The turmoil of Polk’s crowded office shattered the quiet of the outside world. Every chair and sofa seat held a patient or family member. They ranged in age from children to senior citizens.
The modern ventilation system minimized the odors generated by so many people in a confined space, but did nothing to distract from the sneezing and coughing.
This is no place for the healthy, Helen thought.
Rapid movement to and from Polk’s inner office suggested they needed a revolving door.
This is going to take forever, thought Chuck.
Twenty minutes later, she met with Dr. Polk.
Helen Martin had worked with many physicians and had chosen Joe Polk as their family Doc. His self-assurance and confidence brought feelings of warmth and trust. She knew her family was safe in his good hands. Helen had worked closely with Dr. Polk when she worked the general medical wards, but hadn’t worked with him directly in the last few years after she moved to Brier’s skilled nursing facility.
After initial evaluation and lab testing, Polk announced, “Helen, you have acute viral hepatitis. Trust me, it will run its course in three to six weeks and then subside. Meanwhile, there’s nothing to do other than to avoid alcohol or any medications that could damage your liver.”
Entrapped by their own personas, the Martins approached this illness, as all life’s events, with confidence that fate would not disappoint them.
After about a month, Helen’s eyes returned to normal.
“I’m feeling much better,” she said. “My energy and appetite are back.”
“Are you ready to take me on?” Chuck asked, lacing his running shoes.
“Give me another week, then watch out,” she smiled. “It’s great to be healthy again.”
Chapter Two
Brier Hospital evolved from the turn of the century Brier Hills Convalescent Home, a small nursing home and tuberculosis sanitarium located in the East Bay of San Francisco in the hills, just east of what now is the University of California, Berkeley.
Bernard Brier, heir to the Brier Mines near Nevada City, California, lived in a Victorian mansion. Next to the stately residence, he built a convalescent home for his mother and her two elderly sisters, her attendants. Over the years, the sisters accepted the elderly and infirm for care. In 1908, the practice developed into a business and they renamed the convalescent home, The Brier Hills Sanitarium. The facility expanded, and with the death of Bernard Brier in 1928, they converted the mansion into administrative offices, still functioning in this capacity today.
Just before the World War II, following a suspicious fire that damaged about 30 percent of the sanitarium, Brier Hills, by then operated by a board of trustees, decided to rebuild and expand. The sanitarium became Brier Hospital, a private, not for profit, community hospital.
A major confrontation developed in 1962. The hospital needed more beds, an expansion to fulfill the demands on the facility, which by its location and activity generated, had become of concern to the city and local neighborhood. The public uniformly condemned the board’s decision to tear down Brier Mansion for additional space. Political pressure forced an abrupt reversal of the board’s decision and the placement of Brier Mansion on California’s list of historic sites. Finally, after hundreds of hours and many tens of thousands of dollars in architectural and structural engineering fees, plans evolved to expand the existing hospital, adding two floors and two wings. They chose an external Victorian-like façade, a solution greeted less than enthusiastically by most of those outside the planning process.
It was midnight as I walked in silence down the Brier Hospital corridor toward the intensive care unit. They’d designed the one hundred-foot hallway with dim indirect lightening. At its end was the unit’s entrance, the proverbial ‘light at the end of the tunnel’. The large intimidating bright yellow and red sign on the double doors read, AUTHORIZED PERSONNEL ONLY.
I pushed the call button next to the door. “Dr. Byrnes to see Mrs. Archer.”
After the coarse buzz, I pushed the heavy door and entered.
Well, this is it. I’d spent a good portion of my life waiting for this day. The triumph of delayed gratification, they say. To me, during training, the horizon, finally getting to practice, had constantly receded, and I never felt certain of getting here.
My senses read the ICU immediately. Each one has its own smell, its own ambience, and its own sense of urgency. Smelling is reflexive, a primitive defensive response like you see in animals like Mike, my dog, who checks out her world with twitches of her cold wet and sensitive nose. Fortunately, tonight the odor of disinfectant overwhelmed the room. The aroma of ICU could challenge the senses, often creating the instant desire to make an about-face and escape.
I walked through the shadowy room, assimilating the sounds and sights. It wasn’t silence, but more a soft background blend of unobtrusive sounds: the clicking and whirring of respirators, the hissing and bubbling of oxygen masks, the soft groaning of vacuum suctions and the shuffle of feet moving back and forth from bed to nursing station.
As I entered the unit’s open space, my face felt the soothing green flickering hue from the many monitoring screens at the bedside and at the nursing station.
I don’t know why I felt tense tonight, having virtually lived in one ICU or another for the last six years while training, first in internal medicine, then in intensive care. I have the certificate from the University of California in San Francisco that bestows on me the title of Intensivist. It’s an unfortunate term that makes one think I need a psychiatrist or Valium, but just means that I’m specially trained to deal with the sickest patients in intensive care areas. I love working in ICU, the high-pressure, high-risk environment that requires rapid decision-making in the care of the critically ill. The frenzy of intensive care is addictive, my drug of choice like the adrenalin high of the skydiver or mountain climber?
I’m not in training anymore. This is the real world and I wanted to do well.
