I presented Carrie’s case to two of UC’s most experienced clinicians, the chief of the intensive care program, and an aggressive, and experienced general surgeon. They shared my frustration, and as much as I twisted their arms, all I got was, “You could go either way Jack and nobody would disapprove.” They could get away with this, they were at the university, and didn’t have to decide.
After one final discussion with Arnie and Alice, I prepared myself to go ahead with anticoagulants, blood clotting factors, transfusion, and anything else needed to maintain Carrie’s blood pressure and general condition. When she became as stable as possible, we would wheel her into surgery.
At the nursing station, I sat clutching Carrie’s chart, my cold hand poised over the order sheet. It was different this time. I was about to write orders, my best try, that I hoped would help, but writing these orders was different; they could kill her. The counsel of experienced physicians for objectivity and dispassionate analysis in making life and death decisions was a fantasy. No normal human, no normal physician, knowing this patient and understanding the risks, could remain aloof.
Harvey Ross would have one golden moment—forty-five minutes to maybe an hour and a half, their best guess, to get in, drain the abscess, and get out as quickly as possible. If surgically feasible, and if he had the time, Harvey would remove the entire mass of infected abscessed left fallopian tube and ovary.
Carrie’s family kissed and hugged her as they wheeled her from ICU on her trip to surgery in the basement. Their faces reflected fear, their eyes, hope.
Harvey and I called for Mickey Katz, our best anesthesiologist. To assist Harvey, we called Julie Kramer, a general and vascular surgeon, whose skilled hands made her a near legend in the surgical community. When anyone got into trouble in surgery, especially with uncontrolled bleeding, the call went out for Julie.
I planned to remain in the operating room to help Mickey with control of Carrie’s pressure and bleeding.
Carrie’s mind would remain blissfully in a fog. She’s only be faintly aware of her circumstances and the risks of surgery. In a dreamlike state, she’d be faintly aware of her family looking over her, holding her hands, whispering things she would not understand.
I appreciated this insensibility, this unawareness to one’s mortality in the critically ill, as nature’s one great kindness in the face of her havoc wrought, often without reason. In case after case of the severest of illnesses, surgeries, resuscitations, survivors blessedly remembered nothing.
Mickey began induction of anesthesia with intravenous sedation, and then placed a tube into Carrie’s windpipe without difficulty. He’d keep anesthesia as light as possible, reducing the insult on her already frail constitution.
Harvey and Julie were into Carrie’s pelvis in minutes, but as her skin parted under the scalpel their worst fears were being realized. Carrie was bleeding uncontrollably. They worked with the electrocautery, burning the bleeding vessels, cauterizing them as the room filled with the aroma of cooking flesh.
I hung the fresh blood, donated, in part, by compatible members of Carrie’s family, a great source of fresh clotting factors.
The surgeons carefully approached the left side of Carrie’s pelvis. Harvey took one look and said, “My God! Look at this, what a mess.”
Harvey looked over his shoulder at me. “The entire area of tube and ovary are congealed together as one mass of infected material. No wonder this girl’s so sick.”
“Can you get it all out?” I asked.
Harvey looked at Julie for the answer, and he said, “It’s messy. We can do it, but it will be difficult and time consuming with all this bleeding and her anatomy distorted by infection. I can feel multiple abscesses in this tissue we can drain, but it would be a better for Carrie if we can get the whole infected mass out.”
I turned to Arnie, seeking his eyes and his assent to the implied question. Arnie looked at me and nodded in return.
“Go for it Harvey,” I said.
The surgeons were working as quickly and as carefully as possible, trying to separate a plane of normal tissue from the infected. Carrie bled massively. Julie spent most of her efforts suctioning away blood, clearing areas for dissection using clean absorbent cotton sponges and surgical towels, and tying off bleeding blood vessels.
After fifty minutes, I felt a slight relaxation in my tense shoulder muscles as Carrie’s vital signs remained stable, and they were able to keep up with her bleeding and loss of clotting factors.
