The over the bed speaker blared, “Mary, are you there?”
“Yes, what is it?” she answered her ward clerk.
“I need you out here.”
“I’ll be back in a few minutes,” Mary said to Andrea as she departed.
Polk scrubbed the left side of McDonald’s abdominal wall with Betadyne antiseptic, turning the skin an angry brown. With Andrea’s help, he draped the abdomen with green sterile towels. He then instilled a small amount of a local anesthetic into the abdominal wall and inserted a plastic catheter. Clear, yellowish fluid dripped from the catheter. He directed the fluid through a plastic line and then into the vacuum collection bottle, transforming the drip into a steady stream as the bottle filled rapidly.
“This is what I want you to do Ms. Green. When each bottle fills, clamp here,” pointing to the clear plastic tube, “then remove the needle from the vacuum bottle and reinsert the needle into an empty collection bottle.”
“Dr. Polk,” exclaimed Andrea Green, “I’ve never done this before. I’ve never seen a protocol for this procedure. I’m not comfortable doing this.”
“What’s the big deal? Just follow my orders to the letter and everything will be fine,” Polk said, putting on his coat and preparing to leave.
Visibly upset now, Andrea tried again, “Dr. Polk, sir. I can’t do this alone. I don’t know enough about this procedure.”
“Trust me, you’ll do fine,” Polk said as he departed.
Andrea stared around the room, eyes jerking. A light sheen of perspiration erupted suddenly on her upper lip. Polk’s sudden departure stunned her.
I can’t believe this–Just follow his orders and everything will be fine, she thought.
“You know, Andrea, my breathing is much better now,” Fred said after she removed the third quart of fluid.
Fred’s comment encouraged her as she continued removing fluid. Her anxiety increased with each quart removed. She stared at the ten quarts and panicked.
How many more?
She’d been checking Fred’s vital signs every ten minutes as Polk instructed. His blood pressure started on the low side and the last few readings were falling.
“I’m not feeling so good, Andrea. I’m gonna throw up,” Fred said as a sea of bile-green watery fluid spewed from his mouth spraying the bed and Andrea.
Panicked, she pushed the call button. After the longest few minutes of her life, the ward clerk answered, “Can I help you?”
“I have an emergency,” Andrea shouted. “I need some help, stat!”
Mary was first to enter the room, “Where’s Dr. Polk? What’s going on?”
Andrea briefly told Mary briefly, what happened.
Mary took Fred’s blood pressure, pulse, and after she assessed his skin condition and mental state, said, “He’s shocky. Get that catheter out now. Put in a stat page for Polk.”
McDonald suddenly became poorly responsive. He paled and began sweating profusely. Helen inserted an IV line and pressed the Code Blue button.
CODE BLUE, FIVE WEST, SOUTH CORRIDOR, blared the hospital’s loudspeaker system repeatedly.
Within twenty seconds doctors, nurses, and respiratory therapists, all part of the Code Blue team, filled the room.
“He’s in shock,” Mary said as fluids poured into his IV line. Next, they gathered all the equipment and transported him immediately to ICU.
Joseph Polk never returned the stat page…
Mary shook her head. “That’s what we deal with on a daily basis with Polk and a few of his cohorts, though nothing compares to can the infamous Joe Polk.”
I agreed with everything Mary said and I searched for some profound statement, but the platitudes choked in my throat before I could utter one.
I held Mary’s gaze, then said forcefully, “Believe me, I understand. So do most of the docs on staff. While we can’t fix all the worlds’ medical problems, we sure as hell ought to be able to control our own space. This shit’s going to end. I promise.”
It felt good to let it out, but could I keep my promise? Mary had heard it all before, and until the nurses saw overt changes in the status quo, all the talk in the world was unlikely to change their attitude.
I’m impatient. If I need to change something in my life, I change it. This situation, however, was largely out of my control and all I could do was to sit back and hope that over time, our good faith efforts would mean something.
Chapter Nine
For some unexplained reason, I found myself making rounds in ICU earlier than usual. I had a good rationalization; just an early start on my active schedule, but finally I confessed; this was a lame excuse for seeing Beth before she left after her night shift.
We’d become friends, but my interest extended well beyond that. I hoped hers had, too. This morning, I caught her right after morning report and before she left for the day.
Beth smiled. “Jack, it’s good to see you again. You’re getting to be an early bird.”
“Well, to be truthful, I try to get here before you disappear into the morning. Do you exist in daylight or are you like a vampire, avoiding daylight at all cost?”
“Not only do I exist,” she said, “but I thrive on the little daylight that’s left for me before I need to return for my next shift.”
“If you can get yourself up in time, how about joining me for dinner tonight?”
“Love to.”
She grabbed a notepad and wrote out her address and phone number. “What should I wear?”
“A smile will do,” I said, pausing for affect.
She looked up at me with that smile and those great blue eyes. “And what else?”
“Nothing fancy. I know a great little trattoria in downtown Berkeley. I think you’ll like it as much as I do. Pick you up at 6:30.”
Beth winked. “Hopefully, they serve red meat.”
