Warren, well warmed to the task, leaned over and smiled. “It shouldn’t surprise you that I’ve been subtly altering the composition of the QA Committee and the Medical Executive Board over the last few years, adding docs with backbone. I feel sure now they will agree with us about Joe Polk and we can finally do something about him.”
“And that would be?” I asked.
“I’m torn between kicking his ass off the staff or imposing severe enough restrictions on his practice, he’ll decide to resign and leave his hospitalized patients to the care of others. Emotionally, I would enjoy giving him the boot, but I know he won’t take it lying down. He’ll fight it all the way through the medical staff structure, hospital board, and the courts. It won’t be pretty. Everyone involved in this process will be taking sides. It’s easy to predict the thoughtful and unbiased review process, designed to be rational, will degenerate into politics where sanity will become its first victim.”
“In my youth, I never shied away from confrontation, but the scars of past battles, and the frustrations I’ve had to endure, have made me more careful in picking my fights. I have great fantasies of Polk run over by a truck, but we can’t count on it. I hope that at some point, he’ll decide the fight is too costly and he’ll agree to limit himself to outpatients. This does nothing for those poor souls he treats in his office where he’s accountable only unto himself.”
“What about the administration? If we let them, they would take the ostrich approach,” Warren said, “and pretend none of this happened. In addition, they are hypersensitive to the potential for a lawsuit and the negative media attention. We can count on them to do the right thing only if we give them no choice in the matter.”
“I should thank you and Polk for my first fight with Beth,” I said. “She’s so pissed off at me, the staff, the hospital, and Polk, she’s unapproachable.”
“Beth’s reaction is a fair indication of the depth of feelings of many of our nurses and physicians. They recognize that this problem has been going on for too long, injured too many and frustrated all those who are concerned about what’s going on at Brier Hospital.”
“I’ll do what I can, Warren, but I don’t like the perception I’m taking the point position in the Polk case. Use your charm on more of our brethren and maybe we’ll all get through this intact.”
“Charm? You must have me confused with someone else.”
Chapter Twenty-Three
Carrie Palmer knew something was wrong when she awakened Monday morning.
I blew it last night, she thought, —clubbing, drinking, and smoking weed.
At the age of twenty-three, Carrie couldn’t believe that partying had affected her this much. She was healthy and fit and maintained her gymnast-trim five-foot four one hundred ten pound body by careful diet and three times a week Jazzercise.
Carrie had been reluctant to join her friends last night. She wasn’t much for the frenzy of the clubs, and she had a report due this week.
“C’mon,” they said, “we’ll have a great time.”
Carrie was a beautiful young woman with blond curly hair and the wholesome innocent girl-next-door look. They still carded her at clubs and bars. She had to admit that after the first few drinks and the first few drags, she’d had a great time. Maybe this was payback.
Carrie had come to University of California, Berkeley campus to complete her masters in social work. Her ultimate goal was a position with Child Protective Services. Her first-hand experience, the abuse of a close childhood friend and its immediate and long-term consequences, moved her deeply. She had become a passionate supporter of children’s rights, volunteering at clinics, and participating in fund-raising.
She’d grown up in Truckee, California, a small town near Lake Tahoe, with loving parents and two sisters. Her parents, Jim and Sally Palmer, had started a small real estate brokerage in the 1970's and survived the bad times. Well positioned for the real estate boom of the 1980s and 1990s, they were thriving.
All three daughters graduated from college with honors. Terry worked as a buyer for a San Francisco retailer, Suzanne had two children, and Carrie had gone to graduate school after finishing at UC Santa Barbara.
Her sheets were soaked and true chills replaced the chilliness she felt when she first awakened. Her body shook and her teeth rattled. Carrie stared at the thermometer, 103.8 degrees.
I’ve never felt this bad in my life, she thought.
She reached Arnie Roth’s exchange and explained her problem.
“We’ll page the Doctor,” the operator said.
