He began, “Dr. Tom Starzl performed the first liver transplant in 1963 in Colorado. Right now, there are approximately four thousand done each year. That’s about half of those needed. The cost per transplant is between two hundred and three hundred thousand dollars. Here, in San Francisco, we do an average of two to three transplants a week with excellent graft and patient survival. He went on to describe the surgery, the expected hospitalization and the postoperative care required.”
He paused to give them a chance to digest this material, then said, “If you’d like, I can arrange for you to meet with some of our patients. They can tell you, in personal terms, about their own experiences.”
It’s fascinating, thought Chuck. We’re getting all the details from Dr. Cohen in a matter-of-fact way. It almost makes me forget it’s Helen’s life on the line.
Dr. Cohen’s experience and quiet confidence, and the excellent reputation of UC San Francisco program encouraged and reassured them.
“Several important elements will determine the success of your transplant,” Cohen continued. “One of these I know won’t be a problem; following your medication schedule precisely. The other is in the hands of fate. Specifically, since we don’t know when an organ will become available, it’s important your health be optimal at the time of transplant. In general, the better your overall health, the better you will do with surgery and the post-op period. I suspect, based on what I know about you and your physicians, this will not be a problem. Dr. Polk will be sending reports of your condition and your lab work while we await a suitable organ. This may take weeks, if you’re lucky, and months to years if you are not. When we get your tissue type, I can be more accurate in estimating when an organ might become available.”
They departed the university with a professionally-created binder about the program and with a pile of brochures. Holding up the material, Helen said, “What a load of information to swallow at one gulp. I’m lucky to have this experienced program right in our own backyard. I have good feelings about Dan Cohen.”
“Me too,” Chuck said, but his mind whirled in the attempt to absorb the information and with his concern for Helen.
The next few months passed without incident. Gradually, Chuck began noting some decline in Helen’s thinking. She’d become more forgetful and sleepy. He sensed that she knew it, but since she failed to raise the issue, he let it go, fearing for her feelings.
On his own, he’d called Dr. Polk and got a ‘just as I anticipated’ response, and no further suggestions.
Soon, Helen couldn’t work even part time. She spent her days sleeping, while restlessness kept her wide-awake throughout most of the night.
Alarmed, Chuck called Ken Peters, explaining Helen’s situation.
“I’ll talk with Dr. Polk. Call his office tomorrow morning for an appointment.”
Before they could phone, Polk’s office called early the next morning. Polk saw her in his office, ordered a special diet, and placed her on an oral antibiotic, neomycin.
Within two to three days, Helen had returned to her own self.
“You know. Sweetheart,” Chuck said, “I’m not all that happy with Joe Polk. He’s taking everything too lightly for my taste and frankly, he’s been rude and dismissive to me. If he hadn’t been your physician, I’d have been tempted to lay him out.”
“Joe’s that way, honey, it’s just his manner. He’s taken heat at Brier Hospital from the nurses, but with me, until lately, he’s been reasonably well mannered and supportive. Most consider him one of the best physicians in the community. I’ve worked with him enough so I should have seen any problems if they existed. His poor relationship with our most vocal nurses may be at the root of questions raised about his practice.”
“I don’t like taking any chances with you babe if Polk turns out to be a problem.”
“Well I can’t say I don’t have misgivings, but Joe’s been good for us and he knows my case better than anyone. I’m hesitant to make a major change at this point,” she said. “Maybe it’s a case of ‘the devil that you know’…”
One morning about ten days later at breakfast, Helen said, “I couldn’t sleep again last night, too restless, and my stomach’s killing me. It feels like an ulcer.”
“Take Maalox,” Chuck said, “That always helps.”
Helen did have some relief, but found that while she took ever more Maalox, she achieved less relief. Her stools had become dark brown to black, which she noted casually. She became more confused and sleepy. Frantically, Chuck called Polk and told him in detail about Helen’s symptoms.