Beth surprised me with a soft kiss on my cheek. She smiled again, captured my eyes, and then walked toward the exit, turning to me one final time as she rounded the corner. I stared after her as she disappeared, my mind churning with a world of possibilities.
The intravenous line or IV line is the Achilles Heel of the hospitalized patient. The young and healthy, those least likely to need good veins, had large, bulging, blue worm-like structures just below the skin, beckoning for the needle, while those who needed them most, the elderly and chronically ill, had none within eyeshot.
Physicians, once holding holy dominion over this procedure, delegated this routine task to the IV Team, a group of specially trained RNs who did 98 percent of IV line placements. The tough cases, the remaining 2 percent, fell back into the physician’s lap.
There’s something metaphysical about the insertion of a foreign body, particularly a sharp one, through that most sensitive of the body’s organs, the skin. Though paradoxical and strange as it sounds, this penetration repels and invites.
I recall watching one of my patients, a long-standing heroin addict, inject himself with the needle alone–no drug. The immediate transformation from the face of high anxiety and agitation to the broad smile of peace and pleasure, made an unforgettable impression on me.
Most normal reactions to the sight of a needle ranged between mild apprehension and outright panic, so doctors and nurses tried to hide the intruder for as long as possible. Children were the worst, and all efforts to disguise its effects, ‘it won’t hurt a bit’, only served to make the next time more difficult.
When the IV team failed to place a line, the physician had a choice; try again himself or insert a central line into one of the body’s deeper veins, useful but more risky.
“Bad news, Jack,” the IV nurse Andrea Hopkins said. “Poor Edna Parker is out of veins. I tried several times, but no go.”
The number of times an individual will subject a patient without veins to the needle is character driven. Some physicians and nurses push on, pride controlling; and keep repeating the attempt way beyond anyone’s sense of propriety. Similarly, medical st
udents and nurse trainees must learn venipuncture, so the experience for the student, supervisor, and not forgetting the patient, could often be painful and frustrating. Having the courage and trust to extend that now black and purple arm, entitles a patient to an appreciation of the responsibility carried by the needle bearer, who must place ego where it belongs, in the backseat.
Mrs. Parker’s arms were a mess. Her veins had been bad from the onset and now, on her thirty-fourth day of hospitalization, they were gone. I could place a central line through a large vein in the groin area or below the collarbone, or perform a cut-down, a minor surgical procedure to place a catheter directly into a vein. I preferred to avoid this option as long as possible since this patient was susceptible to infection. Infection in an IV site annoyed and disappointed physicians, while infection in a central vein could be outright dangerous.
I had called ahead to the nursing unit and had hot packs placed on both Mrs. Parker’s arms and forearms in an attempt to dilate and expose whatever veins she had left.
No experience practitioner would do this task while standing bent over, so I sat at her bedside, trying to get comfortable. Unpacking the right arm first, I felt dismayed, but not surprised, at the sight of this swollen and tortured limb filled with dark dots on fields of black and blue with hints of green. I lifted her heavy arm, rotating it ever which way, hoping for divine guidance, exploring for any sign of a useful vein. I repeated the search several times, discovering only the most tenuous of tiny vein segments, nothing to inspire confidence. I moved around the bed, unpacked the left arm, and realized what should take me but a few minutes, would likely consume most of my morning.
I took a moment from my exploration of this barren territory, and looked up at Edna. “Bad news. I’m can’t find a new vein.”
“Yes I know, Dr. Byrnes, the IV Team has had a heck of a time with these old arms in the last week. They try so hard. When they get so upset, it makes me feel sad for them.”
She’s feeling sorry for them?
I felt the extra burden of dealing with these arms in this forgiving patient. It would only make things worse for me.
Hell, I’d give it a shot before going on to a more invasive solution.
I returned to Edna’s right arm for a final detailed exploration. The search required both visual and tactile approaches for some veins existed more deeply below skin level and I could find them only by touch. I twisted and poked at her arm for another ten minutes finding two short, desperate vein segments. In the most optimistic of terms, were worth a try if you were into long shots.
“I have two small veins to try, Edna, but I’m not hopeful.”
“Go ahead Doctor, I understand.”
I scrubbed around the pathetic, blue segment of vein with an antiseptic solution, placed a tourniquet on Edna’s arm, and began snapping my index finger against that pathetic vein in an attempt to obtain its surrender. The IV needle, called a butterfly, had a three-quarter inch segment of sharpened stainless steel attached to a winged plastic structure, hence, butterfly. The system attached to a narrow plastic tube segment then into a syringe.
Perspiration erupted on my face. I grasped the needle’s wings. “Here we go.” I plunged the stainless steel needle into the vein, getting an immediate backflow of dark blood and a sense of relief.
Mrs. Parker looked down on her arm expectantly and said, “Did you get it?”
“I think so. Let’s try some IV fluid before we celebrate.”
I attached the IV line and began running a small amount of saline solution when Edna grimaced and said with alarm, “That’s burning me.”
I immediately shut off the IV line and scowled my disappointment when I a lump of infiltrated IV fluid rose above the needle site.
“I’m so sorry, Edna, but that vein won’t work.”
While I held pressure on the puncture site, Edna’s eyes were filling, yet, she still refused to become angry. “It’s my fault for having bad veins.”
