Tobi hugged him tight. “Hush, Benny-baby, it’ll be okay. Funerals aren’t for the dead. Funerals are for the living.”
Chapter 1
Present Day, 2019
The pelting rain brought an early evening, and the flashing blue and red lights reflected off the droplets, brightening the misty twilight in the parking lot, as the EMTs hurriedly pulled the stretcher out of the back of the ambulance. It bounced once on the wet pavement before they steered it into the urgent care office, where the receptionist was holding the door for them.
Inside, Dr. Tobi Lister had just finished putting an IV into her patient. She used the back of her elbow to push aside her dark brown hair, and for a second, hints of gray reflected the fluorescent light. Her face was tense, but she smiled kindly at Barry as she reached up to adjust the oxygen cannula at his nose. His damp hair was stuck to his forehead, and his breathing was rapid and shallow. Tobi’s medical assistant, Esther, glanced at her anxiously and started cleaning up the IV tray.
“You’re going to be fine, try not to worry,” Tobi told him.
“Have you ever seen this before?” Barry’s voice was weak and tremulous. “I thought I just had the flu.”
“You do have the flu, and yes, I have seen this before. Your heart is an organ that can get an infection just like any other.” She had actually only seen it once before outside of the hospital. It was a long, hard road back, but that patient had made it.
“Yes, but it’s my heart. I have two kids at home, and a wife.”
Tobi could not get over how much Barry looked like Reuben. He had the same forehead, and the same beard thing going on. Reuben had been a scuba instructor and underwater photographer as well as a genius with computers, so he had ditched the mustache to be able to make an airtight seal with his face mask, but he had kept the beard, trimmed away from his cheeks. Barry had the same unusual facial hair. She felt the familiar guilt again too. Her own brother, and she hadn’t kept close enough tabs on him. How easy it had been back then to believe they were invincible.
“You’re going to be back home with them soon,” she said.
The paramedic’s wet jacket dripped on the tile floor as he brought the stretcher alongside the “cardiac” room where Barry was lying. That room was designed with a curtain instead of a door and was just behind the providers’ work station, so patients could be observed more carefully. The crash bag, defibrillator, and IV supplies were all stored in there too. “Talk to me,” Jack said.
Tobi pulled him aside and spoke quietly. Since telling Barry he needed to go to the hospital, he had become frightened and short of breath.
“This is Barry, he’s thirty-nine years old, and he came in with classic flu. Three days of fever, cough, and sweats, and his test is positive for Influenza A. He has no cardiac history, but his heart was too rapid and very irregular, so I did an EKG.” She showed the paramedic the tracing.
Jack raised an eyebrow. “Heart rate 217, really? What were his initial vitals?”
“The pulse oximeter read him at 95, which was consistent with his 102-degree fever, but, look—he’s in atrial fibrillation,” Tobi replied. “So far his BP is stable, 126/82.”
Reuben had had a-fib too, she thought, diagnosed when he infarcted his spleen and part of his left kidney. But this is new onset, she told herself, and Barry isn’t going to die. She still wasn’t sure why Reuben had died, since he’d been undergoing treatment for his cardiac disease.
“He came in today because he felt a little lightheaded when he got out of the shower this morning,” Tobi added.
Jack nodded. “Good thing he did. Good pick-up.” He clapped her on the arm. “We’ll get him right over. If they can’t convert his heart rhythm in the Emergency Department with medication—or synchronized cardioversion if he deteriorates—he’ll go straight to the cardiac cath lab and electrophysiology. We’ll take good care of him.”
While they had been speaking, the EMTs had loaded Barry onto their stretcher and transferred his cannula to their own oxygen tank. They hooked him up to leads, and the loud “beep, b-b-beep, b-beep, beep-beep-b-b-b-beep” echoed in the waiting room. As Barry was wheeled toward the door with his jacket tossed over him, he looked back at Tobi in a panic.
“Doctor, I don’t want to die,” he said in a whisper.