Chuck finally concluded that an inverse correlation existed between how anxiously he described Helen’s problems, and Polk’s response. More and more, the responses were the same, “Trust me, we’re doing all we can for her.”
The next two days, Helen got worse. She could barely stand. She had trouble maintaining her balance. Intermittently, Helen was out of touch and confused and she complained of having difficulty hearing.
Steaming after the third unreturned phone call to Polk, Chuck thought, what’s wrong with this man?
Finally, at eight that night, the phone rang, “This is Dr. Polk. What is it now?”
“Dr. Polk, sir, is there some part of what I’ve been telling you don’t you understand? Helen’s not doing well. She’s sleeping all the time, she’s weak, she won’t eat, and her stomach’s killing her. It’s time to do something, don’t you think?”
“How many times do I have to tell you two the same thing?” Polk said, “I’m doing everything possible for Helen. Nature will just have to take its course.”
“What a load of shit…”
“Who do you think you’re talking to?” Polk said. “I’m tired of your incessant calls. If you don’t like it, find another doctor who can do better and is willing to put up with your crap.”
Chuck heard a click as the phone went dead.
We’re through with that fucking son-of-a-bitch. I’ll call Dr. Peters or Dr. Byrnes in the morning. One of them will help us find another physician.
Later that night, Helen suddenly screamed and abruptly vomited several cups-full of bright red blood. She writhed and screamed in pain.
When the ambulance arrived, they took her directly to Brier Emergency.
Chapter Fourteen
Freddie West at the age of thirty-eight had been ICU director of nursing for the last four years. After eight years of front-line acute care nursing, she’d retreated to academia to teach ICU nursing. This fit well into her life since her kids were in school until mid afternoon and she could arrange her teaching schedule for mornings.
Freddie was a bright, caring, experienced, and disciplined nurse, perfect for academia where all too often nursing instructors lacked real-world experience leaving new graduates ill prepared.
Over the years, Freddie developed a close working relationship with Warren Davidson as they fought together the wars of attrition against the forces set on compromising their professions and patients. Warren was partly responsible for Freddie’s decision to return to Brier and for her position as ICU director of nursing.
Warren sat across from Freddie that morning sipping coffee.
“Now listen, Warren,” Freddie said, “I know you’ve heard this before, but hear it again; we’ve got to do something’s about Joe Polk.”
“Tell me something I don’t already know, Freddie.”
“Look, Warren I understand your problems with the medical staff and the administration, but the issue is reaching crisis proportions.”
“Short of putting a bullet through his head, I’m doing everything I can. Moreover, with the newly reconstituted QA committee and the Medical Executive Board, we’re finally getting some action.”
“I know you don’t need any additional pressure from me, but as a friend, I’m telling you we have a core of young, aggressive nurses who have run out of patience with the medical staff and with Brier Hospital. Their next step, you’ll love this, is to go to the m
edia and the state with specific complaints alleging a cover-up of malpractice at Brier.”
Freddie expected an angry response from Warren, so he surprised her with his smile and the comment, “That’s not the best way to go. It will hurt the innocent along with the guilty and damage the reputation of a fine hospital and medical staff.” He waited a moment then continued, “In truth, Freddie, there are times when I’d welcome it. Give us a little more time. We’re almost there with Polk.”
Chapter Fifteen
I knew something was wrong when I entered the fifth floor medical ward on my way to ICU. The ward was quiet—too quiet for its high level of activity. The staffers were avoiding direct eye contact. When I approached Mary Oakes to say good morning, she assaulted me. “They admitted Helen Martin again last night.”
“What’s wrong?”
The delay in Mary’s response and the gravity of her expression said as much as the words that followed, “Helen’s dying, Jack! This may be the end.” She burst into tears and rushed into her office.
I followed, and in a few minutes heard all about Helen’s admission last night in hepatic coma with active GI bleeding and kidney failure. Since Helen’s health had been an ongoing concern for the nurses, I’d been hearing indirectly about her general condition, treatment, and referral for liver transplantation.