Many patients at this stage would have long begun to subject the nurse or physician to the more colorful aspects of their vocabulary. Treating saints should remain in the dominion of the church.
Should I try again? How much failure could she or I tolerate? I hated to hurt patients, even if it was for their own good, and knew the odds were against getting a line in easily.
“I’m going to leave this decision to you, Edna. Should I try again? I’m not that hopeful.”
It disappointed me to hear, “Go ahead Dr. Byrnes, I trust you.”
I could strangle her!
I returned to my seat, and went through the stages of preparing the arm, making sure to complete each step in the right order, a baseball player performing his ritual before coming to the plate. This time I enjoyed my reward as the puncture readily returned a flash of blood and the vein held up as I began running the IV fluid.
It was an experience, almost enough to make you believe in God.
My morning rounds, delayed by my efforts with Edna, went quickly and uneventfully. Although late, I managed to see my scheduled office patients. Warren called and arranged for us to meet for lunch at his office. Eating in, meant business. He was up to something.
Warren’s office was two blocks from Brier Hospital and took up half the fourth floor in a modern five-story medical office building. It amused me to see this office in operation, as it clearly reflected Warren’s personality; too grand and too frenetic. Patients and soft soothing music filled the ornate waiting room. Nurses, medical assistants, and clerical staffers moved in coordinated chorus line routines as they moved patients from room to room. I could only speculate at the overhead of this operation and wondered how they were making it in these times of reduced reimbursement and capitated care.
Capitation payments of so many dollars per patient per month were great if you carried enough healthy patients (euphemistically called lives) on your rolls, patients who required little care. When capitated patients, get sick, and especially if they have complex or chronic problems, each practice faced decisions few were prepared by training or disposition to make comfortably. They faced an unpleasant reality; too much care or too high a quality of care could actually cost the practice money.
Warren had often remarked, “Giving my patients the best care available used to be my main concern. Despite the protestations of managed care enthusiasts and their apologists, those were the good ole days.”
After we ate a pleasant lunch at Warren’s desk, he got down to business, “Jack, I want you on the Medical Executive Board (MEB).”
This pleased and surprised me. This position would be unusual for a newcomer on the medical staff. The MEB was the professional component of hospital operations and it had broad powers over physicians’ practice and policy.
“I’m pleased by the offer, Warren, but I’m too new in the community for that position. Can’t see how you’re going to pull this one off.”
“Let me worry about that. So, can I count you in?”
I nodded and Warren continued. “Times are a changin’. We’re getting more pressure on the institution and the docs. We have too many hospital beds and at least 50 percent of the hospitals in this area will be gone in five years. In addition, I refuse to believe the cynics around the lunchroom table who believe good medicine is dead or dying. Reorganizing the MEB is one step in my plan for self preservation and to allow us to provide quality care despite the world in which we are forced to practice.”
During medical school and in training, I reflected on all these issues but only in the abstract. Now I would be dealing with them in real-time.
Chapter Ten
The remainder of the day flew by. My mind was preoccupied with tonight and with Beth.
I parked my old Honda 750 motorcycle next to my 1999 Toyota Celica, a striking contrast. The Honda was twenty years older and gleamed with bright cherry-red paint and mirrored chrome shining brightly in the intense sunlight. The Toyota, by contrast, had finger-drawn script on the dusty hood plea
ding, ‘Wash Me’.
I’d been riding this motorcycle for years. What began as a utilitarian alternative, cheap transportation and easy parking, had taken on an entirely new dimension. Initially, I’d paid little attention to the aesthetics of riding, even when I’d taken the opportunity to ride through the countryside, as my mind remained entangled with the preoccupations of a busy life. Only after I learned to suppress intrusive thought, could I enjoy the other aspects of my time on the road. Riding in the open air brought with it a sense of personal freedom, and a communion with a world you can’t appreciate while safely imprisoned in the metallic protective turtle shell of the automobile. I saw more, smelled more, and felt more as I moved and leaned through my turns as the 750 moved powerfully over the road.
I loved the hour or so after sunset on a warm spring or summer day. The cool night air called forth the warm earth into updrafts rich with the scent of the land, nearby waters and the rich aromas of organic plant life.
If I hadn’t enjoyed motorcycling so much, I might have succumbed to pressure from my mother, sisters, and many of my colleagues, who’d seen firsthand, the effects of rider vs. car or rider vs. pavement, that I have my head examined. I was getting used to the usual predictable, well-intentioned gibes for claims on my few material possessions and plans for my funeral.
I’d love to take Beth for a ride on the Honda, but that would have to wait as I grabbed a hose and bucket and began washing the Toyota in preparation for our date.
The evening turned cool and fresh after a light rain shower.
I arrived at Beth’s door exactly at 6:30 p.m., exactly on time.
She answered her doorbell immediately and I said, “Can’t help it, I’m always on time, the burden of a neurotic personality.”
“Me too. My best attempts to be fashionably late usually fail. It’s one small component of my obsessive-compulsive disorder,” she said with a big smile and a wink.
First, Do No Harm (Brier Hospital Series Book 1) Page 8