Thursday, December 26, 2013

Next Night Clinic

                                 

“Come on, come on, change already,” I yelled at the light. “Finally. Seven Forty?, I’ll never hear the end of it… Move it up there… Stay green. Finally, there it is….Seven fifty five…I guess that’s not too late. And, it’s a full moon.”
I should never have finished watching that movie; should have left earlier so that I wouldn’t be late again. I’ve already seen it five times. Galaxy Quest. A stupid movie anyway. “Activate the Omega Thirteen*” and go back in time thirteen seconds; what; I need is the Omega ten thousand.
I tried to sneak in the back, but, no luck. Not only was Miss James not there, but the Medical Director was and he did not look happy.
“Sorry, I’m late, Dr. Olsen,” I tried to explain, “but I had trouble finishing my shift at the hospital and traffic was bad and I had to feed Jenny…”
Dr. Olsen just stood there with his arms folded across his chest. He wore black rimmed glasses, was short, bald, and round and he wouldn’t have known a varicose vein from a hemorrhoid. He was the ultimate pencil pusher, rules and regulations were all he knew.
“Jenny?” he asked in his squeaky, nasal, monotone voice.
“My dog, a mutt, part terrier, part collie, and a lot of parts we aren’t sure of,” I explained trying to lighten the mood.
“Stop, Dr. Barnes,” he held up his hand and shook his head. Beads of sweat landed on my scrubs. “I don’t care about Jenny. I don’t care about your other job. I don’t want any excuses. You’ve been warned repeatedly, we’ve even overlooked a few minutes here and there because you’re a good doctor, but fifty eight minutes is unacceptable. It’s my job to see that this clinic is properly staffed; twenty four hours a day, seven days a week, without interruption. I’m afraid that after tonight your services will no longer be needed here. Good evening.”
That was it. He walked out. No discussion, no appeal, nothing.
“That was rough, Dr. Barnes,” the nurse tried to console me. “I’m Judy, Judy Small. I usually work L&D, so I’ll need a little guidance. All the rooms are full. Fifteen year old with belly pain is in one, eighteen year old girl with a laceration of the arm in two, some sort of altercation I think; a patient with a headache in three and swollen legs in four.”
Just great. A rookie nurse, all the rooms full already and I’m out of a job. I knew I should have stayed in bed today.
I picked up the chart to one. Jeremiah Baker, fifteen, no medical problems, lower abdominal pain for two days. No fever, vitals normal. At least he should be fairly straightforward.
I knocked and opened the door.
“Good evening, Jeremiah. I’m Dr. Barnes. What is the problem you are having?”
“Hi Dr. Barnes,” he greeted me with an enthusiastic hand shake. “Jeremiah. I’m really happy to meet you.”
He flashed a huge, wide grin and then winced slightly, as he held his right side. I wasn’t a surgeon, but I already was making a diagnosis of appendicitis.
“What’s the problem you’re having?” I asked again.
“I’ve got this pain in my abdomen, right here,” and he pointed to McBurney’s point. “it started yesterday and just won’t go away.”
“Any nausea or vomiting or fever?” I continued, taking his history.
“I threw up once last night and I haven’t eaten anything all day. It’s appendicitis isn’t it Dr. Barnes. I’ve got all the symptoms don’t I?” and he flashed his grin again.
“So far I’d say you’re batting a thousand. Lay down here and let me check your abdomen,” I requested.
Jeremiah lay on the exam table as I gently palpated and percussed his abdomen. When I reached his right lower quadrant he visibly winced and the localized rigidity was classic peritonitis.
“Well, young man,” I began, “you almost certainly have acute appendicitis. I’m sure you’ll need an appendectomy, but we don’t do surgery here. I’m going to call Dr. Forstey at University Hospital and get you on his service. He’s a great surgeon and he’ll take good care of you. In the meantime, we’ll start an IV and give you some antibiotics and make the arrangements to get you to the hospital. Are your parents around?”
