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

by Lawrence Gold

Joe refused Harvey’s eyes saying, “I put my entire professional life into Brier Hospital, this medical community, and into the care of my patients. Look what it’s got me, trumped up charges and disrespect.”

  “Those damn nurses. That arrogant bastard Warren Davidson and his clone, Jack Byrnes, were having it all their way. They’re all going to pay the price before I’m through.”

  Harvey knew he’d win no battles today. He’d have his say and let it go. “Joe, you were one of the best, maybe the best of our generation. This situation at Brier will not end well if you can’t own up to the problems you’ve created.”

  Suddenly calm, and with a soft smile on his lips, Joe turned facing Harvey saying, “I think not.”

  Chapter Thirty-Eight

  Carrie Palmer’s room looked like the aftermath of a birthday party. Get-well cards, banners, and pictures covered the walls, windows, and every other available vertical surface. Plants fought with stuffed animals for space.

  “How will you get all this home?” I asked as I looked around Carrie’s room.

  “Dad’s bringing the pickup,” she said, smiling. “I’m out of here, right?”

  “There’s only so much we can stand of you Carrie,” I said, smiling in return. It was remarkable how incredibly sick she was and how great she looked now. Enough cases like Carrie Palmer, and I’d never quit medicine. “I want you to see Arnie within two weeks. I’m prescribing iron and multivitamins, nothing else.”

  “After I left ICU, I gradually put the pieces together,” Carrie said. “I almost didn’t make it. I owe so much to all of you, the doctors and nurses, but especially to you Jack. I wouldn’t be here without you. I can never repay you for what you’ve done for me. More than taking care of my medical needs, you cared about me, my soul. I’ll never forget you.”

  I couldn’t have been more pleased. We deal with too many bad results, so it’s great to have someone do so well, to see someone going home after being so sick. It’s what keeps most of us going. “You take good care of yourself and come see me, socially. I’ll supply the coffee and doughnuts.”

  Carrie approached and hugged me, and placed a soft kiss on my cheek.

  “Can I ask you a question, Carrie?”

  “Of course.”

  “Where do you stand with Richard? I know it’s not any of my business, but ...”

  “It’s okay, Jack. To tell you the truth, I’m not sure.”

  “I’m not that much older than you and Richard, and this makes me feel old, but I have a little advice.”

  “Go for it, Jack.”

  “You were in love with him, and he loved you too?”

  “I was sure of it until all this happened.”

  “Richard made a mistake, a big mistake, but he had no idea that this could happen. Guys, especially young ones make mistakes, and he made a doozy—too much drink and yielding to pressure from the guys.”

  “It was more than that, and he even tried to deny it.”

  “Add stupidity to the list of his faults, Carrie, but he loves you. He told me so, and I believe him. I don’t think that great relationships come around that often. Luck’s a big part of it, but when you find one, I wouldn’t let it go too easily. I’ve made mistakes. I’ll make more in the future, and I pray that Beth loves me enough to forgive me. Give it some thought.”

  She smiled, and then said, “I will.”

  The days before the special joint meeting of the QA Committee and Medical Executive Board crept by slowly. You could feel the tension in the air. Whatever one’s opinion, the Polk matter remained topic one.

  I’d developed a strategy that produced the sense of speeding up time. If I wanted a month to pass by quickly, I’d have Janet make an appointment for Mrs. Janice Hoskins. The month would pass in a flash. She wasn’t a terrible patient. On the contrary, she was friendly, happy, and so incredibly grateful for my attention and ‘great skill’, she often embarrassed me. The dilemma was the utter intractability of her problems and my complete frustration in dealing with them. There should be a law; patients should have real medical problems, or they should just be nuts. Janice Hoskins had both, and I’d be damned if I could tell the difference.

  One of the more common aphorisms among internists said, ‘beware the patient bearing lists’. Janice had a complete list of complaints, five pages long. I knew they were bogus, but I could never be sure that one or more weren’t serious.

