Man's 4th Best Hospital, page 10
“Me ’n’ Olive will be asleep and we need our sleep bye—”
“Wait! I’m sorry, Foozle. Love ya.”
A pause. From the time she learned to talk, she would always answer me with an automatic “Love ya too.” This time she said, “Here’s Mom.”
“So when can we count on you being home?”
“Eight thirty. Nine latest.”
“Let us know if it’s later. Because it usually is.”
I felt the jab. She was, of course, right. “Sorry.”
“Me too.”
Dazed, feeling like crap, I followed the fast-moving Fats and Humbo out the clinic door into the suddenly ugly, pungent summer night and up the grand lit-up driveway toward the soaring 4th Best monolith and Ward 34.
7
Who’s my doctor?” I would soon come to realize that this was the main question asked by patients in Man’s 4th Best Hospital. Most fervently asked between the hours of seven at night and seven in the morning—when all hospitals are scary places. Why didn’t they know who their doctors were?
In the House of God, we interns had been on call mostly every third night. We would follow our patients continuously all day, all night, all the next day, and then go home after 36 hours, exhausted. Well over 100 hours a week. But we got to know our patients well—and often it was thrilling. Now this had changed radically, because of the Libby Zion case: a young woman treated by an exhausted intern died, and the court held the exhaustion as cause. Suddenly interns were strictly limited to shifts not lasting more than 14 hours in a row, totaling a maximum of 80 hours a week. This meant they had little continuous contact with patients—never following a patient they’d admitted through a day and a night and a day.
The effect of these lighter hours for medical trainees—and medical students—was profound. At the House we had been dedicated “professionals” who would work on our patients for as long as it took to get them stabilized and handed off to another intern on our team who was on call. All of us knew all the patients because we were always at their bedsides, human to human on morning work rounds and end-of-day handoff rounds. If they had private doctors, they rounded on them in hospital, both morning and evening.
During their hospital stay, patients knew their doctors.
Now, rather than “professionals,” interns and residents were “shift workers.”
When the bell rang at the end of shift, if they weren’t outside the legal confines of the hospital, they would be reported and warned. This artificial shift-work mentality fractured ongoing connection and care. Given the 80 percent of their time spent in front of screens and on billing, and the pressure to discharge patients as fast as possible in order to admit other patients just as fast as possible and thus maximize Man’s 4th Best’s money, the ward team was fractured, hardly a team at all. Hardly any teaching took place. No one had time.
And now there was a brand-new shift-work subspecialty: “Hospitalist.” (In Obstetrics, there were now even “Laborists” and “Deliveryists.”) Patients’ regular doctors were barred from caring for them in the hospital. Instead, Hospitalists, who had chosen the ultimate shift work, saw patients only in the hospital. Shifts of twelve hours exactly, responsible for all the inpatients on a ward, but rarely on the same ward two nights in a row. Never getting to know their patients. It was the fastest-growing specialty in all of medicine. Strange, since they had no ongoing relationship with patients—the very reason that most of us busted our butts to become docs.
There was a sub-subspecialty of Hospitalist: Nocturnalist—nicknamed Somnambulist. These worked only night shifts, prowling the hours of darkness, slipping away quickly at dawn’s early light. They rarely saw patients, and patients never really saw them. And if a patient did chance to see one, it would be a doctor they had never seen before and would never see again.
* * *
We got up to Ward 34 at 7:04, as Jack Rowk Junior was handing off to the night-float intern, a bearded man in a blue Sikh turban. Other docs were rushing off shift to avoid censure.
“Remember, Dr. Montek,” Jack said to him, “you just do admissions. Do not take care of any other patients. You do not wanna mess with tonight’s nocturne. I’m gone.”
“Don’t you do a face-to-face handoff of your patients to the nocturne?” Fats asked.
“Nope.” He yawned. “Whoa, am I tired. Really beat. Finally going home.” He raised his arms in triumph. “Home!”
“But there are fifty of your patients in his care.”
“Sixty-four, tonight. In her care. She doesn’t do handoffs with people—she does screens. Phobic of faces, of humans—some such shit. Have a nice night.” He left.