“My mom was here, but she had to go to work and left about five minutes before you came in, but I’ll call her,” Jeremiah said.
Then he added, “You know Dr. Barnes, I knew it was appendicitis. I did some reading and I knew I had all the classic symptoms. And, I’ve been studying really hard, because I’m going to be a doctor, like you. There are a lot of bad things which go on in this neighborhood, gangs, drugs, lots of crime, but most of the kids they know about you. They know that you come here from the University and that you care. That’s the kind of doctor I’ll be; one who cares.”
He gave me one of his big smiles and I smiled back.
“Thanks for the compliment, Jeremiah,” I replied. “Just lie here and the nurse will be in a few minutes.”
I scribbled some orders on his chart and called Nurse Small and told her to start an IV and begin Jeremiah on IV Zosyn. Then I called Zack Forstey and arranged for transfer to University Hospital. I moved on to room two and the lacerated arm.
I glanced at the chart for Kelly Montague, eighteen, laceration of the left arm. No medical problems, no allergies…
Hmm, did that boy with appendicitis have any allergies? I don’t remember what the chart said.
I went back to room one and looked for Jeremiah’s chart.
The nurse must have it in the back.
 I stuck my head in the room.
“Do you have any allergies?” I inquired. I saw Nurse Small hanging the IV fluids and the medication. One thing about those L&D nurses: they were really good at starting IV’s. I still did not see his chart.
“Not that I know of, Dr. Barnes,” Jeremiah answered. “Do you want me to check with my mom?”
I thought for a moment.
He’s fifteen; he should know.
“That’s OK. I’ll be back in a few minutes and the ambulance is on the way.”
I went back to the lacerated arm.
“Good evening, Miss Montague. How did you cut your arm?” I started what I hoped would be a short interview.
“I did it Doctor, I cut it. I wanted to kill myself. That’ll show that Gerald. He’ll miss me when I’m gone, that miserable creep,” she ranted.
Just what I need, a hysterical, suicidal teenager.
“Calm down, Miss Montague. I’m sorry about Gerald. I’m sure he is the biggest creep in the world, but I need to know about your arm.”
“How dare you call my man a creep. Who do you think you are, Mister Dr. Bigshot? Gerald is ten times the man you are. I’m not staying here and let you insult him and me. Good-bye Doctor Bigshot.”
And she stormed out of the clinic. Oh well, you win some and you lose some.
I made a note on her chart: “Left AMA, did not sign the form” and went on to the next patient, Elias Trowbridge, fifty three, with a headache for twelve hours.
I started to knock on the door when I felt a grab on my sleeve.
“Come to room one, something’s terribly wrong,” Nurse Small shouted. She was white as a sheet and her hand was shaking.
I raced back to one and found Jeremiah on the table, IV in his arm, he was blue from head to toe, convulsing and not breathing.
“What happened?” I screamed as I picked up the ambu bag and tried to ventilate him. I vainly felt for a pulse. “Get the crash cart and give me some Epi.”
I saw the bag of antibiotics hanging, half of it infused and strongly suspected anaphylactic shock.
“Epi, open up the IV, start chest compressions,” I commanded.
Nurse Small dutifully obeyed as I picked up the laryngoscope.
“All I see is a big swollen tongue. I can’t get passed it. Get me a scalpel.”
I’d never done an emergency trach or cricothyrotomy on a live person, only on a dummy, but I had seen my surgical colleagues do them. I saw no alternative at that moment.
I splashed some Betadine on Jeremiah’s neck, felt for the appropriate landmarks and started to cut.
There’s a first time for everything.
After an eternity of slicing through skin and fat and I’m not sure what else, I entered the airway. After a few missteps I managed to slide a size 6 ET tube in and stared to ventilate Jeremiah. I had been at it for a total of twelve minutes, but it seemed like twelve hours. Jeremiah wasn’t responding, however. No effort to breath, no pulse and the EKG was flat.
