First, Do No Harm (Brier Hospital Series Book 1)

by Lawrence Gold

Patience wasn’t one of Warren’s virtues. Over the years his participation at the university and in the leadership of Brier Hospital, he’d developed an aversion to politics in any form, but particularly the petty politics of power and personality intrinsic to medical care and to the education of physicians.

  “I hate all this political bullshit,” he told his wife Annie, “but politics is the only game in town.”

  Annie had heard it many times before, “Take a moment and reflect on all you’ve already accomplished. Age sure hasn’t mellowed you, babe, and I don’t anticipate it ever will.”

  “I suppose not,” he said, “but it hasn’t become any easier.”

  Warren slid his chair forward peering at me above his half spectacles. “Let’s get to it, sonny. Did you really mean to say that Professor Greg, my Professor Greg, has to wait an entire week to see you in consultation?”

  I caught myself before rolling my eyes upward. Warren wouldn’t miss the gesture.

  “I’ll see him this afternoon, Warren, and I’ll call you immediately afterwards.”

  “Listen, Jack, Justin Greg is an important man, and he’s to get the best we have to offer. His blood pressure has been sky high and I haven’t been able to keep it down. Work with him until he’s in control and then send him back to me.”

  One thing was sure about dealing with Warren, I always knew where I stood and what he expected of me. With many referring physicians, you’d need a crystal ball or divine guidance to decide how you dealt with an individual case. This uncertainty, more likely than not, lead to mistakes in evaluation and treatment, which came with fragmented responsibility. Sometimes, I disagree with Warren, but at the very least, we know each other’s responsibilities.

  Warren switched subjects; “I’m having trouble again with Joe Polk. He’s a swift pain in my ass. The prick thinks he knows everything and he doesn’t have a clue when he’s over his head. The Director of Nursing is on my back to do something about his patient on the fifth floor medical unit, so I’m passing the buck to you. See the case, Mrs. Helen Martin, write orders, and talk with Joe using the best of your diplomatic techniques. He won’t be happy I’ve insisted on the consultation, but screw him, he’ll never learn.”

  “This is the famous Joe Polk of Ask Doctor Joe on the radio?”

  “That is he,” Warren said. “Ask Doctor Joe’ is the brainchild of some genius in Brier Hospital’s marketing department, and one giant pain in my ass.”

  For the past five years, Joe Polk spent two hours every Saturday afternoon discussing the medical news of the week and answering questions from his radio audience. He was great, the local Dean Edell, frank, authoritative and unaffected.

  “I can’t believe the guy,” Warren said. “He’s unabashedly self-promotional, and self-aggrandizing.”

  I’d heard the program on occasion while driving. That would be a great job for me some day.

  Polk fielded all questions and gave appropriate responses to those whose answers were straightforward. His responses in problematic areas were evasive or much too definitive for my taste, and often, Polk had been flat out wrong.

  I hadn’t paid much attention to this program until I heard rumors about Polk’s practice and his many confrontations with the nurses and medical staff. How could this physician carry the banner of Brier Hospital?

  I looked up at Warren. “Joe Polk wouldn’t be the first physician on this staff I’d choose to represent Briar Hospital.”

  “You can be sure that yours truly had no choice in that matter.” Warren said. “Going forward with Polk may be great marketing, but it’s an embarrassment to me and to the institution.”

  This was not where I wanted to be. Warren was forcing me to tackle a powerful and venerable physician, not the kind of introduction I wanted for an important member of the medical staff. The case must be going badly or Warren might have taken a less direct approach.

  I had two patients to see in the office, then forty-five minutes to see Helen Martin before the noon Quality Assurance Meeting.

  I arrived at the ward earlier than expected, and when I asked for Helen Martin’s chart, the charge nurse, several other nurses, and aides on her case, closed in on me.

