Chapter 16: Defeated

July 6, 1989, McKinley, Ohio

"A heart attack?" Mrs. Valerio gasped.

"Yes. Your cardiac enzymes show you had a mild heart attack."

"But you didn't see it on the machine!" her husband protested.

"Not every arrhythmia, that is, an irregular heartbeat, shows on an EKG, and women often don't have the classic symptoms that men have. And the enzymes show that it was mild. I'm going to call for a cardiologist to see you. He or she and I will discuss what we do next, but for now, I'm going to give you some nitroglycerin, which will relieve the heavy feeling in your chest and bring down your blood pressure. Wendy, sub-lingual nitroglycerin tab, please. Len, call for a cardiology consult, please."

The nitroglycerin reduced Mrs. Valerio's chest pain and brought down her blood pressure. About ten minutes later, Doctor Javadi came into the room with her student.

"Morning, Mike," Doctor Javadi said.

"Morning, Leila," I replied. "Mrs. Valerio, this is Doctor Leila Javadi from Cardiology."

"Good morning, Mrs. Valerio," Doctor Javadi said.

"Good morning, Doctor."

"What do we have, Mike?" Doctor Javadi asked.

"Mary Valerio, seventy-eight, presented dizzy and weak, with mild chest pain, mild hypertension, and slight tachycardia. EKG showed no arrhythmia. Cardiac enzymes are slightly elevated. Nitroglycerin sublingual resolved the chest pain and hypertension. Len, the test results, please, for Doctor Javadi."

He handed them to her.

"Thanks, Mike," Doctor Javadi said. "Mrs. Valerio, I'd like to examine you, please."

Doctor Javadi reviewed the test results Len handed her, then performed her exam.

"Mrs. Valerio, I'm going to admit you to cardiology for an echocardiogram, which is an ultrasound of your heart. Mike, we'll need a portable EKG. Janelle, call for an orderly, please."

"Right away, Doctor," her student said.

"Len, you'll go with them. Cardiac patients are always accompanied by three."

"Will do," Len confirmed.

"Mrs. Valerio," I said, "Doctor Javadi will take good care of you."

"Thank you, Doctor."

I made notes on the chart, signed it, then left the room and went back to the admit desk.

"Who's next?" I asked Bob.

"Er, I thought you decided."

"Yes, but you tell me what you have and which patient you think I should take."

"Seventeen-year-old female with a sprained knee; twenty-nine-year-old male with a week-long productive cough; sixty-five-year-old with a minor forehead lac and contusion. I would take the cough, as the forehead contusion shows no neurological symptoms."

"Did you mask the cough?" I asked.

"Yes. That's on the standard procedure list."

"I agree that's who I should take first. Do a second neuro check on the contusion in ten minutes, please."

"Will do!"

He handed me the chart, and I went to the door and called out, "Mr. Kennedy?"

"Me!" came the muffled reply through the mask.

He stood up and walked over to me.

"I'm Doctor Mike; follow me, please."

I led him to Exam 5, then asked Ellie for a nurse. She assigned Julie, who accompanied me to the exam room.

"How long have you had your cough, Mr. Kennedy?" I asked.

"About a week," he replied.

"OK, we'll get your vitals, and I'd like to listen to your heart and lungs. Julie, we should mask."

"What do you think I have?" Mr. Kennedy asked.

"I don't know," I replied. "The mask is simply a precaution. I'll put one on because I'll need to have you remove your mask to check your breathing and look in your mouth and nose."

Julie and I both washed our hands, put on gloves and masks, and she took Mr. Kennedy's vitals. Once she'd done that, and written the results on the chart, I had Mr. Kennedy remove his mask and performed a basic exam. The only thing that stood out was that he had significant crackles in his lungs, along with slight tachycardia. I had him put his mask back on before I continued.

"Does your chest hurt?" I asked.

"Yeah," he replied.

"While you're coughing, after you cough, or all the time?"

"At first just when I was coughing, but now it feels tight and aches."

"Do you sweat at night?"

"Yes."

"Is that new or something that's been true for some time?"

"It started about the time the cough got bad."

"When, specifically, was that?"

"Let's see, it was after I came back from Mexico. I was coughing a bit after the flight, but I figured I'd picked up a bug in Acapulco. So, maybe ten days."

"Have you been sick recently? Besides the cough?"

"No."

"Any other problems? Diarrhea? Fever?"

"No."

"Are you on any medication?"

"No."

"Any history of trouble with your immune system?"

"I don't think so. I don't get sick very often."

