Code Blue

by Debra E Blaine

  She put in the details of the procedure, indicating the wound had been cleaned, debrided, and dressed with a PolyMem bandage, and she added the charge to the billing page. Then she opened the box that said, “right hand x-ray” and recorded her reading, specifying in the redundant but necessary manner “three views of R hand,” and typed “no fracture or dislocation, moderate degenerative joint disease.” She documented the neurosensory exam she had performed and then described the injury precisely. Then she grabbed the empty tetanus syringe to record the lot number, expiration date, and where she had given the injection. Next, as instructed by the billing auditor, she chose the most specific diagnosis she could find in the long list of ICD-10 codes, so the maximum bill could be sent.

  Each part was on a different screen, and each screen had to refresh, so notation took several minutes to complete—and that was with the EMR running at its usual painstaking speed. When it was sluggish, it could easily take twice the time. But if she did not do it correctly, she’d get persistent emails from billing telling her she needed to unlock the chart at a later date and adjust the documentation, and she hated to do that. If a chart ever went to court, the lawyers would be able to see that she had modified it after the original visit, and that could potentially discredit her. She’d been taught over the years to treat every chart as a potential court document. You never knew.

  Jorge had just turned over another exam room, and Esther had finished cleaning and spraying down the cardiac room. She was already triaging the next patients.

  Tobi saw two quick sore throats, and a shingles patient named Antonio. He was there with his daughter Amelia, who was a regular patient of hers. Despite the bothersome shingles, they were very excited about their good news. Antonio’s kidneys had shut down about five years ago, but he had just gotten onto the kidney donor list. Tobi allowed herself an extra sixty seconds to warmly congratulate him and wish him luck. He was a relatively young guy and a sweetheart and he deserved a chance to escape dialysis for the rest of his life.

  For a bit, it looked like she might actually catch up, although the longer times still showed in red on her spread sheet. There was nothing she could do about that. She completed Antonio’s chart, noting his renal failure and new kidney donor status. It helped her to remember her patients’ stories so she could ask about them the next time she saw them, and it made her job feel more personal and satisfying. Corporate might have frowned about the extra time it took to write those additional notes, as they preferred the turnover be as fast as possible, but they also expected her to be friendly and appear unrushed so the patients would want to come back. It was a no-win scenario. As she glanced through the next chart, she overheard Jorge down the hall, standing at the scale next to a mother and her little girl.

  “Just step up here, little lady, we need to see how much you’ve grown.”

  “No!” The little girl stamped her foot and grabbed her mother’s leg. “You can’t make me!”

  Jorge looked at the mother. “We need her weight in case the doctor wants to prescribe any medicine,” he said.

  Mom looked down. “Please, Jilly? Do what the nice man says.”

  “No! I don’t want to!” She clutched tighter at her mother’s leg and glared at Jorge.

  Mom shrugged her shoulders and looked at Jorge. “She doesn’t want to.”

  Jorge looked exasperated. “It doesn’t hurt, Jillian, see? Look, I’ll step on it first. All you have to do is stand here for a few seconds.” Jorge demonstrated, and looked again to the mother for support.

  At that point, Jillian, who looked to be about five years old, started screaming and stamping her feet, and buried her head in her mother’s leg. Tobi shuddered and went in to see the next patient, a simple ear infection after a diving vacation in the Caribbean.

  The visit took less than five minutes, but when she came out, the waiting room looked even more crowded than before, and Ismar’s visage hung in the air. Tobi did her best to record everything in the EMR quickly, but it kept stalling on her, especially when she tried to send prescriptions. She would get the little spinning circle, which she called the “blue circle of death.” If she became impatient and clicked again, the whole screen would fade, and the program threatened to shut itself down, so she just had to wait it out. She didn’t have time for this today. She had already spent a half hour with just Barry in an office where she was expected to see forty-five patients a day by herself. At least Ismar was nowhere to be seen.

