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

by Lawrence Gold

  Esther Dobbs sat alone in the CCU waiting room crying quietly. When she saw me, she said, “Oh, Jack, I wanted to thank you for all you did for Barton. He liked you and appreciated all your effort and support.”

  I sat directly across from her chair, head down, and said, “I have something to tell you, something that’s not easy to say.”

  “What is it?” she said, alarmed.

  “There’s no other way but to say it outright. I made a mistake during the code blue and gave Barton too high a dose of a medication we were using to try to bring him around.”

  She suddenly sat bolt upright, staring at me, “The wrong dose? What does that mean?”

  “You have no way to tell if what I’m about to say next is truthful or self-serving. I suggest after you hear me, please confirm this with a physician you trust.”

  I paused for a moment to organize my thoughts. “When Barton developed a slow heart rate that we call heart block, I ordered Isuprel, a medication that should help increase his heart rate, stabilizing his condition. What I did not appreciate is the standard solution of Isuprel used in this hospital is ten times stronger than the solution I intended for him to receive. It was my fault. I should have known this or at least checked the medication. I honestly do not feel, and again, please check this out, the mistake had anything to do with the eventual outcome, which I attribute to total failure of his heart’s electrical conduction system.

  “I’m so sorry,” I said softly, head down.

  When I heard no response, I slowly raised my head to look directly at Mrs. Dobbs. She had a big smile on her face. “Look, Jack, we understood Barton’s condition and all the time, energy and dedication you and the staff have put into his care, a losing proposition from the start. Everyone knew that. I’m forever grateful. In addition, I’m stunned that you came to me with this admission. This only reinforces the opinion we had about you all this time that you’re a good man and a great physician. I need say no more.”

  When I told Beth about Mr. Dobbs, she grabbed my hands, “She’s right, and I couldn’t be happier.”

  A note would appear in my professional file, an admonition to be careful in the future. As a result of the incident, the cardiologists would develop a program to educate the medical staff on the standard dosing regimens used in the hospital, particularly during resuscitations.

  Chapter Thirty-Nine

  The afternoon fog bank made its way across the San Francisco Bay into the East Bay and rolled over the hills into nearby Contra Costa County. No matter the season or time of day, the dense fog brought bone chilling cold. I unbuttoned my windbreaker as I entered Brier’s lobby and made my way to the Boardroom.

  Physician members of the Medical Executive Board and the QA committee filled the room to capacity and beyond. They’d placed extra chairs around the enormous conference table and in both rear corners. They set the table with soft drinks, cheese, and crackers, largely untouched. Muted conversational tones and long periods of quiet replaced the usual boisterous atmosphere, a reflection of the mood of the participants. It would be all business tonight.

  As a member of both bodies, it impressed me that all players were present and accounted for, and were, for a change, on time.

  A meticulously attired man in his sixties, his attorney, accompanied Polk. They waited eagerly outside the boardroom in anticipation of an invitation to enter. Polk paced like a caged lion in the anteroom, glaring his challenge as each board member entered.

  Paul Morris, the president of the medical staff, stood in quiet conversation with Arnie Roth, the chair of the QA Committee, in preparation for the meeting. Paul was semi-retired, a general surgeon, before he took on the obligation of the presidency of the medical staff. This position was a major undertaking and the staff considered it the equivalent of a halftime position with appropriate compensation. “I do meetings,” Paul said, “starting at seven a.m. for staff committee meetings and going on to evening meetings of the Board of Trustees and lay groups.”

  Paul Morris was particularly well suited for this job. He had the appearance of an aristocrat, tall and thin, with a full head of gray hair, and had the easy manner of a populist politician. These qualities made him effective in representing the hospital and medical staff to the public. While he was an average clinician, Paul had proven to be a superior hospital politician who earned the respect of administration and docs for his skills.

