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

by Lawrence Gold

  After working my way through six levels of the university’s annoying phone answering system, and transferred four times to different places in the hospital, I finally got Dan Cohen on the line.

  When I heard the heavy breathing and the words, Dan Cohen, I said, “If you’re going to make an obscene call, Dan, it’s better not to use your name.”

  “Hey, Jack,” Dan said laughing, “Just ran up thirteen flights of stairs. Gotta keep in shape.” Pausing to catch his breath, he continued, “The coma workup has revealed zilch. We may have to wait this out and see how much squash damage has been done.”

  The ‘squash’ reference to brain damage made me wince, though I’d used the term myself. Physicians don’t mean to be insensitive, and Dan was a caring and kind physician. Jargon, intended for physicians’ ears only, served to deal with frustration and disappointment, but I was too close to Helen, and the phrase offended me.

  “I went back over Helen’s office chart this a.m., and I noted the possibility that Helen may have had post partum thyroiditis several years ago. That sets the stage for future hypothyroidism. I’d ask endocrinology at least consider it.”

  Dan responded with a lack of enthusiasm. “I don’t think so, Jack. We’ve already checked her thyroid function as part of our evaluation of her coma.”

  “Do me a big favor, Dan. Check again, and pass this information to endocrinology.”

  Dan reluctantly agreed.

  “Beth and I will be over tonight to visit.”

  It amused me to discover that Warren had chosen me to serve as part of a highly select group I immediately dubbed, Operation Polk. I arrived at the boardroom exactly at noon. Attending the meeting were Paul Morris, Warren, Bruce Bryant, Al David, Arnie Roth, and two well-dressed men who were introduced as Milton Morrisey, the Chairman of the Board of Brier Hospital, and Curtis Spitzer, the litigator brought on board by Al David. The small group congregated at one end of the large conference table.

  Bruce Bryant stood and walked over to me, placed a hand on my shoulder. “Some of you may not know Jack Byrnes, a protégé of Warren’s. Jack has had the great pleasure of riding herd on Joe Polk in the past few weeks. Jack and Warren know best what’s currently going on with him.”

  Bruce moved on and stopped beside Curtis Spitzer. “Curtis will be handling this case for us and will litigate it himself if necessary. He’s the senior partner in Cooper, Spitzer and Campbell, one of this country’s most respected firms.” When he returned to the head of the table, Bruce Bryant continued, “I’ve asked Curtis to comment on the case and what he’s learned thus far.”

  Curtis Spitzer was tall, rail thin, and Lincolnesque. He had a dour demeanor, and began softly and facetiously, “You’ll be pleased to learn we don’t think this case is as open and shut as you led us to believe.

  “The hospital and medical staff’s decision that this physician is incompetent was based on observed practice behavior and review of his patients’ hospital records. Even to a layperson, there’s more than enough justification for dismissing Dr. Polk. Please understand, however, that Polk’s attorneys have or will obtain expert testimony that will question the accuracy and impartiality of the medical staff’s conclusions. Dueling expert witnesses confuse the court and lead to uncertain outcomes.”

  Warren was angry and agitated. “I’m not naïve. Expert witnesses who are more than happy to prostitute themselves for a buck can muck up the truth, but to quote your own words, anyone can see what’s going on with Polk. On a personal note,” Warren continued, “I’m embarrassed that it’s been going on under my tenure. I’ve rarely seen such blatant malpractice.”

  “I agree with you, Dr. Davidson,” Curtis Spitzer said with a smile limited to his lips, “but you must know what we’re up against.” Spitzer paused a moment, then continued, “His claim that he’s been illegally restrained from his trade under the Sherman act is, in my opinion, unsustainable. Additionally, his claims of discrimination by the nursing staff are laughable. I’d love to present a fraction of the nurse’s notes about Polk’s behavior. He claims that the medical staff denied him due process and there are discovery issues involving the QA Process. Both claims involve complexities of the law where there may be technical reasons why they could question the hospital and medical staff’s actions.”