“Start CPR,” we said simultaneously. But, it was futile. He was gone.
Now what? Call Mrs. Baker and tell her, ‘Good evening, I’m sorry to inform you your son is dead. This night has gone from bad to worse.
“Dr. Barnes?”
“Yes, Miss Small.”
“I’m sorry. I don’t know what happened. I started the Zosyn and then, all of a sudden, he turned blue, he stopped breathing and started seizing. Was it something I did?”
I looked at her face. Tears were streaming down both cheeks.
“No, nurse. It was what I did.”  
Why is it always people like Jeremiah? Why do good people have to die? Why? Why?”
Where is his chart, anyway?
I left to go back to the break room, closed the door, sat down and stared at my hands.
“Dr. Barnes, please come to room two,” Miss Small’s voice sounded over the intercom.
I shook myself free from my moment of anguish and trudged down the hall towards exam room two. I heard a woman scream.
“What’s going on in…?” I started to ask as I bulled my way into the room. My question was immediately answered by the sight of a young woman, maybe fifteen years old, up in stirrups, obviously in labor. Miss Small was checking her as I walked in.’
“She’s ten and ready to push, Dr. Barnes,” Miss Small reported.
I hate delivering babies.
 “It says she arrived two hours ago. Why didn’t she transfer to the hospital?”
“With all the excitement, I guess she feel through the cracks,” Miss Small answered.
I glanced at her name, Barbi Genter, then I donned a gown and gloves and went to work.
“OK, Miss Genter, when I tell you to push, you push, like you’re trying to send this baby across the room. When I tell you to breathe, you should take quick, deep breaths until I tell you to push again, OK?”
She grunted, which I took as an affirmative. I could see dark hair and then the head was all the way down.
“Easy, no Barbi, wait for the next contraction and we’ll have this baby out in no time.”
I was hoping to get the kid out without an episiotomy. I had my hand on the baby’s head when my patient gave a hard push and the head popped out followed by the rest of a healthy looking baby girl, which was followed by a large amount of blood from somewhere. I quickly passed the baby off and then went to work trying to find the source of what was a lot of bright red blood.
“Check the baby fast, Miss Small. I’m going to need some help here. Oh, and turn on that Pitocin.”
Maybe that will help.
No such luck. Blood was pouring out and I was feeling helpless to stop it. I reached my hand up inside and felt the disrupted uterus and then I picked up the sheet which lay across Barbi’s abdomen and saw the low transverse scar.
“How many C-Sections have you had before, Miss Benton?”
There was no answer as I glanced at the monitor which revealed a heart rate of 140 and BP of 60.
“Open up the IV and call an ambulance, Miss Small,” I screamed as calmly as I could, as I quickly delivered a torn placenta. The bleeding didn’t stop, however. I started to pack sponge after sponge into the uterus and vagina and then watched as her abdomen started to get bigger and her blood pressure and then her pulse started to sink even lower.
“Epi, Bicarb, Calcium, the kitchen sink,” I ordered.
The ambulance arrived, finally. She was alive, but barely. She had a heart rate of 120 and BP of 70 as they packed her into the ambulance and sped away, both mother and baby.
How many more hours until seven?
There was a woman waiting for me as I walked out of room two.
“Dr. Barnes?” she asked.
“Yes?”
“I’m Dorothy Baker. I got a call about my son? The lady told me it was urgent.”
I’m not ready for this.
“Wait for me in Room three. I’ll be with you in a moment,” I asked, trying to calm my trembling voice.
“Is Jeremiah OK? Please tell me.”
I stepped into the room with her. I’m sure she sensed that something was terribly wrong.
“Jeremiah is dead,” I reported to her, far too matter of factly, I decided, too late. “We were sure he had appendicitis and we were getting him ready to go the hospital, he was given IV fluids and antibiotics, and then he suddenly arrested and I couldn’t save him.”