  In the past few weeks, Paul had been the object of Joe Polk’s attention, if not his affection. “Let’s get together for dinner or drinks. Let’s catch up on old times,” was Joe’s less than subtle attempt at currying favor with Paul since his suspension. To Joe’s dismay, he got nowhere. “Give it a break, Joe. This is no time to resurrect old friendships.”

  Paul stood. “I call this special meeting of the Medical Board and the Department of Medicine QA Committee to order. This meeting is to review the recommendation of the QA Committee that Dr. Joseph Polk have his privileges revoked and that we expel him from the medical staff. Our purpose tonight is threefold, first, to review the findings; second, to give Dr. Polk his opportunity to rebut these allegations, and finally, to make our recommendation to the Board of Trustees who has ultimate authority in these matters.”

  Paul paused for a moment, and after looking around the table, he continued, “The QA Committee has already spent enormous amounts of time reviewing and discussing these cases. I do not propose we delve into them in detail again, and accordingly, we will present you with a written review of the salient points of each and the deficiencies noted.”

  Paul held up a thick packet. “Arnie Roth, the chairman of this committee, has prepared this packet for you. The blue pages contain a detailed description of the cases and the results of the committee’s evaluation. Included in this packet are the pertinent parts of the Medical Staff By-Laws pertaining to disciplining of medical staff members. The packet doesn’t leave this room and my staff will take them back when we are done. Know from our experience and on the advice of counsel, we must not deviate from our bylaws.

  Afterwards, we’ll ask Dr. Polk and his attorney, Mr. Phelps to join us.

  “Any questions?”

  Ross Cohen, a psychiatrist in his early sixties, raised his hand to speak. “I see in reading through the committee notes, some members suggested Joe Polk may be impaired. Have we considered this?”

  Warren Davidson replied, “More than once, I’ve asked Polk to meet with our Committee for Physician Assistance. We used to call that the Impaired Physician Committee. Who wouldn’t want to go to a group with that title? All I got was, ‘What are you nuts?’ I also passed on to him the recommendation of the QA Committee that he might benefit from psychiatric counseling, but his response included the retort that the committee should, I paraphrase, insert that recommendation forcefully up its rectum.”

  Amidst the chuckles, Ross continued, “I still feel whichever way we go, some kind of psych evaluation is in order, voluntary or not.”

  “We have a lot to get through tonight, so absent any other crucial questions, let’s go on with the case summaries,” Paul said looking around the room. Seeing none, he nodded to Arnie Roth.

  Arnie went through the seven cases, enumerating each practice and behavioral problem as committee members followed along with the detailed summary sheet.

  When he finished, he took a deep breath, then said, “Beyond the specifics described in these cases, there exists in virtually all of Dr. Polk’s charts, evidence of conflict with the nursing staff relating to their disagreement with how he cares for his patients, their inability to reach him in critical situations for orders, and unconcealed and often public disrespectful behavior by Dr. Polk toward the nurses. Of grave concern to the nursing staff has been that Polk, in ignoring their observations and recommendations, has taken actions or failed to take actions which have resulted in injury to his patients.”

  Arnie, exhausted with the presentation of these cases, continued, “We, the QA Committee, were not on
ly shocked by the nature of these cases, but we are embarrassed that these practices could have been going on within our institution. Amazingly, until these events surfaced, we thought we were doing a good job in protecting patients and monitoring physician performance. We could not have been more wrong. This situation has compelled us into a full review of our activities with the hope that never again must we have to describe for you such a litany of deplorable medical practices.”

  After twenty seconds of absolute silence, the room suddenly filled with outbursts, cries of disbelief, outrage, and disturbed muttering among the membership.

  Phil Banks had been around for a while. He started in practice about the same time as Joe Polk. “I know where this is going. This whole thing pisses me off. I’ve seen all sorts of ideas, philosophies, and biases ramrodded through committees by the force of will by an individual or a group. This business with Joe Polk is more of the same damn thing. I’ll have none of it. I never trusted Warren Davidson and his flock. They’ll do anything to achieve their aims. Maybe I’ll be next. If I’m smart, I’ll be careful.”

