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

by Lawrence Gold

  Sherrie Brooks, a new graduate said, “I’m always behind although I find myself racing through the corridors. They’re asking too much of me,” she said, tears coming. “All I ever wanted to be was a nurse. I see that gradually slipping away from me as I look ahead to years of frustration.”

  Mary Oakes knew this would come, though she’d done everything possible to postpone the inevitable. She’d run out of tricks. Nursing administration had ignored her pleas and she suspected it would take a high profile tragedy of some sort to reorder the hospital’s priorities.

  Intellectually, she knew many in hospital and nursing administration were people of goodwill, trying their best to provide care in an all but impossible system. In any world of limited resources, gaming the system, an unseemly strategy in treating patients, had become the requisite survival skill.

  “Well, who has the story of the day,” Mary said, trying to lighten the depressing atmosphere?

  Sherrie smiled. “Who can I thank for making creative patient assignments today? I know Jason Adams in 514B has become the current focus of nurse fantasy, but I detect someone’s wry sense of humor in assigning him to me today instead of someone more a bit mature.”

  They were all smiling now as she continued, “Giving a bed bath to a twenty-year-old hunk whose arms are in splints, made for interesting moments this morning, especially when it came to genital care. I never knew I could do that by the Braille Method. Not even a peek, though somehow I felt the expanding effects of this encounter on poor Jason, who spend most of his time apologizing. He was having a hard time—I mean difficulty—in dealing with his involuntary response.”

  The room erupted into laughter and Mary reflected on the astonishing quality of these people, their goodness, and dedication and how little it took to hearten their spirit.

  Chapter Thirty-Six

  I found Mary at work in her office, and when she motioned me in, I moved to sit beside her desk.

  “Saw Helen Martin today,” I said. “She’s doing well, but has a little anemia. That will improve over time. Her general strength and sense of well-being are much better and some of that famous optimism is back. The family’s had a tough time, but they’re back in the groove for a transplant.”

  Mary smiled. “It’s about time for that woman to get a break. What’s happening with Polk?”

  “Polk...Polk? Somehow that name sounds familiar.”

  After Mary’s sneer subsided, I continued, “I can’t get myself away from that question these days. Nothing about that situation is open for public discussion. Nevertheless, I’m sure you’d be pleased.”

  “You’ve already heard my diatribe, so I won’t burden you again,” she said smiling. “Now if we could only get him admitted to this ward? What a fantasy.”

  “Remember, if I’m admitted here, I was on your side.”

  As I left the ward, they paged me to Warren’s an all too familiar extension. I dreaded calling that number. The man answered himself.

  “What’s the matter, Warren, can’t afford to have someone answering your phone?”

  “It’s only because I knew it would be you, Jack.” He paused. “I hate to do this to you young feller, but I know what resiliency and determination you have to…”

  “Give it a rest, Warren. As long as this has nothing to do with your buddy, Joe Polk, I’m okay.”

  “Well since you mentioned that name, you can do one small thing for an old and rapidly deteriorating friend…”

  “You missed your calling, Warren. Let’s have it.”

  “Joe has admitted a patient into ICU and he needs concurrent monitoring. If the patient had any other problem, I’d have spared you this blessing, but this patient, Mrs. Joan Faber, has moderate kidney failure and her potassium is elevated. Right in your ballpark.”

  “I thought I told you that when it comes to your buddy, Joe Polk, the ballpark is closed for the season.”

  “Be a good boy. Watch over Polk’s shoulder and make sure he doesn’t hurt anybody.”

  I looked at the receiver in my hand. I thought that it was smiling.

  I walked slowly toward ICU trying to formulate a plan of approach. It was no use. Polk sat at the charting table, and looked up, glaring as I entered.

  This is going to be great, I thought.

  “I don’t like this anymore than you do Dr. Polk, but I need to monitor Mrs. Faber’s case. I’m not here to nitpick or give you a hard time.”