She looked at me in a funny for a moment, then put her hand to her mouth and her eyes became wide, as she began to fathom the true meaning of my words
“NOOOOO, NOT MY BABY,” she screamed and she pounded on my chest. “Antibiotics? You gave him Penicillin, didn’t you? He almost died when he was two from a dose of Penicillin.”
I took a step back and almost passed out, collapsing into the chair.
“I asked him if he had any allergies and he said no,” I muttered.
“I WROTE IT ON THE FORM, IT WAS THERE IN BLACK AND WHITE, YOU…YOU KILLED MY BABY,” she screamed and then she slapped my face and walked out.
I’m sure it said NKDA, or did it? Did I even look at the history?
I felt my medical career slipping away from me as I jumped up and ran to check Jeremiah’s medical history. The chart had magically appeared at the nurse’s station. She was right. Allergy: Penicillin.
How could I miss that? How can I keep being a doctor when something like this has happened?
Miss Small came in at that moment, ashen, tears streaming down her face.
“How could we both overlook something like that?” she asked, not expecting an answer. She sat next to me, neither one of us knowing what to say.
“There’s only one more patient here, everyone else has left,” she finally remarked. “maybe you can see her real quick and then we’ll close the Clinic for the last hour.”
I turned and looked at her, nodded my head and managed to drag myself down the hall to room four. There was a smell emanating from beneath the door, a familiar scent of dried sweat, unwashed clothes and decaying life which was common among the many homeless individuals who came to the Clinic for medical care, warmth and the occasional handout. I glanced at the name, Gladys Wentworth, “Gussie” to those of us familiar with the neighborhood population.
“CC: Swollen legs…”
“Hello Gussie, legs still bothering you?” I asked, obviously barely interested in her answer.
“The demons are out tonight,” she whispered. “They’re all over; saw a nasty one right outside. Full moon. No one’s safe. Here take this quick. It’ll keep them away.”
She handed me a garland of dried apricots and prunes.
“Put it on,” she commanded.
I complied just to speed things along.
Gussie was about five foot nothing, weighed about three hundred pounds, despite having only two teeth. She always wore a heavy coat over seven or eight layers of clothes, even if it was a hundred degrees. Her skin was wrinkled and grimy and she was accompanied by a small cart which contained all her worldly possessions. She was diagnosed with schizophrenia; her state of cognition dependent on whether she had remembered to take her medication. And, she was plagued by chronically swollen legs which brought her into the Clinic on a regular basis.
“You taking your meds, Gussie?” I asked as I started to look at her legs.
“Twice a day, without fail,” she answered. “If I didn’t I’d be seeing things and hearing voices.”
“But there are demons out tonight?” I inquired. Normally I ignored her commentary, limiting my work to treating her legs. However, with all that had happened this night I was grasping at any explanation for the series of disasters.
“Terrible demons. The devil’s workers. That necklace will keep them away,” she whispered in my ear. “If you still see them, add a few cloves of garlic and for sure they’ll leave you be.”
Her legs weren’t as bad as usual. Discolored and edematous, but no ulcers or signs of infection.
“Keep doing what …” I started, but she interrupted me.
“This is the last one. I stole it from Aladdin. His last wish. He thinks it’s in that lamp, but I took the wish and now it’s mine. I just can’t decide how to use it.”
She held up a small glass jar with a cork in the top.
“It’s just an empty bottle,” I said, being in no mood to humor her. I was growing tired of our encounter and just wanted her to be gone.
“Just elevate your legs as much as possible, Gussie and you’ll be OK. I see that you’re supposed to be seen at the Hospital next week. Please keep that appointment.”
“But, Dr. Barnes…the demons, what about them?”
I looked at her eyes, which were looking around wildly and I took the garland from around my neck.
“Here, Gussie. You wear mine too. That way you’ll be twice as protected.”
She smiled at me and took the wreath of fruit and gleefully put it on.
“You’re all set now,” I reassured her.
“Thank you, Doctor, thank you,” she said effusively and she shook my hand.