  Spitzer paged through the familiar yellow legal pad studying his notes, and then continued, “There’s a significant omission in the charges,” he said looking around the room for dramatic effect. “Dr. Polk provides us with one of the best examples I’ve ever seen of a ‘disruptive physician’ as defined by your own bylaws. That alone may have been good enough to terminate his privileges. By my reading of your bylaws, this action would not automatically support his right to appeal, which is present when the medical staff is dealing with straight quality of care issues.”

  “There’s absolutely no question that his behavior, on its own, has compromised patient care and nursing staff morale,” I said. “How often can a physician verbally assault a nurse or ignore a nurse’s findings? She’ll think twice before calling or offering suggestions. I hate to approach Joe Polk myself knowing each encounter will be a confrontation.”

  Curtis Spitzer ignored my comment. “We’d be much better off if we raised this issue before the decision to dismiss Dr. Polk, but it’s too late now.”

  With no attempt at hiding the disdain in his voice, Spitzer rose from his chair, leaned forward on his hands and stared around the room. “Won’t you guys ever learn? We can best serve if you call us in before you have a chance to screw things up.”

  “What a load of crap that is,” Warren cried. “Absent the legal system’s constraints, Polk would have been out on his ass a long time ago. You guys make the rules and we have to live or die by them, or more accurately, patients do. It’s a great system you attorneys have created where Polk’s rights come at the expense of patients’ lives.”

  Unperturbed, Curtis Spitzer continued, “This is what we’re up against. I’ll meet with MEB and QA Committee members regarding compliance with the bylaws and whether or not they violated the sanctity of the QA process in a way that any of the meetings on Dr. Polk could become discoverable. Frankly, gentlemen, if Polk can breach this barrier of confidentiality and use our own doctor’s words in his defense, we’ll be in deep shit.”

  Curtis Spitzer returned to his seat. The room remained silent for an uncomfortable minute when Bruce Bryant spoke. “I’m not sure what I’d do, Curtis, if one day you actually brought us good news. The floor’s open for discussion.”

  Warren was as tense as a sprinter in his blocks at the starting line. He erupted, “I’m sick of this whole thing. Let the attorneys do what they must and let the chips fall where they may. This is all a bluff, since Polk ultimately won’t chance public revelation of his malpractice and behavior.”

  “I hope you are right, Warren,” Milton Morrissey said, “but I wouldn’t depend on his common sense, since poor judgment is part of the reason he’s in this situation.”

  By two p.m., I had enough. We discussed the situation extensively and expended much angst, but we added nothing new.

  As we left the boardroom, Warren was uncharacteristically quiet, the most ominous sign I’d seen since the whole Polk affair began. Warren had single-handedly carried the burden of supporting and inspiring the medical staff. He was paying the price.

  “I’m sick and tired of fighting the same battles over and over again,” he said. “It’s burnout, aging, or whatever, but my tolerance for frustration ain’t what it used to be.”

  “Don’t crap out now, boss,” I said. “I know this hasn’t been easy, but you’re the one who said I shouldn’t expect fairness in this life.”

  “I said it and I meant it, but can I live it? At my core, I see the glass as half-full, not half-empty. I’m as pissed off as I’ve ever been, but mostly, I’m frustrated. The time is rapidly approaching when what we do, and how we practice, will no longer be in our hands. That’s my worst nightm
are.

  “Too many of our medical leaders have elected to become politicians, and thus suffer from the limitations of that choice. The values that brought docs to the profession in the first place, independence, honesty, and integrity, are often the polar opposites of those we see in today’s leaders.

  “It’s easy to understand why docs have perversely developed distaste for the only real opportunity they have to exert influence on their own professional lives. Many physicians identify medical staff leaders as part of the problem, not the solution. Maybe it’s a predictable consequence of the general level of dissatisfaction physicians’ feel in practice today.

