First, Do No Harm (Brier Hospital Series Book 1)

by Lawrence Gold

  Several voices cascaded together at once, but Sharon got the floor. “Impairment is only speculative at this time and for me, Joe, has exhausted whatever goodwill he had left. He must be held responsible and if we don’t draw the line in these extreme cases, we will have failed again, only this time it will be in the full light of day.”

  Arnie Roth continued, “I’m not sure how much responsibility we have toward Joe. Some might think that imposing the ultimate sanction would be an overreaction to our previous failures, but the malpractice is extreme and longstanding. I’m prepared to recommend we remove him from the staff. I do not say this lightly, since it’s clear that Joe will fight this decision with all his resources. In addition, our role here is to make recommendations to the Medical Executive Board. They will pass on their own decision to the Board of Trustees of the hospital. This fight has only begun.”

  “I call the question,” said Sharon.

  Arnie turned to Sharon. “Make a specific motion, Sharon.”

  “I move we recommend to the Medical Executive Board that Dr. Joseph Polk have his hospital privileges revoked and that we expel him from the medical staff.”

  “Any further discussion?” said Arnie.

  Arnie called the question. “All in favor on the motion raise your hands.”

  He counted nine hands.

  “Those opposed?”

  Two hands.

  “Any abstentions?”

  One hand.

  “The motion passes nine to two with one abstention,” Arnie said. “The meeting is adjourned.”

  I left the Board Room at eleven p.m. and went up to ICU to visit for a moment with Beth.

  She couldn’t wait to hear the committee’s recommendation, so I let it out. “We’re expelling Polk from the medical staff.”

  She stared ahead, saying nothing.

  Her subdued response surprised me. “I thought you’d be elated.”

  “I thought so too,” Beth said, “and I am pleased to hear that the medical staff is finally doing something about Polk, but all I feel is sadness. I can’t explain it. Maybe it’s a compilation of all the losses and all the anger I’ve felt over the last few months. Maybe the decision is anticlimactic. I’m glad it’s over.”

  “I hate to be the bearer of ill tidings, but this is a long way from being over. Polk will fight this through the Medical Executive Board, the Board of Trustees and I suspect, through the courts. Thinking about it gives me a headache.”

  Chapter Thirty-One

  Mary Oakes hadn’t slept well since Loretta Harrington’s death. What had been troubling about Polk’s manipulation of the Harrington family, festered into a boil ready to pop.

  Her husband, Richie tried again. “You’ve informed nursing administration, and the medical staff’s QA committee, isn’t that enough?”

  “The Harrington’s need to know what happened. I should be the one to tell them, I owe them at least that much.”

  The next morning Mary retreated to the solitude of their darkened den, placed the phone in her lap, and dialed.

  A child answered. “Harrington residence, Amanda speaking.”

  “This is Mary Oakes from Brier Hospital. Is Janelle Harrington in?”

  “Mommy, it’s for you,” said the fading voice.

  “This is Janelle. Can I help you?”

  “Janelle, it’s Mary Oakes from Brier Hospital.”

  “Mary. It’s so great to hear your voice again. How are you?”

  “I’m fine, but I need to discuss something with you.”

  “Sure, go ahead. What is it?”

  “No, I can’t do this on the phone. Can we get together?”

  After a long pause, Janelle responded. “Well of course Mary, but what’s this all about?”

  “If you’re free, I can drive out now.”

  “I’ll expect you in about thirty minutes.”

  “See you then,” Mary said.

  The day should have been overcast and gloomy, to match her mood, but instead it was bright and warm. Mary drove through the countryside trying to rehearse what she’d be saying to the Harringtons. The facts were simple but ugly, and she couldn’t get them out painlessly.

  Mary had been obsessing on the events surrounding the death of Loretta Harrington and her role in this matter since the day she died. Before Mary could realize what happened, she became deeply involved with the family and their grieving. At the time, she couldn’t bring herself to confess to them what actually happened and what her role had been. She still blamed herself.

