The pompous ass could swagger sitting down.
“I’m finishing rounds, I’ll be back in a couple of hours,” I said.
Polk ignored me as he went back to the chart.
After finishing rounds, I sat in the doctor’s lounge stewing over this latest indignity. I called Beth seeking a sensitive, sympathetic ear.
“I know it’s petty, and I agree with you in advance that I shouldn’t feel this way but I do. It drives me crazy they have asked Joe Polk, the least responsible and least competent physician on staff, to render an opinion on my case. I almost managed to have the family kick me off the case rather than face up to having Polk sticking his nose in.”
I could visualize the smile on Beth’s face as she said, “What’s changed here, Jack? Has anyone diminished you in any way? Has Polk been rehabilitated in anyone’s mind? I think not. Welcome to the human race, sweetie.”
“Do you know what’s going to happen? Polk is going to write a long note that adds nothing to the case. Then he’s going to charm the family with his talent and experience and their good judgment in asking him to consult. Then, he’s going to sit back, watching as the patient gets better, which was going to happen anyway, and he’ll accept the family’s accolades when he does.”
“But,” Beth smiled, “I’ll still love you, Jack.”
My next morning rounds went quickly. I had scheduled a few office patients, saving about forty-five minutes to review Helen Martin’s last admission. I would present her case at the QA Committee today.
I arrived at the meeting in time to quickly down my lunch and chat briefly with friends.
Physicians’ chat had changed since I left training. Much of it was simple, though often bitter, griping about managed care or the hospital’s administration. Understandable and foreseeable in the current medical climate, it didn’t take long for me to turn it all off. I’d only been hearing it for less than a year and already found it annoying and worse, totally non-productive.
Arnie Roth called the meeting to order. He briefly reviewed the minutes of the last meeting and got immediately to chart review.
Before they could begin, Warren Davidson entered the room and sat. “Ignore me. I’m here only as a visitor.”
This wasn’t a random visit, since Warren knew Polk’s case was on the agenda. The group rapidly disposed of twenty some odd charts. They noted minor deficiencies and wrote a few letters to the involved physicians.
I presented QA cases often, both here and in training. With Polk’s case, I knew to be especially careful.
My mouth was dry as I began. “Helen Martin is a forty-three-year-old female registered nurse, a patient of Dr. 67896. Her physician admitted her on September fourteenth in hepatic coma. Her lab results showed a slightly prolonged clotting time, elevated ammonia level, mildly elevated liver enzymes, and a normal blood count, except for a white blood cell count showing signs of infection. She improved with protein restriction and lactulose, and subsequent liver biopsy revealed chronic persistent hepatitis.
“By September twenty-first, she began deteriorating with abdominal pain and worsening appetite. Nurses noted the complaints of abdominal pain for several days. They reported this to Dr. 67896 who attributed it to side effects of medication.”
Sharon Brickman interrupted me. Impatient and hostile as ever, she said, “Cut the crap, Jack. We all know who Dr. X is. We’re talking about Joe Polk.”
Arnie Roth, the chairman responded, “Sharon, we’ve tried to avoid personalities in these presentations, but Jack, it’s up to you.”
I continued, “The nursing notes are full of vivid descriptions of the patient’s deterioration, her continued complaints of abdominal pain, and their difficulty in reaching Polk. When they finally got hold of him, they still couldn’t get appropriate orders.
“By September twenty-third, the staff had enough, and called Warren to review the case. Unable to reach Polk, Warren asked me to consult. After examining Mrs. Martin, reviewing her lab data, and finding a tender belly, I performed a paracentesis, removing 60 ml of cloudy fluid from her abdominal cavity. The fluid contained many white cells and bacteria. She had primary peritonitis.”
“You have to be kidding,” Sharon said. “What’s wrong with Joe?”
I ignored the comment and continued, “My problems with this case are as follows: first, Dr. Polk failed to diagnose an obvious life-threatening and treatable illness; second, he continued to disregard repeated observations of the nursing staff; and third, he remained unreachable to deal with patient care problems. In my opinion, this behavior is medical malpractice at its worst.”