  “I remember when Dr. Dean Edell first came on the air,” Warren said, “He spent a lot of his time bashing doctors and medical institutions. His rhetoric today suggests he sees medical institutions and doctors as victims of government and health care insurers. He asks his public if they want to be under the care of unhappy and dissatisfied physicians, and treated in hospitals constantly on the verge of bankruptcy.

  “I see it so clearly,” Warren said, “yet I can’t motivate our own staff to act, I dare say, in their own interest.”

  “You’re too hard on yourself and I suspect, too impatient,” I said. “Wasn’t patience one virtues you promised to me as I got older?”

  “Patience is beginning to feel like acquiescence, the one outcome I can’t stomach.”

  “I’m sure not the one to be giving you advice, boss, but you’re constitutionally incapable of giving up or compromising on principle. Let’s gather our forces, chose our fights and move forward.”

  Though distressed by the meeting and Warren’s reaction, Helen Martin hadn’t left my conscious mind for more than a few minutes.

  Chapter Fifty

  Steve McIntyre stared at Laura. Even without makeup, and with the blue surgical cap covering her blonde hair, she looked lovely.

  “Don’t look at me like that,” she said, turning her face away, “I look awful without makeup.”

  “You’re out of your mind, you look terrific. You always look terrific.

  Mac sat at her bedside, holding her hands. Only a few minutes remained before the gurney would arrive to take her to surgery.

  I don’t know what it is, thought Mac, the intimacy of the last few months, or the chance of losing Laura, but I’ve never felt so close to anyone, and I’ve never been so frightened.

  “Don’t look so sad,” she said. “I’ll be fine. They’re the best. They’ve done this hundreds of times.”

  Mac lowered his head to the bed. Laura began stroking his head and neck, “Please don’t worry.”

  He looked up, into her eyes, “I love you so much. I can’t bear the thought of being without you.”

  Laura rubbed her hand across her chest and between her breasts feeling the smoothness of her skin. “It’ll be a scar–a big, ugly scar here, I just hate it. I hate that you’ll see it.”

  She’d never accept how little I care about a scar, he thought.

  “All I need to see is you, Laura, that’s all I want.”

  She lifted his head and sat upright.

  “You know me, Mac, so don’t get upset... “

  Mac waited.

  “Whatever happens...”

  “Laura...”

  “No, Mac. Hear me out. Whatever happens, I don’t want Polk to get away with it. I can’t allow him to do this to someone else. You must promise me you won’t let it happen, promise me.”

  “I promise,” he said, tears filling his eyes.

  Chapter Fifty-One

  Beth and I were anxious to get to UC Hospital. We weaved through the downtown congestion, naturally again at its worst. The streets were wet with recent light rain and the fog so dense that we could only see one block ahead. We didn’t say much on the trip over. When we finally arrived at SICU and entered the waiting room, Chuck’s appearance startled us. He sat bent over, head down, sobbing.

  We stared at each other, thinking the unthinkable.

  Beth placed her hand on Chuck’s shoulder. “What’s happened?”

  Chuck raised his head slowly, mechanically, eyes drifting and finally fixing on Beth then me. “They put a tube down her throat and placed her on a ventilator. Helen couldn’t breathe. They had no choice. She still in a coma and no one’s got a clue.”

  While Beth sat with Chuck, holding his hands and whispering softly, I entered the SICU and found Dan Cohen rounding with his residents and fellows.

  When Dan saw me, he immediately moved toward me saying, “Sorry, I didn’t have a chance to call you. Twenty minutes ago, she went into respiratory failure. We had no choice but to intubate and place her on a respirator. We still don’t know what in Hell’s going on.”

  “What’s her lab showing and how’s the liver doing?”

  “Your timing is perfect, Jack. Follow me to the conference room. We’re presenting Helen’s case to the academic staff.”

  I passed by the waiting room, stuck my head in and told Beth and Chuck about the staff meeting on Helen and that I’d be back to them afterwards.

