Mangled Care

Chapter 1

JANUARY
















CHAPTER 1

“Above all else, do no harm.”
Or something like that.
I couldn’t remember the exact wording, but the Meaning, the Sentiment of the statement, part of the Hippocratic Oath I had taken, was totally engrained in my mind, my entire being.
After ten years of struggling, I had finally achieved my goal. I had invested my life savings to open a clinic to diagnose and treat patients with chronic headache and pain, as well as traumatic brain injury. Why? Because I could help those folk. I didn’t have to just watch them die of a neurological disorder I couldn’t truly help.
That’s why most people call neurologists ‘grave-diggers’. There’s not much we can do to fix things. We can only hope to watch patients mark time with the immutable flow of the typical neurological disorder.
We can help people with headache and pain.
I had struggled, working for several large medical corporations over the years, until I had grown both tired and disgusted with what passed as medical care in those environments.
Finally, after many long discussions with my friends and colleagues about the possibility of financial ruin, I had left the uncompromising world of corporate medicine. I had always wanted to do medicine for the patients, not for the bottom line of some faceless corporation dictated by bean counters, who influenced medical whores whose decisions were based on the corporate bottom line, not good patient care.
I have been told that I am too reactive, too aggressive when I believe in something, to just go along with the herd. I guess that’s true. I don’t react well to stupidity, or ignorance. Especially not when it’s purposeful.
I guess I’ve seen too much of it over my first decade in medicine. Too many patients allowed to suffer.
No, required by contract to suffer.
Looking out of the window from my brand new office, my thoughts turned backward in time.
I had started out with the proverbial gleam in my eye and a desire to help people. That was the reason I had spent ten years of my life after college learning my trade: medicine.
I was lucky. I was selected to join the medical school of my choice, one of the top ten institutions in the country. Medical school had been hard, but I had expected no less. My internship was even harder. Residency, in neurology, my chosen field, was difficult, but for the most part, rewarding. The first warnings of conformity or exclusion were made evident to me during those years.
As a resident, I was passed the internship year of constant scut work, doing the most mundane tasks imaginable. Still, in the pecking order of the teaching hospital, the residents had to deal directly with the attending physicians. Whatever the attendings said, well, that was supposed to be gospel.
In my first year of residency, I was taking care of patients in the neurology ward of the major university hospital. One specific attending, the former Chairman of the Department of Neurology, then the Chairman Emeritus, was always quite insistent that all things be done his way. Per guidelines, the residents’ responsibility was to co-sign any order written in a patient’s hospital chart. Only then could the order be implemented. This enabled both the resident and attending physicians’ being kept up to date regarding what exactly was being done for a patient.
One morning, I was seeing a new patient admitted to the hospital the night before. The attending would see him later, after I had done a history and a complete general physical and neurological examination and wrote whatever orders were necessary.
Mr. Charles was a 63-year-old man who had a history of Parkinson’s Disease. This disorder, secondary to the death of specific brain cells, created great difficulties in a patient’s abilities to move, both smoothly and accurately. It made it difficult for the patient to speak louder than a hoarse whisper. He had difficulty swallowing. Mr. Charles had great difficulty eating and drinking, and had become cachectic and dehydrated. This was why he was hospitalized. The dehydration had also made it difficult for him to have a bowel movement. He had become impacted, the stool in his large colon being unable to move forward and out.
The first appropriate treatment was to hydrate the patient with intravenous fluids. To do this too quickly could create cardiovascular problems, such as congestive heart failure. Another important consideration was the necessity of keeping the electrolytes, the important common blood chemicals such as sodium and potassium, in balance. If they became very unbalanced, cardiac, or heart problems could occur.
I did my history and neurological examination and documented these things and wrote new orders on the patient’s chart. Then I went to see my other patients.