Ten minutes later, the phone rang, “Carrie, it’s Dr. Roth. What’s up?”
“Sorry to bother you, Dr. Roth, but I’m shaking all over and have a temperature of 103.8 degrees.”
“When did this start, Carrie? Do you have any other symptoms?”
“It started this morning when I awakened. I’m achy and sore, but the only other thing I noticed is pain in my lower abdomen.”
“Is your urine cloudy? Does it burn when you urinate? Any vaginal discharge?”
Carrie answered, “No, no, and no.”
Arnie then said, “I can’t tell what’s going on, Carrie, but the high fever and chills concern me. Come to Brier Emergency. I’ll meet you.”
Carrie dressed as quickly as possible, feeling suddenly weak and dizzy. Fearful about driving in this condition, she called her fiancé Richard Bloom to take her to the hospital. Richard arrived ten minutes later. They drove as the sun crested over the East Bay hills and arrived at Brier emergency twenty minutes later.
She’d been with Richard for a year, and they’d made it official three weeks ago at their engagement party. Richard was three years her senior and had a great position as an associate at Holmes, Carleton, a large commercial law firm in Emeryville, California. While he was tall and classically handsome, he appealed to Carrie more for his easygoing nature and a self-effacing sense of humor. More than anything, Carrie felt comfortable with Richard and knew him as a good, caring man.
Arnie had called ER before her arrival. This early in the morning, the department was nearly deserted. They moved Carrie immediately in an examining room where they drew blood and obtained a urine sample for analysis.
Steve Davis, an experienced ER nurse, stood next to the gurney taking Carrie’s vital signs. With his hand placed on her forehead awaiting the thermometer reading, he said, “You’re burning up, honey.” He pulled out the oral thermometer and stared at the reading. He shook his head and reset the electronic thermometer to try again. Twenty seconds later the number repeated itself, 104 degrees. He immediately repeated her blood pressure, down from the initial reading of 100/60 to 86/60.
“Get Dr. Roth, stat,” he shouted to the ER clerk.
Something’s terribly wrong, Carrie thought. She continued to shake, felt dizzy and lightheaded, images of the ER and her nurse blurring and fading in the distance.
“What’s wrong with me?” Carrie uttered, barely a whisper.
“Don’t know yet, honey, but Doctor’s on his way.” Steve began rubbing her down with alcohol in an attempt to lower her raging fever. The cooling alcohol made her shake more.
“We expect high fever in kids,” Steve said, “but such fever in an adult is unusual and suggests a severe infection.”
Arnie Roth arrived five minutes later.
Her falling blood pressure, raging fever, and confusion; septic shock, he thought, tension rising. He started an IV immediately and began administering fluids. Infection entering the bloodstream could produce shock and a whole sequence of dire consequences. What was the source of the infection?
Arnie did a quick general physical examination. She looked dreadfully ill, but the examination revealed little except the tenderness in Carrie’s lower abdomen. She showed no signs of peritonitis. Several suspicious red spots appeared over the joints in her knees and ankles. Her pelvic examination revealed a markedly tender uterus and exquisite pain around her tubes, especially the left, makin
g the diagnosis. Carrie had acute pelvic inflammatory disease, PID.
Arnie obtained samples from her cervix then had the lab draw multiple blood cultures. He then ordered two potent intravenous antibiotics best suited to treat PID until cultures suggested otherwise.
“Carrie,” Arnie said standing next to the gurney stretcher and holding her hand, “can you hear me?”
A voice, a familiar voice… coming from some distance away. “Is that you, Dr. Roth?” she said in a whisper.
“Yes, Carrie. You’re pretty sick. I’m admitting you to the hospital.”
“What’s wrong with me?” she again whispered, “I feel so bad.”
“You have a bad infection. I’ve ordered antibiotics.”
Before Carrie could respond, Arnie noted a spasm in her right cheek and right side of her upper lip followed by twitching of her entire face then a generalized convulsion shaking her entire body and the gurney.