"OK. Julie, CBC and sputum sample. Mr. Kennedy, I'm going to order a chest X-ray."

"Chest X-ray?" he asked.

"You have fluid in your lungs," I said. "It's a standard test to rule out any number of respiratory diseases."

And would give me strong evidence that my preliminary diagnosis was correct. I wouldn't bet the farm on it, but my suspicion was that he had infectious tuberculosis. I wrote my orders on the chart and excused myself while Julie drew blood and obtained the sputum sample. I went to find Doctor Williams and made my report.

"Good precautions," he said once I'd reviewed the case with him. "Make sure he stays masked and come find me when you have the X-ray. If it shows what you think it will, we'll need Mark Hammond to examine him."

Doctor Mark Hammond was the hospital's infectious disease specialist.

"And report to the CDC and County Health Department," I added.

"What's the lab test for TB?" Doctor Williams asked.

"Initial test is for acid-fast bacilli, but definitive diagnosis requires sputum cultures, but that can take weeks as MTB is very slow growing."

"That's correct. Get the X-ray and lab tests and we'll take it from there. Chart?"

I handed him the chart, he made a few notes, then signed it and handed it back. I went to the nurses' station and called Radiology to set up the X-ray, then returned to the exam room.

"Someone from Radiology will come get you in about ten minutes," I said. "Just relax, and I'll come see you when you're back."

"Thanks, Doc. What do you think it is?"

"Right now, all I can say definitively is either a viral or bacterial infection. The X-ray, blood tests, and sputum sample will point us in the right direction."

"Something I picked up in Mexico?"

"Possibly," I replied. "I'll see you in a few minutes."

I washed my hands, left the room, then disposed of the mask in the appropriate waste bin. As I went back to the admit desk, Len returned from Cardiology.

"Patient transferred," he said. "Nothing to report."

"Good. Bob, any change on the contusion?"

"No neurological signs."

"Then I'll take the sprained knee."

He handed me the chart, and I laughed, "First Kennedy, now Nixon!"

"I know, right?" he replied.

"Len, get a wheelchair, please."

He did, and we went out to the waiting room, where a young woman with an ice pack on her knee was sitting. She looked vaguely familiar, and with her last name, I realized she might be related to Sheila, whom I hadn't seen since my wedding.

"Cynthia Nixon? I'm Doctor Mike, and this is Len, my student. Let's get you into the wheelchair. Is this your mom?"

"My softball coach, Mrs. Paul," she said.

"Mrs. Paul, you can wait here while I examine Cynthia. We'll update you once we complete the exam."

She nodded, and Len and I helped Cynthia into the wheelchair and pushed her into the ED, where I asked Ellie for a nurse and was assigned Becky, who followed us into Exam 3. We helped Cynthia onto the table and I began taking her history while Becky took her vitals.

"Any previous injuries to your leg?" I asked.

"I had a hamstring pull on my other leg last year, but that's it."

"How bad would you say the pain is?"

"It aches, but the ice helps."

"We're going to need to do an X-ray. Is there any chance you might be pregnant?"

"Only if my name were Mary and you're the Angel Gabriel!"

Len, Becky, and I all laughed.

"'Angel' is probably the last word anyone would use for me!" I said. "Len, call Radiology and arrange for a knee series."

"Right away!" he replied.

I filled out the chart, then handed it to Becky.

"Cynthia," I said, "I'll update your coach. Do you want her to come in? It might be as much as an hour before we get the X-ray results."

"Sure."

I left the room and went out to the waiting room.

"Coach Paul? The sprain doesn't appear to be severe, but you can't always tell with an exam, so we're going to get an X-ray of Cynthia's knee before we decide how to proceed. She'd like you to come back and sit with her."

"Thanks, Doctor."

I escorted her to the exam room, then had Len come with me back to the admit desk, where I asked for the chart for the forehead contusion.

"Mr. Abrams?" I said, walking up to him. "I'm Doctor Mike. Are you OK to walk?"

"Yeah, I just banged my head on the cabinet and my wife insisted I come have it checked out."

"Because you collapsed!" she said.

That was not noted on the chart, which concerned me.

"Mrs. Abrams, you can come back with us if it's OK with your husband."

"If I say 'no', I'll probably need a surgeon," he said.

The four of us went to Exam 1, where I washed my hands and put on gloves.

"When you collapsed, were you unconscious?"

"No. It hurt like a motherf ... hell. I saw stars for a few seconds, but that's it."

"OK. Let me take a look, then we'll get your vitals, and I'll do an exam."

"The doc and nurse out front did three exams!"

