the chart, including necessary cardiac testing and prescribe the right medications. They would also educate the patient and family. The great Dr. Skinner would go along with the plan—another one saved. Fortunately, Skinner would not make his rounds today until early afternoon, so there was time.
“What do you have planned for Mrs. Hart’s heart?” asked Jack.
“We should look for cardiac ischemia with a stress test. Start her on aspirin, Coreg, Altace, spironolactone and Lipitor and stop her Lasix and digoxin. Correct her potassium and magnesium,” answered George.
“And—” Jack queried inquisitively with eyes wide open.
“Defibrillator,” replied George and several other residents, almost in unison.
“Yes, if the heart doesn’t improve on optimized medical therapy, she is at risk for sudden cardiac arrest and is a candidate for implantation of a defibrillator. Great job, people! Go write up the chart and talk to Mrs. Hart and her family about our recommendations. Remember to be kind to Dr. Skinner, but truthful. Be politically correct. I mean don’t and I emphasize don’t say: ‘Your doctor hasn’t read the literature in ten years and has you on all the wrong meds.’ I’ll go by and co-sign your orders and notes later.” These issues with doctors not following appropriate guidelines really infuriated Jack.
One of the residents gave a review lecture on the use of Plavix in patients who undergo a coronary angioplasty with stent deployment. This was scheduled the day before, when the subject came up during morning report. By the time he was finished, it was nine o’clock in the morning and time to go make bedside rounds. The group discussed the steps to be taken the rest of the morning and plans to meet for lunch. The medical students followed Jack out of the classroom, like a group of ducklings following momma duck.
“Some doctors don’t keep up with the literature?” asked Pete rhetorically, as they walked out.
“It’s like if you go to an accountant to do your taxes, but he hasn’t read about the recent loopholes and does your taxes with the information he learned in school twenty years ago. Can you imagine?” said Jack angrily, obviously irritated with the notion. “Don’t get me started.” He continued to walk toward the elevator, the students following in his wake.
“What do you call the guy who graduates last in his medical school class?” inquired Jack a few beats later, briefly looking back at the students who were walking slightly behind him. The three young men looked at each other puzzled. A slight grin on their faces suggested they understood a punch line was about to be delivered.
“Doctor,” answered Jack, after a few seconds. The elevator arrived on their floor.
“Going up?” asked Jack holding the doors opened for the others to enter. He pushed the button with the number eight, illuminating it. Four older people stood quietly in the elevator staring up at the numbers over the door, seemingly unaware the others had entered. Number two was illuminated, announcing they were on the second floor. The complete silence inside the car was broken by the sound of the motor revving up. The car ascended slowly with an almost imperceptible jerk. Jack looked at the students then back at the numbers, imitating the others.
On the third floor, one older woman exited the elevator and an even older man entered. He pushed number six which then also became illuminated. On the fourth floor, a beautiful woman entered the elevator. No words were exchanged. All stared at the numbers over the door, although they would much rather ogle at the lady. As the door opened on the sixth floor all exited except the medical team and the gorgeous woman. She was to die for. She was blonde with beautiful hazel eyes and long hair. She stood straight resembling a model about to strut down the runway of a fashion show. All her features were perfect. Her lips were just right, resembling a doll’s. She wore a skirt and blouse that revealed close to nothing but concealed a world of sensuality, the likes of which the young men could only imagine. The elevator door closed and the car resumed its upward climb.
“The one of you that can tell me what number I’m thinking of gets to have an unforgettable evening with me,” she said sexily, still looking up at the elevator numbers.
The medical students looked at each other in disbelief. The most beautiful woman each had ever seen just proposed to go on a date with the one guessing the right answer. Was she toying with them? Was this a dream?
“Zero?” exclaimed Jack, confidently.
“That’s right,” she answered excitedly. She turned to the medical students.
“Do you guys mind getting off at the next floor?” she asked in a very sensuous voice, slithering her elegant body towards Jack. Behind him, she massaged his shoulders and ran her hands down his chest and her right leg up Jack’s thigh. Her skirt rose up her leg ever so slightly, exposing her knee and the lower portion of her shapely thigh.
The medical students were flabbergasted. Speechless. They could not believe their eyes; their hearts began skipping beats.