  She’d opened herself to Beth who was less than sanguine about Mary’s self-flagellation. Beth was a good friend and tried to put perspective on her feelings. “How sure are you that anything would have helped Loretta at that stage of the game? That family trusted and respected Polk; I don’t see how you could have made a difference. We all second-guess ourselves on decisions that circumstances forces us to make. Are they the right ones? Did we make them in good faith? Are we responsible for every eventuality?”

  Janelle met Mary at the door. “Come in. It’s great to see you. Would you like some tea?”

  “That would be nice,” Mary said.

  While they were waiting for the water to boil, Janelle kept up a bright monolog on her recent activities, intermittently inspecting Mary with intense curiosity.

  “Archie’s been having a rough time. All those years living together and now, when he needs companionship the most, Loretta’s gone. Until her death, Dad never lived alone. He went from his parent’s home into one of their own.”

  Janelle added the tea, filled the pot, and stood. “Come into the library. We’ll be more comfortable there.”

  They walked into the oak-paneled room with a stone fireplace on one wall and filled bookcases on the others. Mary sat on one end of the leather sofa. Janelle sat on the other.

  After they settled in, Janelle faced Mary. “You have my attention. What could have been so crucial we needed to meet now and in person?”

  Mary hesitated, and then went on. “You know that I was close with your mother, and it has taken me some time to come to terms with the events leading up to her death.”

  “What events are you talking about?”

  “Well, the pace of events moved so rapidly. Loretta had been well before coming into the hospital, and then progressed quickly to her death. We see death every day at Brier, but it’s more troublesome when a patient goes from good health to the grave so suddenly. We were caught by surprise, not expecting it and so that’s why we had so much difficulty.”

  Janelle shifted and twisted in her chair as she tried to understand. With alarm in her voice, she said, “What’s going on here? What are you trying to tell me?”

  “Certain things were going on which I,” she paused, “I’m trying…”

  “Look, Mary, we love you and trust you. Can’t you speak plainly?”

  Mary could bear it no longer; she began crying. After a few minutes, she regained a degree of control, and looked into Janelle’s eyes. “Things were not going right with Loretta and everything we did for her only made things worse until she lapsed into congestive heart failure.”

  “She was old, Mary. As you watch your parents age, you gradually come to the understanding, and finally an acceptance, that some day something bad will happen to one or both of them. Her time had come. Dr. Polk tried everything to pull her through until she reached the stage when we could do nothing but prolong her suffering.”

  “You don’t understand, Janelle. We were upset by the way Dr. Polk treated her, and I am distraught to this day by the way she died.”

  “What are you saying?” Janelle stood, and then paced the room, “Are you telling me she didn’t get adequate treatment?”

  “Yes,” Mary said, then paused looking away. “And worse.”

  “What could be worse?”

  Mary was sobbing again and barely in control. She spoke in a near whisper. “I don’t think she had to die, or at least she deserved a chance to ma
ke it through the heart failure.”

  “Listen, Mary, you’re obviously upset, but Dr. Polk did his best for mom. We were the ones who decided not to treat her.”

  More composed now, Mary continued. “You’ve heard all the publicity surrounding Dr. Polk’s battle with Brier Hospital?”

  “Yes, but what does that have to do with mom?”

  “The hospital and the medical staff have been trying to protect patients from some of Dr. Polk’s actions. He’s harmed patients, and he didn’t try to save Loretta.”

  “He said trying was useless. He said that anything he did would only worsen her suffering in the little time she had left.”

  Crying out now, “He lied. He covered his ass. He buried his mistake. He buried Loretta.”

  Janelle lost her composure and sobbed. “Do you know what you are saying? Are you sure?”

  “You remember that meeting in the family waiting room? I felt uncomfortable then with the decision not to treat Loretta, but Polk intimidated me. I acquiesced to the family’s faith in Polk’s medical judgment to let her go. I was wrong and should have spoken up. I’ll never forgive myself,” she said crying.