  Janice had somehow developed a power over me to compel just one more test and just one more examination to rule out serious disease. She loved it. The more tests she had and the more frequent the examination, the happier she was. Though she had hypertension and mild kidney disease, she had not developed any other significant medical problems. They had worked her up repeatedly and negatively for cardiac disease, cerebrovascular disease, and cancer, among others.

  I was certain that the first time I dismissed one of her bogus symptoms, she’d have the real thing, and we’d both be screwed. I considered insulting her, though this was out of character. Maybe then, she’d take the hint and leave my practice. The worst I could accomplish was to be abrupt and dismissive of her symptoms. In spite of this, and without blinking an eye, she moved to the next item on her list. I’d tried the old Jackie Mason line on her, “It’s no longer a question of staying healthy, Janice, it’s a question of finding an illness you like.”

  She paused for a moment, mulling over the joke’s relationship to her, then came forward with a knowing laugh. Well, I thought, with relief, she wasn’t due back for two more months.

  I had the dubious pleasure of seeing Joe Polk several times throughout Joan Faber’s admission and we’d discharged her yesterday. Her problems gradually resolved and Polk planned follow-up in his office. I felt disheartened that Polk, a physician practicing at this level and with these restrictions within the hospital, still had total freedom to do as he might without scrutiny in his private office. I worried, as did most physicians, about Big Brother sticking his nose into our business, but how, in conscience, could we ignore this potential for disaster, whether or not it took place within the confines of the hospital?

  I did my job.

  The patient recovered.

  Shouldn’t that be enough?

  Polk worked diligently to make each of our encounters as unpleasant and as confrontational as possible. During this period, I had two urgent needs: To take a course on How to Deal With the Difficult Physician and two, to take Valium. I griped to Beth who found it amusing, “I can’t stand that guy. How he became an icon in this community is beyond me. Ask Doctor Joe, my ass.”

  Smiling, she replied, “So now you’ve had a taste of what we’ve had to go through in dealing with that creep. Moreover, you’re a physician, a peer. Think of how he treats mere mortals.”

  She continued, “Here’s my fantasy; put medical students on the wards as nursing assistants. Arrange for them to work for the Polks of the world and taste first hand such delights. Insights earned painfully might make docs understand how their behavior can affect those around them. I’m not sure in Polk’s case it would have made any difference.”

  “You know.” I said, “Several docs have raised questions about the Polk inquiry. Those who have known him for years have suggested his current performance and attitudes are a marked change. In fact, though nobody ever characterized him as mellow, people did get along with him, and he maintained the reputation as a knowledgeable and skilled physician. The more insightful on the staff have suggested he’s impaired, an explanation for his current situation.”

  “Jack, I don’t want to sound like a hard ass, well maybe I do, but whatever the reason for his behavior, we put up with it for too long and he’s injured too many patients. Don’t leave out all the angst he’s caused the nursing staff. Maybe he’ll be willing to compensate us for the aggravation, the support meetings, and the hours nurses have spent in counseling. Don’t forget the antacids and the Valium.”

  “You know me well enough by now,” I said. �
�I find the medical staff’s behavior in the Polk case, and others, disappointing and irresponsible. Their tolerance and excuse-making for Polk may be understandable by the ‘There but for the Grace of God, go I’ sentiment, but it’s destructive and ultimately dangerous for our patients. It’s just plain wrong.

  I didn’t know what we’d do with all the time consumed in ruminating about Polk, but wished it were behind us. At least we’d limited the scope of the public debate, I thought as I exited the hospital. Once through the massive glass sliding doors of the main entrance, demonstrators, perhaps two hundred in number, marched in the bright sunshine.

  Rachel Hatten and Barbara Murphy, two of Polk’s long term and most devoted patients, had organized the demonstration. They had become outraged when the Polk story first broke. Encouraged by Gladys Wolff, Polk’s office nurse, they marshaled their forces, contacted Polk’s patients, and used their extensive media contacts to promote the demonstration.

  “I’ll be damned if I sit by and let them crucify the best doc in town,” Rachel said.