The room erupted with agitated voices all shouting.
“Order, order,” yelled Arnie Roth, pounding the table with his water glass.
When the room quieted, Arnie said, “I’m willing to make a wild guess, some of you have an opinion about this case, so first I’ll ask for questions and then we’ll go around the table to get everyone’s reaction. Any questions for Jack?”
“How’s Helen doing?” Jim McDonald asked. Jim had worked with Helen and knew her well.
Jim’s first response to the case presentation surprised and touched me. He put aside his concern over the practice issues and focused on Helen. It was a testimony to his humanity. This is the empathic essence of being a physician, this human reaction, this emotional response, and this sympathy to the welfare of patients. It gets to me. Once I had my first taste, I was hooked. It’s part of the fix that brought me to, and sustains me in the practice of medicine.
I replied to Jim. “I started her on antibiotics after irrigation of her abdomen to clear out some of the thick, infected material. Within two days, she was much better. She left the hospital a week later to the continuing care of Dr. Polk.”
“Let’s start around the room this way,” Arnie said, indicating to his right. “You start Harvey.”
Harvey Ross, a general practitioner in his late sixties was troubled. “I’ve known Joe Polk for twenty-five years and this kind of behavior is totally out of character. I suggest there’s more to the story. I need to hear it.”
You could depend on Sharon Brickman to speak bluntly. “What more do you need to know? I agree with Jack. This case is an embarrassment to the medical staff and the hospital. A strong response from this committee is in order.”
Several docs passed comment for the moment, and the next to respond was Edith Keller, an infectious disease specialist. “On the surface, this looks pretty bad. Overlooking this obvious problem could have resulted in Mrs. Martin’s death. I’m especially concerned regarding an attitude that permitted Dr. Polk to ignore the nurses’ observations. I’m more upset that the nurses couldn’t reach him.”
“I agree with Edith,” said Alan Morris, a pulmonary specialist.
Three more physicians concurred.
The next to respond, Brian Daly, a GP. “This case alarms me. In addition, I’ve been on this committee long enough to recognize that this isn’t the first time we’ve had problems with this doctor. If we’ve allowed him to practice in this way, something’s wrong with the system.”
The rotation returned to Arnie Roth. “Let’s try to organize this discussion. First, how big are the practice deficiencies in this case? On a scale of one, indicating a minor problem with this doctor’s practice, to a ten, indicating a severe practice deficiency requiring immediate action on the part of this committee, let’s go around the table.”
“Five, ten, nine, ten, ten, eight, ten, eight, ten, eight, seven, ten,” came the responses.
“Well, obviously we have a severe problem,” Arnie said. “I suggest we take a two pronged approach: first, we must review a series of Polk’s cases and get a better handle on his overall practice patterns, second, we must decide what to do right now.”
Sharon stood. “We should suspend Polk from the medical staff immediately, pending results of further investigation.”
A roar of protest arose.
“You’re kidding.”
<
br /> “Totally inappropriate!”
“Overreaction!”
“Polk’s actions on this case were contemptible,” I said. “Immediate and strong action is mandatory. Outright suspension may be an overreaction, especially since all of us haven’t had experience with this doctor or the chance to review all his more recent cases.”
“Our choices are as follows,” Arnie said; “we either reprimand him in writing and make this a part of his professional file, or restrict his privileges by requiring mandatory consultation on all his hospital cases, or suspend him immediately.”
“Anyone who can live with only a reprimand, raise your hands.”
One hand.
“All agreeing with an immediate suspension, raise your hands.”
Three hands.
“All agreeing with restriction of Dr. Polk’s privileges with mandatory consultation on all his cases, raise your hands.”
Eight hands rose, some like a shot, others more tentatively.
“You are aware,” interrupted Warren Davidson, “that any restriction in a physician’s activities is reportable to the California State Board of Medical Quality Assurance.”
They all understood.