  Paul Morris was equally disturbed. He gave everyone a chance to ventilate, so he waited another thirty seconds for the room to settle down then said, “I fully understand everyone’s response to these charges. I was shocked regarding these cases. Let’s put emotion aside and get on with our discussion.”

  “I’m stunned that these practices are possible in this hospital,” Harvey Russo, a senior OB/GYN said. “Joe has been our family physician for twenty years and I never thought we were getting other than the best of care. True, we’ve had only routine medical problems, but the thought that he might be caring for my own family in this way, sends a chill through my spine.”

  “Paul,” said Jeff Brooks, another senior physician, “this looks terrible. How do we deal with this and what do you expect of us?”

  Paul took a moment to gather his thoughts then replied, “Understand the QA Committee’s case analyses and their recommendations. Satisfy yourselves that this is an accurate picture of Polk’s work. You must then agree or disagree with those recommendations. We will be giving Dr. Polk an opportunity to comment on these cases and the committee’s recommendations. Ask your questions now and feel free to question Dr. Polk about any of his actions when he joins us. Afterward, be prepared to vote on the question before this group, to ratify and pass to the Board of Trustees the recommendation of the QA Committee that Joseph Polk be expelled from the medical staff.”

  Arnie Roth stood. “I suggest we ask Dr. Polk and his attorney to join us. They’ve seen all this material. We’ll allow Dr. Polk to present his response to the charges and then we can try to discuss the cases with him. This may or may not be possible, depending on Polk’s attitude, as he’s not been receptive so far. To preserve order, I’ll be fronting the discussion with the assistance of the physicians who did the actual case review. For efficiency, I’d prefer to limit the questioning to myself and the QA members, but if any of you have crucial questions, please feel free to ask them.”

  Arnie nodded to Paul Morris, who went to the Boardroom door and escorted Joe Polk and his attorney to their seats. Polk made his way to the head of the table looking across the room smiling and not trying to hide his contempt. He sat with his lawyer and leaned over, whispering into his ear, and smiling.

  He just doesn’t get it, I thought.

  Paul began, “Dr. Polk…”

  Polk interrupted, “You’ve known me for 25 years Paul, call me Joe.”

  Paul continued, “Dr. Polk, we’ve suspended you temporarily from the medical staff and tonight we will be making a recommendation to the Board of Trustees regarding your future. Pending, is your permanent expulsion from the staff of Brier Hospital. You’ve seen the cases at issue and the deficiencies in practice noted. Tonight is your opportunity to rebut the allegations made against you and tell your side of the story. You may make any general comments you want and get into the details of any case where you disagree with the conclusions of the QA Committee.”

  Polk rose from his chair and looked slowly around the room, his arrogance no longer apparent. He straightened his bow tie and began. “I’ve known most of you for years, either personally or professionally. I’ve cared for some of you and your families. Some of you have cared for my family and for me. It’s impossible for me to believe we’re to the point where my professional career is at stake. How could this be happening?” He paused for a moment then continued, “Sure, I’ve made mistakes, who hasn’t? Trust me, if I went over your cases with the same biased enthusiasm, we’d have similar lists of deficiencies for the lot of you. Medicine is not perfect and neither am I.

  “Why have I been singled out for scrutiny? I have two theories; first, and most prominently, is I’ve become a cause celeb for the nursing staff because I won’t take any of their crap. Young nurses, who don’t know a damn thing, feel free to tell me how to practice medicine when they don’t have a thousandth of my knowledge and experience. The nurses are constantly on my back to get consultants on cases when I do not need one, or I feel that too many physicians on a case leads to confusion and mistakes. It’s true, my reactions to the nursing staff have, on occasion, been intemperate, and I regret those outbursts. I will find the opportunity to apologize for them. They were, however, in response to my feelings of frustration in dealing with these nurses as a group.