  Local TV trucks, microwave-equipped, disgorged several reporters interviewing demonstrators holding signs that read; SAVE OUR DOCTOR! UNFAIR TO DR. POLK. WHEN’S THE LAST TIME YOUR DOCTOR MADE A HOUSE CALL? BOYCOTT BRIER HOSPITAL!

  As I approached a group of protesters, a reporter held a microphone to the mouth of a middle-aged woman. I overheard her excited and tearful utterings. “There’s never been a doc as good as Joe Polk in this community. He was always there for us and I know he saved my daughter’s life.”

  “I wouldn’t be here if it wasn’t for Dr. Polk,” shouted another protester.

  Another reporter, a well-dressed young woman with heavy makeup, and every hair in place, asked, “Why do you think the hospital and medical staff are out to get Dr. Polk?”

  Taken aback by the question, the woman nervously responded, “Maybe it’s professional jealousy? They’re saying he made a few mistakes, but he’s always been there for us. Maybe they just want to get back at one doc who cares less about money and more about his patients?”

  I’d heard enough and turned to leave when someone thrust a microphone in my face. A group of protesters surrounded me immediately, blocking my way out. “You’re a doctor here on the medical staff aren’t you?” came the angry assault.

  What was this thing about looking like a doctor? I wasn’t carrying a stethoscope or wearing my white coat and yet they made me.

  “I am, but I have no comment.”

  The reporter blocked my escape and bellowing, “Why are all these people accusing the hospital and medical staff of unfair treatment of Dr. Polk? Would you care to comment?”

  With no response, she again shoved the microphone into my face. “Why all the accusations about hiding the facts from the public? Why no response from the medical staff? How do you respond to the claims you are persecuting of one of this town’s best doctors?” came with a smirk.

  This was the ‘when did you stop beating your wife’ question.

  I couldn’t think of an appropriate sound bite that would help anyone but Joe Polk, so I said, “I have no comment. These issues are confidential to the hospital, Dr. Polk and to the medical staff.”

  “Confidential or cover-up?” she asked.

  I’d win no battles today, so I turned and forced my way through the crowd. As I walked away, I heard, “So there it is,” she smirked, “another example of stonewalling by the hospital and the medical staff.”

  Politics and the media, even at the local or personal level, had always left me bitter and disappointed. A political approach to any problem often evolved into an ends-justify-the-means strategy. Truth vanished in political advocacy and expediency, while the media either played out its bias or more commonly, just plain got it wrong.

  During my training, when an issue entered our small world and its political arena, winning triumphed over truth and honesty every time. I’d heard friends and colleagues expound views I knew to be the polar opposite of the true beliefs they’d shared with me privately, a pathetic testimonial to ego protection and gratification.

  When I returned to the hospital, the overhead speakers blared, “CODE BLUE, CCU.” This would be the fifth code blue in thirty-six hours on my seventy-six-year-old patient, Barton Dobbs. Every CODE BLUE, CCU in the last day and a half had been for the same patient, and the same set of problems, heart failure caused by an abnormal heartbeat. We’d reached the point in this patient’s course where all attempts to control his heart rhythm problems failed, and we’d scheduled him for pacemaker insertion, our final attempt at controlling the heart life-threatening irregularities.

  When I arrived in the CCU, I noted the usual Code Blue team, absent a cardiologist who supervised codes in the CCU. I’d handled Code Blue situations often, and was unconcerned.

  “What happened?” I asked the charge nurse.

  Susan Kennedy, an experienced CCU nurse, responded, “More of the same, Jack. Barton suddenly developed a heart rate of one hundred-eighty beats per minute followed by sudden heart failure.”

  The cardiac monitor showed the electrical image of Barton’s heart beats rushing across the screen, a regular stream, so rapid, the heart could not fill fast enough to pump efficiently. As I was about to ask for Adenosine, a drug that we’d used successfully before to control this problem, the heart monitor alarmed and showed a marked change in the electrical pattern of the heartbeats, now suddenly slow at twenty beats per minute.