The additional intensivist training served as a bonus professionally, as medicine at the millennium was evolving. Soon, hospitals would permit only specially trained physicians to care for patients in the hospital and especially in the ICU. This was a two-edged sword with the benefit of having M.D.’s with the greatest skills caring for hospitalized patients, balanced against the shortcomings: the sacrifice of continuity of care and the deprivation of the ability of non-hospital docs to experience the full spectrum of disease, an arbitrary limitation of their practice.
I knew what I was doing. I’d been tested during the war zones of my residency and fellowship training completed nine months ago.
The years in residency and fellowship brought physicians in training progressions of knowledge and responsibility, though not always in parallel. In a sane world, knowledge would precede responsibility, while during medical training, they got it backwards. To my surprise, the results for patients were reasonably good, a testimonial to three factors: good luck, a teaching environment that demanded excellence, and the degree of effort necessary to injure a patient, not that some young physicians didn’t work hard at it. The few, who were either unaware of their ignorance or too arrogant to ask for help, posed the greatest risk. This was inexcusable, since all accredited training programs had a built-in hierarchy of assistance from residents at varying stages of training, to chief residents, to subspecialty fellows, to attending physicians and department heads, all available on a real-time basis for assistance.
I loved my last two years in training where I finally achieving the knowledge and experience to justify the responsibility I wielded on a daily basis.
My evaluations during training had used the phrases, bright, easygoing, and optimistic. I’ve always got along with my supervising physicians, nurses, and house staff, but here, with the start of a career, much more would be at stake.
I wanted to make a good impression from the start. Life would be a hell of a lot easier if they accepted me and better if the nursi
ng staff liked me. I’d related well to nurses during training because I respected their hard work, and sensed we shared goals when it came to caring for patients.
I recall a few encounters where I had to keep my mouth shut, stifling a critical comment for the sake of getting along, and have to admit that on the rare occasion, I’d lost it when the uncaring or the plain stupid, endangered patients. Fortunately, this was a rare event so my expectations of skilled care and goodwill were met far more often than not.
The twelve-patient ICU had all but two beds occupied. The atmosphere was calm and the staff, having things clearly under control, were relaxed.
I approached the central nursing station and the monitor tech, forerunner of the multitasker. She had an uncanny ability to keep her eyes on multiple monitors while fulfilling a whole range of responsibilities.
“I’m Dr. Byrnes. Who’s in charge tonight?”
With only the slightest glance away from the monitors, and a bright smile, she shook my hand. “Sandy Williams, monitor tech par excellence, great to meet you. Beth Arnold is in charge tonight and she’s in the nurse’s lounge,” pointing to the back right side of the unit.
My gaze across the unit stopped for a second at each bed. Why was each patient here and how likely were they to avoid that dark resting place in the hospital’s sub-basement? After confrontation with the reality of my busy hospital practice, I didn’t look too closely at other physician’s patients and their problems; I had enough of my own.
Assessing patient care was a habit I’d formed as a player in my teaching hospital’s quality assurance program. A gift or a curse, I could review a medical chart and determine the quality of an individual patient’s care. A teaching environment, by its nature, must be confrontational, as one did learn by ones mistakes, so I’d felt comfortable giving and receiving criticism. Who knows how frank exchanges would fly in a private community hospital?
Through the open lounge door, a woman in her late twenties sat under flickering fluorescent lights with forms spread out on a table before her. She was so intent on her paperwork that she did not acknowledge me until I said, “Sorry to pull you away from all that fascinating work. Do you have a minute?”
She looked up and smiled, “Pull me away from this stuff any time you can. I’m Beth Arnold and you are,” she paused, extending her hand.
I took her warm hand and smiled. “I’m Jack Byrnes. Dr. Phillips asked me to consult on Agnes Archer. I’m new here and would sure appreciate a short course on how you do things in ICU.”
Smiling again, Beth stood, wrapped her stethoscope around her neck and honey blonde hair that fell to her shoulders and said, “Let’s do a quick tour of ICU and I’ll introduce you to the staff working tonight. If you need to see your consult first, we can do this later.”
“It’s okay. From what Dr. Phillips told me, this can wait a few more minutes.”
Beth stood and then walked through ICU with me in tow.
She was about five feet, five inches, trim and undeniably female in shape. If she looked this good in scrubs, she was going to be a knockout in civilian clothes.
Beth introduced me to her staff and continued in a bright monologue to describe the ins and outs of ICU, taking time to show me the location of the supply cart.
“This cart has everything you’ll need for routine care in the unit,” she smiled and I thought, winked. I got the subtle message, ‘Now Doctor, that you know the location of the supply cart, you’ll do better by helping yourself and not bothering my busy nurses when you need something’.
This was a skilled pro, doing her job, drawing boundaries and radiating goodwill all at once.
I liked Beth Arnold right away.
“Mrs. Archer is in bed three,” she said pointing toward the corner. “Andrea Marshall is her nurse tonight; she’ll help if needed.”
I walked to the bed. Mrs. Archer had pulled the sheet to her face leaving only her eyes and forehead in view. She awakened at once squinting when I turned on the overhead light.