“She’d been doing so well recently and the prospect of a liver transplant gave us hope that this nightmare was nearing the end. All of that’s gone.
“It’s not just that Helen is one of us,” Mary said, “it’s that she deserves a break. Everyone caring for patients, over time, knows the risk of carrying the label of a good person. I’ve seen ungrateful, incorrigible, self-destructive, noncompliant sons-of-bitches survive serious illness repeatedly, while we watch Helen, uncomplaining, compliant, and life affirming, go down the drain. I don’t know what I’ll do if she doesn’t make it.”
“Who’s taking care of her?”
“The good Dr. Death, otherwise known as Joseph Polk. He’s working alone as usual, but I’ve put in a call to Warren Davidson. He promised to review her case before noon. We don’t know for sure what’s happened, but if she’s been ‘Polked’ again, like the last time, there’ll be hell to pay.”
I almost grabbed Helen’s chart, but resisted the temptation. I might have done it if no one else had been around. “Let me know if I can do anything, Mary,” I said and departed for ICU.
I was happy to find Beth waiting for me, since I was later than usual. She’d completed her shift, and although she was ready to go home thirty minutes ago, she’d found enough excuses for dawdling until I arrived.
She took my hand. “You look kinda glum this morning partner.”
“You heard about Helen, didn’t you?” I asked.
“Heard about it. It’s all we talked about last night. She should have come here to ICU, but Polk, as usual, doesn’t get it. It’s as if he wears blinders and sees only what he wants. I’m sure if the nurses insisted Helen stay on the ward, he would have chosen to send her to ICU.”
“Look Beth, Warren’s going to see her soon. He’s had it with Polk and I know he’ll get things moving in the right direction. Even here at Brier, Polk may have finally gone too far.”
“Jack, I know how you feel about this situation, but we don’t have the luxury of time. Polk’s hurting patients and the nurses are fed-up with unfulfilled promises. You’re looking at demonstrations, resignations and the most deliberate of public disclosures about the failure of the hospital and medical staff to rid itself of such a menace.”
Before I could respond, the loudspeaker blared, “Dr. Jack Byrnes, Dr. Jack Byrnes, stat.”
When I dialed the operator, an agitated Warren said, “I’m transferring Helen Martin to ICU under your care. Polk’s off the case. I’ve had it with that bastard and I’ll be damned if I sit by and let him kill another patient.”
My mind raced, but quickly I put it all aside and responded, “Send her up.”
Five minutes later, Helen Martin’s, hospital bed burst through the ICU door. A cloud of white uniforms surrounded her, holding IV poles, pushing oxygen tanks and suction equipment, all moving with the bed en mass.
In five minutes, they transferred Helen to an ICU bed with all lines and tubes neatly rearranged.
She looked terrible.
My mind flashed back to the early days of my internship…
When I saw Maggie Wilson, a patient I knew well, in the ICU, I didn’t recognize her; the transformation in her appearance was so dramatic. Nobody looked great when they had a cold or the flu, but Maggie’s change was a radical alteration of her essence as she struggled for life.
Like many young physicians with medical school behind, I fell in love with my accomplishments, my intelligence and felt supremely confident. When experienced physicians and nurses spoke mystically about the scent of death, the look and feel of death as they approached their terminal patients, I dismissed their comments as myth. When they said things like, ‘It’s a waste of time’, ‘she doesn’t have a snowball’s chance in hell’, statements of defeat, I knew they’d lost touch with modern medicine where we had so much to offer. It didn’t take long until I was uttering those phrases too.
“I’m going to die,” Maggie said. “I just know it.”
“Don’t be ridiculous. You’re getting better. You’ll be home with your kids in a week.”
She grasped my hand. “Thank you, Dr. Byrnes. You’re a good doctor and some day you’ll be a great one.”