Suddenly the elevator door opened. It was the seventh floor. A well-dressed older man in his sixties walked into the e
levator in front of the medical students. It was Dr. Thomas Lindsborg, Head of the Department of Medicine and, as such, he was Jack’s boss. Dr. Lindsborg was a pleasant and kind man with a special knack to make those in his presence feel welcomed and at ease. Jack and the young woman stopped and stood up straight, as if the principal had just almost caught two mischievous teenagers engaged in a high school prank. As the medical students moved aside to give room for the older man in the car, Dr. Lindsborg glimpsed at Jack and the pretty woman.
“Hi Jack. Claire, good to see you. I wish my wife worked in the hospital, too. You are a very lucky man, Jack,” said the distinguished older man.
“Good morning, Dr. Lindsborg,” said the young woman. “Yes, I love to come and see my husband now and again. I want to make sure he doesn’t stray with all the beautiful nurses on campus,” she continued.
“Claire, Jack is so in love with you, you need not worry about such things. Isn’t that right Jack? Oh, are these your medical students for the month?” asked Dr. Lindsborg, turning towards Jack.
“Yes, sir. This is Pete, Taylor and Chris. We just finished morning report and are about to start ward rounds,” answered Jack.
“Okay, carry on, I’ll meet up with you later,” said Dr. Lindsborg, as the elevator door opened on the eighth floor and all got off, except the older physician who continued on to the tenth floor.
“Claire,” said Jack sounding irritated. “What if I didn’t get the number right this time and one of these guys guessed it?”
“Baby! Honey! Don’t you know you and only you have my number? No one else.” Claire answered using a sweet tone of voice. “Good to meet you guys. Did he tell you the one about the dog pile yet?”
Mesmerized and totally enthralled, the wide-eyed students nodded nervously, still unable to speak.
“Meet you later for lunch?” asked Jack.
“Sure, see you all later,” answered Claire with a stunning smile. She walked in the opposite direction and turned the corner.
Practically paralyzed and dazed, the young medical students stood there speechless, silent and motionless, the events of the last few minutes still playing wildly in their heads.
“Wow,” whispered Taylor softly, finally breaking the weary silence. Amused by it all, Jack walked ahead.
“Come on, knuckleheads! We’re behind schedule already.”
*****
9:24 AM
Jack and his students walked briskly towards the nurses’ station. Jack knew there was a lot of work to be done and he didn’t want to take a chance of missing lunch with his lovely wife. They had to work fast.
“Code blue, CCU, bed five,” repeatedly announced an excited voice over all the beepers in unison. The men made a beeline to the Coronary Care Unit. On their arrival, they saw many people inside the small cubicle that contained bed number five. A petite brunette nurse kneeled on the bed, her knees touching the seemingly lifeless body of the patient. She was performing chest compressions. Other nurses in the room performed the other duties necessary for a successful outcome in a case of cardiac arrest. Dr. John Connor was already in the room.
“What’s the 411?” asked Jack calmly looking directly at John. Jack continued before Dr. Connor could say a word. “Can we get whoever is not directly involved in the code to step outside? We got too many people in here.”
Some people turned and backed out of the cubicle giving Jack room next to the bed of the motionless body. CPR was ongoing with a distant cadence: “one-one thousand, two-one thousand, three-one thousand, four.” At each count of five, a respiratory therapist would squeeze a bag that was both hooked up to the oxygen outlet on the wall as well as a tube coming out of the patient’s mouth, which had previously been inserted into the windpipe.
As words were exchanged, Jack automatically and almost unconsciously eyed the chest excursion when the bag was squeezed. Jack compared the patient’s chest movements to that of the stomach area, which was minimal. The patient’s color was generally pink. With this rapid visual assessment, Jack was confident that the tube was properly inserted into the airway and that oxygenation was being performed adequately.
“This is a fifty-seven-year-old man who presented with chest pains. Cardiac markers negative times two. He just arrived a few hours ago. Sudden arrest with v-fib, shocked times three; we’re on our second atropine and second epi. No results. Asystole on the monitor,” verbalized John.
“Okay, John, you go ahead and run the code. Students stay here and watch a pro at work. Do not try this at home, kids. Leave it to the professionals,” ordered Jack as he winked at John. Jack exited the cubicle to find the patient’s chart. He wanted to assess all the lab data for this case.
“Where’s bed five’s, Bessie?” asked Jack of the ward clerk who anticipated the request and immediately handed the chart to the young doctor. As he sat down at the nurses’ station with the chart in front of him, in the background the telltale escalating hum indicated that the external defibrillator was charging up to deliver another shock.
