Suleman was on the schedule to scribe for her, which could cut her documentation time in half. He had made it a point to learn both her and Ellie’s styles and preferences, so he could anticipate how they wanted to chart, and as she told the patients what she was going to prescribe, Suleman would order it. He also entered tetanus shots and documented splinting and laceration procedures. He was a foreign medical school graduate, passing time while he applied to American residency programs, and Tobi had written him a superb recommendation. He wouldn’t be with them for long, but for now, he was a huge blessing as a scribe and made a fifty-patient day much more palatable. Often, however, he ended up working as a medical assistant, because they had none scheduled. This Monday, he had been sent to another office at the last minute because they had no MA, so now Tobi’s office was short-staffed instead.
Around ten o’clock, Tobi walked into a room to see Susan, an overweight thirty-three-year-old with a cough that had been going on for two weeks and was getting worse, with a new low-grade fever that had started two days ago. It was a pretty straight forward visit on the surface and should have been quick, but when Tobi looked at her past history, everything changed.
“Do you have diabetes? The medication record shows you’ve been on insulin in the past but are not currently taking any meds, is that correct? Did you lose weight, and no longer need it?”
“I wish, doctor. No, I just stopped taking everything a few years ago. I had to change to Obamacare, and my doctor wasn’t on that plan. And then, well, I just never got around to getting a new primary. I have no time. I have three children with disabilities who I take care of.”
“But this is so important, Susan. Do you know that if you don’t treat diabetes, you can go blind? Or have kidney failure, and need dialysis? Or develop heart failure?”
Susan sighed heavily. “I know. And I can lose my legs, and all that. I’m just too involved with taking care of my kids. I don’t have time for myself.”
“How old are your kids?”
“Twelve, ten, and seven. My youngest is autistic, and the older ones have learning disabilities. Plus, Matthew has juvenile arthritis, he’s the middle guy. So, I’m constantly doing what I need to take care of them. They have to come first. That’s just how it is with mothers. Do you have children?”
“Yes, I do,” Tobi said. “And I know that we women in general tend to put ourselves last on the list when it comes to our families’ needs. It’s like we’re encoded that way. But if you fall apart, who will take care of your children? Taking care of yourself is taking care of your kids.”
Susan sighed again. She looked completely exhausted, and her respiratory infection wasn’t helping.
“I’m going to give you some clarithromycin, an inhaler, and a cough medicine; you’re wheezing a tiny bit. Would it be okay if we also check your glucose before you go? And I’d like to look at your feet too. Do you check your feet every night?”
“Okay, you can check my sugar. I know I’m supposed to look for infections in my feet, but I don’t take the time,” she said, as she started taking off her shoes and socks. “And seriously, it’s not easy to find an endocrinologist on Long Island, especially one that takes Obamacare, and the truth is, those medicines they put me on gave me terrible side effects. I couldn’t take them. The doctor must’ve tried four or five. That’s why she put me on insulin, but then I got skin reactions to the shots. So … I just stopped going.”
Marta went in to check Susan’s glucose, while Tobi documented in the chart. “Blood sugar is 211, Dr. Lister, but she says she just had a big breakfast.”
Tobi went back in with Susan’s discharge papers and told her how high her sugar was. “Don’t give up, Susan. There are new medications out there now, maybe they will work out better for you. And try to cut your carbs in half and avoid really sweet things, that’ll help some. We know where this road you’re on will lead, and I don’t want you to have to deal with the complications of untreated diabetes. They’re often not reversible and are much worse than the medication side effects.”
“Okay. Thanks, doc. And I’ll look for an endocrinologist on my plan.”
Marta came over after Susan left. “She sounds like she’s given up. I feel sorry for her,” she said.
“I know,” Tobi answered. “She’s obviously just trying to get by. I wonder, do humans really have it easier than we did a couple of centuries ago? We don’t have to hunt our own food or build our own houses anymore, but we still have to find a way to pay for them. We’ve just substituted one struggle for another, and we live in a culture that only puts a value on helping people if money can be made off them.
“It’s true,” Marta said. “A lot of the new medications that have fewer side effects are probably not even covered on her insurance. We had a patient in last week who said all his meds had to be changed when he switched insurance because the old ones weren’t covered, and he had insurance through his job. He said it had taken his cardiologist a year to get him settled on medicine that controlled his blood pressure and didn’t make him feel sick, and now he has to start all over again. His pressure was, like, 160/90.”
“Well, some blood pressure medications aren’t available right now because of contamination with a carcinogen. If it was an ARB—”
“No, Dr. L, it wasn’t one of those. He was so happy that his medicine wasn’t in that category, but they still had to change it, because it just wasn’t covered anymore.”
Tobi shook her head. “What’s happened to our country? We don’t take care of our own people anymore.”
Chapter 23
Troy felt the blood rush to his face. How long had he known Robain Sacks? He had lived his life always trying to be honest, but if he answered the inspector truthfully, he’d never get out of there, and Tobi might be in trouble. But if he lied and they caught him, he’d be there even longer.
