****
Except for the lighting, it was as bleak inside the 5th Floor ICU as it was out on the rain-swept streets of Baltimore. Fluorescent white shown upon the linens of the dying and the recovering alike — and upon Pam, who was stuck somewhere in between, in a world of bruises and stitches and blood and gauze. For all the chirping electronics and humming machines and dripping drips, she wouldn’t wake up. She was spiking fevers of unknown origin. Grim looking fluids oozed through a tube that had been inserted between her ribs.
All the while, her eyes were only halfway shut and she stared vacantly into the exam light that seemed to be always hovering overhead at full intensity.
Days passed, and a sort of routine emerged. Pam’s mother Jackie or I would drive to the airport to pick up Pam’s sister or her son or her daughter, and we would give them the latest on her condition, set them up in our new digs and then take them over to see her. Kristi is as much best friend and sister to Pam as she is her daughter, and it was Kristi who first suggested to the staff that perhaps Pam’s eyes should be lubricated or taped shut against the bright light and dry air.
Hugh Calkins would occasionally make an appearance to repeat the story he told Jackie and me; that he’d turned away momentarily and the catheter got caught in the mitral valve muscles. He told that same story to Kristi and to Pam’s sister Lisa on consecutive days — two sites ablated, mitral valve demolished — then off to surgery.
Sorry, he says, again and again, but now it was starting to have a ring of tough luck to it. Sorry. Oops. Oh, well. And as the days wore on, we began to see less and less of Hugh Calkins.
****
“ETT repositioned to right side of mouth by RT. Pt more awake and restless, coughing and gagging.”
I can see it as if it were happening right now, right in front of me. Gagging on the ventilator tube lodged in her throat, choking and gagging, wrists tied to the bed rails and she pulling against them, pulling herself up from the bed, heaving forward, straining, neck muscles taught, choking, the pressure popping her eyes open, red veined and raw, hot tears, and the fierce frantic struggle for air, for breath, for life itself.
Now I understood what she had sensed after the botched ablation — that sooner or later they will kill her. She would never get out alive and I’d been wrong to reassure her, I’d been wrong to believe in this place, wrong to bring her here.
****
ICU Subsequent Care Note: Delerium; pt remains very agitated on fentanyl and received dose of haldol this AM. Will again attempt to decrease fentanyl but we have not had any success. Once it is decreased she becomes agitated and has respiratory compromise. We will continue to attempt to wean fentanyl so that we may assess her for extubation. Neuro consult obtained.
So now they’re in a Catch-22 trying to wean Pam off a ventilator. When they reduce the sedatives so she can start breathing on her own, she becomes agitated to the point where it’s not safe to take the breathing tube out.
editing editing editing editing editing editing
We demanded to see the doc in charge.
He was a hard man to get a hold of, and this issue of The American Medical News explains why:
“Johns Hopkins Penalized for Resident Hour Violations”
“The Accreditation Council for Graduate Medical Education has disciplined its first resident program for work-hour violations since new rules went into effect for all programs July 1. Johns Hopkins Hospital’s internal medicine program was cited for exceeding the 80-hour work week and requiring call more than every third night in the intensive care, counter to ACGME work hour standards.”
Johns Hopkins Magazine dutifully reports that “Nine days into the new enforcement period, a new Hopkins intern sent an e-mail to ACGME officials stating that some Internal Medicine residents were working more than 100 hours per week.”
The person upon whom Pam’s life depended was working about 90 hours a week, maybe a hundred. I tracked him for days and finally snagged him at a nurse’s station. The man was obviously exhausted, but so was I, and I pressed him about why she wasn’t coming around. He had reached the point of exasperation and he told me more or less that he was a very busy guy with lots of patients and they all had families who wanted answers and he had a family of his own to worry about.
I decided to call Dr. Yuh, the surgeon who installed Pam’s mechanical heart valve. I was told that he was on vacation – in Hawaii.
While Dr. Yuh had his toes in the sand and a drink in his hand outside the Hyatt Regency Waikiki Beach Resort and Spa ($627 per person per night), I was picking through the offerings in beautiful downtown Baltimore. A decent room in Charm City, USA was going for $186.77 a night for a room with a double bed.