In full panic, Arnie yelled, “Get me IV Valium stat, take her vital signs again, and get Jack Byrnes down here now.”
Arnie quickly placed a padded tongue depressor between Carrie’s teeth. She continued convulsing for about thirty seconds more until the Valium halted the seizure. Her mouth bled from a small laceration of her tongue, too small to require suturing.
Chapter Twenty-Four
As I entered Brier through the physician’s entrance, the operator announced, “Dr. Byrnes, stat ER—Dr. Byrnes, stat ER.”
I could get there quicker by foot than by phone, so I rushed to the ER. The staff directed me to the examining room where Arnie stood next to the gurney surrounded by nurses and respiratory therapists. An impending code blue?
“What’s up, Arnie?”
“She had a seizure Jack, just moments ago. She came in this morning with shaking chills, fever to 104 degrees. I’m sure it’s PID with sepsis and early septic shock.”
I examined Carrie quickly. The seizure and the falling blood pressure concerned me the most.
We stepped into the hallway outside the examining room.
“It’s too early to be sure,” I said, “but this girl looks like trouble to me. We should plan for the worst. Let’s get her up to ICU where we can watch her closely and put in pressure monitoring lines. That will prepare us for any eventuality. Did you notice those skin lesions on her legs, Arnie, maybe it’s gonorrhea?”
Due to our concern, Arnie and I accompanied Carrie as the orderly and the nurse wheeled her from the ER to ICU. While I placed monitoring lines into Carrie’s groin area, Arnie reached Sally Palmer in her Truckee office, “Carrie’s been admitted to Brier Hospital, and is in intensive care.”
Following an audible gasp, Sally said, “What’s wrong with her Dr. Roth?”
Arnie explained our diagnosis and emphasized that while unstable right now, Carrie’s infection should come under control soon. Informing, but not panicking the family took great care, an art form. Arnie knew no skill or artistry could mitigate against the facts, what he needed to say next. “It would be wise if the family were to get down to see Carrie right away.”
Sally gasped. “I’ll call everyone. We’ll be there as soon as possible.”
Arnie remained at the bedside with me until he needed to return to his busy office, now packed with angry patients. A vocal few were complaining loudly about damn doctors running late for their appointments. Who do those damn doctors think they are? My time’s as valuable as theirs. His office manager rescheduled several patients, but Arnie’s appointments would be way behind.
I remained close by ICU for the next four hours, monitoring Carrie’s blood pressure, urine output, and mental status. She regained consciousness but remembered little after awakening that morning. The laboratory tests showed definite signs of infection and mild anemia. Cultures had yet to grow a specific organism.
After introducing myself to Carrie, now more alert, I told her I’d be working with Dr. Roth until her condition improved. Though unsure about how much information she’d retain, I explained to her she had a severe pelvic infection that had spread to her bloodstream.
Pelvic infection? What kind? How did I get it? How sick am I really? —were all thoughts dancing, racing through Carrie’s still foggy head.
I monitored Carrie carefully through the night. Her blood pressure stabilized at 104/60, a normal reading for her, and her temperature had come down to 101 degrees. The shaking chills were gone and she remained alert. The red lesions in her lower extremities developed into blebs containing a grey, thick fluid. I punctured one of these lesions and had the fluid examined immediately under the microscope. The lab tech confirmed my suspicion—gonorrhea.
Carrie’s parents and sisters arrived early in the morning. They were anxious and frightened. They looked up expectantly when I arrived. I introduced myself and directed the family to follow me to the ICU waiting room.
“Please have a seat,” I began, “Carrie was pretty sick yesterday when we admitted her, but today, she’s doing much better.”
“What happened?” said an anxious and angry Jim Palmer.
“This is what we’ve put together so far, all the data are not in yet. Carrie has an infection in her pelvis that spread into her blood stream. We call that sepsis. The infection appears to be under control, but it’s still too early to know if she’s out of the woods.”