"Which I asked them to do to ensure I could safely ask you to wait while I treated patients who had arrived before you."

I looked at his forehead, and I felt it didn't even need a butterfly bandage, let alone sutures, and he showed no neurological deficits upon exam.

"Len, clean the wound and apply a gauze dressing. 600mg ibuprofen PO. Monitor for an hour with neuro checks every fifteen minutes."

"Will do, Doctor!"

"Mr. Abrams, you don't appear to have suffered anything more than a minor abrasion and a headache, so we'll get you some ibuprofen, then monitor you for an hour. If there are no signs of concussion or other problems, we'll send you home."

"I told you, Mildred!" he said to his wife.

"Better safe than sorry, Max!" she countered.

I filled out the chart, signed it, and went to check on Mr. Kennedy, who hadn't returned from Radiology. I took the charts for Ms. Nixon and Mr. Abrams and went to see Doctor Williams. He reviewed both charts, made notes, and signed them.

"Kick the contusion as soon as you're happy. Let me know if you call an ortho consult on the knee."

"I'll want you to look at the film with me," I said.

He nodded, "Bring that to me when it's ready. Anything on the possible TB case?"

"He's not back from Radiology."

"We're keeping them busy this morning! This is four now. Varma had two, and you've had two."

I left his office and almost ran into Ghost, who was moving quickly to the ambulance bay.

"Mike, I have a hot MI being transported in full arrest. Varma and Lincoln have traumas, and Nielson is on break. Can you assist?"

I was basically waiting, so I could.

"Yes."

I grabbed a gown and a fresh set of gloves and followed him, his Fourth Year, Jack, and Nurse Alice into the ambulance bay.

"Jack," Ghost said, "EKG and monitor, then Foley; Mike, intubation; Alice, trauma panel with stat cardiac enzymes."

A full arrest meant a fireman and paramedic performing CPR and a less than ten percent chance the patient would make it, and that was being optimistic. Two minutes later, the EMS squad pulled up, a paramedic jumped out and called out the vitals, which were basically non-existent, and moved to the back of the squad. There was a bit of shuffling as the gurney was moved out, and the fireman got on, straddling the patient, performing chest compressions as the second paramedic bagged.

"Trauma 1!" Ghost ordered.

The team performed the choreographed routine efficiently, and five minutes later, the patient was on a respirator, but despite two amps of epi, an amp of bicarb, and continual chest compressions, we couldn't bring him back. With no heart sounds, no signs of electrical activity, and his pupils fixed and dilated, there was nothing left to do.

"Time of death: 08:19," Ghost said. "Alice, death kit, please."

We left the trauma room and stripped off our gowns and gloves.

"He was very likely dead when the paramedics got to him," I observed. "If you figure best-case response time, he was down ten minutes before they showed up."

"You know they prefer to bring everyone in because all it takes is my signature here, whereas it's a four-page triplicate form if he's declared dead on-scene."

"Oh, I know," I replied. "I know this is going to sound crass, but that's a lot of resources expended to avoid paperwork."

"And if that were you? Would you want the paramedics to say 'fuck it'?"

"No, of course not! It was just an observation."

"You make some strange observations!"

"Maybe, but what is our number one problem here?"

"Besides people smoking, drinking to excess, and not seeing a doctor once a year?" Ghost asked.

I chuckled, "Yeah, other than those."

"Know-it-all Interns."

I chuckled, "Yes, yes! Besides that?"

"Lack of resources, of course, followed closely by ODs. I get your point, but your answer to my question points out the reality of the situation. Frankly, between you and me, if I had to conserve resources, I'd start with 'save my ninety-five-year-old grandma at all costs'."

I nodded, "And as crass as that sounds, as much as 80% of all healthcare expenditures are made in the last five years of life. I already have an agreement with Kris that if either of us is in a situation where there will be zero quality of life, we'll end any heroic measures. When we get older, that will apply in general. The last thing I want to do is spend the final years of my life confined to a hospital bed on a vent."

"You and me both," Ghost said.

"I need to check on my patients."

"Then hop to it! Thanks for the assist."

I nodded and went to check on Mr. Abrams, who was showing no neural deficits or signs of concussion, and Cynthia, who was being helped into a wheelchair for her X-rays. Ellie called out to let me know that Radiology had the films on Mr. Kennedy, so I sent Len to get them.

"What did you see?" I asked when he returned.

"I didn't know I was supposed to look," he replied.

"I was always curious and couldn't help but look. Go ahead."

