Her one bedroom apartment in a fifties-era complex made for an easy three-block walk to the hospital. The units were well maintained and their proximity to the hospital led many of Brier’s staff to live there.
Paintings, pencil drawings, and photos covered freshly painted walls. Beth had filled the shelves and tables with a variety of indoor plants, reflecting her commitment to the creation of her own space, full and alive. I felt disheartened and embarrassed when I considered my own space, bare and sterile. I vowed to do something with my apartment.
I wore my only decent pair of slacks and a long-sleeved, collared shirt, my best informal outfit.
She looked great in a short red skirt and matching knit top. She had her reddish-blond hair down and she wore, as far as I could tell, little makeup, except something that made her eyes appear bluer. As we walked to my car, I took her hand. It felt great.
Pasquale Russo, my patient, owned Pasquale’s Trattoria on a side street in the center of Berkeley. Fortunately, the street urchins who inhabit downtown Berkeley were gone and we made our way to the restaurant unmolested. As we entered, Pasquale caught me in a bear hug and lifted me off my feet, “Doc Byrnes, so great to see you. Welcome—welcome.”
I was mortified.
Beth smiled in amusement.
My discomfort worsened when Pasquale stood, faced his customers, rapped on the table for silence, and announced, “This is Dr. Byrnes. He saved my life.”
I reddened with their applause.
Pasquale made a great show of selecting the best table in the house for us. He’d covered each table with a traditional red and white checkerboard tablecloth. A candle in an old wax-streaked bottle of Chianti sat in the center of the table.
After succumbing to his enthusiastic and a bit too effusive service, we accepted his menu recommendations and settled into one of the best Italian dinners we ever had, and possibly the largest.
Stuffed, I couldn’t believe how quickly the time passed. After perfunctory small talk, I was pleasantly surprised to discover how comfortably Beth talked about herself, her life, and her feelings.
“I was the second of three children with a brother on either side. It was symbolic of my sheltered upbringing. I begged for a little sister, while savoring my role as the only girl. My parents thought three was enough, so I had to settle for the center of attention.
“We were comfortable,” she paused. “No, more than comfortable, we were privileged. My dad recognized the problem immediately. He took no crap from any of us and so we avoided the damaging indulgences of the affluent.
“High school and college were a breeze for me. I had the ability, the means, and the drive to pursue any career. I volunteered at our community hospital and considered medical school, but something about watching the nurses with their patients, made me see that nursing suited me better.
“I struggled with disturbing thoughts of selling myself short by becoming ‘only a nurse’ rather than a physician, and my mother didn’t help.”
“Nursing school,” her mother had said with disbelief in her voice. “That’s dirty demeaning work; not for people like us.”
“Go for it,” my Dad said. “Do what feels right for you. I trust your judgment.”
“And so I did, never looking back.
“I can’t figure it,” Beth continued, “I was one of the boys, never played with dolls and I can’t remember feeling any maternal instincts, yet here I am. I do remember,” she winked and smiled, “playing doctor and nurse.”
“Thank you, God,” I said, smiling and looking skyward.
Beth had another talent, which I recognized only after the fact. She had me talking about myself, my life, and thoughts, although I couldn’t recall her asking a single question.
Not much had come easily for me. “I was an average student doing as little as possible to keep out of academic trouble. Without goals or obvious talents, and with nobody in my corner, I drifted on a sea of doubt. I fell into medicine by default, after I discovered I had an interest and aptitude for biology. From that point, I struggled, first to convince the world and myself that I had discovered a purpose in my life, and second, to get into medical school. That was a nightmare. At last, I found a medical school that saw beyond the first two years of my college transcript.”
I took another sip of wine, and continued. “All but the most arrogant student fears failure in the first years of medical school, but after I aced my exams, I knew the path to my future was clear. I traveled the short trip to internship, residency, and if that wasn’t enough, specialty training.”
“Some short trip that was.”