  She walked into Jillian’s room next. The little girl was sitting on the exam table, plastered against her mother who stood beside her. Tobi noted that vital signs were miraculously in the chart, including a normal temperature, and the weight read forty-seven pounds, or twenty-one kilos. She didn’t even want to know if that was today’s weight.

  “Hi, Jillian, I’m Dr. Lister. Those are cool boots. Is Frozen your favorite movie?”

  Jillian pouted but nodded slightly.

  Tobi looked at the mother. “Are you Jillian’s mom?”

  “Yes, I am. Jilly felt a little warm today, so I brought her in. She’s also had a stuffy nose for a couple of days.”

  “Did you happen to take her temperature?”

  Mom shook her head and smiled. “She doesn’t like thermometers.”

  “Okay, any other symptoms? Has she been coughing or complaining of a sore throat? Is her appetite normal? Or has she been cranky or clingy recently? Sometimes kids get like that when they’re sick.”

  “Nope, just her usual adorable self,” the mother smiled again. Jillian was quiet, but she kept her eyes riveted on Tobi as they spoke, and Tobi felt their daggers. She would hate to see this child when she was cranky.

  Tobi picked up her stethoscope and addressed Jillian in her most reassuring voice. “I’m just going to listen to your lungs, sweetie, like this.” She placed the end of the stethoscope on her own arm, then on Jillian’s arm. “I’m going to put it on your back now and I want you to take deep breaths.”

  Jillian held her breath and jerked about, but Tobi held her gently but firmly by the shoulder. “See? That’s all. It doesn’t hurt. Can you take a big breath for me?”

  Eventually, Jillian had to breathe, but she sure wasn’t making it easy. Tobi managed to auscultate her lungs and then her heart. She pressed gently on her tummy while Jillian squirmed, but she displayed no additional discomfort and did not push Tobi’s hand away. Looking in her ears was equally tricky, but the real trouble was looking at her throat.

  “Would you open your mouth for me? I have nothing but a light, see? No sticks. I’m not going to put anything inside your mouth.”

  “No!” Jillian pressed her lips together tightly and covered her mouth with both hands.

  Tobi wondered if this child ever said yes to anything.

  Tobi looked at the mother, who made no move to help or take the child’s hands away. “I need your help with this,” she told her.

  “Jilly, we can go for ice-cream if you open your mouth,” her mom said.

  “No! You always promise, but we never do!” she said from behind her hands.

  Tobi hated to reward bad behavior with treats, but she was feeling desperate. “We have lollipops and potato chips. You can have either one if you help us take care of you today—if mom is okay with that. I just want to look.” She glanced at the mother, who had squatted down on the floor to plead with her daughter.

  Suddenly, Jillian turned her back to her mother, looked straight at Tobi and opened her mouth wide. No tears, no fuss. Her throat was irritated, but not swollen and no exudate.

  “You did great!” Tobi told her. “You get to choose which snack you want.” She turned to the mother. “She has some minor irritation, but no swelling or pus. It looks viral to me.”

  “So, you’ll give her an antibiotic?”

  “I wouldn’t treat her with antibiotics, I don’t think they will do anythi
ng for her. Not unless she had a positive strep,” Tobi said. “But her throat doesn’t look excessively red, I think it would be negative.”

  The mother frowned. “Jilly, do you think you could let them take a throat culture?” She looked so doubtful, it would have been a miracle if the child had agreed.

  “Nooooo!”

  At that point, Tobi was done. The child was not seriously ill, was afebrile in the office, and she felt like her job was over.

  “I think she will do well with fluids and Tylenol and you can take her to her pediatrician if she is not improving,” she told the mother.

  “Can’t we just try?” She turned to Jillian. “Please baby?”

  After another resounding “No!” they headed up to the front. Tobi wrote up the rest of the chart and was printing instructions when they came back with Jillian trailing her mother by the hand and whimpering.

  “Doctor, she says she’ll let you do it. I’d rather know.”

  Tobi turned to Jillian, trying to erase the picture of The Exorcist from her mind. “Okay, sweetie, but we will only try once, okay?”