“Clear,” then a thump was heard coming from the cubicle.
“No pulse. Again at 360. Continue CPR until ready to shock,” requested John in a firm but calm voice. The process was repeated.
“No pulse,” assessed John a few seconds after the shock. He continued: “What’s the down time, Heather?”
“Thirty-two minutes, Dr. Connor,” answered a woman’s voice from within the room.
“Okay, let’s call it; note the time of death,” ordered John. Soon afterwards, one by one, the rescuers exited the room, a look of failure and sadness on their faces.
“Is this a coroner’s case?” asked Jack, as John and the medical students joined him at the nurses’ station.
“No,” answered John quickly. “This is a clear cut cardiac event.”
“Well, the guy just came in less than twenty-four hours ago, he ruled out, I think we need to call the coroners’ office,” disagreed Jack.
“Okay, I’ll call them in a bit; first, I want to call the family,” said John.
“What are you doing here, John?” asked Jack.
“I was here trying to recruit the patient into one of the research studies,” answered John sitting down.
“Guys, this is John Connor. John, these are the guys.”
The three medical students and John shook hands, each stating their name. As this was being orderly carried out, Jack continued: “John is one of our research fellows. He’ll tell you what types of patients he needs so you can scout for him.”
“I’ll give each of you the inclusion and exclusion criteria for what I need. I’ll have my beeper number on there so you can contact me ASAP if you find a potential candidate,” stated John in a professional voice. With a complete change of demeanor, John playfully and excitedly turned to Jack.
“Hey Jack, what time’s the game on Sunday?” Then turning to the students he asked, “Any of you bozos play soccer? We need a goalie on Sunday.”
The students shook their heads.
“You gotta stop taking on students that don’t play soccer, Jack.”
“Well, to pass this rotation, they have to learn soccer. If we have time, we’ll teach them a little cardiology,” Jack continued. “Are you coming over Saturday for the Chelsea versus Major League Soccer all-star game? Plenty of beer and pretzels.”
“Sorry, I forgot to tell you. The head coach for the MLS all-star team called and wants me on the team. Can’t say that I blame him,” said John.
“Oh, why, do they need a water boy?” stated Jack, smirking.
“I don’t know, but since I’m on the team, I’ll put in a good word for you, Jack,” said John.
“Are you coming over to watch the game?” inquired Jack once again.
“I’ll come. I want to hang out with your wife. I have to try to talk her into leaving you and marrying me. The game’s at five, when should I show up?”
“Come at eight. If the door is locked and nobody answers, go back home.”
/>
“Very funny,” said John sarcastically. “Good to meet you, boys; I hope you can be a good role model and provide adult supervision for Dr. Jack Norris these two months. Gotta make a phone call and get back to the laboratory,” said John, pronouncing the last few words in a Transylvanian vampire accent, mockingly, as he left the nurses’ station.
Heather McCormick and Julie Gerharp entered the room and sank down onto a large couch, expelling deep breaths as they did, sounding exhausted. They were both young but dedicated nurses that had worked in CCU for a couple of years. They were bright and thorough, qualities Jack really admired. He felt very confident in their patient assessments. Julie had been in charge of doing CPR. Heather took notes and gave the intravenous medications ordered by the code leader. Here and there, Heather would give a suggestion that was usually respected. She would say: “It’s been five minutes since the last epi.” This would be a clue that it was time for the doctor in charge to re-order the administration of epinephrine in the resuscitative efforts of the dying patient. Instead of saying: “Don’t stop CPR for so long,” she would ask: “Doctor, do you want us to continue CPR?” She knew very well that the answer was yes, but she had mastered the way to contribute positively to the situation and yet give the appearance that the mighty doctor was really making all the decisions. Julie was totally devoid of this quality. She called it like it was. If something was being done incorrectly, she would simply point out the facts and demand an explanation for the deviation from protocol.
“Dr. Norris,” started Heather. There was something bothering the two nurses.
“What’s up?” answered Jack with a concerned tone. The students remained quiet.
“Why do you think Mr. Roper died?” asked Heather.
“Well, because rule number one: patients die; rule number two: doctors and nurses can’t always change rule number one.”
“Come on, we’re serious,” interjected Julie, getting the notion that Jack was teasing.