The hesitation showed on his face, and he knew he’d given himself away. There was no reason not to trust the Australian police, except that Reuben’s paranoia had been contagious. Troy’s first concern was Tobi, and he felt in his gut that she was in trouble now. Perhaps Bent could help him find out who this assassin was. Whether or not she hated Troy, he owed it to her to warn her, at the very least.
Bent was still waiting for an answer.
“I think you haven’t been completely honest with me, Mr. DeJacob,” the inspector said.
“No, sir, that’s not true. Everything I told you is the truth.”
“Well then, there is more to the story than you have let on. I think you know who killed Marcus. Let’s have it, mate.”
“Inspector, I swear to you, I have no idea who killed Marcus. I wish I did, he was a friend of mine too.” Troy exhaled deeply. Between grief, shock, packing, and sixteen hours of jet lag, he was worn out. He hadn’t been able to sleep the last couple of nights, either.
“Well, then, you know something about Robain Sacks, or whoever he was, that no one else does. He doesn’t seem to have a history before he came here in 2002, but I hear he was a real decent type. Good to people, caring, part of our community. It sounded at first like his death was an accident, but now with all this ….” Bent’s hands swept the room. “He’s a dead man without a past, and that don’t fly by me. And now two more people are dead. Good people. Is there a connection between his death and Marcus’s?”
“I have no idea. I only heard about his death from Marcus,”
Troy said.
Bent nodded. “But you know something about who he was before he came here. We can’t find a thing on Robain Sacks. It’s like he didn’t exist until he come to Port Douglas seventeen years ago. How long have you known him?”
Troy suddenly gave in. He felt exhausted and alone, and he needed help to figure out who this Russian guy was before he got to Tobi.
“Inspector … I will help you all I can, but I would ask a favor from you ….”
>
Bent scowled at him. “I don’t make deals like that, Mr. DeJacob.”
“No, no, I don’t mean it the way you think. My rush to get out of here … it’s because I believe someone I love is in danger. I need to protect her. I will tell you everything, it doesn’t matter anymore. But I would like to know what you find. She is in the United States, and she is Robain’s sister. For some reason, this killer offered to help Marcus find Robain’s family, so I’m worried that she could be his next target. I need to get to her first, she has no idea––”
“You’re talking riddles, mate. Why don’t you just start from the beginning. You want some coffee?”
“Sure.” Troy hadn’t had coffee in years, but he needed something to help him get through this nightmare.
Bent turned around and poured him a cup of Jaques. Then he pulled out a notebook and a pen, old school, and looked at Troy expectantly.
Troy took a deep breath and sighed. “Robain’s given name was Reuben Sokowsky ….”
Chapter 24
Mrs. Waletski was in room five. She and her family were frequent flyers, and she came to the office several times a month, either with one of her three children, or for herself. The nurse at her son’s school had called home at 11:30 a.m. to have nine-year-old Dennis picked up because he had a tummy ache and was feeling dizzy, so she brought him straight over. When she arrived at the front desk, there were two people signing in ahead of her, and she announced that she had to be out of the office in forty-five minutes. Connor told her that was unlikely, since there were other patients already in the back and it could be forty-five minutes before she was even seen. She signed in anyway, complaining loudly about the wait time.
Tobi walked into the Waletski’s exam room just about forty minutes later, and had a hard time reconciling the hostile person she’d heard signing in at the front desk with this friendly, familiar patient. Mrs. Waletski looked up and smiled and said, “I’m so glad you are on today.” Dennis was bouncing up and down on the exam table playing his video game.
After exchanging the usual pleasantries with Mrs. Waletski, Tobi turned to Dennis. He said he wasn’t dizzy at all and his tummy didn’t hurt anymore. He denied having any nausea, vomiting, or diarrhea, and he had no fever. Tobi checked him from head to toe and found he had a completely normal exam. He even asked Mom what was for lunch.
“He seems to be better,” Tobi said. “I don’t find anything wrong right now.”
“You know,” Mrs. Waletski said as she eyed her son, “we went to a friend’s house for a party last night. There was a ton of food, and I think he ate way more than I usually let him, including desserts and things. Could that be it? He does look pretty okay now.”
“Could be,” Tobi answered. “Just have him eat lightly today and watch him. Let me or his primary doctor know if anything changes. Shall we fax these notes to his pediatrician for his records?”
“You know,” Mrs. Waletski said, “I called the pediatrician for an appointment today, and—can you believe it? They couldn’t get him in until three o’clock!”
Tobi left the exam room shaking her head in disbelief. She went back to her tablet to find the EMR had timed her out again, and as she signed back in, Ismar walked into the office with Molly Baker. They were smiling, as if enjoying a private joke. Ismar stopped to look over Tobi’s shoulder as she was charting Dennis’s visit. He smelled sour from sweat and garlic.
“Come talk to us in the back when you have a minute,” he said.