“I’m Dr. Byrnes. Dr. Phillips asked me to see you tonight.”
She’d heard me, I was sure, but her delayed response and her flat expression suggested she hadn’t processed this little bit of information.
Bob Phillips had said that Agnes had struggled to reach age seventy-two and looked more like ninety-two. Her face had coarse wrinkles, the classical prune face of a heavy cigarette smoker. Her hands showed typical brown tobacco staining between the index and middle fingers and around the nails of her right hand, confirming my conclusion. Someone should have done one of those identical twin studies where they matched smoking versus nonsmoking twins. When they posted pictures of identical twins, side-by-side, their appearance would tell which one smoked. In women, at least, this might motivate a few to consider the cosmetic effects of this unfortunate habit, a threat more potent than merely death.
“I’m going to take a few minutes to look at your chart and review your tests.”
Again, she showed little or no response. I walked back to the nursing station and sat, chart in hand.
I liked to approach each chart in a structured way. First, and it had better be first if my office manager had a say in it, I grabbed a patient information sheet from the rear of the chart. This contained demographic and insurance information for billing. I dared not return to the office without this and had developed the habit of using the rear of the sheet for my notes, lest I forget.
I first reviewed Mrs. Archer’s H & P (her history and physical examination) performed by her surgeon as a requirement before surgery. Nobody got to surgery without an H & P. Surgical H & P’s had a reality of their own. They had little to do with the patient’s actual condition that surgeons outlined as briefly as possible. One of my own patients was going to surgery a few months ago, and before I had a chance to place my own H & P on the chart, the surgeon completed one of his own. That particular patient, age seventy-six, on multiple medications, had at least six significant medical diagnoses. My H & P took five typewritten pages, while the surgeon’s occupied only three-quarters of a page. Although technically complying with the requirements, the surgeon’s efforts had little resemblance to an accurate description of the patient’s condition. Whenever possible, surgeons tried to con primary physicians or consultants into doing the H & P’s.
Agnes Archer, in her eighth decade, had a history of high blood pressure and coronary artery disease with a mild heart attack three years ago. She was well below our expectation of one drug for every decade of life over age fifty as she took only a diuretic and a cholesterol-lowering pill. She’d not aged well and had become inactive and physically weakened that walking had become difficult for her. She’d fallen and fractured her hip.
Her blood tests had revealed a serum sodium concentration mildly depressed before surgery. It had gone rapidly downhill over the next four days without comment from either the surgeon or the primary doc. Only when she became confused, disoriented, and periodically semi-responsive, did her attending physicians recognize they had a problem.
She’d been eating poorly and remained on IV fluids containing low concentrations of salt or no salt at all. She remained on her preoperative medications.
Review of her I & O records (intake and output of all fluids) showed what I’d anticipated. Agnes Archer had received too much fluid from drinking and from her IV’s and peed too little. She’d managed to dilute out her own body’s chemicals.
When I looked at Mrs. Archer’s lab results, they were, in technical terms, all out of whack. The serum sodium concentration reached levels low enough that her brain couldn’t function normally and put her at risk for more alarming complications such as convulsions. Clearly, neither Bob Phillips nor the consulting surgeon Dr. Craig Alan, had the slightest idea how she got to this stage or what steps were necessary to fix these abnormalities. Worse still, when I checked her IV, she continued to receive the kind of fluid that could only make things worse.
Déjà vu, all over again. Inst
ruction on how to work with the referring physician is the one area of practicing as a consultant that they never covered formally during my training. We learned these lessons informally, the hard way through watching other consultants in action. I’d seen it all; from the obsequious kiss-ass, stroking the referring physician, to the hard-liner, rude and overtly critical of everything the referring physician had done. Surely, I’m not the latter. It frustrated me at times when dealing with referring docs. Sometimes it was a power struggle about who ran the case. Sometimes it was confusion about who was responsible for what, and too often, it was the intractability of the referring docs’ mistakes that just pissed me off. I struggled to avoid these feelings as I dealt repeatedly with the same diagnostic and therapeutic primary care physician and surgeon screw-up’s. Though each of us had his or her unique set of responsibilities, sometimes it’s difficult to duck these feelings. Many referring physicians never learned from past mistakes, and, some didn’t give a damn.
Putting this all aside, I continued with Mrs. Archer’s evaluation. After examining her, I ordered changes in her IV’s and diet, and stopped her diuretic. I ordered follow-up lab tests.
A call to Bob Phillips awakened him and after I made sure he was fully aware, said, “You were right to be concerned about Mrs. Archer. Her serum sodium had reached a dangerous level where she’s likely to have a seizure.” I went on to explain in the most tactful of ways, how she got to this stage, and what changes I’d made in her orders.
“I appreciate your help, Jack,” Phillips said. “Those damn electrolyte problems drive me crazy.”
I smiled with relief then agreed to meet Dr. Phillips later that morning.
I completed my chart note and dictation, and thanked the bedside nurse and Beth Arnold.
“Call me if you note any significant change in Mrs. Archer’s mental state. I’m heading home to try for a few hours of sleep.”
First, Do No Harm (Brier Hospital Series Book 1) Page 2