  Jillian hiccupped and nodded. Esther went into the room with them while Tobi went to collect the lollipop she had promised and Jillian’s printed discharge instructions. Esther was back after a short minute. “It’s not happening, Dr. L., not unless you want me to hold her down. But her mother won’t touch her, so ….”

  “No, Esther, you’re right. Mom has to participate, otherwise we’ll be in trouble.”

  She walked back to her work station and found that her tablet had restarted itself. In fact, it didn’t seem like the same tablet, but she hadn’t looked carefully beforehand to see which one she was using, and they all looked the same except for the numbers on the back. Now she was losing her mind. It was true that any of the tablets could restart themselves at any time, even while she was using them. Tobi often blamed it on “office gremlins,” since there seemed to be no rhyme or reason to it, but something felt weirder about it this time. She looked at the bookmark bar—no, it was definitely a different tablet. Now what was that about?

  Tobi was exhausted. She felt like she should care about this but was just too tired. Twelve hour shifts seemed to get harder and harder, even though she should have been used to them by now. Maybe I’m just getting older, she thought. She downed the rest of her Sprite Zero and dreamed for a split second of the untouched turkey sandwich she had in the fridge before heading into the next room.

  By 7:30 p.m., Esther had the last three patients in rooms, all stuffy noses without fever for less than two days. Those visits were such a waste of resources, both time and money. When she was a kid, no one had gone to the doctor for a stuffy nose, but these days, people piled in, complaining about the wait time and their $30 copays, while the insurance companies forked over the same reimbursement for each visit, regardless of whether it was a concussion or a sniffle—if it was billed properly—and B. Healthy made sure of that. These spurious visits were the only context in which she understood the rising costs of insurance premiums and decreasing benefits.

  It was even more frustrating when the very sick patients needed imaging or expensive procedures and were not able to get authorization for them or had huge out-of-pocket expenses. It was as if they got stuck paying the price for all these unnecessary office visits.

  Mrs. Perrin was the last patient. She was wearing a sleek charcoal-gray dress and three-inch heels and had just applied fresh bright red lipstick. Despite the rain, her hair was perfectly coiffed to show off heavy sapphire earrings and a matching sapphire pendant. She said she’d had a runny nose and a post nasal drip that had woken her up last night, and it hadn’t gone away all day. She had no fever or muscle aches, no fatigue, except for not getting a good night’s sleep, and no cough, wheezing or trouble breathing, but she did have a slightly scratchy throat. “I suffer from sinuses,” she said. “I need a Z-Pak, it’s the only thing that works for me.”

  It was always such a challenge to practice responsible medicine with patients like Mrs. Perrin, especially when providers were being encouraged by corporate to be people pleasers. Tobi told her that without fever or other systemic symptoms, this was a cold, which was a viral infection, and colds can make a person feel uncomfortable for up to a week. It happened to be in her sinuses, so yes, technically, it was a sinus infection, but not a bacterial one that would respond to an antibiotic like azithromycin. Viruses were not affected by antibiotics at all, because they were too small, and they lived inside the cells where the antibiotics couldn’t get to them.

  Mrs. Perrin looked at the doctor as if she were an ignorant child, and told her she knew her own body, and she needed her Z-Pak.

  Tobi sighed, thinking it would be so much easier to give her whatever she wanted so they could all just go home. She wondered if she should try to explain that the inappropriate use of antibiotics for viral infections was causing massive resistance across the globe, and that in some areas, people were dying from simple infections that were once easily treated. Antibiotic research was barely able to stay ahead of the mutating bugs, which led to “super bugs,” like “flesh-eating bacteria” and MRSA (she saw several cases a month), and it was even getting harder to treat something as basic as gonorrhea.