“Another fifteen minutes,” Julie said, “and we’re done.”
“Jack,” Mickey said, alarm in his voice, “her pulse rate has increased, and her pressure is down to 82/50.”
“Let’s give her more blood,” I said, “her monitoring lines show she should tolerate more fluid.”
We placed the plastic bag of fresh blood into a pressure bag and pumped. The high pressure on the bag forced the blood quickly into Carrie’s bloodstream.
“Pressure’s coming up, Jack,” Mickey said, and then turned to face Harvey. “Get out ASAP. She’s getting ready to crash.”
Harvey grit his teeth and growled, “We’ve moving as fast as we can. Give us a few minutes more.”
“She’s crashing,” Mickey shouted, “Her pressure is down to 40 over nothing—Jack?”
I started Dopamine intravenously to support Carrie’s blood pressure saying, “Don’t push the Dopamine too hard, Mickey, she can still tolerate more fluids.”
We ran in the Dopamine and the fresh blood. Carrie’s blood pressure rose slightly to 60/34.
Harvey and Julie noted immediately an understandable but unanticipated result; the low blood pressure had slowed Carrie’s bleeding. One simply bled less with low blood pressure.
“We’re almost out,” Harvey said as he dropped the infected mass, Carrie’s tube, ovary, and surgical clamps, with a loud clang, into a Stainless Steel basin. “Let’s close and get the hell out,” he said to Julie as they worked intently over Carrie.
A minute after they removed the large mass of infected tissue, Carrie’s blood pressure rose to 86/50, and her bleeding stopped.
She’s going to make it, I finally allowed myself.
Ninety minutes later, we finally called Jim and Sally Palmer into surgical recovery.
Carrie’s appearance, her pallor, the tubes, monitoring lines and wires, alarmed them, but they were instantly relieved when Carrie opened her eyes and smiled.
“Mom, Daddy, I’m so glad you’re here,” she whispered softly.
“It’s so great to see you, baby,” Sally said. “We were so worried.”
“Dr. Byrnes said they were able to remove the infection. I should be fine.”
“Don’t you worry about anything,” Jim said, “Mommy and I will be right by your side.”
“You guys are the best,” Carrie whispered, as she nodded off to sleep.
Carrie remained stable in recovery and they returned her to ICU three hours later. Jim and Sally never left her side.
Chapter Thirty-Three
Maybe it was temporary insanity or maybe it was the logical extension of their carpe diem philosophy, because when Mac said, “Let’s do it. Let’s get married,” Laura said, “Yes.”
Well into her third month of cardiac rehabilitation, her exercise tolerance had improved, a glimmer of hope rekindled.
After a civil ceremony and the small gathering of family and friends, they boarded a plane to St. Lucia in the West Indies. Anse Castanet, the romantic resort and honeymoon favorite, sat on the southwest coast of the lush tropical island. They could reach it only via barely passable roads. The resort sat on a hillside overlooking the deep blue Caribbean with rooms and suites extending to the hilltop. Mac was concerned about the climb so he reserved a room immediately above the restaurant level.
Everything was perfect, the lush tropical paradise, the great food, and the privacy of their balconied room overlooking the volcanic Pitons in the distance. They made love, relaxed on the beach a
nd snorkeled in the clear warm waters.
After another gourmet meal, they’d retired at ten. Laura was feeling unusually full following dinner and had difficulty sleeping. She sat under the reading lamp with a book until about midnight when she finally felt tired enough to try to sleep again.
Laura swam peacefully under the warm, clear blue Caribbean waters. She stopped periodically to enjoy the bright iridescent colors of the marine invertebrates and the tropical fish. Suddenly she could not breathe. She sprinted for the surface.
Laura was awake and suddenly terrified. She sat upright, unable to breathe. Air refused to leave her throat as she tried, but failed to call out. She shook Mac awake–finally. Gasping, she barely choked out the words, “I…can’t…breathe.”
Mac panicked as he saw his wife sitting bolt upright struggling for breath. Her face turned dusky blue and her neck and shoulder muscles strained to assist her breathing.