  Mary Oakes, the nurse supervisor looked relieved “We are so glad you will be seeing Mrs. Martin. We can’t get through to Dr. Polk about how poorly Helen’s been doing. He keeps saying everything is under control and going as expected, but it’s as if he’s talking about some other patient. We asked politely and as diplomatically as possible if he wanted us to call a consultant. After a few minutes of outrage, feigned or real, he replied, ‘Listen, honey, you may need a consultation, I don’t.’”

  Mary took me aside and in a whisper through clenched teeth that had the intensity of a bullhorn said, “We’re sick and tired of standing by and watching another of Polk’s patients going down the tube while he pats us on the back and tells us not to worry our pretty little heads. We won’t tolerate this kind of care and his patronizing attitude. Someone has got to stop it before he kills somebody.

  “The family is in the dark about how sick Helen is and they continue to be steadfast in their faith in Polk,” Mary said. “We thought this a.m. she was going to code, so we called Dr. Davidson.”

  I’d heard it all before. I learned from my early medical school days that skill and dedication would take a back seat to the charismatic physician. I remembered one medical student who didn’t know which way was up and cared less. Now his patients held him in such high regard that he had managed to fill his huge practice–a testimonial to incredible good luck, and served as proof that as Voltaire said: The art of medicine consists of amusing the patient while nature cures the disease.

  After years of experience, I had come to understand the psychological consequences of significant medical illness and especially of life-threatening illness. Fear and uncertainty makes it difficult for patients, or even a health professional, to judge the quality of their own care. When someone is seriously ill, stress impairs judgment and changes how you relate to your physician. Simply stated, this was not the time when most patients would choose to pick an argument or question his or her physician, not when one’s life was at stake.

  This is a fact of my professional life, and I try my best to assure my own patients’ meaningful participation in their treatment.

  I sat with Helen Martin’s chart and began reviewing her history, lab findings, and clinical course. What’s going on here? I thought.

  Polk had admitted this forty-three years woman six days ago with a diagnosis of ‘acute hepatitis’. She had a long history of chronic hepatitis and several past admissions for acute hepatitis, a bizarre sequence of diagnoses. In the hospital, she got progressively worse with large amounts of fluid forming in her extremities and abdomen, low-grade fever, alterations in her mental status, and a variety of electrolyte abnormalities. If that wasn’t enough, she was wasting away. By her appearance, and adjusting for all the extra fluid she carried, she must have lost ten to fifteen pounds from her already lean body.

  Polk had done little else than ordering lab tests and adjusting her diet.

  My evaluation made me even more concerned as I confirmed what I’d read on the chart while examining her. Her belly was tender all over, a sure sign of something seriously wrong.

  I called Polk’s office, but his office nurse said, simply, “Dr. Polk is unavailable for the next two to three hours.”

  “This is an emergency.”

  “I’m sorry, Dr. Byrnes, but I’m unable to reach the doctor now. I’ll leave him a message.”

  I returned to the bedside, and after explaining to Mrs. Martin that I needed to drain a small amount of fluid from her abdomen to run tests, she signed the permit for the procedure.

  I turned to Mary. “Please bring me an abdominal paracentesis tray and lend me a hand with Mrs. Martin.”

  Ten minutes later, I displayed four vials of cloudy fluid that had come from her abdominal cavity. We sent these “stat”
to the lab for immediate analysis and culture with the presumptive diagnosis of primary peritonitis, an infection inside the abdominal cavity. This was a dreaded complication of advanced liver disease. It astonished me that Helen had made it this long without any treatment. We see many untreatable, life-threatening illnesses with only marginally effective therapy, but only a handful of illnesses responded to simple and effective measures, especially if caught early. Primary peritonitis is an excellent example.

  I wrote antibiotic orders and called Mrs. Martin’s husband to explain what happened and what I planned. Chuck Martin thanked me and said he’d be in to see Helen that afternoon.

  I prepared to leave for my noon meeting when Mary Oakes, the charge nurse, asked to speak with me in the privacy of her office.

  She’d covered her walls with pictures of staff, current and past, framed articles about some of their patients and letters of appreciation to the nursing staff.