“Hi,” said Mo Ahern. “I’m on call with the night float.”
“Good,” I said. “How did Mrs. Burke do?”
Mo glanced around. The Sikh was in front of his screen. Mo nodded to follow her out into the corridor and then into the utility room, all mops and slop buckets and power floor polishers, all ratchets and rollers.
“She’s much worse,” Mo said. “I know, I know. All we had to do was ‘do nothing’ except transfuse her platelets and monitor her. She was all set to be my first patient in the FMC, with Roy supervising.” A deep breath. “But as Jack said, she’s a ‘fascinoma’—a case so unusual that it’s publishable—and he said we had to study ‘it.’ He wouldn’t tell us what he was doing or let me or anyone else see her. Ran all kinds of weird immunoassays on her blood. And then—he has hands like a butcher—his bone marrow biopsy hit spinal cord and it got infected and the new antibiotic mixed with the residue fluconazole and . . . she went unconscious, may’ve had a stroke.”
“‘Bone marrow biopsy hit spinal cord’?” Fats cried. “The iliac crest is nowhere near the spine. Now, that . . . that’s publishable. Damn—she’s young enough to die! Where is she?”
“She’s in the TLC—a clinical—”
“The Tender Loving Care?” Fats cried. “In a WASP hospital?”
“The Translational Leverage Consort. A clinical research unit, with all the ‘cases’ that might lead to ‘translation’ into patents and drugs, partnered with Big Pharma.”
“Uh-oh. I love research—so why do I suddenly feel sick? TLC funded by . . . ?”
“Merck. Merck has first-refusal drug rights to all discoveries.”
“Merck, of the billion-dollar drugs Vioxx for arthritic pain—which causes heart attacks—and Fosamax for women’s osteoporotic bones—that can lead to broken bones.”
“Sí, sí. Merck Vioxx kill my madre!”
“Mo, listen up. Drug trials usually last only about six months to a year, but patients take most drugs for decades, even lifetimes. Promise me: never prescribe or take a drug that hasn’t been used for ten years, okay?” Mo nodded. “And never go to a doctor you see on TV, or prescribe or take a drug you see in a commercial. Swear?”
“Hey, wait a second, Fats,” I said. “That’s going a little far, don’t you think?”
“More than a little. But it’s only by going for more than a little that we can get a lot.” A shake of that global head. “Where’s this ward? Let’s go save her.”
“You don’t have clearance,” Mo said. “It’s a level-alpha restricted zone.”
Fats nearly fell over with laughter. “Lead on.”
“What about the night-float mess you needed me for?” I asked as we walked.
“We triage it. First, we got to save Mrs. B.”
The TLC was hidden in shadow, down dimly lit corridors and mossy, winding ways, over a bridge between skyscrapers with lovely views. The brass plate on the door:
TLC: MERCK/FOX FOR HEALTH
“Fox?” Fats said. “‘All the News Unfit to Print’? Merck and Fox, together at last?”
Mo had the code. “Jack said that working with him would look good on my résumé. I get that creepy feeling that he wants to date me. Yuck.”
Inside, we donned stiff, sterile gowns, shower caps, gloves. Passed walls lined with banks of computers and, in one glass-walled room, floor-to-ceiling ones quivering with data.
“DNA sequencers,” Fats said. “Industrial-strength, ultrafast. High volume.”
There were maybe ten beds and six nurses. They all knew Mo, clearly liked her.
Mrs. Burke lay still, but for her ventilator raising and lowering her rib cage with a precision no normal muscles could. IV line with pink fluid was going in; a catheter with brown fluid was coming out. She looked sunken, but in no obvious distress. Everything had been subdued to measurement. All too quiet. I felt her feet. As cold as any stone.
Fats was all business, working on her around the bed like a dancing bear—laying on hands, percussing, palpating, stethoscoping, tapping with his foot-long British reflex hammer—and then barking orders to me to print out her last data from HEAL: the hard-to-find, “clinical” info, sequestered and obscured in the linguine of billings. It was the first time, since the House, that I’d seen the Fat Man’s Promethean medico talent in action, and it was so—I don’t know—so damn elegant and caring, it took my breath away. By the time I’d printed out the info, he was done with her exam, and with a quick look at her numbers, he perked up: “Ah, yes—I noticed her eyes were a bit pinned. Roy, get me a vial of Narcan from the crash cart. Jack, after he infected her and she was screaming in pain, gave her too much morphine, lighting her up to keep her quiet.”