After lunch, I returned to the nurses’ station to see if any attending physicians had written orders which I would have to co-sign. I went through a half dozen charts, dutifully placing my signature under any attending’s orders. I came to Mr. Charles’ chart. The Professor Emeritus had written an order for a barium study of Mr. Charles’ large intestine. This was understandable. Then I saw the next order. It was for three enemas, and it was to be done immediately.
I rolled my eyes and muttered something obscene. I would have to call the Professor Emeritus and discuss the problems of doing three enemas, at that time, in the very dehydrated Mr. Charles. While an enema is certainly useful in cleaning out the colon, it also will leach out electrolytes, a very dangerous thing to do to Mr. Charles.
The major problem, I knew, was that I would essentially be challenging the Professor Emeritus.
Now, questioning everything is a good thing, in medicine. The vast majority of professors expect it and understand it. It also keeps them on top of their game, keeping ahead of the residents. The Professor Emeritus, unfortunately, had become emeritus when it was widely acknowledged that he, while currently in his seventies, might have been having some memory problems. Many of the residents suspected it was more serious than that. Serious like early Alzheimer’s disease, also called senile dementia.
So, hoping for the best, I placed a call to the Professor. When he picked up the phone he answered in his prototypic manner.
“What?”
“Uh,” I started, “Sir, this is Jason Stone. You ordered three enemas for Mr. Charles. I’m afraid that if we did that now he could go into a cardiac arrhythmia. He’s too dehydrated.” I then read him the results of the patient’s complete blood count and chemical panel, all of which demonstrated that the patient’s blood was very concentrated secondary to lack of fluids. His kidney function was marginal at best.
Respectfully, I asked if we could put off the enemas for at least 24 hours, during which time the intravenous fluids would help immensely.
The Professor’s answer, unfortunately, was also stereotypical.
“You listen to me! I am the Professor Emeritus and you will do what I say! Co-sign my order and don’t bother me.”
With that, he hung up the phone.
I remember thinking that I was between a rock and a hard place, to put it nicely. If I followed his directions, Mr. Charles’ health could be seriously compromised. If I didn’t, my hopes of completing my residency could be negatively effected. No one argued with the Professor Emeritus, especially some lowly first year neurology resident.
I must have sat at the desk for a while. I’m not clear about how long. But finally, I got up and went to speak to the Head Nurse, Ms. Thompson.
Residents learn very early in their lives, when they are interns, that one must never, ever, become a problem for a staff nurse. If you did, your life would become miserable. The nurses had the power to make sure you were paged every half-hour, every night you were on call, if they didn’t respect you or didn’t like you. And there was nothing you could do about it.
Just go along to get along.
Ms. Thompson was known by all the resident’s to be of the old school. She thought nothing of doing her best to intimidate and demean interns and residents. Part of the rite of passage for would-be doctors.
I showed her the Professor Emeritus’ order for three enemas and asked her advice as to what I should do. I explained my concerns and asked her, as humbly as I could, to see if she could talk to the Professor Emeritus, as she knew him so much better than anyone else. In fact, rumor had it that she had once worked in his office.
She glared at me and snapped, “Just sign the order. You know the rules!”
I went to see Mr. Charles again. His IV fluids were dripping in at a relatively slow, but steady rate. His tongue was still dry and his skin still tented when I pinched it, definite clinical signs of dehydration. His rheumy eyes stared off at the ceiling while I examined him. I wasn’t even certain that he knew I was there.
My heart was beating at approximately twice its normal cadence when I walked back into the nurses’ station and replaced Mr. Charles chart in the chart rack. I did not draw the yellow tag that would tell the desk clerk that there was an order to take off.
I didn’t co-sign the Professor Emeritus’ orders.
Knowing the trouble I had started brewing for myself, I walked off the ward and down to the neurology clinic, where I had a number of patients to see that afternoon. I knew what would be coming; I just didn’t know when.
I worked through the afternoon, seeing my patients, doing what I could to help them deal with their neurological problems including multiple sclerosis, Parkinson’s Disease, brain tumors, peripheral neuropathy (pain from injured nerves), and headache and other pain problems.