  After settling behind her highly organized desk, Mary managed a wry smile. “I see you’re getting off to a good start with this case and with the charming Dr. Polk.”

  “Well, I’m learning lots of things they never taught in medical school.”

  “If you don’t mind, Dr. Byrnes,” Mary said, “I’d like to help you understand this case and some circumstances surrounding it.”

  “Please call me Jack.”

  I sat next to her desk as Mary talked. “Helen Martin worked as a nurse in this hospital for many years. Through a sequence of bad luck and misadventure, she is as you saw her today. She has chronic hepatitis C, and, in the absence of a specific event, such as a documented needle puncture, she’s been on her own regarding insurance and other needed support.”

  “Though everyone, except hospital administration, believes her hepatitis was job related. Helen has received little support from the hospital or the nurse’s union.”

  Mary paused a moment, trying to control her emotions then continued, “We all know how chronic illness can affect a person, and a family, but none of us has been this close to a friend’s case for this long. Helen may need a liver transplant, but she recently deteriorated and wound up here in the hospital. We’re used to accepting the inevitable outcomes of diseases for which there are no effective treatments, but we’ve been beside ourselves with anger as we watched her deterioration under Polk’s care.”

  She began crying, her face contorted. “I’m so angry and frustrated, I could spit! It’s guilt. We’ve been standing by watching Joe Polk injuring patients. It’s reached a point beyond anyone’s tolerance. We must do something.”

  Her outburst, so heartfelt and sincere, touched me immediately, especially as it was so clearly justifiable. Additionally, I felt embarrassed and angered by the reality of what I’d seen too many times before; the belief, the conviction, held by health professionals and laity alike, that physicians were essentially good, a belief so intractable that only extreme evidence to the contrary could shake it.

  I hesitated, and then took Mary’s hand. “I share your rage and frustration about this case and the way the hospital and the medical staff have handled it.”

  It wouldn’t be easy to reassure the nurses that we were committed to Helen’s care and that we will finally do something about Polk. I wouldn’t believe me either if the medical staff and the hospital had ignored all my prior complaints.

  A simple statement of fact would have to do. “Dr. Davidson understands the gravity of this situation and so do I. We’re on this case and I promise you the nurses will no longer have to stand alone.”

  I was late for my noon Quality Assurance Meeting.

  Chapter Seven

  Joseph Eton Polk was the only child of Clarissa and Everett Polk. He came into the world just in time. They had all but abandoned hope. Everett, the headmaster of the Rensselaer Academy in Troy, New York, a small university town seven miles north of the state capital in Albany, was rigid and demanding of himself and others. Clarissa, the academy’s librarian, was his polar opposite, warm and accepting and fulfilled in every way except through motherhood.

  Clarissa doted on Joseph, while Everett ignored his son until, to their surprise and pleasure, they discovered his gifts. He was walking and speaking early and reading well by age two. Joseph had a phenomenal memory. He delighted his parents and amused friends and family with his ability to recite passages of text, poetry and anything he’d learned recently. Joseph loved and thrived on the attention, seeking every opportunity to take front stage.

  In their happiness, his parents failed to notice the degree of their son’s self-involvement and difficulty in dealing with other children. Joseph refused others any part of the stage, and showed, to an alarming degree, an insensitivity and hostility to all others, even toward his mother.

  “Everett, I’m becoming ever more concerned about Joseph,” Clarissa said. “He’s eight years old and something’s not right with the boy.”

  “I haven’t the slightest idea about what you’re talking about. He’s a gifted child. That alone makes him different.”

  “I’m not just talking about his differences. Something’s missing from the child. He knows all the facts, but he shows none of the sensibilities of a normal child. Nothing brings him joy unless he’s the center of attention. Last week, when I fell in the kitchen and sat on the floor crying, Joseph asked me to get him cookies and milk. He couldn’t have cared less that I’d been injured.”

  “You’re making a mountain out of a mole hill. His mind is preoccupied, engaged with thought processes that we cannot begin to comprehend.”