“I’m assigning Harvey and Alan to review Joe’s cases over the last year. I’ll have those charts pulled for you and we’ll have a special meeting within two weeks.” Arnie leaned back on his chair and turned to Warren. “I’ll leave it to you to notify administration and Dr. Polk of our decision. I don’t envy you.”
Warren stood to leave, smiled, and said facetiously, “As Churchill said: responsibility is the price of greatness.”
This slap in Polk’s face, this insult, was the first step on the shaky bridge over the chasm of his outrage and hatred. I couldn’t forget his outburst, ‘You’re finished around here…’ It was, at the least, unsettling.
I walked out with Warren, when we heard from someone still in the room, “The shit’s gonna hit the fan.”
Chapter Twenty-One
It had been a tough night for Beth Arnold and the ICU staff. The unit was a madhouse at shift change. Ten of their twelve beds were already in use. The patients were among the sickest she’d seen in a while. She added an extra nurse for the shift from the nursing registry, a warm body at least. Beth assisted with the care of two other patients herself.
On paper, Beth had the appropriate staff for the unit, but this group of patients had so many problems, that in reality, they were working short-handed. To make things worse, she had to release one of her nurses twice before two a.m. to help with Code Blues in the hospital. One survived and occupied ICU bed number one.
By five a.m., Beth and her nurses managed to restore a degree of sanity to the frenzied shift.
Only two hours more to go, she thought.
She finally found a few moments to complete paperwork in the nurse’s lounge when the intercom announced, “Beth, I have the supervising nurse on line three.”
“Hi, Carole,” Beth said. “What’s up?”
“I know you’ve had a bad night and you’re busy enough, but Dr. Polk wants to transfer a patient to the unit. I don’t think the transfer is absolutely necessary,” Carole said. “We could make do on the ward, but Dr. Polk insists. The patient, Nina Massoni, has inflammatory bowel disease and Polk admitted her with severe diarrhea and dehydration. Her pressure is on the low side and Polk’s anxious.”
Beth had no choice in the matter. Open ICU beds were available. If the unit beds were filled and they needed one, Beth would triage, and set priorities for which patient needed an acute bed the most. This was a minuet of patients, nurses, and physicians. With goodwill and consideration, it allowed accommodation without forcing the physician director, Jack Byrnes, to decide.
The patient arrived ten minutes later. Beth assigned her to Carla Watts, one of her most capable and tolerant nurses.
Beth watched as Dr. Polk entered ICU shortly afterwards. He strolled leisurely across the unit with the air of a health inspector, wrinkling his nose as if he’d smelled something noxious.
He’s looking for a fight, Beth thought.
“Where’s Massoni’s chart?” he demanded, staring at Beth.
I’m not biting, she thought.
“It’s right here, sir,” she said, offering him Nina’s chart.
Polk pulled it roughly from her hands then sat at the nursing station writing transfer orders.
Ten minutes later, as Beth worked on her nursing schedule, the monitor tech was on the intercom. “Beth, you’d better get out here ASAP.”
Polk stood across from Carla Watts. His fingers were jabbing at her chest as he shouted, “These are my orders, carry them out at once.”
Carla stepped back, “Dr. Polk, if you dare to touch me again I’ll file an assault charge. Do you understand?” Absent a response, Carla remained remarkably calm and controlled for a young nurse. She continued, “I have misgivings with these orders, sir. Can we discuss them?”
“I didn’t ask for discussion,” Polk shouted, “I write orders. You carry them out.”
Carla Watts was in her mid twenties and had recently completed her first year in ICU. Though she was tentative in her decisions, her judgments were unassailable.
“Dr. Polk,” Carla tried again, “This woman is dehydrated, and her pressure is already on the low side. Giving her a powerful diuretic can only make things worse.”
“What’s going on here?” Beth asked, approaching the two.
“I’m trying to care for my patient,” Polk said, “But all I get is crap from this nurse.”
“Can we please bring this discussion to the nurse’s lounge?” Beth said, indicating that they follow.
