Man's 4th Best Hospital, page 32
“Okay, okay. Write me a ‘scrip’ for propranolol, and if I have another one of these, I’ll follow up with you later.”
Berry and I left. Relieved, sobered.
Spring was up, waiting. Chris had told her I was having a “heart flutter-wutter” and would be fine. She ran up the hall to me and I squatted down and she jumped into my arms, and her arms around my neck felt as strong as the woven-leather lanyards on one of those Navajo necklaces she’d made last year and she said:
“Olive had a bad heart flutter-wutter too. It was scary but she’s okay now.”
* * *
After that, both Berry and my FMCers were adamant: I had to stop working so hard for money and take care of myself. Fats was gone again—he’d had to go back to the Left Coast: “Presenting great news to investors about the calcium boxcars and L-amphetamine proving how memory works.” When he heard about the A-fib, he called at once.
“Probly just once-in-a-lifetime, Chinese-food-induced,” Fats said. “Surviving A-fib without chest pain for all those hours is a stress test of your heart and you passed and don’t worry about it.”
Berry reminded me that I’d never done anything just for money, except summers as a toll collector on the midnight-to-eight shift at the Rip Van Winkle Bridge—money to take her out that summer when we first met, when she had been wowed by me in my Bridge Authority uniform and the gun in the booth, not fired since it had been put there in 1939.
“We’ll get through it,” she said. “I’ve got a waiting list. I’ll take more patients.”
“And you’ll wind up in the Grossman EW alongside me, getting cardioverted.”
“Don’t think so. When I get stressed, I get more involved with all my people, get more support. When you do, you withdraw, try to do it alone, draw a line in the sand, double down—”
“I’m just trying to make enough money to keep us all going.”
“Spring and I—and Cinny—want you alive.”
“Not the rabbit?”
“No. She knows you don’t like her.”
I upped the propanolol but kept going, startled to see how much I’d inherited the “male provider role.” Luckily, our FMC insurance was great. Made me think of all the poor and middle-class patients I’d seen who were only one illness away, in our nation’s piss-poor health-care system, from bankruptcy.
Got cancer? That’s the good news. The bad news? Y’lose your house too! But hey, you’re in good company. A million households a year.
I soldiered on, sometimes with that jolt of the heroic. Or that sweet hit of masochism.
“I’m really worried, and I wish you’d stop it!” Berry said after a while.
“I haven’t had any A-fib since that night. It had a clear etiology—the egg foo yong.”
I understood her concern, but lately I was on edge with her, more and more—maybe because of my close call with Molly.
* * *
After a month of moonlights, I paid old bills. Without Chinese food, I hadn’t had any further atrial fib. But my big challenge would be April 15. Not only taxes, but several other big payments, including the 7,000-dollar quarterly payment to the Whole World—the cruelest cut, because my 24,000-dollar city taxes would have paid for excellent public school. But we’d tried it with Spring—it didn’t work. She was terribly shy, and with the Navajo, she had learned to be even more reserved. I needed money. I dived deep into a lot more seven-to-seven emergency shifts.
All of us were stretched by the new, huge FMC load—and attending on Ward 34. With Fats gone, we no longer took time for check-in and checkout. We just came in and opened the gates, and in they came.
At four one afternoon, I went up to 34 with Mo, into a nightmare. Jack Rowk Junior, promoted to best chief resident of all less-best chief residents, in Fats’s absence had claimed more authority to suck humanity out of care. That afternoon as he “taught” residents with Mo and me, someone asked a question about a guy dying in a room. Jack had never seen him, but he rushed into the room, parting the gathered sad family, and said:
“I know you’re dying, but I’ve gotta look into your mouth!”
He did so, searching for something publishable in there—maybe a fungus or a lost tongue depressor—and, finding neither, rushed back out. I blasted him in front of the team, told him to “Get the hell off our ward!” and got ready for the blast back from the Krash.
I was getting ready to drive to my night shift at a horrific EW two hours away when I got a stat page to the FMC. When I got there, everyone was gathered at the nursing station, in shock, as if someone had died.