  The conference room, more a miniature amphitheater, had a small stage area. The surrounding seats, sloping upwards toward a skylighted ceiling, were hard and small, designed for the bottoms of an earlier generation, and I suspected designed to make it difficult for its users to doze off.

  The room, with a capacity of forty or fifty people, contained about twenty-five, medical students, interns, residents, and specialty fellows. I recognized several well-known department heads.

  Dan began, “Mary Cobb, my chief resident will present the case.”

  Mary Cobb, Jack knew, must be at least thirty-five to have arrived at her current position, but looked like a teenager until she began her presentation. She was bright and crisp. “Helen Martin is a forty-three-year-old registered nurse, a patient of Jack Byrnes from Brier Hospital.”

  After pointing me out, she continued, “Dr. Byrnes referred Mrs. Martin for the transplant. She had chronic persistent hepatitis leading to end stage hepatitis with cirrhosis.”

  She reviewed Helen’s status before surgery, the surgical and postoperative course, all in exquisite detail that it sounded more like an internist’s presentation than that of a surgeon. I hoped her capacity for detail persisted beyond training and into the real world. After her description of the development of respiratory failure, she opened the floor for discussion.

  “What does her EEG show?” a resident asked.

  “It shows diffuse slow brain waves. Nonspecific and consistent with any general impairment of brain function.”

  “Review for us Mary, her medications before and during this hospitalization,” said Arthur Goldberg, the chief of internal medicine. Mary reviewed the medication list and all agreed it was unlikely they were seeing some form of drug toxicity. The chief of anesthesiology then reviewed the operative record and went through the differential diagnosis of failure to awaken from general anesthesia. Nothing fit.

  After a wide-open, extensive, and largely unproductive discussion, I asked, “Have her repeated thyroid function tests returned?”

  “No,” said Mary, “but since the first series was normal, we don’t have much hope there.”

  “When I reviewed her office records,” I said, “I found evidence suggesting postpartum thyroid inflammation, and, as all of you know, there’s a significant incidence of low thyroid state that can occur years afterwards. Absent any other explanation and with the unexplained combination of coma and respiratory failure, I’m not ready to exclude this diagnosis. Moreover, since we have nothing to lose by administering a small dose of thyroid hormone, I’d consider a therapeutic trial.”

  My suggestion produced a great deal of discussion, the tenor of which reflected the differences between the stringent rules required at the university for diagnosis and treatment, the so-called Ivory Tower philosophy, and the more empirical approach, what the elitists at the university called the shoot from the hip philosophy of community physicians
. None of the academicians were happy with a therapeutic trial, but nobody would willingly stand in the way.

  After the meeting, I convinced Dan to administer several small doses of thyroid hormone pending the results of the repeat thyroid function tests.

  Time moves of its own volition, mindless of our urgent need to know.

  When I returned to the waiting room, I described the meeting candidly and told Chuck, “The docs here are great. We don’t have the answer yet, but based on Helen’s office records, we’ve decided to treat Helen with thyroid as if she had low levels of this hormone. We call that hypothyroidism. It’s a long shot. It may not help, but it can’t hurt.”

  We sat together for the next few hours saying little. The nurses allowed us to see Helen several times for a few minutes.

  Chuck stood at her bedside. He watched as the ventilator clicked and whirred, breathing for his wife, forcing air into her lungs and providing oxygen. His sad eyes darted around, grasping for hope while he held her hand and found space amidst all the tubes and lines to place a soft kiss on her lips. It was heartbreaking. I thought of my own work in ICU’s and reflected on the time spent with anxious families in waiting rooms. I realized the enormity of the difference in this experience. Docs often talked about their side of the stethoscope, a distinction I understood more now than ever before.

  By nine-thirty, we needed to leave to get Beth to work on time. Chuck refused to consider the suggestion that, for his own sake and for Helen’s, he needed to take a break from standing his watch at her bedside. “It’s ritualistic, but I can’t conceive of leaving Helen alone here, even for a moment.”