  After a minute, Mary said, “Furthermore, I’ve discussed Loretta’s case with one of our best docs, I can’t tell you who, and he feels that simple medical treatment was likely to control your mother’s heart failure. She could have survived. At the least she deserved a trial of medical therapy for the heart failure before abandoning all hope.”

  They were both crying now.

  The library door suddenly opened and Archie Harrington entered. “What’s going on here?”

  Janelle took a tissue, blew her nose, and said, “Dad, you remember Mary Oakes from Brier Hospital?”

  “Well of course I do. How are you, Mary?”

  While Mary sat still sobbing, Janelle paraphrased the nightmarish information she had received. Archie stared alternately at his daughter and at Mary.

  Archie froze in place, and when Janelle explained Polk’s actions and manipulations, he took one step back, muscles tensed, then ever-so-slowly he collapsed into the sofa, head bent down.

  Janelle, alarmed said, “Dad, dad. Are you okay?”

  His head slowly rising, eyes ahead and face reddening, he said, “That fucking bastard! I’ll kill Polk. Just let me get my hands on him.”

  The outburst exhausted Archie, but suddenly he regained control. “We trusted that bastard with the thing most precious to us, and he betrayed us all. He’s going to pay for this if it’s the last thing I do on this earth.”

  Chapter Thirty-Two

  By Carrie Palmer’s fourth ICU day, I considered, but rejected the idea of moving her to the ward. The monitoring lines in her groin would become problematic if they remained in place for many more days as they could become infected. Her fever wouldn’t go away. Hell, I could have accepted low-grade fever, considering the magnitude of her infection, but her temperatures reached 102 degrees several times and her white blood cell count, a marker for ongoing infection, remained elevated.

  Saturday morning, four a.m., my phone shook me out of a sound sleep. “It’s your service, Dr. Byrnes. I have Brier ICU on the line.”

  I sat up in bed and shook my head. “Put them through.”

  Carla Watts, Carrie’s night nurse, was upset. “Jack, you’d better get in, right away. She’s spiked to 104 degrees, she’s chilling, and her pressure is down to 94/60.”

  God damn it! She’s septic again.

  I ordered plasma expanders, gave Carla pressure parameters for their use, and said, “I’ll be right in.”

  I threw on my clothes and raced to Brier arriving at Carrie’s bedside in twelve minutes flat.

  “What’s happening, Carla?”

  “Her pressure came up, but her urine output is down and she’s bleeding from her nose, mouth and her IV sites. Her skin is developing large patches of black and blue marks.”

  My God! She’s developing DIC…Disseminated Intravascular Coagulation, the most dreaded complication of blood stream infection.

  In this condition, the blood begins to clot within the circulation consuming normal clotting factors needed for control of bleeding. This leaves the patient unable to control bleeding from anywhere in her body.

  We could lose this girl, I thought. This will be all out war.

  “Carla, you’ll be one-on-one with Carrie. Get your other patients covered.”

  I ordered more lab tests to document the DIC, had blood set aside for transfusion, if needed, ordered a stat ultrasound, and got on the phone for help. I called Arnie and asked him to notify Carrie’s family, then called in Alice Levy, a hematologist, and Harvey Russo, an experienced gynecological surgeon. After repeating more blood cultures, I decided to broaden her antibiotic coverage.

  Although anyone would notice the increased activity in the care of this critically ill young woman, there was a more dramatic alteration in the atmosphere of ICU; the air crackled with excitement and determination.

  We’d be damned if we lost this girl.

  Thirty minutes later, I stood with Harvey Russo next to the radiologist reviewing the ultrasound study just completed.

  “No question, Jack, it’s an abscess,” said Bernie Myers, the radiologist. Everything, the fallopian tube and the left ovary have congealed into a large infected mass with pooling of infected material at its center, an abscess. What’s her condition now?”

  “She’s unstable with DIC and septic shock,” I said.

  Harvey shook his head and stared at the floor, “Surgery might well be her last rights in this condition, and I sure as hell don’t want to be her executioner.”