“In retrospect, the time did fly, but it’s too long a journey for anyone who doesn’t love it. I’ve worked with many a doc who was in medicine for other reasons. You know them. Some were okay with the perks and practiced well, but many were clearly in the wrong field and unfortunately it showed in their work.”
“I hate to ask you this because it sounds so corny, but I’d like to know, why did you choose medicine?”
That question intrigued me when I first flirted with the idea of going to medical school. Why wasn’t I surprised when that damn question raised its ugly head, in one form or another, in my mind and at my medical school interviews? Why go through all the trouble?
I had been determined to answer the question honestly, or at least as close as possible. The answers then were frank and sincere, and appropriate for that stage of my life. “I’d be good at it. It’s interesting and challenging. I’d enjoy the prestige and material benefits.”
I fantasized giving the Miss America response; that I wanted to give my life to serving my patients and humanity. That, without a doubt, I was fully committed to world peace, but I didn’t know if I could deliver the lines with a straight face. In addition, you can never count on an interviewer’s sense of humor.
I took a deep breath and continued. “Believe it or not, in my third year of residency, I suddenly recognized what should have been obvious; I simply got off on helping patients. In retrospect, it was no coincidence that I found myself in situations where someone needed me and I could help. Is this psychopathology or, in reality, a higher state of being? Give me ten years on the analyst’s couch and I’ll have the answer.”
“Well, you should see things from my perspective,” she said. “Though most docs we work with are great, we have a few whom I wouldn’t wish on a slug. The irresponsible ones and the ones who don’t give a damn. It’s a headache,” she said, “right up there with the economics of medical care.”
“I hate the word epiphany,” I said, “it sounds so pretentious. Let me share something close to that word with you…”
The fifth month of my internship—where had the time gone? My days, and many nights and weekends, were an endless conveyor belt, an oppressive array of maladies, all types and all severities.
I neared the end of my thirty-sixth hour of a forty-eight-hour span, and had reached exhaustion. Being on call for extended periods was bad. Being on call, compounded with bad luck—no opportunity to catch even a few moments of sleep—was painful and depressing. My mouth was dry. I tried to check myself for bad breath. My eyelids were encrusted.
The soft, aged leather couch in the doctor’s lounge gave an extended whoosh as I stretched out for a nap. Suddenly, my pager vibrated vigorously on my belt and shook me awake. The pager read, “Call Four East—stat.”
Although it was a teaching hospital with house staff in training abounding, Four East served as the one ward where attending physicians could opt out of exposing their patients to doctors in training, though they still took advantage of the house staff on site nights and weekends to deal with emergencies.
I walked down the darkened corridor to Four East, noting most of the rooms here were private and the amenities were several steps up from those on the teaching wards.
When I arrived at the nursing station, the charge nurse, Marcie Henley, had been waiting. “We’re glad you’re here Dr. Byrnes. Mr
. Richard Lyle, room 4102, is not long for this world. He’s a fifty-one-year-old man admitted five days ago with a diagnosis of congestive heart failure. The attending physician is Alan Caldwell. Something’s peculiar about the case. Mr. Lyle never responded to treatment and in the last eighteen hours he’s deteriorated further.”
I grabbed the patient’s chart and began reviewing Mr. Lyle’s history and physical, lab data, x-rays, treatment, and clinical course. Immediately, I saw inconsistencies in the findings. Dr. Caldwell had designed a workup to learn the cause of this patient’s heart failure, but it was unrevealing, except that tests of cardiac function were perfectly normal. Moreover, he had no history whatsoever of cardiac disease.
Richard Lyle was bathed in the stark white rays of the overhead fluorescent light. He looked dreadful as I approached his bedside. His wife, who looked to be in her mid thirties, sat at the bedside holding his hand. Richard, at age fifty-one, looked to be seventy. He was markedly cyanotic—lips and fingers a dusky blue. He gasped for air as his brain stimulated to the max all his muscles of breathing in a futile attempt to restore oxygen to his starved brain.