An hour later, she died.
Why should that surprise us? Often the body knows more than the doctor does, especially about death…
“Helen, Helen,” I shouted. “Do you hear me?”
No reaction.
I placed my knuckles against her chest and pushed.
She groaned with the painful stimulus.
Her skin was cool, her pulse thready and her blood pressure low.
I grabbed her chart and rapidly paged through, scanning for essential information. I then ordered stat lab tests and had blood set aside for transfusion, if needed. I spent the next forty minutes looking at Helen’s old charts and trying to reach Polk for her office records and an update. Polk, as usual, had exquisite timing about when to disappear.
I ordered IV medication to cover the possibilities of bleeding ulcers, and to try to lower the pressures within the liver circulation, another possible source of bleeding. Next, I called Ken Peters, the GI consultant, to see her, and arranged for a surgeon to familiarize himself with Helen’s case, should she need an emergency operation.
“Jack,” the charge nurse said, “the family is in the waiting room and wishes to speak to you.”
“Tell them I’ll be there in ten minutes.”
After reviewing Helen’s labs, ordering two units of blood, and writing orders, I walked to the waiting area. Chuck, the kids, and Helen’s brothers, sat in the empty room waiting expectantly for me. It was good to find the room empty, as discussing a case with a family was difficult enough without a crowd of strangers listening in. I’d met Chuck and the kids before. Helen’s brothers introduced themselves.
“This is an unusual situation,” I said, “Dr. Davidson, the Chief of Medicine at Brier, has asked me to take over Helen’s care.” I hesitated, unsure about what to say next and how frank to be with this family.
“What happened to Dr. Polk?” Chuck asked.
“Dr. Davidson is concerned about Helen’s unstable condition. He feels that a change of physicians would be helpful. He asked me to consult.”
“I had it out with Polk last night on the phone,” Chuck said. “He finally called back after my thousandth call. I told him that Helen was really sick, but the man wouldn’t listen. He argued with me when I demanded some action, and then he hung up on me. If he’d been there, I might have killed the man.”
Chuck paused, and then continued, “I’d planned to call you or Dr. Peters this morning to transfer her care when she suddenl
y vomited blood. Worse, I had to stand by last night watching Polk admit and treat her. What could I do? All I wanted was beat his brains out. A change of physicians, you ask. I couldn’t be happier.”
I felt more than a little relieved. Had the family protested Warren’s action, everyone, including the hospital, would be in an awkward position.
I spent the next few minutes getting a rundown of Helen’s course in the last few weeks.
“I told Polk about Helen’s fatigue and sleepiness, her stomach pain, and the black stools, but he did nothing.”
My opinion of Polk had reached a new low, but I still found it unbelievable that he could have disregarded so much information pointing toward an impending crisis. These actions couldn’t be cognitive failures. Maybe he just didn’t give a damn or was it something else?
“Let me tell you where we are now,” I said. “Helen is in hepatic coma. This may not mean her liver disease has worsened. The dark stools and vomiting of blood means she’s bleeding heavily from somewhere, most likely in the upper part of her digestive system. I’ve asked Ken Peters to see her again, and I’ve asked for a surgeon to stand-by, just in case.”
Alarmed, Chuck said, “Can she make it through surgery, she’s so weak?”
“Surgery will be our last resort. We want someone to be familiar with Helen’s case if we can’t stop the bleeding by medical means. Lots can be done short of surgery to bring this situation under control.”
“What were you going to say about the coma, Doc?”
“Well, bleeding itself combined with kidney failure can make hepatic coma much worse without any change in her liver disease. Once we get the bleeding stopped and get her kidneys functioning better, I think she’ll wake up.”
Turning to the family, Chuck said, “I’d like a few minutes alone with Dr. Byrnes. Why don’t you wait outside.”
Chuck stared at the floor shuffling his feet. “I’ve been struggling to confront this nightmare scenario since Helen’s recent deterioration.
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