“What’s up?” I asked.
“Man, the worst,” said Chuck.
“Worse than that!” said Eddie. “We’re gonna be on our knees, forever.”
“What?!”
“OUTGOING,” said Naidoo. “It’s back!”
“It’s the worst,” said Hooper almost in a whisper, his lips trending down. For the first time ever, he was still, hands and arms dangling down by his sides lifelessly, as if dead.
“Can’t we fix it?” I asked.
“Fix it? What the hell are you—”
“I mean, keep it broken. Sorry. I’m really, really tired. What’s the Fat Man say?”
“He ain’t answerin’,” Chuck said.
“What? He always answers—”
“Ain’t!” he shouted. Him shouting at me? “We tried everythin’ stat—nuthin’.”
Silence.
This could be the death of the clinic.
“What are we gonna do?” I asked.
More silence.
Glancing at my watch: “Sorry—gotta run—got an EW gig tonight up in Lawton.”
I drove fast to the tough, understaffed, and ill-equipped hospital—I don’t remember the name, but I know it was whoever is the Saint of Lost Causes. I would serve as primary-care doc, general surgeon, and every specialty in between for poor, sick people barely making it through in a Catholic mill town that still had a bare, ruined cathedral but had not had a mill or another job maker since 1916. From the car, I called 789 on his secret flip phone. “The number you have dialed is not in service. Please check the number and—”
“Fuck you!” I screamed. “And fuck you too, Fat Man. Where the hell are you?!”
The hospital was the catchment area for the worst health neglect I’d ever seen, fueled by drugs and violence. A phantasmagoria the whole long way through my twelve-hour shift. For a while my mantra was Edgar’s eloquent one in King Lear: “The worst is not / So long as we can say ‘This is the worst.’” But near the end of my shift, something happened that was pure down-in-the-shit Beckett: “I can’t go on, I’ll go on.”
It might have been about four a.m. I’d gotten almost no sleep. Once in a chair, once standing up, nodding off—and then, like a cop was snatching me up by my collar, snapping to, taking a few seconds to figure out where I was. I was so exhausted, and the patient load was so big, that I had a hard time remembering what I was doing with whom.
Hazel Thompkins was her name, an African American, accompanied by her pastor, Reverend Carter. A short, roundish woman with a wrinkled chipmunk face and white hair making her look older than her 62 years. She’d worked for most of her life with a large and kind family as maid, babysitter, and cook, but they’d recently moved to Florida. Her children, unable to make it in America, had moved far away: a daughter to Chile, a son to Africa—maybe Togo? She’d been in pretty good health—well, I mean, with diabetes, asthma, high blood pressure, and arthritis—but had awakened at two in the morning with a scary fever, rigorous chills, and drenching sweats. She felt she was dying and had no one else to call but Reverend Carter, an aged, frail-seeming man who looked, from his tremors, fearful eyes, and breathlessness, as if he needed my care too.
“Are you okay?” I asked him.
“N-no,” he said with a stutter, “b-but not so b-bad as to need you, Doctor, yet.”
“Well, tell me if you do,” I said, a little loopy. “We’re featuring a special tonight—bring a friend, no extra charge.”
They smiled. And that kind of got me, her smile. It was just, well—maybe in the way she shook her head in resignation, in a “What a life!” way—it was just so real, clear, enduring. And no one else for eight hours had smiled at me that night, nor I at them.
It got me. Calling me to cinch up my belt and to be real and clear and enduring as well.
She had no doctor, no health records, no insurance. I took a history, examined her. Even without the labs, from her vitals and her history, I was worried she was brewing up a sepsis. I put her on a saline IV, drew the bloods, sent them off, and went to work on the rest of the packed waiting room. Finally, the labs came back. Everything pointed to sepsis—but mild. I had to jump on it right away, or it could kill her.