She walked over to him. “You’re going to be fine. I’m going to call your wife and tell her to meet you at the hospital.” She squeezed his hand as they wheeled him away. It was soaked in sweat.
Tobi turned her attention back to the busy waiting room, where six or seven people were watching the activity. The energy level was high with a mix of impatience and curiosity, and most were either looking at the wait time or staring at the ambulance personnel. A little girl in a pink ballerina outfit under a pink hooded jacket was wearing Disney boots and twirling between the patients’ chairs, sometimes stepping on their feet, while her mother was too engrossed in her phone to notice. Two more people had just arrived and were waiting to check in.
Two more exam rooms were still full, and Tobi’s mouth was dry. She washed her hands and turned toward the breakroom to grab a soda, when she heard a commotion at the front desk. A middle-aged woman in a black workout outfit and large clanging bracelets with matching earrings was shaking rain off her umbrella and onto Patty at the front desk.
“I just need to get my throat swabbed. It’ll only take a minute, I’m not even feeling sick,” she said. “My son’s friend was over yesterday and the mother just called to tell me he has strep. Can you have someone just do it real quick so I can leave right away?”
The ambulance was lingering at the curbside, and the lights were now blinding in the rainy darkness. They created a strobe effect inside the office, and thunder crackled overhead.
Patty braced her posture, as if she knew what was about to come. “I’m afraid that won’t be possible. We just had an emergency. We still have two patients in rooms, and there are four more waiting to go in who are ahead of you. The wait time is at least an hour.”
“But this is supposed to be urgent care.” The woman spoke very slowly as she pulled off her wet gloves, as if Patty were daft. “That means I should be able to be seen right away.” She took off her rain-soaked jacket and regarded it at arm’s length. “Why did that person even come here?” she nodded at the ambulance. “He should have gone straight to the hospital.” She turned to Patty. “All I need is for you to swab my throat.” She presented Patty with her insurance card and smiled, as if it were a done deal, flashing long pink and gold acrylic nails as she did so.
Patty frowned but took her card. “That’s not how it works, ma’am, I’m sorry. We don’t operate like a lab. We have to get your medical history and do an exam too.”
Patty was in her late forties, mouse-brown hair pulled back in a short pony tail. She was forthright and old-style Italian, not the type to debase herself for entitled people who could not conceive that the needs of others might be greater than their own. In short, she wasn’t really cut out for customer service medicine, but she did the best she could. “They’re not ‘customers,’” she’d say, “they’re patients, and they should behave like patients.”
“Well, that’s ridiculous!” said the woman, but she let Patty sign her in, and then sat on the edge of her seat, tapping her foot restlessly. Then she looked around, pulled up Yelp on her phone, and started writing a nasty review.
Tobi had never liked the layout of her office. The exam rooms were arranged in two half circles on either side of her work station, which allowed for visualization of all of them at once, and each had stylish wood doors, except for the oversized cardiac room, which closed with only a curtain. From this circle, there was a straight path back to x-ray, the stock room, and the break room, and a short, wide hallway leading up front to the reception desk. From her work station, Tobi could pretty much see the entire office. This meant the entire office co
uld also see her.
She turned back toward the break room, trying to shut the woman out of her mind for now. She was still trying to stem her adrenaline rush. If Barry had coded … well, it could have been bad. The last time she had seen such severe myocarditis, or a viral infection of the heart, in the outpatient setting was over twenty years ago, and she had been working with RNs. Together, they had started intravenous cardiac meds when the patient developed heart block, but the patient’s pulse had still dropped to 32 and her blood pressure had plummeted. Miraculously, the patient never actually lost consciousness, and they didn’t have to use the defibrillator paddles or the intubation set, but they had taken them out in preparation. That patient had grabbed Tobi by the arm and commanded her: “Don’t let me die! I have two small children––you can’t let me die!” Tobi had prayed for her every day of the two weeks she spent in the ICU in total organ collapse at New York University Medical Center. The woman had come back with flowers twice over the years to cry on Tobi’s shoulder.