  Polk threw the chart across the table. “I’m old enough to have delivered you and don’t need you or anybody to tell me how to practice medicine.”

  I refused the challenge, and sat down to review the chart.

  Polk’s patient was seventy-four years old and a long-term devotee. Her history revealed slowly progressive kidney failure. Polk had recently started her on Aldactazide, a combination diuretic. I understood at once that this medication combined with a low salt diet, resulted in dehydration and potassium retention. Mrs. Joan Faber simply needed to stop that drug, and receive intravenous salt solution. Polk had done neither, just placing her on a low potassium and low protein diet.

  “Sir,” I started, “I changed in your orders. I hope you understand?”

  “Don’t have much choice, do I?”

  “If we give her a little salt solution and stop the Aldactazide, we can accomplish two things; first, her kidney function is likely to perk up and second, her ability to get rid of potassium will improve,” I said, trying to be upbeat.

  Polk grabbed the chart, scribbled additional notes, and threw the chart on the nursing station where it landed with a bang, upsetting a stack of charts and toppling a full cup of coffee. Without another word, Polk departed from the ICU, leaving behind the last vestige of sympathy I might have felt for him.

  I reviewed all the orders then called over to the ICU charge nurse and explained the situation with Polk and my role. I gave her parameters to indicate when they needed to contact me, and departed.

  That evening I was moody and depressed. I’d spent most of the day trying to save the life of Harold Hopkins, the one patient I’d least like to lose. In spite of weeks of effort and the best minds available, Harold succumbed late this afternoon. Nature, as an act of kindness, rendered most patients near death unaware, insensate. Harold, as lucky in death as he was in life, remained awake and alert to the end.

  The last two of Harold’s seventy-one years had been miserable. This once proud and vibrant retired army colonel had fought bravely against the ravages of end-stage kidney disease, dialysis, transplantation, transplant rejection, and about every known complication of the disease and its treatment. His once six-foot, one hundred eighty-pound body was wasted due to severe bone disease. His weight was a fraction of normal, down to one hundred twelve pounds.

  I worked hard on Harold’s case over the past few months. My efforts were futile. While I’m always conscientious, my work on Harold resulted more from our friendship. Selfishly, I didn’t want to lose him.

  Harold was bright, disciplined, and a bit iconoclastic, especially for a career military officer. With his long experience as a leader of men, he learned the finer techniques of skewering the affected, the pompous, and the ill prepared.

  Harold’s jibes offended me at first. He had an argumentative nature and he refused to substitute anyone’s will for his own. Soon I came to understand and respect this unique man for doing it his way in the face of insurmountable problems. I also came to understand Harold. He enjoyed, no, he reveled, at the poking and prodding, especially of physicians, all too comfortable with passive patients.

  As I stood at Harold’s bedside, pumping in the fifth unit of blood, he turned to me with a sardonic smile on his face. He glanced up at the unit of blood and whispered, “You gotta be kidding, Doc. You’re wasting good blood and everyone’s time, I’m done.”

  Moments later, he was gone.

  “It never ends,” I said to Beth. “How much is one willing to put into a case?”

  “Be kind to you
rself. You worked your ass off with Harold. What more could you do?”

  “You can always do more,” I said, “and that’s the question, isn’t it? When a case ends badly, I ask the same set of questions, the ‘could I’s’ or the ‘should I’s’. Could I have spent more time at the bedside? Should I have spent more time in the library researching the case? Should I have solicited more assistance, and picked the brains of any and all experts that I could have laid my hands on?”

  “Who could live that way?” Beth replied. “If practicing medicine is only for saints and martyrs, who is going to provide care? Do the highest achievements in practicing medicine preclude a normal life?”

  I’ve come to terms with these realities and learned to accept them. However, the uncomfortable truth comes crashing through when you lose a patient like Harold Hopkins.

  Chapter Thirty-Seven

  Laura and Mac sat before Rick Adams’s large, oak desk. The sun shone through his window and on ten years of Circulation and the American Journal of Cardiology that filled the shelves behind. Yesterday, Laura spent a good part of the day in the cardiology diagnostic lab. Rick studied the results.

