Code Blue

by Debra E Blaine

  At noon, Tobi walked into room four, another person with flu-like symptoms.

  John was sitting on the table, looking slightly agitated. His nose was red and dripping and he had a fever of 101.6.

  “Do I have to have that flu test thing? I don’t like things stuck up my nose.”

  “That’s okay,” Tobi said. “My name is Dr. Lister. We can do without it. They’re not always accurate anyway.”

  “Oh, thank God. I’m sorry, I don’t mean to be difficult. I just had a bad experience once.”

  “It’s no problem. Tell me how you’re feeling.”

  “Okay, so I’ve had fever of 102 for three days now, my sinuses are all stuffed, and I have a headache; I ache everywhere and all I want to do is sleep, but I started coughing last night and couldn’t manage to rest at all.”

  “Certainly sounds like you have the flu. Has it definitely been three days?”

  “Yes it started day before Christmas Eve, so … wait, it’s been four days. Why?”

  Tobi shook her head sympathetically. “The Tamiflu only works in the first forty-eight hours. I can still give you some other medication to help you feel better.”

  “That’s okay,” John said. “I’ve heard bad things about that flu medicine, I don’t think I’d want to take it anyway. I just wanted to know if you think I have the flu—without using that swab in my nose.”

  Tobi nodded. “Yes, you have the flu, like half of Long Island right now.”

  Tobi looked at his medications. “Let me just get your history verified and see how I can help you. It says you’re on levothyroxine and oxycodone. The levothyroxine is for your thyroid, right? What do you take the oxycodone for?”

  “I don’t take oxycodone. Never have. Why, does it say that? I didn’t tell her that.”

  “Hmm … sometimes the meds come over through the program as something you’ve had in the past. Maybe you’re no longer on it?”

  “No, never took it. That’s a narcotic, isn’t it? Can you take it off?”

  “Let me just check something ….” Tobi looked John up in the New York State Prescription Monitoring Program and he did not appear. She checked ten other states, as well, and still, no John.

  “That is a controlled substance, so I’ve just cross-checked it, and no, I don’t see your name. We’re starting a partnering process with Hospitals for Health, and it looks like our program picked it up through them. Have you seen a doctor in that system?”

  John started sneezing. “Yeah, my endocrine doctor is in Hospitals for Health.”

  “That must be where it came from, then,” Tobi said. I’ve taken it out of our records here, but I can’t take it out of the system. As far as I know, only the office that entered it can do that. When you’re feeling better, you should give their office a call and talk to them about it.”

  John was upset. “That’s not right. What if you hadn’t asked me? How long has it been there? I could have been labeled a drug addict.”

  “We wouldn’t label you an addict if it’s a legitimate prescription for a legitimate problem, but I do understand your concern. I will bring it up with our IT department, but I think the problem is on the end of the office that misentered your data. That would be human error. Unfortunately with digital everything these days, one mistake has a ripple effect now.”

  “Yeah. And those records go with me everywhere, right?”

  “I think you can opt out of the sharing process. I’m sorry this happened, but I’m glad we discovered it so you can get it fixed.”

  “Yeah, great,” John said. “Just what I need to be doing right now.”

  Tobi verified the rest of his history and allergies and found no other mistakes. She sent over a nasal spray and a cough medicine and gave him a note for work, and John left. She was sure his resentment would translate to a zero Press Ganey score that would be assigned to her, even though all she did was point out a preexisting problem that needed correcting.

  There was, of course, the larger problem. Narcotics could be tracked easily in many states, but what if other medications or allergies were entered incorrectly, or medical history was either omitted or entered improperly? And if that patient arrived in the ED and the attending went by an erroneous account of the patient’s medical problems and medications, theoretically, someone could get hurt.