I saw Jeremiah in that handshake and pulled my hand away.
“You’re OK, Gussie, but please leave,” I muttered as I opened the door.
She looked at my face, her eyes betraying a look of fear, but not fear of unseen demons, it was fear of me, as if I was the demon. She wheeled her cart out the door and disappeared into the early morning. The sun was starting to rise and there was light fog. It was six forty five.
Fifteen minutes left in my medical career.
Back at my apartment I lay down reflecting on the night’s events, mulling everything over and over, but always coming back to the smiling face of Jeremiah and the unseen words written on his chart: ALLERGY: PENICILLIN. ALLERGY: PENICILLIN. ALLER... Of course it wasn’t the first time I’d made a mistake; residency is an endless stream of “learning experiences” as Dr. Gottlieb liked to call them. But, there is a difference between mistakes in judgment and carelessness. It was a difference I didn’t think I could live with.
I lay back on my couch and knocked my white coat to the floor and heard a loud “Thud.”
What’s that?
I picked up the coat and felt something in the pocket, an empty jar, crazy Gussie’s wish in a bottle. I stared at the empty jar and looked at it from every angle. It was just an empty jar.
Hmm… no she’s loony. Still, it can’t hurt to try. Now what were the Genie in Aladdin’s rules?1. Can’t kill anyone,2. Can’t bring people back from the dead and 3. Can’t make anyone fall in love with someone else. I don’t need one or three. But number two is a problem. Maybe there’s a way around it…
“What am I thinking? It’s just an empty jar. Gussie’s crazy. Besides, Jeremiah’s dead,” I concluded out loud. “Maybe if I…”
I took the cork out and closed my eyes.
“Nothing.”
I put the cork back in the jar, tossed it in the garbage and lay down on the couch, trying to decide if I should become a dishwasher or a waiter.
Maybe I’ll end up in jail.
Hours later I was awakened by the phone ringing.
“Hello,” I answered, sleep still in my voice.
“Don’t tell me you’re sleeping. Get your ass up and get to the Clinic,” Miss James commanded. “You can’t be late again. Edith told me that Olsen is going to be there and that if you’re late one more time, you’ll be fired.”
“Uh, Ok, but I was already fi…” I started to say, but then I stopped myself. “Hold on just a second.”
I looked at my phone. It was yesterday and I had an hour to make it to the Clinic. I looked in the garbage, no empty jar.
“Thanks for calling me, my sweet wonderful nurse. I’m on my way.”
I jumped into a new set of scrubs and hopped in my car. I hit every light on the way and made it to the Clinic twenty minutes early. Dr. Olsen saw me, said “Good Evening” and left.
Jeremiah was there with his mother, was diagnosed with appendicitis and started on Levaquin. He was transferred to the hospital for an uneventful appendectomy. Kelly Montague had her arm sewed up and was released to Psych. Barbi Genter showed up in labor and was transferred to the hospital before she had progressed too far.
Finally there was only one more patient to be seen, a homeless woman with swollen legs, Gussie.
“Good evening, Gussie, what’s the problem you’ve been having? Your legs again?” I started my usual speech, trying to hide the excitement in my voice.
“It’s a good night to be out. No monsters or demons. The streets are safe from evil spirits,” she announced.
“I agree with you Gussie. Now, let me take a look at your legs.”
Her legs showed their usual swelling and changes of venous stasis. I admonished her to wear her support stockings and keep her legs elevated and to keep her appointments at the hospital clinic. As she was getting ready to leave I saw the empty glass jar.
“A wish?” I asked her pointing to the jar.
“A wish? Nope, just a glass jar I found in a dumpster over on Maple,” she said in her mumbling voice. But, she looked at me and smiled as she gathered her cart and belongings and left.
I smiled back.
True second chances should be cherished. They are a rare and precious gift.


*In the movie “Galaxy Quest”, the Omega thirteen is a device which, when activated, allows an individual to relive the last thirteen seconds of his or hers life.