I remember that I was writing in my charts, after the patients had all been seen, when I received a call from the Chief, the current Chairman of the Department of Neurology. I picked up the phone and said hello. He immediately got to the point.
“Listen, I got a call from Ms. Thompson. She said you refused to sign the Professor Emeritus’ orders. You know that can’t be tolerated! Now, get over there and sign them!”
“Look,” I said, “ Please let me run this by you first.”
I told him about the case. As I expected, the Head Nurse had not told him the facts. He had just been told that I was being recalcitrant. When I finished, there was silence on the line, as he absorbed what I had told him.
“Sir?” I asked after almost a minute of silence on the phone.
Finally, he spoke up, but his tone of voice had dramatically changed.
“You are a first year resident. You show promise. Don’t screw things up; just sign the orders, OK?”
“Sir,” I began, but he cut me off, his voice much harder this time.
“Damnit, just do what I said. If you do not, then I expect to see you in my office at O-eight hundred in the morning. Do you understand?”
“Yes, Sir,” I replied.
I remember finishing my charts and slowly walking home, back to my apartment several blocks away from the hospital. I avoided looking at the hospital as I walked past it.
Early that evening, I heard a knock at my door. I was surprised to find the Chief Resident himself standing at my door. Carroll and I were, I hoped, friends. I thought him to be an exceptional physician and a good man too.
“Hey,” he said as he walked into my small apartment, “The Chief told me about what’s going on. I really think you should sign the damn orders and forget about it. You can’t fight the Professor Emeritus; he’s got too much pull.”
“Wait a minute; let me tell you about the case!”
He shook his head. “Look, I reviewed the chart before I left the hospital. I know where you are coming from, and, frankly, I agree with you. But, you’ve got to do it.”
I must have looked pretty pathetic, because he added, “Confidentially, I think the Chief also agrees with you, but it doesn’t matter. Mr. Charles is the Professor Emeritus’ patient. He calls the shots. So, you sign the orders, and if Mr. Charles crumps, that’s not your problem. I’ll check the chart at seven in the morning. Make sure you’ve signed the orders by then.”
He looked me straight in the eyes and winked.
“You know, you have to go along to get along.”
Without another word, he turned and left the apartment. I closed the door and locked it, then sat on the chair in my living room and turned on the television. I think I watched it all night, because I don’t remember getting any sleep.
I was dressed and ready to go back to work at six thirty the next morning. I had debated what I should do all night. I still had problems with the idea of signing the chart and having something happen to Mr. Charles.
I was in the wards at a quarter to seven. I walked directly into Mr. Charles’ room and re-examined him. His tongue wasn’t as dry, but his skin was still tenting.
I ignored the pointed looks from the nurses when I went into the nurse’s station and picked up Mr. Charles’ chart. I checked the most recent laboratory results and they showed some improvement, but it was marginal.
It was five minutes to seven. Carroll would be here very soon to check the chart.
Who was I to not go along? Why screw up my residency because of one old patient?
I didn’t know the answer to either question, but my gut told me that signing the orders would be a big mistake.
Of all the things and people in the world, I listen most often and most closely to my gut.
I closed the chart, left it on the desk and walked off the ward. I went to the cafeteria to get a cup of coffee before I went to the Chief’s office in an hour.
I managed to choke down a bagel with my coffee. While I sat there, two of my fellow neurology residents stopped by the table to tell me I was wrong.
Word really travels fast in hospitals.
I was sitting outside the Chief’s door at a quarter to eight, his secretary looking at me, I thought, rather accusatorily, though I may have imagined it. How could she know?
At eight straight up, the Chief opened his door and motioned for me to come inside. I followed him into his office and sat across the desk from him. He looked at me silently for a few moments, and then said, “I instructed Carroll to co-sign the orders if you didn’t. He signed them about six this morning.”
“He told me I had until seven this morning,” I ventured.
The Chief ignored me.
“You know how the hospital works. You know the chain of command. You know you should have signed the Professor Emeritus’ orders.”