  Rick raised the tracings, echocardiographic studies, and scans. “I’m sorry, Laura, but I don’t like what I’m seeing.”

  Laura paled and grasped Mac’s hand.

  “While there’s no evidence of blockage to the blood supply to your heart, we’re seeing severe impairment of your heart’s pumping ability.”

  “What does that mean?” Mac asked.

  Rick turned the computer monitor on his desk so they could see the screen.

  “This will look like watching a football game in the fog, but give me a moment to orient you.”

  He ran the echocardiogram.

  Laura looked at the contracting ovoid image, her heart. “I guess that’s my heart, but I can’t see anything else.”

  “Look at this area. It’s the wall of your left ventricle, the most powerful pumping element of your heart.” Rick pointed with the tip of his pen. “See, this part of the ventricle contracts well with each heartbeat, but,” he pointed lower on the screen, “this part does not contract at all. If you look carefully, you’ll see it bulge a little with each contraction. This is an aneurysm, a balloon-like thinness of the wall that’s weakening your heart.”

  Laura could see it now. “What caused this? What can we do?”

  Never assume, Rick thought, that what’s so apparent to me is equally obvious to patients.

  “That weakened area, the aneurysm, was the major point of injury from the heart attack. The heart muscle in that area is largely gone and replaced by scar tissue. Scar tissue can’t contract.”

  “What about treatment?” Mac asked.

  “We have no medical treatment, only surgery.”

  Laura’s eyes welled with tears as she stared at Rick. She blew her nose and took a deep breath. “Let’s have it.”

  “I’m referring you to University of California Medical Center in San Francisco. They’re doing a procedure that’s perfect for your condition. They call it ventricular reduction. None of this is going to sound great, but we’ve come a long way to make this type of surgery safe. You’ll go on the cardiac bypass pump and while your heart is at rest, the surgeon will cut out that scarred section, that ballooning part, and sew together the edges of normal heart muscle. The results have been good.”

  “You’re scaring me,” Laura said.”I don’t know how much more of this I can take.”

  “This is all Polk’s doing,” she cried. “That monster ruined my life. He’s killing me!”

  Rick had the strong urge to be anywhere else but here.

  They want me to say something, but what can I say?

  “You’re not going to deny Polk’s responsibility for Laura’s situation, are you?” came Mac’s challenge.

  Rick did not hesitate. “Not on your life. At trial, Polk will buy expert witnesses who will prostitute themselves and agree with his actions and will cite the inevitability of your heart attack and the resultant damage. As God is my witness, they’ll be lying.”

  “That bastard won’t get away with this. I promise,” Mac said.

  Apple Hills Country Club was eight minutes out of town and had its own private road forestalling the uninvited. The grass-covered spring-green hills, soon to be brown with the end of the rainy season, drew Joe Polk to this oasis of serenity just ahead. A large redwoods and eucalyptuses grove marked its entrance.

  Joe had been a member of the club for nearly twenty-two years. He served in a variety of roles, most recently as its president. He’d enjoyed his tenure, especially its ceremonial aspects, but in recent years, the job had become so time consuming, he’d begged off the last suggestion of the nominating committee that he extend his term for four more years. He remained an active participant in the club’s activities including membership and fund-raising.

  The bright afternoon sun highlighted the trees and rhododendron that lined the white Italian brick driveway leading to the Colonial-style clubhouse. As he approached, Polk savored the air, rich with the scent of jasmine. He was late for his tennis game with Harvey Ross, an eight-year Wednesday afternoon tradition. They were evenly matched, so their games were exciting.

  After Joe checked in with the front desk, they informed him that Harvey had been on court one, their best clay court, for the last fifteen minutes. As Joe approached, he saw Harvey practicing his serves, repeatedly driving the ball accurately across the net.

  He’s always trying to one-up me, Joe thought, it won’t do him much good today.