  “He’s developed heart block,” I said. “What’s his blood pressure?”

  Susan shook her head. “It’s down to sixty and I can barely hear the beats.”

  “Start an Isuprel drip, stat,” I said, knowing we needed to do something to get the pulse rate up and raise the blood pressure.

  “Isuprel started,” Susan said.

  The heart rate immediately increased to one hundred beats per minute and the pressure improved to one hundred-eighteen over eighty. My relief was short-lived, as twenty seconds later, the sudden cessation of all electrical heart activity stunned us. The patient had straight-lined showing no heartbeat at all.

  “Start CPR,” I shouted.

  The team swung into action, but after eighty minutes of CPR with complex heart rhythm problems, multiple medications, and repeated attempts to shock his heart, I called off the code and pronounced Barton Dobbs dead. It was two forty-three p.m.

  I was disappointed, but understood it had been remarkable this patient survived all the prior codes, considering his age and the severity of his heart disease. I stood at the bedside, chart in hand, writing my final note. I casually looked upwards at the IV bag containing the Isuprel drip and was shocked to see a two-hundred microgram/ml solution instead of a twenty-microgram/ml solution, ten times as strong as I expected.

  Stunned and disbelieving my eyes, I grabbed the plastic bag and stared at the label, hoping I’d read it wrong the first time. I hadn’t. I watched and waited for someone to recognize my error, as the code blue team reorganized its equipment and the nurses began cleaning the room and preparing the body for removal to the morgue. Nobody looked my way. I’d never made a mistake like this before. My mind flashed through every possible scenario, every possible consequence of this error.

  Susan Kennedy sat in her office completing the code blue form detailing the resuscitation, its events, and all the supplies and equipment used. When she saw me enter, she said, “I’m sure glad that one’s over. That man suffered enough.”

  Susan, who worked with me often, saw immediately something was wrong and said with alarm, “Jack, what’s the matter?”

  This is entirely my fault. I should have checked or specified the dosage of Isuprel. I can’t put this on Susan. “I checked the Isuprel. You hung a two hundred microgram solution. I thought it was the twenty microgram.”

  Suddenly, sharing my alarm, Susan said, “Wait a minute, Jack, you thought we were using low dose Isuprel solution?”

  “Yes,” I said softly, failing to meet her eyes.


  “Jack, the standard solution around here is the high dose infusion as recommended by our cardiologists.”

  “No, I didn’t know, but I should have known or checked. I screwed up.”

  “What are we going to do?” she said. “Did this error affect the outcome on this case?”

  I noted the use of the ‘we’ pronoun. “I don’t think so.” Everything about the sequence of events says that these were terminal cardiac events and nothing we could have done would have altered the outcome.”

  “Jack, I have to complete this form,” she said, lifting the complicated code blue sheet that records all actions taken during the code, including all medications used. “What should I do? This information will go to the pharmacy and ultimately to the code review committee. I don’t think they’ll ever notice the Isuprel dosage, and they have no way of knowing your intentions.”

  My moment of truth was cliché, but accurate. A moment that could affect me for the remainder of my career. A moment I knew would come—a moment I’d feared I would fail. Exposure of this mistake could have dire consequences for me both personally and professionally. I was frightened, and created in my mind a sequence of rationalizations, justifications for hiding my mistake. After all, my error did not affect the patient’s ultimate outcome and why then should I suffer any consequences?

  We sat in silence, intense internal dialogues raging.

  The images passing through my mind were graphic as I took a step back mentally and smiled. I remembered the cartoon character with an angel on one shoulder and the devil on the other, each whispering their seductive appeals into his ears.

  My inappropriate smile startled Susan. “Jack—?”

  “I’m okay Susan. It’s not every day we’re forced to confront who and what we are, it’s not so easy.”

  I took Susan by the hands. “I can’t thank you enough for your support. Fill out your forms and complete the incident report about these events and my mistake. I’ll deal with it. While I’m in the full bloom of sainthood or insanity, I’ll take the opportunity to speak with Mrs. Dobbs.”