My God! What’s going on here?
The patient’s fever, elevated white blood cell count, and the clinical course suggested not heart failure, but pneumonia that had gone untreated for days. Richard Lyle looked terminal.
“Put him on a non-rebreather mask stat,” I said to the nurse. “I’m running down to radiology to review his films.”
Fortunately, I found the night radiology resident standing before an array of images from the emergency room. I retrieved Richard’s images for the third year resident, Bonnie Clark. “What do you think?”
“Looks like bilateral pneumonia to me,” she said. “Let’s see how they read the films,” she said as she called up the written report to the screen.
She sat in the glare of the x-ray image display reading the report, “Bilateral pneumonia, most likely; possibly some degree of heart failure needs to be clinically correlated” read the report.
“That’s some CYA (Cover Your Ass) interpreting, if you ask me,” Bonnie said.
She spent a few minutes pointing out features: heart shadow, absence of vein distention, and several findings making the diagnosis of heart failure untenable.
I rushed back to the bedside. My first reaction, outrage, lasted a few moments, and then I felt an overwhelming sense of dread and despair, emotions far removed from my normal response to any medical problem. I was the typical glass half-full personality who, if anything, leaned too far toward optimism in my belief in modern medicine and my own skills in dealing with severe medical illness.
I rifled off a whole series of orders, canceling all the futile treatment for heart failure and substituting treatment for overwhelming pneumonia, antibiotics, vigorous respiratory therapy etc.
Too little. Too late, I thought.
Additionally, I had to inform Mrs. Lyle about her husband’s condition and my plans for treatment. I had my usual immediate reaction, to avoid, and to escape from this onerous responsibility, but knew there would be no hiding the facts; Richard Lyle would not be around too much longer.
The kindest, most sensitive and caring physician could do little to insulate Mrs. Lyle from the reality of the situation. “Mr. Lyle is desperately ill. To be perfectly honest, he’s near death. I’m trying everything know to pull his through, but it may be too late.”
“Dr. Caldwell said it was heart failure and he expected Richard to do well.”
What could I say?
“He may have had an element of heart failure at the beginning, but his major problem is pneumonia.”
“That’s funny. Dick said he felt like he was getting pneumonia.”
As I finished my explanation, she collapsed onto the nearby sofa in despair, sobbing uncontrollably.
Fifteen minutes later, Richard Lyle died.
I tried to explain, to understand, why I was so angry, so outraged, by this unnecessary death. I’d seen all forms of poor medical care before. Why was this case so different? Is this an exaggerated sense of myself—my abilities or the capabilities of modern medicine—even academic medicine?
My outrage carried into morning report. I presented Richard Lyle’s case in graphic detail to the chairman of the department of internal medicine, Mike McPherson, the chief resident, and several attendings. I berated Mr. Lyle’s attending physician, Dr. Caldwell, and the system in its entirety for permitting these things to occur.
“You’re not going to let him get away with this, are you?” I demanded.
“Do you know whom you’re talking to Dr. Byrnes?” McPherson said. “We run a tight ship here and we know how to deal with Dr. Caldwell without your assistance. Come back and talk to me about the disciplining of physicians when you’ve been practicing a while. By then, you’ll have lived with your own errors, and the corpses you helped to their graves.”
Mike McPherson’s reaction shocked me into silence.
Was it me? Was it my too holier-than-thou reaction, or was it the message itself?
Their letter-perfect response, refer the case to the Quality Assurance Committee, was a bloodless and worse than useless gesture.
When ultimately Dr. Caldwell received only a minor rebuke from the QA Committee for an unfortunate judgment error, a matter of interpretation, I was less than sanguine in my response. By now, I replaced my outrage with a cool determination to protect patients, at all cost, from the incompetent, the indifferent and the heartless…
We were the last ones remaining at the tables. I’d lost all track of time.