I of course had treated a lot of sepsis on the wards of Man’s 4th—mostly nosocomial, acquired while in the hospital. Not long ago, Fats had given us a talk on a brand-new nationwide study and a new protocol, a three-drug bolus treatment. I’d been totally wiped out from being up two days in a row. He’d started to talk about “algorithms,” mathematical formulas that turn Big Health data into treatments. Now I recalled him saying, “This research was done using a complex algorithm that analyzes data based on a simple binary rule: if this, then that. If this is the sepsis data, then that is how you treat it. But there’s a core problem in any computer algorithm, and it’s called GIGO: if you put Garbage Into the computer, you get Garbage Out of the computer. Algorithms are useful only if the data are valid. If not? You all know that the ‘I’-phones have an app designed to calculate when and how much insulin a diabetic needs to take? Well, guess what. Studies show that seventy percent of the time, the dosages are wrong. The more complex the algorithm, the more difficult it is to maintain. . . .”
At that point I’d fallen asleep, waking up at the end with “national sepsis health-care protocol.”
So I asked the nurse at the desk if she had seen this new national sepsis protocol. Yes, they were using it. She handed me a copy. The usual directions in terms of hydration and blood pressure maintenance to save renal function, etc., but a new three-drug combo was listed for treatment. We had always used the first two, with success. The third was a brand-new Big Pharma drug called Xylolaxenda, which, in my blitzed-out fatigue, sounded like a combination of a laxative and a sugar substitute. I looked at the protocol’s small print instructing me in what kind of sepsis—mild, medium, hot-severe—the three-drug treatment was indicated: in all sepsis. Then, with my nose to the page to decipher the even smaller print, I checked out the side effects. They ranged from minor to disastrous, ending with “sudden death.” But hey, almost all new drugs had side effects from minor to disastrous, ending with “sudden death.”
Fats had always said, “Never give a drug that hasn’t been on the market for ten years.”
Clearly he’d been exaggerating—what would he say about his boxcars?—but I agreed with him; irreversible side effects can appear years later, like with the antipsychotics that turned coping schizophrenics into crippled tardive dyskinesiacs for the rest of their lives. I was ultraconservative in trying new drugs to treat old diseases.
So I hesitated.
But now it was a nationwide directive for treatment, for all cases of sepsis. Did I really want to risk this with that nice Hazel Thompkins, with only mild sepsis?
I stood there at the nursing station, wobbly on my feet, trying to think.
The nurse came up and said that a family shooting was on its way in, and had I signed the med orders for “the sepsis case”? I heard the siren, signed the order, and asked the nurse to please, please, check on Hazel Thompkins every 15 minutes—all the usual vital signs.
Before I went to the wounded spouse and child, I pushed the bolus of Xylolaxenda into the IV port, into Hazel’s system. I wanted to be there in case she had an allergic reaction to this new drug and suddenly went into anaphylactic shock. I watched, epinephrine in my hand, for two minutes, the nurse trying to drag me away. No sign of reaction. I left to stabilize the mother and child awaiting the surgeons.
Soon I was in overwhelm, maybe for an hour or so.
Suddenly, the nurse grabbed me, ran me to Hazel’s cubicle. She had crashed and was unconscious. Temperature way up, blood pressure way down, heart racing horribly to try to keep pushing blood through her vital organs. A disaster.
I snapped to attention. Asked the nurse to look up Xylolaxenda on Google stat to see if there was any antidote to it. Nope.
With adrenaline clarity, I used everything I knew to save Hazel.
The morning shift came in, and I signed out, but said I’d like to stay on with Hazel Thompkins.
When I’d done all I could do, I invited Reverend Carter to come in and sit with me and her. He was praying, hands sometimes in his lap, sometimes lifted, palms up, to God. At one point he took my hand in his. I too prayed—to any divinity who might be out there beyond me. At times like that, we all do “God” in some form, even us docs. Y’got to.
Finally, she seemed to stabilize. She woke up, dazed but alive. Whatever the drug had done had passed. As long as no one did her any more harm, she’d make it.
With relief I let go and let myself feel like shit.
How could you do that? Go against yourself? What the hell were you thinking?
Before I left, I wrote notes on what had happened—there actually was space for notes on the old, clunky surplus Veterans Administration machine.