He looked at me, but I had nothing to say. I had screwed myself.
The Chief had the grace to look uncomfortable when he said, “This matter will have to go before the committee. You will probably lose your residency, because you willfully didn’t follow directions, even after Carroll and I both told you to sign the orders.
“Do you have anything you want to tell me?”
I felt angry and sad and frustrated all at once. My life had just gone down the toilet. I felt I had been right, but so what? I think I remember wondering if I should beg and plead for another chance. I was so overwhelmed with different emotions I couldn’t say anything.
I did reach up, take my badge off of my blue coat and place it on the Chief’s desk. I knew if I sat there any longer, tears would defeat my efforts to stay in control, or, worse, I would say something that I would regret.
I got up and was walking to the door when the Chief’s phone rang. I heard his secretary tell him that radiology was on the phone. I heard her voice through the door. A chill ran down my spine, as I turned to look at the Chief. He mumbled a couple of words into the phone and slammed it down into its cradle. He turned his chair around to look outside and said, “That was radiology.”
I hadn’t been sure he even realized I was still in the room.
“They did the three enemas on Mr. Charles. He developed ventricular fibrillation. He coded. He died.”
He turned his chair back and looked at me.
“So, you were right,” he said flatly.
“So what?” I almost shouted. “Mr. Charles died. I almost wish I wasn’t right, at least the old guy would still be alive.”
Shamefully, I must admit that I also realized that they couldn’t throw me out of my residency spot now, as it would expose the Professor Emeritus’ failings.
The Chief picked up my badge and held it out to me.
I looked at it and I remember feeling only one thing. Anger.
“I don’t know if I want it back,” I said. “Mr. Charles is dead, and I was right. None of this had to happen.”
The Chief looked at me and said, “Take the rest of the day off, but be here by seven tomorrow morning to get this thing back. Otherwise, you are out.”
I was there at six thirty the next morning, still feeling angry, but, thankfully, I was not a complete idiot.

The intercom in my office buzzed. I looked at my watch and saw it was only eight in the morning. My first patient was scheduled for nine.
“Yes?” I answered into the air.
“Doctor, I just wanted to see if you needed anything. Would you like some coffee?”
“Yes, thank you Susan. I would appreciate it.”
“I’ll bring it right in.”
It was my first day in my new office. My office! I was elated, and frightened. It wasn’t the patients or the medicine that made me cringe; it was the realities of my financial situation. All my savings had gone into the place. It was nicely decorated, not ostentatious, but comfortable. I had hired my staff, eight people in all. I was responsible for their salaries, insurance and benefits. That was what scared me. The buck literally stopped with me.
Susan, the secretary, receptionist and patient scheduler, knocked on the door and entered my office carrying a big cup which said “Hail to the Chief, For He Needs Hailing!” It was a little present from the staff, who were standing behind the open door looking in my office.
I took the cup and stood up, thanking everyone. I made an impromptu speech thanking everyone for the gift and telling them I was really excited about starting the practice. I told them that I knew with them behind me, we would do extremely well.
We congratulated each other and, very soon, I was left alone again in my office, behind the closed door.
The problem with treating pain was that no one person was able to do it alone. The most appropriate way to do it was with an interdisciplinary treatment team. This meant that I needed to work with other clinical specialties, all under the same roof. This provided the patient the most reliable and tested treatment opportunity to get better.
Some docs just sent their patients out to other clinical specialists, wherever they happened to be. This created a poor excuse for coordinated care, as it was almost impossible for all the treating clinicians to talk regularly and keep a patient’s care coordinated, fast and cost effective. It also made it impossible for the medical “Captain of the Ship”, the doctor who was responsible for all aspects of a patient’s care, to be more than a figurehead, as there was really no way for him to control what the other consultants did.
I had formed an in-house interdisciplinary treatment program. I had, on my staff, a clinical and neuropsychologist, a physical therapist, a biofeedback specialist, an occupational therapist, a speech and language therapist and a nurse rehabilitation specialist. All of these specialties were needed to deal with the complex pain, headache and mild to moderate traumatic brain injury patients we expected to be seeing.