After Beth closed the lounge door, she turned to Carla. “What’s up?”
Carla’s eyes moved as a pendulum from Polk to Beth. She’s pinched her lips with determination. “She looks bone dry to me, Beth. Urine output is down and her labs are consistent with dehydration. Now Polk wants me to give her a diuretic. That can only make things worse. I won’t do it.”
Polk glared at Carla. “First of all, I’m Dr. Polk, not Polk. I’m the doctor. You’re the nurse. I’ve written orders, you need not agree with them. Just carry them out.”
What’s with this guy? Beth thought.
Beth turned back to Polk. “I can’t force a nurse to act against her better judgment, Dr. Polk. Maybe if you’d take a moment to explain your thoughts about treating Mrs. Massoni, we can work our way through this impasse.”
Polk looked up as if for strength. “I don’t feel she’s dehydrated, her urine flow is down, and she needs the diuretic. If she,” pointing to Carla, “can’t or won’t follow my orders, get someone who will.”
“I can’t force a nurse to follow orders she deems ill advised, Dr. Polk…”
“Ill advised!” Polk shouted. “I told the staff that this would happen, but they wouldn’t listen.”
“What would happen?” Beth challenged.
“If nurses want to be doctors, tell them to go to medical school.”
“Sir,” Beth responded, “You put me in a difficult situation. I’ll assess Mrs. Massoni myself, but it’s doubtful I’ll be disagreeing with Carla. The only other alternative is to call in Dr. Byrnes or the chief of medicine.”
“I’ll give the diuretic myself,” shouted Polk as he rose and went to the medicine cabinet behind the nursing station. When Polk found it locked, he became irate. He grasped the door handle and shook the entire cabinet, yelling, “Give me the god damn key.”
“Call security,” Beth said to the monitor tech, “and call Dr. Davidson.”
Chapter Twenty-Two
Thirty minutes later, Warren threw Polk off the case, and asked me to take over.
I ordered IV fluids. Soon, Nina Massoni’s condition improved. After change of shift, Beth sat in the nurse’s lounge with me. She was beat.
“If I have another night like this, maybe it’s time for me to find another profession.”
Wha
t could I add? I placed my hand on her shoulder and massaged gently. “Go home. Get some sleep. I’ll put Champaign on ice and give you the famous Dr. Byrnes massage after work today.”
“Thanks, Jack. You don’t know how much I need that.” We hugged then she turned and walked slowly down the corridor, finally escaping ICU.
The next four days saw gradual, but sustained improvement in Helen Martin’s condition. The bleeding had stopped. She was alert and oriented, but several new problems became apparent. Her nurses concluded that part of Helen’s earlier lack of responsiveness came from a significant hearing loss. In addition, they reported that when she tried to stand or walk, she was unable to balance herself. The latter may have come from her prolonged time in bed, but I was suspicious these findings reflected drug toxicity, as if she hadn’t had enough problems.
Polk had kept Helen on high doses of Neomycin, an antibiotic, for a protracted period in an attempt to control her hepatic coma. This drug could, under the right circumstances, produce ototoxity with hearing loss and inner ear damage with loss of balance.
I forced myself to inform Chuck, “You can see for yourself Helen’s doing well, but she may have suffered other complications, like damage to her hearing and balance.”
“Doc, I can’t tell you how much we appreciate all you’ve done for Helen and this family.”
I blinked and stared at Chuck, realizing that his response was a perfect example of a disconnect, of selective hearing, so I tried again in my most directive way, “Chuck, listen to me. Helen may have problems with her hearing and balance. I’m calling in an ear, nose and throat consultant and an audiologist to evaluate her.”
Chuck sat there for a moment, a blank look on his face. Finally, after digesting this additional news, he said, “How did this happen, Doc?”
“Well, there might be any number of causes, especially in someone as sick as Helen. One possibility might be the effects of the Neomycin she took before entering the hospital.”
First, Do No Harm (Brier Hospital Series Book 1) Page 15