  “Once they brand you as a problem physician or a hard ass, you’re tainted forever. I tell you now, I could go up to the medical ward today, and while solving the most difficult of medical problems and practicing at the highest level, and the nurses would still subject me to second-guessing and criticism of my work. This is the main reason I’m here today.”

  Polk pulled his handkerchief, wiped his forehead, and continued, “No one here wants to admit it, but we have a conspiracy between the nurses and most of our new super specialists and sub-specialists to take work away from the general practitioner and general internist. Don’t call me paranoid. I appreciate the benefits specialization has brought to medical practice, but who decides when we need specialists, the specialists themselves or their surrogates, the nurses? I’ve been in practice long enough to know when I need a consultation. At one time, I did nearly everything specialists do; biopsies, surgery, EKG interpretation, obstetrics etc., and I did all of them well. Now, I do little, and each year I’m doing less and less.”

  Polk continued with his eyes down, agitated but resolute. “I’ve reviewed these cases. I made mistakes, but nothing of a magnitude that would justify the extreme action of terminating my staff privileges. Mark my words, my downfall should serve as a warning to all of you.”

  He paused for effect, then said, “You should take some note that I’ve had a long, and, if I must say, a distinguished career with this hospital. Those among you who have been here for more than a few months,” Polk added, looking straight at me, “will recognize I’ve made major contributions to the institute and to the medical staff.”

  Polk looked around the room and said, “I’m prepared to answer any and all of your questions.”

  Paul turned and nodded at Arnie Roth. “Dr. Polk, the number, and severity of the deficiencies in care are way beyond simple mistakes any of us might make. You injured patients, missed diagnoses, and at least one patient died unnecessarily. We cannot tolerate this unprofessional behavior. If you like, I’ll give you some examples.”

  Polk remained silent.

  Arnie Roth grabbed the first chart on his stack, “In MRN 1908871, the case with pneumonia, you omitted important elements in her history, you often were unreachable, and you discharged the patient prematurely with persistent fever and without follow-up films. She had to be readmitted a few days later and almost died.”

  Polk began animatedly, “Look, if you were as busy as I am you might leave a few things off the H&P too. She was feeling better and insisted on going home. I asked to see her in the office in a week. What more could I do? I’ve heard all I can stand abou
t not being reachable for my patients. Why do you think I carry a beeper? For my health?”

  “You’ve been unavailable or unreachable for this patient and for many other patients in these charts. Where were you and what were you doing?” Arnie asked.

  Reddening, Polk replied, “What I do and where I go is none of your damn business.”

  “It is our business when your patients are critically ill and you’re not there, and when the nurses can’t reach you.”

  Arnie took a moment, shook his head, and continued, “In MRN 190421, the elderly woman admitted with dehydration and confusion, you failed to identify what happened to produce the dehydration and the kidney failure. Worse still, you treated her inappropriately with too much salt solution, throwing her into congestive heart failure. If that wasn’t bad enough, you chose to treat the patient expectantly and let her die. Nurses overheard you telling the patient’s family all was lost and further treatment would be futile. We concluded that any reasonable approach to the treatment of her congestive heart failure had a good chance to succeed. She had a reasonable shot at life yet you stole that from her and buried your mistake.”

  Polk turned red with anger. “Who do you think you’re talking to? Mrs. Harrington was my patient for twenty years and made it plain to me she did not want any heroics in her care. Who are you to second-guess me on the decision to terminate care? I did discuss this decision with the family, as you’ll see if you reviewed the chart.”

  Arnie, now equally agitated, responded, “Yes, after you left them with no hope, they agreed with your decision to terminate care. How might they have responded if you told them the truth that with treatment of her heart failure, she might have survived?”

  Polk starting to rise. “I’ve had enough of this shit.”

  Jason Phelps, Polk’s attorney grabbed his client by the arm, holding him down. They engaged in a heated whispering exchange, after which Polk regained control. “Any of you might become excited if you too were subjected to unjustified and unfair criticism.”