I was lucky, too. I had developed something of a good reputation regarding my abilities to diagnose and treat these problems. So, when I let out the word that I was striking out on my own, sending out information cards with details of the new practice and speaking with my friends in the medical community, I was gratefully surprised to find I was opening my practice with a full schedule going three weeks out.
That was a blessing.
I glanced at my watch. A half-hour to go until business started.
I looked around my office. The plaques were on the wall, the bookshelves were full. The furniture was new, but not at all fancy. The chairs were comfortable, but they were not where one would expect them. In the middle of the room was a small round table. That was where I would see my patients. I instinctively didn’t like the idea of talking to people across from a big, wide desk. To help people, you had to be close to them, accessible, and not cut off from them by a large block of wood.
I picked up the phone and stared at the receiver for a moment, wondering who I wanted to call. The decision to leave corporate medicine had effectively cost me my marriage. My soon to be ex-wife liked the prestige of my being a Medical Director at the big HMO. She didn’t like the idea of my spending our accumulated savings and starting my own practice. A risky venture she was not prepared to accept. The fact that she was a highly paid executive making more money than I did appeared to be irrelevant. I think she would have been happier if I just stopped working and let her pay the bills. That would have been better in her mind than my taking such a demotion, from Medical Director to private practitioner.
Although I had tried my best to explain my frustrations about what I was going through at the HMO, and how much I disliked what I had to do, she just shook her blonde hair and looked at me, shaking her head with the rationalization that I must be crazy. Too crazy for her to want to spend her life with me.
Well, maybe I was crazy. Time would tell the story.
But it grated in my mind. I wanted to share my desire to help people, really help them, with my wife, but she thought the entire concept was bullshit. That was no way to be married. Contentiousness was us, unfortunately. The hurt was there, but I did my best to compartmentalize it somewhere in my mind where it wouldn’t affect the rest of what I had to do.
Twenty minutes to nine. I put the phone down and straightened out the things on my desk. I almost laughed, knowing that within hours, the desk would be covered with paper, a form of chaos that I seemed to thrive in. A clean desk was the sign of a sick mind. I read that somewhere. If that was true, I was one of the healthiest people around.
I re-read the patient list next to my phone. I had seen some of them before, when they had belonged to the HMO. When their insurance changed, after they realized the Big Lie, a good number of them had called my new office, wanting to continue working with me.
That engendered some hope that things would work out. I must have done some things well.
Susan called me through the intercom again.
“There’s a Dr. Jackson on the phone. He wanted to know if you would give a lecture at some meeting. Line 2.”
I picked up the phone.
“Hello, Dr. Jackson. This is Jason Stone.”
“Dr. Stone, thank you for speaking with me. I’m putting together a program for the University Pain Center. I was wondering if you would consider giving a talk about headache. The meeting is scheduled for June 19th, which would give you almost six months preparation time.”
“I’d be honored,” I answered truthfully. “Who is the audience?”
“Typically, University physicians, with a good number of local doctors. This is our third annual Pain Symposium. We usually get 500 to 600 attendees.”
“Well, I’d be happy to give a headache talk.”
“Excellent. I’ll write you a letter giving you all the particulars. Appreciate your time.”
Dr. Jackson hung up the phone, as did I.
I thought for a moment, clenched my fist and threw it into the air. An enthusiastic “Yes!” escaped into the silence of the office.
This was starting to be a good day. A great day!
“Dr. Stone, your first patient is here,” Susan piped into the office.
I looked again at my patient list. A jittery feeling hit my stomach.
It was show time.
The door opened and Giselle, my nurse, led my first patient into the office.
I stood and walked up to the patient and shook her hand. I moved to the small round table and sat down, indicating that she and Giselle should each take a seat.
Giselle handed me her chart and I looked over her scribbled notes. My heart sank.
There was a big problem. No question about it.
There was a good chance that the day would not end up so well after all.