“What caused the infection?” Sally asked.
“Don’t know yet,” I said deflecting the issue of sexually transmitted disease.
“What can we expect now, Dr. Byrnes?” Terry Palmer asked.
“I’m encouraged, but she’s still at risk. This is a severe infection and it’s dangerous until we have it controlled. I’ve scheduled Carrie for an ultrasound examination of the pelvis and abdomen to visualize her organs and see if we can find any obvious sources for the infection. Give me a few minutes alone with Carrie, and then you’re free to visit.”
I dreaded what would come next—informing Carrie of the diagnosis. Men were often angered and embarrassed at the diagnosis of STD, while women, especially young women, were mortified.
Carrie awakened as I entered. She sat at a thirty-degree angle in her bed and looked tired and frazzled, yet sweet and innocent. Tubes protruded from the right groin area, IV’s dripped, and heart monitor leads ran from her chest wall to the video display hanging from the wall. They’d inserted nasal prongs into her nostrils for oxygen support.
“How’s it going, Carrie?”
“I still feel as if a truck ran over me, but I’m a lot better.”
I paused, trying to find the right way, the gentlest of ways to make Carrie understand her situation. “I need to tell you what we’ve discovered so far Carrie.”
As my smile disappeared, Carrie’s eyes widened in fear. She sat upright, wrapping her arms around herself. “What’s wrong? What is it, Dr. Byrnes?”
“I can’t think of an easy way to say this Carrie, you have gonorrhea. It’s the cause of your pelvic infection.”
“How is it possible I have gonorrhea? How did I get it?” she exclaimed.
She was a highly intelligent young woman and she didn’t need a lecture on sexually transmitted disease, so I said, “You only catch gonorrhea one way, Carrie.”
“Richard—my fiancé. I can’t believe he would do this to me,” Carrie exclaimed. “He couldn’t do this to me. There must be some other explanation, Dr. Byrnes?”
“He may not have known,” I said. “Sometimes the signs are subtle, easily overlooked.”
“Please don’t say anything about this to my family, I’d die of embarrassment,” Carrie said then went on, “What does this mean for me? What can I expect?”
“The infection should be easily treatable, but we need to look at your tubes to find out how bad the infection is, and see if they’re damaged.”
Carrie sat up, wide-eyed. “Damage to my tubes? What about babies? Can I still have babies?” She began sobbing uncontrollably.
I brought her close to my chest, arms around her sho
ulders. “It’s too soon to know how much damage, if any, and way too soon to have you thinking the worst about future problems with having children.”
Carrie took several deep breaths while still holding my hand and gradually regained control of her emotions. She reached for a handful of tissues, blew her nose, and then squeezed my hand saying, “Thanks Dr. Byrnes. I’ll be all right.”
I was relieved, but understood Carrie’s torment and her uncertain future. We’d worry together. “I must report gonorrhea to the Department of Health,” I explained. “They’ll treat those infected and trace their contacts. What’s Richard’s last name?”
“Bloom. I can’t wait to tell the bastard.”
“I’ll see you later this afternoon.”
I brought Freddie West, the ICU director of nursing, up to date on Carrie’s case, “She doesn’t want to talk about gonorrhea. Carrie will deal with her family and the infection on her own terms.”
Chapter Twenty-Five
That evening, Richard Bloom stood at Carrie’s bedside. He reached for her hand. “This whole thing scared me to death.”
Carrie withdrew her hand immediately.
“What’s wrong? You’re so quiet.”
Carrie couldn’t think of a subtle segue into the next question.
“I can’t think of an easy way to ask this question, Richard.”
“What question?”
“Have you been checked for STD’s Richard?”
“What are you talking about Carrie? STD’s? Why should I be checked for STD’s?” he said with excitement.
First, Do No Harm (Brier Hospital Series Book 1) Page 17