  Everett’s denial would not put off Clarissa. After all, he did not spend his days with the child. Joseph’s insensitivity and his meaningless pathological lying alarmed her even more. When the family cat and several neighborhood pets began showing signs of abuse, Clarissa had enough.

  “I’ll be damned if I send my son to some idiot shrink,” Everett said.

  “You can choose to ignore any number of problems in our lives, Everett, but not this one,” she said with determination.

  With persistence, Clarissa got his acquiescence and they sent Joseph to the Albany Medical Center Child and Adolescent Psychiatry Clinic. Once there, he charmed and lied his way through the evaluation process. The final report confirmed Everett’s opinion; Joseph had only minor adjustment problems, expected in a gifted child.

  Clarissa bought none of it, and when Everett gloated as he read the psychiatric report in Joseph’s presence, she understood the meaning of her child’s glare, and his smirking, triumphant smile.

  Clarissa’s relationship with her son would never be the same.

  Joe Polk moved through his school years and into Harvard at the top of his class. Although popular for his bright mind and wit, he had no close friends. He excelled in medical school and into residency where, in his final year of training, they chose him Chief Medical Resident, a highly desired and prestigious position.

  His role as chief resident revealed a Joe Polk few had seen before.

  Joe’s primary responsibility was to teach medical students and house staff. In addition, he carried many administrative responsibilities over the hospital’s medical service.

  His new role revealed rigidity, inflexibility, and a dogmatic approach as he micromanaged the medical service. He drove everyone crazy.

  On hospital teaching rounds, Polk was merciless in his criticism of students and house staff for any fault in technique or procedure or in the knowledge of their cases. Public humiliation was a cruel but effective tool, he thought, and no student or member of the house staff ever came to rounds with Joe Polk unprepared.

  All respected Joe, but most disliked him, and more than a few hated him.

  Hectic, best described Tuesday morning rounds, for the medical service admitted eighteen new patients overnight, nearly a record. Joe spent the morning grilling the medical students and interns on each of their cases, extracting his usual pint of blood.

  Carrie Harris was a twenty-four-year-old in
tern educated in the Dominican Republic. She was next to present, and facing Polk had her near panic. Under the best of circumstances, her presentations were tentative.

  She began, “Adele Carter is a thirty-seven-year-old African American female admitted last night with abdominal pain.”

  Polk raised his hand to stop her. “What’s African-American? Is a Caucasian born in Africa an African-American? Race is pertinent in an H & P, what race is she?”

  “She’s a black woman, sir.”

  “Go on, go on.”

  Carrie went on to describe Mrs. Carter’s symptoms in detail and her long history of alcohol abuse. After concluding her presentation with the patient’s laboratory data, Polk interrupted again. “Let’s have your primary diagnosis and the differential diagnosis.”

  Hesitation was chum in the water for Joe Polk. He stared at Carrie Harris, preparing his attack.

  “I think the most likely diagnosis,” she began cautiously, “is alcohol induced acute pancreatitis. In the differential diagnosis I include acute gallbladder inflammation, gallstones…”

  “What is Cullen’s Sign?” he demanded, interrupting her for the third time.

  “Cullen’s Sign, sir?”

  “Yes, Cullen’s Sign.”

  “I never heard of Cullen’s Sign, Dr. Polk.”

  Polk turned his attention to the house staff, staring and smirking at them as they stood in a semicircle around him avoiding eye contact.

  “Can anyone tell me about Cullen’s Sign?”

  The silence was oppressive.

  Finally, Polk turned to the gastroenterology resident, Sarah Jessup. “Tell them, Doctor.”

  “Cullen’s Sign is a black and blue mark that surrounds the bellybutton in some cases of pancreatitis,” she responded, “but it’s a bit arcane, an uncommon finding.”

  “Excellent,” Polk said. “It’s in every discussion of pancreatitis in your texts, don’t any of you read?”

  Polk turned again to Carrie Harris. “Doctor Harris, describe for the group the root causes of pancreatitis.”