Nurses were too expensive for most medical offices these days, so Tobi had no idea how a full code would have gone here at B. Healthy, LLC—or even what life support training her medical assistant had. Although Esther was exceptionally competent in their day-to-day routine, the angry woman at the front desk had been right about one thing: this was no place for super critical emergencies.
And now I have another “unsatisfied customer,” even before she is seen, Tobi thought. I’m sure I’ll get a zero for her visit, and that will drive down my “scores.” Her review will be counted instead of having saved Barry’s life—since he is unlikely to take a customer satisfaction survey while he is in the cardiac care unit. She quailed. Welcome to 2019, where modern medicine has degenerated into a high school popularity contest.
Jorge met her halfway to the breakroom. He was always upbeat and full of energy, and although he was actually an x-ray technician, he’d do anything to help with patient care except draw blood. Tobi had known him for years and had personally recruited him to work at B. Healthy. She hoped he didn’t regret it now.
“Don’t worry about that crazy lady, Dr. L., we saved a life today. Who cares what she thinks?”
“Umm, corporate?” Tobi grinned. “I just can’t wrap my mind around the things they consider important sometimes.”
Jorge fished a Sprite Zero out of the fridge for her. “They have no clue,” he said. “They don’t work the front lines, they don’t deal with sick people, and their only concern is dollars. But I’ve never known you to care what anybody else thinks, not even in the old days when we both worked for those creeps on the south shore. You always just do what’s right. I respect that, and we all love you for it.”
“Thanks, Jorge. I love you too.” She flashed him a smile. “How’s your new little bambino? How old is he now?”
“He’s a handful, but he’s amazing! He was two months yesterday. I want to be home with him more, but I need to pick up more shifts too. We need the money now; kids are so expensive! And—I’m not getting any sleep at night!” Jorge was grinning from ear to ear as he thought about his newborn.
Tobi chuckled. “It doesn’t get easier anytime soon, I’m afraid, but it’s definitely worth it.”
“Oh, yeah, don’t I know it. The whole world feels different now. I never knew I could love anyone so much.”
As they turned to head back up front, Dr. Ismar Rufini walked in. Tobi’s stomach lurched and tightened as he came straight toward them. He was a swarthy, saturnine, and unscrupulous man in his late thirties, with a stocky build, getting larger as the months wore on. He had been educated in his native Turkey before coming to the States, and he seemed to find capitalism very favorable. He was their regional lead physician, and by far the slimiest person Tobi had ever met. He was barely a mediocre doctor, and for some reason she could not quite put her finger on, he always made her skin crawl. The other regional leads were intelligent, caring, and valued high-quality medicine. She wasn’t sure why her zone had drawn such a short straw.
“Hello, Dr. Rufini,” Jorge said. He gave Tobi a knowing look and quietly slinked back up front.
“Hey, Tobiii,” Ismar drawled in his thick accent. “You look busy.”
“Hey, Ismar, what brings you out on this rainy night?” Tobi tried to sound casual but was feeling self-conscious about the overcrowded waiting room, as if it were her fault.
“Yes, I just stopped by to pick up some flu tests for the south shore,” he said in his sing-song voice. “I see your wait time is, like, over an hour.” Ismar squinted his eyes and peered at her as if she had just committed a crime.
“Hopefully you left us some,” Tobi said. “We’ve been going through them pretty fast.” She ignored his comment about the wait time and took another quick gulp of her Sprite Zero as she started to walk past him to get back to her patients. He had to have seen the ambulance and she didn’t have time to discuss the case with someone who wouldn’t even care. Tobi noticed the strobe lights were no longer illuminating the waiting room, but they were clearly visible through the front windows as the ambulance exited the parking lot to head up the block toward the hospital.
He surprised her by taking an interest. “That patient was cardiac, yes? And young. The young heart patients are expensive ones.” He gave a self-amused laugh, and there was an odd sort of hunger in his eyes. “You know, you are not the primary care doctor here, you don’t have to spend so much time. Just give patients, like, some helpful medicine and discharge them. That is what they want. The patient in room four says he has been waiting a long time.”