I walked out of the Day’s Inn and fished a card out of my pocket that said Patient Relations and got in my car and went back to the hospital.
Looking back, I see the question was hopelessly naive, but I had logistical problems with all these people coming to be with Pam, and so I had to ask. Pam’s son, her daughter, her mother, her sisters, her stepfather — all these people needed places to stay. They could do hotels for a while, but there was no end in sight here. I went into the office with the idea that when something like this happens they probably had some deal with the local hotels for discount vouchers – or something.
They gave me some vouchers — for free coffee down in the cafeteria.
Then I heard that there was a woman who rents out apartments in the immediate area for just such purposes.
She’d started the program years earlier when she arrived in Baltimore with a sick child for the hospital and no place for her to stay. So she got in touch with local property owners and became the rental agent and manager for several apartments that were let to visitors for days or weeks – or months. She didn’t seem to be getting rich off the scheme.
It was said that a lot of the rental properties in the immmediate vicinity of the hospital were owned by doctors and that they kept the rents artificially high. I’m not saying that I know that to be true, but it is what I was told.
While Pam’s mother went to get her sister at the airport, I arranged for an efficiency apartment near the hospital with three bedrooms – about $650 a week if I remember correctly.
****
The little conference room was crowded and tension was high. Pam’s relatives and hospital personnel and me and my brother the priest who’d come down from Connecticut. The meeting had the atmosphere of a Teamsters’ bargaining session.
The women in the family had revolted. They wanted action. They wanted something done. They wanted answers. They wanted Nurse Kevin off the case. Complaints were made. People were called. Finally someone took control and a Family Meeting was scheduled wherein relevant staff and family members could come to an understanding.
There was talk of “clearing the air.”
A Conciliator had descended from the upper reaches of management to bring the two sides together. She was a handsome woman with a warm smile who sat poised with an expensive pen on her notepad. She projected confidence and control. She sat in a chair against the wall and crossed her professionally sexy legs in the manner of a TV anchorwoman.
“Well, let’s all see if we can do a better job of communicating. We all have Pam’s best interests at heart and we have to remember that…”
Staff feelings seemed to run as follows: generally, the lower in rank, the techs and nurses, tried to have patience with us. The doctor types were indignant – as in we are wasting precious time here. Nurse Kevin was not in attendance.
The reason Pam’s mother Jackie, and her sisters Laura and Lisa, and her daughter Kristi wanted Nurse Kevin gone was because Nurse Kevin viewed the overwhelming attention that Pam was getting as an invasion of his professional space. He had an attitude.
“What’s her blood pressure now? Does she have a fever? Why don’t her eyes close all the way? Shouldn’t you be putting drops in her eyes?”
Nurse Kevin snapped at Kristi one morning. He made it clear that all of his energies were focused on caring for the patients and that if Kristi wanted to speak with a doctor he’d get the doctor for her — which Kristi insisted upon — which made Nurse Kevin look foolish and unprofessional — which made him resent the family all the more.
We family members were chastised for abusing visiting privileges and of repeatedly violating the one spokesman per family rule. It was agreed that staff would give info to one person who would inform everyone else – sort of like pool reporting.
We said that all of us had to ask anyone we saw for information — any chance we had because information was hard to come by.
It had quickly become apparent to all of us that the nursing staff was stretched too thin. I could see why Nurse Kevin was on edge. They pile too much responsibility on these people – and I don’t think you’d find a nurse in America that disagrees with that.
Plenty of times, in plenty of hospitals, I have heard a voice as I walked by a patient’s room, some traumatized victim of disease or disaster or old age, someone who couldn’t reach the Styrofoam cup of ice water on the tray before them, calling out for help.
The first thing the Conciliator did was to toss Nurse Kevin overboard, which satisfied us, but made the staff clench together in solidarity and resentment. Maybe we’d gone too far. But the Conciliator kept things moving and pretty soon guidelines and boundaries were established and the meeting broke up to mutual grumbling.
I have a brother who is a priest who had been consulting with the staff. He asked me if it would be a good idea to administer Last Rights.