“I’m going for help,” he shouted as he bolted from the room. He returned in a moment with the night clerk and the hotel’s emergency medical kit and a small oxygen tank. Mac opened the valve and applied the plastic mask to her face. The translucent balloon at the bottom of the mask slowly filled with oxygen, then contracted and expanded with each breath. Moments later, gasps changed to deep breaths then to more quiet respirations.
Six hours later, after visiting a local French physician, they were back on a plane to San Francisco.
Their first visit to Sunshine Manor convinced Joe and Marion Polk that even if they tried, they could not have named the place more unsuitably. The facility was a modern one-story glass and redwood building sitting on the outskirts of town. Its broad decks and large skylights created a bright and cheery atmosphere. Joe Jr. had been transferred here, his permanent home.
They considered bringing Joe Jr. into their home, but his physical requirements were too much for them, even if they contracted for round-the-clock nursing care.
Joe approached the main entrance in the bright morning sunshine. The sliding glass doors hissed open automatically, and he entered the lobby.
Whatever his mood, once entering Sunshine Manor, Polk became depressed. To Joe Polk, in spite of the best of intentions, the home reminded him of a twenty-first century version of The Snake Pit, the 1948 movie with Olivia De Havilland sans the melodramatic and stereotypic portrayals of the insane.
As he approached the main nursing station, Barbara Humphries, the charge nurse waved. “Dr. Joe, so good to see you. He’s out on the patio getting sun and physical therapy.”
Polk nodded to acknowledge her comment, and then turned toward the corridor heading for the patio.
Photos, art reproductions, and the arts and crafts work of some residents decorated the off-white walls. He cringed as the scene evoked an image of open school night, except for the age and condition of the student body. Polk shuddered at this scourge of age and disability, his worst nightmare. Several inmates were shuffling, hands on walkers, empty eyes down, through the corridor, fixed by an umbilical cord, the tether, to an attendant immediately behind. Others, also head down, were wheelchair-bound, literally tied into the chair by a broad canvas waistband around their torsos. Diapers protruded from trousers and hospital gowns. The stench of disinfectant, Desitin, and excrement defiled the air.
When Joe closed his eyes, the happy and joyous tones, the words and phrases of the staff, would have fit perfectly into a nursery school or a kindergarten.
What a way to end your life, he thought. What the hell is my Joe doing in a place like this?
The large tree-covered patio overflowed with patients and staff. Most gathered around a large TV placed in the shade. The sound of Hollywood Squares, closed-captioned and loudly adjusted for the hearing impaired, overwhelmed the scene making normal conversation difficult.
Polk found his son on a gurney in the shade of a large Magnolia tree with Bessie Brooks, the physical therapy technician at his side. Bessie, a dark-skinned, wiry-thin, twenty-five year old Jamaican woman, put Joe through full range-of-motion exercises in an attempt to prevent the contraction of his unused joints. In spite of all this attention, Joe had several fingers on both hands permanently bent. Bessie worked on Joe Jr.’s hands, extending the contracted joints. To anyone not in a persistent vegetative state, the pain of this stretching would have been unbearable, yet Joe, Jr. showed no response as he lay there, eyes open, unmoving.
He looks normal, thought Joe, except for the well-healed scar across his right temple and those vacant eyes.
“Hey Dr. P., great to see you mon. Joe boy’s doing good today,” Bessie said with her island lilt.
“How much longer, Bessie? I want to read him the latest Time Magazine.”
“I’m almost done, Doc. Go right ahead. I love it when you read to Joe.”
Polk had been reading to his son on each visit. He read the newspapers, Time magazine, and from several fishing and hunting magazines, Joe Jr.’s favorites. After the first few months at Sunshine Manor, reading is what remained of Joe’s attempts to touch, to stimulate, and to reach any part of his son’s damaged brain. They’d tried a whole range of sensory inputs, music, TV, movies, smell, and massage. Nothing helped.