Tobi gave him a cheerful, “Sure thing,” but inside she felt the acid bubbling in her stomach. The EMR continued freezing intermittently, and it took her a while to complete the chart. It was almost like it didn’t want her to go back there, either.
“Hi,” she said as she entered the break room. “To what do I owe the pleasure?”
Molly gave her a bright smile. “How are you, Dr. Lister? I haven’t been out here in a long time. This office has certainly gotten busy!”
Tobi would have preferred to use these few moments to eat something, but although her lunch was three feet away in the fridge, she didn’t think she could swallow any of it.
“Yes, it has. We’ve missed you. Did you guys just come to visit?”
Back in the early days of B. Healthy, the leadership had actually done that. They’d stop in and tell the staff what a great job they were doing, and what their latest gimmick was. All that had stopped about twelve months ago, when the company had tripled the number of sites they opened, and each office picked up volume. Now everything was about maintaining the numbers.
Molly started. “Actually, we came to see how you are doing. Dr. Rufini has noticed your performance has been slipping, and there have been a few complaints.”
“Yes, your door-to-door times are up and your Press Ganey scores are down,” Ismar said. “And a patient from last week wrote a bad review on Yelp because the wait was too long. She said she didn’t even get to be seen. She was told it would be over an hour, just for a simple strep test. You know, those reviews are very bad for business. They can reach thousands of customers and discourage people from coming to our offices. We wanted to check on you and see if maybe you aren’t feeling comfortable here.”
Tobi hated that she let these people rattle her, but she forced herself to look at Molly. “I think I know the person you are referring to. We were having a very busy day and she walked in just as we were sending a very sick patient out to the hospital with new onset a-fib. I did a call back on him, and the family told me he actually coded in the ED. Thankfully, he was cardioverted and is doing much better now. He did take precedence over several other patients—I’m just glad he didn’t code here. We’re not really equipped to handle that. You were in the office that day, Ismar. You saw him go out by EMS.”
“Yes, yes, and I told you the patients were getting restless.”
Tobi stared at him. “Are you telling me I should have left a critical patient to see someone who didn’t even have a sore throat, but just an exposure to strep?”
Molly broke in. “No, Dr. Lister, of course you need to take care of a sick patient like that first, but bad reviews hurt our reputation. We have to keep customers happy so they don’t write things like that.”
Ismar looked unconvinced. “We also have a complaint from another patient that same day. She said she waited a very long time and did not get her Z-Pak, and her visit was a waste of money.”
Tobi took a moment before she answered. She sorely wished Ellie were here with her, but she resolved not to let them bait her. “Have you read up on the CDC recommendations for the use of antibiotics recently?” she asked as evenly as she could muster.
“Your overall times are high, Dr. Lister, and that is why we are here,” Molly said, diverting the conversation from something Ismar might lose.
“Well, charting takes a lot longer these days,” Tobi said. “There are about six extra fields we’re told to fill out and some of our patients resent our asking these additional questions. We’re now trying to do a primary care function in the time frame of an urgent care visit.”
“Those questions are required by the insurance companies in order to collect the contracted fees we agreed upon,” Molly said.
“That’s fine,” Tobi said, “but it does slow us down. And the office is often not staffed to par, and some visits require a more thorough evaluation. People come in with a wide range of problems, from the sniffles to a heart attack. You know, faster is not always better, not if you want to take proper care of the patient.”
“Yes, but what about the other patients, hmm?” Ismar persisted. “They do not have a good experience if they have to wait, and many times they, like, leave and don’t get taken care of.”
“Well, then perhaps those people weren’t that sick in the first place,” Tobi was getting exasperated, despite wanting desperately to keep her cool. She wondered if Ismar had heard a
word she’d just said. “I think it’s important to take care of the staff as well and give us backing and not just criticism. We’ve gotten much busier, but we have not gotten any added support. I don’t think we’ve been consistently staffed in weeks. What it says on the schedule is often not who is actually working in the office, and if you look on the schedule for this month, there are a large number of unfilled slots. Even today, Suleman is scheduled, but he was called away to cover another office.”
“Why are you looking at the schedule?” Ismar asked. He had taken out his laptop. “It’s not something you should be looking at, anyway. Like, here are the average times patients are spending in the office over the last month. It’s getting longer and longer. That’s not good for business. So, Tobi, that is what we want to know. Like, to see if you are happy here.”
Is he asking me to quit? Tobi wondered. Damn, Ellie would have been much better at arguing their defense. Tobi twisted a little, trying to view what was on his screen and tardily realized she had not been meant to see any of it. “Yes, that’s what happens when you have more patients and less staff. It takes longer to see everyone.”
Tobi knew Ismar did not have the authority to fire her. She wasn’t sure about Molly, but she thought she would have gotten a call from Steve Chagall if she were in that kind of trouble.
“How is Dr. Meloncamp doing? Is he going to make a full recovery?” she asked, pointedly trying to illustrate their complete lack of sensitivity.
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