He shot the Narcan into the IV line, and in seconds there she was, a reconstituted Mrs. Burke, groggy but clearly alive. He took out her breathing tube.
“Ohhh. What . . . happened?” she asked.
“Lots of bad stuff, dear, but we’ll get restraining orders on Dr. Rowk ever coming near you again.” Fats went out to charm the TLC nurses.
“Okay,” he said to them, “call me Fats, for obvious reasons, and why don’t all of you take the rest of the night off ’cuz I got your backs?” To their stares of What the hell? he went on. “I wish. But we got work to do, together, on that sweet Mrs. Burke.”
By the time we’d read the whole TLC record, and finished writing new orders, almost an hour had passed, and I was in deep trouble about Olive’s birthday.
When I called Berry, she was curt and said she had to get back to the party, which was “going great, and Spring and Olive and friends are having a great time, so I’m not even going to tell her that you called or when to expect you. I gotta go—”
Click. How I’d come to hate those severing clicks over the years, daggers of guilt that still, still, brought up as if it was yesterday our Big Breakup after college as I’d boarded the Queen Elizabeth 2 for Oxford and left her on a dock in Manhattan, both of us crying our eyes out, I waving good-bye back to her until she was a speck and then nothing human, the ersatz-human Statue of Liberty waving good-bye to me too until she sank into the chill October waves. That jolt? Still fresh? Could it happen again? Destroying all we’d created—she, I, Spring, the dog, and the rabbit. Fucking clicks.
“Shit,” I said to Fats. “It’s bad. Gotta go.”
“Basch, Basch,” he said, eye to eye, “we need you. Very complex what they did to her, lots of ups and downs, ins and outs. Luckily, it’ll stand up if she sues for malpractice. But it’s gonna be really tough to do as much nothing as possible, with her under the fiscal-pinned eyes of Merck/Fox.” He turned to Mo. “Listen up, kid. The treatment now is on two fronts—the real treatment of Law Thirteen: Doing as much nothing as possible—and the harder fake treatment of hiding it, by BUFFING up HEAL.”
Mo looked puzzled. “What’s ‘buffing’?”
“Like buffing a car so it looks good. In the House of God, all of us docs in internal medicine learned to BUFF the problem patient so that we could TURF them to surgery or psychiatry without them BOUNCING back. With Mrs. Burke, we’re BUFFING HEAL so it doesn’t know what we’re really doing—saving her by doing a helluva lotta nothing.”
Mo was staring at him, wide-eyed.
“It’s hard to understand how it was key to our survival in the House,” Fats said. “I mean, y’had to be there. Anyway, Mo, your job is just to go back in there and be with her. Got it?”
“Sorta kinda.” She looked at us as if we were insane, then nodded and left.
“A real tough case, Basch, especially with this woo-woo, hush-hush TLC shit—high visibility. Gotta be deft. I need you with me.” He noticed my dismay. “Okay, go. I’ll try to handle it. But this is big. This time we’re not just up against a hospital—we’re up against the whole pharma-entertainment industry. I can’t do it alone. Without your help, her odds go way down.”
We looked into Mrs. Burke’s room. Mo was sitting beside her again, holding her hand, talking to her. No response. We could hear Mo’s voice cracking, watch her hand falling back down into her lap. The scene, the cracking voice, the falling hand, brought back my own first patients as a real doc, all that sorrow so damn fresh. And that fear.
Fats, I, and Humbo stared at them, and then at one another. I wanted to cry or scream.
How could I just leave? So we started her back to full Mrs. Burkehood. HEAL turned out to be a lot easier to dupe than paper. With so much faked data coding going in already, fake data was easy to hide. And if the fake data could outbill real data, what bean counter would choose reality? It’d be like reporting an error in your favor to your bank.
Thus, the state of the art of the Delivery of Medical Care.