  Tobi finished documenting in the chart. She needed to input at least two positive or negative signs in at least five systems for the maximum appropriate bill to be sent for this diagnosis so that B. Healthy would get paid. Under ENT, she wrote “nasal congestion and sore throat” and under respiratory, she entered “cough, no wheezing” and continued on for the other physiological systems. She detailed the medication issue in separate notes at the bottom of the chart as Esther came in to clean the room.

  “Esther, were John’s meds already in the chart when you triaged him?”

  “No, Dr. L., but they tell us to do it like this now …” she showed her on the tablet. “If you click here, it pulls over all the medication history. A lot of times, the patient’s don’t remember the names of their medicines, so this helps us out. It’s in the new workflow they sent us.”

  “Yes, I see how that can help a lot. Unfortunately, this last guy had meds in there that didn’t belong to him. It’s always a good idea to verify everything verbally with the patient.”

  “I didn’t put it there, though, it just popped up.”

  “I understand that. Someone in another office, probably his endocrinologist, made the mistake, and now it’s being carried over. I took it out for us, but it’s in the system, so the next time someone uses this workflow, it will pop back in again unless the original office takes it out. Just try to remember to go over everything you see with the patient. The program isn’t always right. Pass that along too.”

  “Sure, Dr. L.”

  At one o’clock, Tobi went into room five to see forty-seven-year-old Patricia. She was there for a urinary tract infection, but when Tobi asked about her medical history, she revealed that she’d been getting severe, debilitating headaches. They used to be worse with her cycle, but after she went into early menopause, she had expected them to improve. After eight months, she was still waiting. She had been to four neurologists, and had had an MRI, EEG, and a lumbar puncture, but no one could identify why she was in pain. They offered her a myriad of medications and were now suggesting spinal cord injections.

  “All they want to do is throw drugs at me,” Patricia said, “but I’ve read the side effects. They cause weight gain and I already have a family history of diabetes. And then blurry vision, dizziness, jerky movements? Like, really? Oh, and headaches. That’s crazy, I don’t want to chance it. And why would I take them, when no one even knows why this is happening? I’ve tried changing my diet drastically. I’ve gone gluten free, lactose free, paleo, then vegetarian, vegan, fat free, carb free—I started magnesium, selenium, chromium, and glucosamine chondroitin. I even completely eliminated artificial sweeteners and stopped drinking alcohol and caffeine. I’ve sacrificed all my pleasures, and nothing seems to work. It’s getting to me!”

  Tobi’s heart went out to her. “I assume you had your vision checked. Have you ever tried meditation or acupuncture?”

  Tobi didn’t bring this up very often. One, because time did not usually allow, and two, because most people wanted their quick fix pill and did not want to put much effort into their recovery. Patricia was obviously not that person.

  “I’ve been considering that. I’m glad not all physicians are against such things.”

  “I think you should try. It won’t hurt you, and you never know.”

  Patricia said, “You know, none of the neurologists ever spend more than fifteen minutes with me anymore. I wait two hours for my appointment, and I feel like they barely even listen. I’m in pain and I’m frightened because I don’t understand why, and they barely
look at me—they just look at those tablets.” She waved at the iPad. “Doesn’t anybody care anymore?”

  “They do care, or they want to,” Tobi sighed. “They’re just pressured. Too many patients, not enough time. People complain about the wait, and most just want the quick fix pill they offered you.”

  “Why do they schedule so many people, then?”

  “They try to take care of everyone who needs help, but it’s also not entirely up to them these days. It’s become almost impossible to have a private practice, so they have to kowtow to whichever corporate they signed on with, and those corporations want to see volume. I’m sure your neurologist would rather be able to spend more time evaluating patients like yourself and less time writing prescription refills.”

  “Why can’t doctors work for themselves anymore, and make their own rules?” Patricia asked.