He read to his son for forty-five minutes, then caressing his head and cheek, departed. He followed the same routine each time. Joe Polk had become a fixture at Sunshine Manor, appearing at his son’s bedside, any time of the day or night.
Joe knew that Marion’s world was one of sorrow and emptiness. With time and support of her children and the family, he saw that she had partially restored function to her life. Joe, on the other hand, instead of grieving, had taken the loss as a personal affront, an insult generating an icy, intractable rage. Joe had been distant and emotionally dysfunctional before, now, she claimed, he became unreachable.
“It's too painful,” Marion said after each visit to Sunshine Manor. “My visits serve no purpose. I can’t do it anymore, Joe. Each encounter sets me back, making it more and more difficult.”
“I understand,” Joe said, “I know it serves no good, but I can’t stop going.”
When Polk arrived home the next night, he noticed Marion’s Lexus was not in the driveway. He entered the home with the phone ringing. He rushed to answer.
“Joe, my car’s not ready,” Marion said. “You’ll have to come and pick me up.”
“They promised the car would be ready by noon today and now in the evening it’s still not ready,” he shouted.
“They were out of stock on a part they need to complete the repair. The part’s back ordered and here’s not much we can do about it.”
“We’ll see about that. I’m on my way down.”
When Polk arrived at the Lexus dealership, he demanded to see the service manager, Artie Collins. The receptionist paged Artie, and after waiting for another ten minutes, he entered the reception area with a broad smile. “Dr. Joe, it’s great to see you.”
“What kind of crap are you guys pulling? You promised Marion’s car by noon today and now who knows when it will be done.”
Artie Collins paled. “I’m truly sorry Dr. Polk, but the distributor promised us the part by nine this morning only to find it had been recalled yesterday afternoon. We’re making a statewide and western U.S. search for the part.”
“What a load of crap that is,” Joe said. “You guys always find the parts when you want to.”
“Dr. Polk, sir, I give you my word ...”
“I don’t want to hear it,” Polk said, pointing his finger at Artie. Polk. “We’ve been coming here twenty years. Do you know how much service we’ve brought here and how many cars I’ve purchased in that time?”
Finally, Artie replied excitedly, “Dr. Polk, why in the world would we do anything to sabotage our long-standing relationship. If I could have found the part anywhere in the bay area or the surrounding areas of Northern California, I would have sent someone out to get it immediately.”
“It’s no big deal, Joe,” Marion said. “Just ta
ke me home. You’re embarrassing me.”
“You’ll get over it,” Polk replied, and then returned his attention to Artie, “Don’t bullshit me. I don’t give a damn how you get that part, that’s your problem. When you promise completion of a repair at noon, you better be sure you do so, at least when you’re dealing with me.”
“What can I do to rectify this situation? I’ll pull out all stops to get that part. I have a brand-new Lexus you can use until the repair is done.”
“Give me the damn keys,” Polk said. “I’m not through with you guys.”
Marion and Joe departed in silence.
By the time they returned home, Joe’s anger had subsided. He went immediately to the kitchen table and began reading the day’s mail. Marion sat across the table.
“That outburst was uncalled for,” she said. “What’s wrong with you lately?”
“Nothing’s wrong with me, I won’t let anyone push us around.”
“That’s not saying much these days,” she said. “I don’t know what’s going on at Brier, but it's affecting you, and me, too.”
Joe turned away.
“Damnit, Joe, I need to know what’s happening at Brier. All the hospital wives are talking about it, yet you’ve not said a word to me.”
Marion stepped away, awaiting Joe’s reaction. “This whole Brier thing has been blown way out of proportion. It’s getting to me. I’m sleeping poorly and I’ve been more irritable and angrier than usual.”
“This is hard on you, Joe, I know it.”
He stared across the table. “I know more than anyone about my imperfections, but until recently I’ve had things under control. Medicine has changed. I’ve changed. It used to be fun, but now, I just don’t know.”
First, Do No Harm (Brier Hospital Series Book 1) Page 21