We moved to a light board, and he put them up and I saw some dark areas that might well be indicative of TB.

"I have no idea what I'm looking for," Len said.

"I'm pretty sure this dark spot supports a diagnosis of TB," I said. "What does the wet read report say?"

He looked it over, "TB indicated and calls for further testing."

"Did we get the lab results?" I asked.

"Yes. Everything was normal except for an elevated white count. The sputum sample was positive for acid-fast bacilli."

"TB, almost certainly, but we have to wait for the culture to know for sure. And that takes weeks."

"So what do we do?"

"Call the infectious disease specialist," I replied. "He'll take Mr. Kennedy to Medicine, put him in isolation, and begin treatment, even before the results come back. It's a six-month course of an antibiotic cocktail. The CDC and County Health Department will be notified as well."

"Contact tracing?"

"Yes. Let's go see Doctor Williams."

We went to the Attendings' office, and I handed the chest film to him. He put them on the light board and looked them over.

"What do you see?" he asked.

"A dark area here," I said, pointing. "I'd say that's indicative of TB, and the Radiologist agrees. The sputum sample was positive for acid-fast bacilli."

"Let me call Mark Hammond," he said. "Keep everyone away from Mr. Kennedy except you two and the nurse. Just wait here while I make the call."

He picked up the phone, dialed, and then explained the situation.

"He'll be right down," Doctor Williams said.

Five minutes later, Doctor Hammond came into the office, looked at the film, looked at the chart and lab results, and nodded.

"I'll take him," he said, then turned to me, "Let's go see your patient, Doctor."

The three of us went to see Mr. Kennedy, putting on masks before we entered the room to which Julie had attached a 'quarantine' sign.

"Mr. Kennedy," Doctor Hammond said, "I'm Mark Hammond, an infectious disease specialist. I've reviewed your case, including the X-rays and lab test results, and discussed it with Doctor Loucks and his supervisor, and we all agree you most likely have active tuberculosis."

"TB?!" he exclaimed.

"You have all the classic signs, though a definitive diagnosis requires a culture, and that takes anywhere from two weeks to two months. We're going to admit you to our isolation ward, and we'll notify the County Health Department."

"Doctor," I said, "he was on a flight about two weeks ago."

"The County Health Department and CDC will deal with that. Mr. Kennedy, is there anyone you spend a lot of time with?"

"My girlfriend, my parents, and work, of course."

"Everyone will need to come in for a TB test," he said. "But the Health Officer will take care of that. Doctor Loucks, please arrange for transport. Mr. Kennedy, I'll see you upstairs momentarily."

He left, I had Len place the call for an orderly along with the instructions that they mask before they came into the room.

"How bad is it?" Mr. Kennedy asked.

"A course of antibiotics usually clears it up," I said.

About ten minutes later, he was on his way to the isolation ward, and after carefully washing my hands, I went to check on Mr. Abrams, who I felt was ready for discharge. I filled out the paperwork, signed the forms, and then directed him and his wife to Patient Services. A few minutes later, the films for Cynthia Nixon came back, and Len and I went to see Doctor Williams again.

"What do you see, Mike?"

"No tears or obvious damage," I said. "So, a low-grade sprain."

"Athlete, right?" he asked.

"Yes."

"Refer her to a sports physiologist; there's no need for an ortho consult."

"Wrap the knee, ice, and ibuprofen?" I asked.

"That's the textbook treatment."

I acknowledged him, then Len and I went to see Cynthia and explain the diagnosis.

"How long do I have to stay off it?" she asked.

"At least until you see the sports physiologist," I replied. "We'll get you a set of crutches. We'll wrap it in an Ace bandage, and you should keep it wrapped except when you're in the shower, and use ice and ibuprofen for pain and swelling."

"I know someone you can see," her coach said. "And I think I can get him to see you today."

"Thanks, Coach."

"I'll write out the referral just in case," I said. "Len, an Ace bandage, please."

He retrieved one from the cabinet, and after getting permission, I wrapped Cynthia's knee. Len got her crutches, we showed her how to use them, and then, with discharge papers and the referral in hand, Len escorted them to Patient Services. I grabbed a quick cup of coffee, then Len and I went to see Bob.

"Nothing at the moment," he said.

"OK. I'll be in the lounge."

It was typical to have peaks and valleys, where things were utter chaos, and I'd have to juggle multiple patients, or they were very quiet. The quiet times rarely lasted long, so I took my coffee, went to the lounge, sat in a recliner, and sipped my coffee. The quiet lasted all of about two minutes before Alice opened the door to the lounge.