“I’m finding, over time, my threshold for getting pissed off is declining,” I said to Beth. “I read that in the average three or four-day hospitalization, a single patient may have contact with up to seventy different hospital employees. That’s a lot of potential for error.”
“Well at least you haven’t become a cynic or an apologist. We see too much of that around here.”
“Look, I’m no saint. I make mistakes. I’ve taken the easy way out, and yet I consider myself a decent physician. These thoughts have been bouncing between my neurons for some time and I think they’ve found a pathway to answers. First, I strongly identify with patients and their losses, and second, the world, corrupt and mindless, leaves us with less and less control over the circumstances that affect our lives.”
I paused before completing my thought; “In my universe I want my existence to mean something. At the least, I should be able to make my own world a little better. I’m convinced that if everyone spent their time trying to improve their own space, then we might be able to avoid the good intentions and the disastrous consequences created by the petty minds so anxious to rule and control our destinies.”
Beth smiled then took my hand.
I felt flushed. Had I said too much for one night?
I wanted the conversation to drift back to us, and it did.
Suddenly, I realized the hour. I had to get Beth back home in time for her to change and make her eleven p.m. to seven a.m. shift.
“I had a great time tonight, Jack,” she said smiling.
“Me too. Now you know why I’ve been making early rounds.”
She came close, stood on her toes to meet me, and placed a soft kiss on my lips, which I met with growing intensity. After a few moments, she gently pushed me away saying, “If we keep this up I’ll never make my shift on time. Next time, let’s get together on my day off,” she winked and smiled.
I hated the evening to end. It felt good being with Beth. I smiled to myself while enjoying the fantasies of a future with her. I gave her a firm hug that felt great, and said, “See you tomorrow.”
Chapter Eleven
When I returned home, I noted the sharp contrast to Beth’s apartment. My living space was functional, with bookcases galore, a large antique oak desk, and a large folding table for my computer, printers, scanners, and stacks of computer disks and CD’s, but it was not a home. My walls were cracked a
nd pealing and were bare except for the large aerial view of California and the Robinson map projection of the world, the primer for my travel fantasies.
Lying in bed, smiling and pleasantly reliving my date with Beth, I could still smell her perfume and the taste of her lips. I finally fell into deep sleep.
The worst time for a nighttime consultation was between eleven p.m. and two a.m., where the odds of getting back to sleep were remote.
When I fumbled for, and finally silenced the offensive ringing of my phone at eleven-fifty. I’d been sleeping all of twenty minutes. The answering service announced that Dr. Franklin needed a consultation on his ICU patient.
Jerry Franklin was an endocrinologist about my age and one of the brightest young physicians on staff.
“Jack, sorry to wake you at this hour, but I need help on one of my diabetics in ICU.”
“It’s okay Jerry, I had to get up to answer the phone anyway. What’s up?”
“Myra Collins is a sixty-eight-year-old patient of mine, an insulin dependent diabetic. I admitted her yesterday in a diabetic coma. I’m having a hell of a time getting her glucose under control and she’s developed kidney failure with multiple electrolyte abnormalities. She’s had mild kidney failure with function down to about 50 percent of normal, but in the last twenty-four hours, she’s produced only one ounce of urine, virtually nothing.”
I could hear him flipping through the pages of Myra’s chart as he continued, “The kidney ultrasound showed no obstruction. One of her kidneys is small, probably not functioning, and the other shows only calcifications. I don’t know what’s going on, and with so little urine output, she’s going to be in deep shit before we know it. Furthermore, the family is driving me crazy. They want me to stop treatment, though she’s early in this illness and has a good chance of making it.”
“What’s with the family and how well do you know them?”
“I know the patient well, much better than I know the family, and she never told me she wanted to depart from this earth. At my urging, she completed and Advanced Directive for Health Care to prevent overly aggressive treatment in the event there’s no hope for meaningful survival. That document has now come back to bite me in the ass. Their motives? I don’t have a clue.”
First, Do No Harm (Brier Hospital Series Book 1) Page 9