We left her room and turned toward the door but heard, from farther down in the bowels of the TLC, a faint cry:
“Hey Doc wait hey doc wait yeowww!”
And then silence. We looked at one another. Could it be? Harry the Horse from the House of God, here?
“Hey Doc wait yaoww! Hey Doc . . . yeowwwww!”
Harry the gomer, adding a new pain word—“yeowwwww!”—to his House of God signature call? Must be bad!
We hurried toward him.
It was Harry, and it was not pretty. Jack was in a combat stance at the bedside. Harry was connected to so many wires and tubes that the poor old guy looked like a shrunken meatball in a bed of spaghetti. Jack was jabbing randomly at Harry’s bruised chest with a large-bore big needle—probably trying to put in a central IV line. Clearly frustrated by repeated stabs with no pay dirt, he was cursing and, enraged, jabbing wildly, way off line.
“Stop!” cried Fats. “You moron! Were you born in a barn?”
Jack kept on stabbing.
“Estop!” echoed Humbo. “Pene-cabeza!” And in an instante, he had pinned both of Jack’s arms behind him and was jerking them up and up. Jack screamed.
Silence. We stared at Harry. Then a whimper. “Hey Doc wait hey . . . hey Doc you fucker wait. . . .” But then petering out like a car motor sputtering after the engine had been turned off. For the first time in living memory, Harry the Horse was silent.
Fats took his pulse. Paused. Took it longer. “No pulse.”
“Thump him!” Jack cried. He tried to break free. Humbo, like jerking up a barbell, cranked Jack’s arms higher, into dislocation zones. Jack turned white and went limpish.
“We know you’re an idiot, Jack,” I said, “but we didn’t realize you’re crazy too.”
“He’s . . . he’s dying!”
“Agreed. You tried hard to kill him,” Fats said. “Luckily you even fucked that up.”
“He’s got no pulse.”
“He’s just taking his time recovering from your Angel of Death torture routine.” Fats looked at his watch. “Fifteen, fourteen . . .” He counted off the seconds. “Ten, nine . . .” When Fats got to “four,” Harry’s cataracted eyes opened, and at “two” suddenly he said faintly: “Hey . . .” Big gap. “Hey Doc . . .” And bingo, like a car ignition catching: “Hey Doc wait!”
“Jack,” Fats asked, “what the fuck were you doing?”
“Looking for genes. Longevity genes. Merck/Fox mission—Nobel Prize protocol. Law Number One from the House of God: Gomers don’t die—okay? So logically they must be a subset of humans that has a gene mutation for pretty eternal life. We’re gonna find that gene!”
“And how are you going to do that?”
“The standard method—we’re gonna knock it out. Once we knock it out of Harry—he’s the experimental subject; Jane Doe is the control case—we make a drug to put back into Harry! We CRISPR it, insert it in people when they’re young. A blockbuster drug. We’re gonna monetize! Monetize the gomers into drugs! Billions!”
“But, Jack,” I said, “if you successfully knock out the gene in Harry’s DNA that’s keeping him alive ‘pretty eternally,’ he’ll die.”
“It’s the price y’pay. For success!” He beamed. “And I got animals we’re workin’ on too. Long-lived turtles. Maybe the gomers and the turtles have the same gene. How cool would that be—”
“Turtles?”
“Yeah. I got two, hundred-plus-year-old Galápagos turtles!”
“What? Galápagos tortoises?” I cried. “They’re a protected species!”
“Not from my dad, they’re not!”
“Killing gomers and those sweet Galápagos tortoises too?
“It’s the price y’pay. What kind of life do gomers have, really? Not human, really.”
“It’s immoral, unethical, and Nazi!” I said.
“Way bigger fish than you—Merck/Fox and the ethics boys—they all say it’s fine.”
“You moron! You neo-Darwinist!” Fats shouted. “Where’s your brain, man, in your scrotum? It ain’t the genes. It’s their regulation—the feedback from all levels of their environment, from RNA to climate change! Not the notes, you fascist baboon, the music.”
“Oh yeah? Well, after my dad hears about this, you’re chopped liver. Finished. Nothing good is gonna happen to you here at Man’s Best, Fat Man. I swear it.”