  “I understand,” I said, “but Harvey, this may be her only hope. We must get that infected material out before it kills her.”

  “Do you think we can get at this abscess to drain it without surgery, Bernie?” I asked of the radiologist.

  “I’m sure we can get in the abscess, but look close here,” he said pointing to the image. “See these bands?”

  Harvey and I looked closely at the image as Bernie continued, “Those structures suggest the abscess is not localized to a single compartment. If we try to drain this abscess, real risky now since she’s bleeding, the odds are we’ll miss one or more of the compartments and leave behind infected material. That won’t change her basic problem.”

  If Bernie ducked an interventional radiology case, he loved to do these procedures, he must be worried about the risks, and about his ability to drain the abscess.

  When we returned to ICU, Alice Levy, a hematologist in her late fifties, had completed her evaluation. She was well trained and experienced, but ultraconservative when it came to treatment, a therapeutic nihilist, some said. Alice was reluctant to use drugs and extremely skeptical of their effectiveness.

  Alice looked up from Carrie’s chart. “You have a tough one here, Jack. I agree totally with your assessment of her situation and its primary cause, the infection and the sepsis. Your choices are difficult. I’m glad I don’t have to decide.”

  I loved that comment.

  Alice continued, “One thing for sure, you must drain that abscess, ASAP. I know no surgeon wants to take a knife to a patient who can’t control bleeding, but absent removal or drainage, I don’t think she has a chance in hell.”

  Alice is a joy, I thought.

  “I’ve ordered replacement clotting factors,” I said, “that might help or make things worse. What about anticoagulants?”

  The use of anticoagulants, drugs designed to interfere with blood clotting in a patient already bleeding, intuitively felt wrong. This dangerous and controversial treatment could be Carrie’s only chance, my only way of controlling the DIC.

  “Jack,” Alice said, “You need somebody braver than I to give this girl anticoagulants under these circumstances.”

  I don’t know why I ask Alice to consult. I rarely get anything useful out of her.

  Arnie and I met with the Palmer family in the private conferenc
e room adjoining ICU. The family had run the full gamut of emotions from fear and anxiety through relief, only to face again the precarious nature of Carrie’s current condition.

  Nurses had told me that I had a way with patients and families, making them understand the complexities of medicine. I could help them to decide without talking down to them. I described her illness in detail, especially the recent developments, her bleeding problems, and the need to drain her abscess. I spoke frankly about the seriousness of her situation and the fact that all available options had their own set of risks.

  “We’re in a bad place with Carrie,” I said. “We can’t sit back and do nothing. I need the family’s help and support and am willing to consider anything that would help her.”

  “What about another opinion?” Jill asked.

  “I’ll take the opinion and the help of anyone who can help in Carrie’s case, but here are my reservations. We cannot transfer her to UC San Francisco or Stanford, and to tell you the truth, they’re going to struggle with these decisions too. I can try to bring in one or more consultants from the university will, but that will take time, time that Carrie does not have. I’m more than willing to discuss Carrie’s case with the best people in the area and pick their brains about anything else we should consider in her care.”

  “We’re only getting to know you, Dr. Byrnes,” Sally Palmer said, “but based on what we’ve seen and what Dr. Roth has told us about you, your character and your training, we trust you. Make your calls and do what you both think best for our daughter.”

  Jim Palmer’s face contorted with pain and fear. He embraced his wife and daughters who were sobbing and reaching out for each other.

  Arnie, Harvey, and I had primary responsibility. In spite of all our protestations and rationalizations, we were about to make a life and death decision for Carrie Palmer, necessary if she were to have any chance. It would piss me off if someone dared to suggest we were about to play God, but I wouldn’t deny that there was an element of truth to it. Jokes about physicians playing God always annoyed me: Why is God running around heaven wearing a stethoscope?—He’s playing doctor. I didn’t see the humor, especially not now, not here and not with Carrie. If my decisions were God-like, at least I made them with full involvement of patient and family, and with my earnest desire to do the right thing for my patient.