  “Because the insurance companies don’t give the same reimbursement to all doctors, even for the exact same service, and individual providers receive a fraction of what corporations get paid. I’m literally talking four to five times less. If you’re part of a large pool—and by ‘large,’ I mean over thirty, and the larger the better—physicians can negotiate a higher rate of compensation. The more patients your doctor’s group has on the plan, the more the insurance company will reimburse. That also makes us fertile ground for entrepreneurs to step in and manage these huge composites of physicians. Most of us hate it, but the lone providers get screwed, and the majority have been forced to buy in or retire.”

  “That’s absurd. Feels like us individuals aren’t important anymore, are we? Except as numbers.”

  Tobi raised her eyebrows and nodded. “Our whole culture has become like that, right? Everything is about volume, not quality, form, not content. American medicine is just a microcosm of American values, which are all about how you look, and not about who you are.”

  “But you’d think some things would be sacred, no? Like, seeing your doctor when you’re sick, and being able to expect them to talk to you? I pay a fortune for my health insurance, but it doesn’t get me time with my doctor. You’ve spent more time with me today than I got at my last neurology appointment.”

  Tobi flinched. She wasn’t supposed to spend this much time with her, either. She raised her hands helplessly. “Medicine has become a profit-driven industry, where the prime objective is to maximize revenue like any other material commerce. We get reviewed the way you’d rate your experience buying a car, or an Apple TV, but those reviews often have nothing at all to do with whether we are making people well. Did you know that Medicare adjusts its payments to hospitals based on the Press Ganey customer satisfaction scores? If the scores are low, the payments are reduced.”

  “I had no idea!”

  “Most people don’t,” Tobi said. “Some hospitals now put their resources into beautification instead of staffing, so they’ll ‘look’ nicer, since that is a big part of what they’re being judged on. But there have also been some studies done showing that higher happiness scores correlate with worse outcomes, because the doctor or the hospital is trying so hard to please the patient. A ‘happy’ patient can still be dead an hour later. But corporate structures use those scores to reward or penalize physicians with bonuses, or in some cases, even salaries. I’m not surprised that your neurologist can’t spend as much time with you as you need. None of us can.”

  “Ugh. How do you stand it?” Patricia asked.

  “It’s very disheartening at times. I just try my best to ignore it, so I can live with myself. I’m very sorry no one has found the source of your pain, but perhaps you can try going to someone attached to a teaching hospital. The academics may have more latitude to take time to ferret out difficult diagnoses.

  “Meanwhile,” Tobi grinned as she continued, “I’m prescribing some nitrofurantoin for your urinary tract infection. For that, you really do just need a pill, and only for a week.”

  “Thank you, doctor. And thanks for taking the time to talk to me. You’ve given me back some faith that doctors do care. What a mess it all seems!” Patricia glanced down the hall as she was leaving. “I’m afraid you have a crowd out there waiting for you now. I hope I get a chance to give you a review, it would be a great one!”

  “Oh, I’m sure you will,” Tobi laughed. “Thanks!”

  Patricia left. As Tobi completed her chart, she berated herself for spending so much time with a simple UTI. This could have been a super quick visit if she’d just redirected the encounter. Why give Rufini ammunition like that? The conversation with Patricia was not relevant to her UTI and must have taken an extra eight or nine minutes, which was eight or nine minutes another patient would be angry about.

  She set her jaw and thought: no. If I can’t take time to be a person to another human being who is frustrated and scared, what is the point? I am not a venture capitalist, and I need to connect with real people about their real concerns. The only thing that makes this job worthwhile is the idea that once in a while, I am able to make a difference in someone’s life, even if it isn’t about exactly what they came in for. If I’m not allowed to do that, I might as well be flipping burgers.

  She tried to send the urine culture and the system froze, the little blue “circle of death” spinning around and around.

  “Don’t you freeze on me now, Evy-baby,” she said under her breath. The screen popped, the culture showed as “sent,” and she relaxed. She picked up her tablet and went back to her main work station.

  “Dr. L., is EveryScripts working for you? Mine just went down.” Esther looked completely flummoxed. “I had to restart, but—wait, it’s back up again. Sheesh!”