  Over the years, Harvey had come to anticipate these matches, alternately enjoying and being dismayed by Joe’s antics; the arguing over line calls, his angry self-deprecating outbursts, and his gloating in victory.

  It was amusing, Harvey thought, a small price to pay for the quality of their games together.

  Harvey had noted subtle changes in Joe over the last few years, accentuating the worst aspects of his game and his behavior on the court.

  Harvey had decided to let go of his certainty that Joe was far too generous in his own favor with his line calls. Recently, Joe’s calls had gone right off the wall with denial of balls clearly in bounds and his vigorous disagreement with Harvey’s calls.

  When Harvey spoke to his wife, Rebecca, he said, “All these years I’ve been willing to overlook Joe’s nonsense. He’s unique and has his flaws, like we all do, but our games were great. I’ve reached the point of diminishing returns with him lately, and may have to pull the plug on our game.”

  After volleying for a few minutes to warm up, Joe served to start the first set and they played more or less evenly, Harvey finally winning six to four. They sat on the sidelines drinking ice water. Harvey had tried to find a way to draw Joe into a discussion about the situation at Brier Hospital, but couldn’t find a subtle segue into the subject.

  “I’ve begun to feel my age now Joe,” Harvey said, “especially after two or three sets of tennis with you. For days after we play, I’m achy and sore, and by the time I’ve recovered, it’s time for our next game.”

  “Well, Harvey, it’s a mistake to depend on tennis once or twice a week to remain in shape. I’m up early three or four times a week for my general workout and I’ve never felt better. Come join me in the mornings and I’ll make a new man of you.”

  “Thanks, but no thanks. I’m not sure Rebecca’s ready for a new man. In any case, I can barely drag myself out of bed by seven a.m. Getting up with you for exercise at five a.m. would kill me.”

  They returned to the court for the second set and Harvey aced out the first game, Joe rarely laying his racquet on the ball. Joe, his jaw set, facial expression fixed, pushed hard into the next three games, but the more intense his play, the worse his performance. His weak excuses stuck like peanut butter in his mouth. Into the fifth game, Joe complained and shook his head with Harvey’s calls, all subtlety gone, “God damn it, that ball was in.”

  “Come see
for yourself,” Harvey said pointing to the ball’s clear mark in the clay, two inches outside the line.

  Thank God, this is not a hard court where the ball left no mark.

  Harvey reacted as usual; this was old Joe Polk’s antics in action. The vitriolic intensity of Joe’s anger as he lost the last point of the fifth game shattered Harvey’s philosophical view of the situation. He had a transient flight response as Joe rushed the net and smashed his expensive racquet into the steel net support bending the metal frame and shattering the strings into fragments.

  “What’s going on here, Joe?”

  Sweat soaked and red-faced, his opponent uttered not a word as he walked to the courtside bench, sitting heavily. Harvey regretted the phrase as the last syllable departed from his lips, “It’s only a game, Joe.” He prepared himself for an eruption that never came.

  Joe surprised him, when he said, “I’ve been under too much pressure lately. Besides the fact I hate to lose, you know that better than anyone, I’m having difficulty putting the Brier Hospital situation into its proper perspective. It’s finally getting to me.”

  Harvey had been seeking this opening, and now that he had it, he didn’t know how to go on. If this had been anyone else but Joe, a straightforward, fact-based, and logical approach would be the way to go. “You’ve kept your own counsel, but Joe, what’s been going on?”

  “You know all about the shit’s that’s been going on. You’re a part of it. Let me tell you, I don’t appreciate your backstabbing—some way to treat an old friend.”

  “You want it, here it is, straight and direct,” Harvey said sitting on the warm wood slatted bench, wiping the sweat from his face with a towel. “You fucked up Joe, fucked up royally. All this crap with the nurses, the fights with other docs and what you’ve been doing clinically, you’re in a bad spot. How much longer did you think you’d get away with it? What’s happened to you?”