  Then there was the risk of getting overgrowth of another gut bacteria, called Clostridium difficile, which could happen when taking any antibiotic, and the more frequently taken, the greater the risk. That kind of intestinal infection sometimes caused so much damage, it would require the patient to have part of their colon resected. Then they had to live with a bag tied to their abdomen, instead of using their rectum to poop the normal way. It wasn’t a pretty sight, but even then, many people still didn’t get it.

  She felt Ismar in her head like a specter, telling her to just give the patient the Z-Pak and keep her happy. Instead, Tobi said, “We have learned we need to use antibiotics more responsibly than we have in the past. There are too many resistant organisms now, and we know for sure that colds are caused by viruses, and that an antibiotic has no effect on them. I’d like to give you some medicine to help you feel better, which is really what you want, right?”

  “You don’t understand. I don’t have time to be sick right now, I have too much to do.”

  In her nearly thirty years practicing medicine, Tobi had never heard anyone tell her “now” was a “good” time to be sick. She plodded on.

  “I’m going to prescribe a nasal spray to dry up your nose. You can also take a decongestant, like Allegra D, and you should drink a lot of fluids to support your immune system. These will make you feel better until the cold passes.”

  Mrs. Perrin stormed out of the office. So much for doing the right thing, Tobi thought, and now I have another bad review for the day. More ammunition for Rufini to yell at me, and Mrs. Perrin will probably find another doctor tomorrow to give her a Z-Pak anyway, just to shut her up. The ISIS extremists may not prevail after all, but the bacteria will get us all in the end. And the insurance premiums will continue to rise.

  Chapter 2

  Ismar Rufini sat in his study in his mansion on Centre Island, a room his wife was forbidden to enter. Downstairs he smelled the after aroma of dinner and what was supposed to be zaatar spiced lamb with couscous. Jennie had tried to read up on his native recipes, but she just didn’t have the right flare. You had to be born into it, he supposed. She made up for her cooking shortfalls with her seductive, exotic silver-blonde hair that flowed back over her shoulders, but he cringed to see her go out in public like that and was glad no daughter of his was growing up in this country. He had even told Jennie they were not having any children unless they could be sure to have only boys.

  He thought his wife was being quite unreasonable. Now that they were married, she should be appropriately modest. It wasn’t like he would have insisted she wear a burka, which would cover her entire face, so what was her problem? He considered
himself to be fairly liberal. He frowned and opened the little locked box in the bottom of his drawer and took out the faded photo. The woman in it was wearing a hijab, so her face was quite visible. High cheekbones and dark eyes under pronounced brows looked straight at the camera, so wherever he moved, the eyes looked right at him. Like an accusation. He tried to ignore the fleeting feeling of guilt as he gazed at her and the two small children by her side and then he put the picture away. Why did he torture himself like this? At least he knew they were safe.

  His life here in America was far more lucrative than it had been in Turkey, and he turned his attention to the present. He smacked his lips and looked at his harvest for the day. Out of the three offices he visited, he had four potential clients for the Project. Lister’s cardiac patient with the new onset a-fib might not be viable, unless there was so much viral damage to the heart muscle that he needed a transplant. It was more likely he would make a full recovery, unless he died, of course, but he was worth watching at any rate. He made a note of the hospital Barry had been transferred to and would check on him in a week. Perhaps Barry could be convinced he was at grave risk of a relapse and could be signed up anyway. Now that was a novel idea Ismar could suggest. The others he’d found would definitely bring him a pretty little lira. Lister was very good at writing notes; the program might not have otherwise flagged the shingles patient just accepted onto the kidney donor list. Perfect.

  The software made it so easy. All he had to do was attach the flash drive to the tablet and tell it to run the RKS program, and––voila! It recorded all the pertinent findings right onto the drive, leaving the EMR program untouched. He could detach the flash drive from the USB port and be gone without even leaving a footprint––unless someone with real computer savvy checked the history of the hard drive. If he were ever found out, though, he’d be screwed for sure.

  He compressed the files, encrypted them, and sent them off on the secure server he’d been given before he stuffed another piece of baklava into his mouth. He smiled and licked the honey off his fingers.