  “Yeah, mine stuttered on me too, but it came back online. Last thing I want to do today is convert to paper and have to document everything again hours from now.”

  Finally, the last patient was Amelia, whose whole family were frequent flyers. Today she was being seen for a puncture wound of her right great toe. Tobi went in to give her a cheerful greeting, but Amelia was not smiling.

  “Hi, Dr. Lister. I just need a tetanus shot, I stepped on a carpet tack this morning. We’ve all been beside ourselves the whole week.” She started to cry.

  “What happened?” Tobi brought her a box of tissues. Amelia was not usually the emotional sort.

  “Do you remember my father? You treated his shingles a month ago, right before Thanksgiving.”

  “Sure I do. Antonio, he’s a sweetheart.”

  “Was a sweetheart.”

  “Oh my God, Amelia, what happened? He wasn’t that old.”

  “No, only fifty-three, but he had kidney failure, and he’d been on dialysis,” Amelia explained. “And they had just found him a kidney! It was a miracle to find one so fast; they said they never expected to, he had a rare blood type. You know he was adopted, and I wasn’t a match, so he was in the kidney pool.” She started sobbing again. “I’m sorry ….” She dabbed at her eyes.

  “I remember him well. He was very hopeful he would get a donor. Did he not make it through the transplant surgery?” Tobi asked gently. She stood beside Amelia and put her hand on her shoulder.

  “He never had the surgery! Last Tuesday, the day before he was supposed to check in … the very day before … his brakes failed … he had an accident on the Long Island Expressway, and he died. He had a Subaru, they’re such good cars, and he had just serviced it in October, getting it ready for the winter.”

  “I am so sorry!” Tobi felt stricken. Amelia reached up and hugged Tobi, crying on her shoulder.

  “He was so close …. Why did that have to happen? We even bought him this super expensive supplemental insurance to cover all the extra costs, but we only ended up making two payments. I just don’t understand … none of us understand. And now it’s Christmas, and instead of a new lease on life, he’s gone! I know, I know I should accept it, I know he’s with Jesus now … but he wa
s so close!”

  Tobi hugged her tight. She had no wise words for an ironic tragedy like this.

  “I’m sorry.” Amelia straightened up and dried her eyes. “I know you need to get going. I just came for my tetanus shot. And I was glad you were on, you knew him—you just saw him! Life sucks sometimes!”

  “I am so sorry, Amelia. May his memory be for a blessing.”

  Chapter 39

  Kavandor had not received an answer to his text message, and he was almost out of time. The subcommittee was supposed to meet right after New Year’s. He was sure it was because the Russians considered him a worthless nobody, and it really pissed him off. They had no idea they needed him now. If he did not bury the inquiry into Kordec, their whole gig could go up in smoke. What a relief it would be to not have to come up with hidden money four times a year! But what if there were an inquiry and somehow Kordec passed, and then they found him in the center of it? Wouldn’t they strike out at him in vengeance and tell all—or kill him? Right now, they didn’t even know he was chairing the subcommittee, as far as he knew, anyway. He would love to have these guys out of his life for good, but if they were scrutinized and not discovered for the murderous wretches they were, he could be dead meat. So, if Kordec were investigated, they had best be fried, all while keeping his connection out of the inquiry entirely. It was all or nothing.

  Albert Wiseman popped his head into his office. “Hey, Blaise. You’re chairing next week?”

  “Hi, Al, what are you doing here? Chairing what?”

  Wiseman was young, bright, and ambitious. Often a pain in the ass, to be sure.

  “Roundtable committee. I was told to sit in on this one, thought I’d pick your brain first. You know the FBI likes to make a show of keeping its nose in the public arena. I’m the new kid on the block, so they stuck me down here where the action isn’t. How am I going to display my talents on a round table discussion that has nothing to do with national security? Someone upstairs doesn’t like me, that’s what I’m thinking. Help me make this interesting, at least.”