And then I stopped, still, and groaned. It came back to me what Fats had said, as part of his algorithm talk. In my night’s fog of exhaustion, I hadn’t dredged up the most important fact—it went something like this:
The Big Health data on sepsis was collected from virtually every hospital in America. And virtually every hospital in America used HEAL or EPIC or some other electronic medical record system that torqued data big-time to “sepsis, severe” for maximum money. Rarely could we get away with “mild” or even “medium.” So the real nationwide data, a combination of mild, medium, and severe sepsis cases, was not the same data that the algorithm analyzed. It was falsified badly toward “severe.” And so the protocol recommended, for any sepsis, using the three-drug treatment for severe sepsis. And it almost killed Hazel Thompkins.
What was it that Fats had said? Ah, yes: “It’s caca! It’s Money In, Caca Out!”
In my note before I left, I described all this fully, ending with:
DO NOT USE XYLOLAXENDA OR THE NEW SEPSIS PROTOCOL ON MILD OR MEDIUM SEPSIS.
Leaving the hospital, still shaky, I flashed on all the “Work-Arounds” and “Cut and Pastes”—which was the phony data we doctors clicked on just to survive the screens, distorting the data and any protocols derived from it! And what other diseases are being maltreated because of how money distorts Big Health data, how money destroys the real?
I drove not to the FMC but to the federal courthouse. We were going in shifts to support Jude in the first days of her harassment-discrimation trial. There had been a couple of days of nice, vicious sparring, the usual parody and injudicious shows of justice. The first objection was filed by Jude’s lawyers, to demand that the judge, Dinny Crisper, recuse herself on grounds that her brother had trained as an orthopedic resident at Man’s 4th under the accused Buck and Barmdun. It was trial by judge, not jury, and Judge Dinny dismissed this with a sneer that said, Just try to appeal that one, you bozos.
Because Buck and Barmdun were members of Man’s 4th, BUDDIES, and the BMS, all three were being sued by Jude. Each institution had its own hassle of lawyers. On their side of the aisle were 16 lawyers all dressed in black pin-striped shark suits. 15 white men and a woman of color. On Jude’s side were two women lawyers in similar black suits, and Jude in an off-white pregnancy outfit. Seated behind her was her husband, in uniform with one of those hard-won green berets.
I was woozy. Lawyer jokes ricocheted around the inner surfaces of my skull: What do you call 300 lawyers at the bottom of the ocean? A good start.
As the morning proceeded, it seemed the kind of event that satire can’t satire. For almost every statement that Jude’s lawyers made, one of the 15 defense lawyers—say, from Man’s 4th—would shoot to his feet and yell, “Objection,” which the judge would either affirm or overrule. And then, like Whac-A-Mole, as each sat down and Jude’s lawyer continued—“Objection!”—up popped another lawyer, for BUDDIES or BMS. Comical.
Many witnesses for the defense were suffering from a contagious disease: acute loss of memory. “I don’t recall.” Worst was Delise Blieberman, an elderly woman in charge of the BMS Office for Discrimination and Harassment. When confronted with hard evidence, a letter she had written that would have helped Jude’s case, with a terrified look, she said, “I don’t recall,” several times, but as she was pressed by Jude’s lawyer to tell the truth, she got more and more flustered and, trapped, said: “To my best recollection, I have no recollection of recalling that.” She did recover and recall, photographically, evidence to hurt Jude’s case.
Another affliction had hit and run through witnesses for the defense: a penchant for perjury. This was most beautifully suffered by a former chief resident in Orthopedics, Pavorad Pene de Capo, a certified dolt central to the case. He had flown his plane up from West Palm for the day, where he had hit gold drilling for gomere hips. Pene had started this whole mess. In the crucial event—Jude’s volunteering in Emergency, after her shift was over, to treat an indigent patient’s hip injury because no one else would—Jude had proof of perfect treatment and follow-up in her detailed notes, with her supervisor’s co-signature. Pavorad Pene said that as chief resident, he’d tried to help Jude, giving her factual—in fact, “kind”—advice: “Your problem is, is that you’re a woman who acts too much like a man, in a man’s world.”