Did he really think she should have just given Barry a cough medicine and sent him to his primary care doctor? She did not have the time to discuss standard of care with a half-wit who was supposed to be her boss, so Tobi just stared at him and chose to say nothing rather than something she would regret.
“Okay,” he continued, “so, I’ll let you get back to work. I will be coming with Molly Baker, like, one day next week. Just routine, we go over all the providers’ productivity and, like, their customer satisfaction scores.”
“Sure, Ismar, see you later then.”
Tobi headed back up front, thinking he had lost his mind, and definitely should not be practicing medicine, let alone be a supervisor. How did he ever end up as lead? He must’ve come cheap, since he had very limited experience. Money was always the deciding factor in a place like B. Healthy. Ismar went into the stock room.
Patty looked back at Tobi as she walked up to check on the next patient in the queue, and rolled her eyes, as if to say, “You need this now?” None of them had eaten in at least five hours, and they still had several hours to go, so their endurance was wearing thin. The two patients before Barry had needed nebulizers and one of those, a chest x-ray. This flu was causing a lot of respiratory compromise, even in the immunized, and there were few simple in and out problems today.
Tobi walked into room three to see an elderly couple who had been in a few times in the past. Mrs. Lenman was eighty-two years old, and a few hours ago, had tripped over her rambunctious miniature Chihuahua, while making her famous potato leek soup to bring to Thanksgiving dinner tomorrow. She had caught herself on the counter, and by some miracle, did not fall to the floor, but her right hand was swollen and bruised and some of the thin fragile skin had been scraped off. She had been holding an old beige dish towel against it, which was now sitting on a chuck on the table, soaked with blood. Esther was in the room, cleaning the wound.
“This is terrible,” Mrs. Lenman was saying. “I didn’t finish cooking. It started bleeding, and we came straight here. How can we go to Thanksgiving dinner without the soup? We get invited for the soup, they wouldn’t ask us otherwise, because I always get in the way, just like little Daphne.” She looked up at Tobi as she came in. “She’s my rescue puppy. But she’s so cute, you have to forgive her. Me, I’m just old.”
Esther sh
ook her head and smiled at Tobi. “I told her that was crazy.”
“Oh my gosh, of course they want you there! Soup or no soup,” Tobi said as she grabbed a pair of gloves. “Let’s look at your hand. I saw you’re on Aspirin; that’s why it bled so much. We’re going to x-ray your hand to make sure you didn’t break anything, and we’ll put a special sponge bandage on it called PolyMem, to help it heal. There’s nothing here to stitch, the skin is too fragile. I’m afraid you won’t be able to get it wet for a while.”
“Oh, Harry,” she sobbed, turning to her husband. “What will I do about the soup? We can’t go without the soup!” She looked at Tobi. “It’s my daughter-in-law, she doesn’t like me much, but she lets me come because our grandchildren insist they want my soup. They say her soup isn’t as good as mine. I think they just say that, though, so she’ll ask me. She makes good soup too.”
Tobi completed her debridement of the woman’s hand and gave her a tetanus shot. Why were people so hurtful to each other?
Tobi saw a patient with a urinary tract infection while Jorge took Mrs. Lenman’s x-ray, then she went back in as Esther was finishing dressing the wound.
“Great news,” she told Mrs. Lenman. “Nothing is broken, but I do want to see you back in three days to make sure there is no infection. I’ll bet you’ll have a wonderful Thanksgiving. Remember, you’re not allowed in the kitchen, so you’ll have to sit in the living room and hang out with your grandchildren.”
That put a twinkle in her eye. “I have a new great grandchild on the way, you know! I hope she likes my potato leek soup.”
The Lenmans left, and Tobi unlocked the EMR. It tended to time out frequently, often even while she was using it. If she clicked on a new window, even within the same chart, suddenly, she’d have to sign back in to the whole program all over again. It was a waste of precious time.
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