Authors: Daniel Palmer
“Dr. Bryant, this is Marianne from the VA. You asked me to call if there was any problem with Patient Abington. He was rushed down to the medical ICU by a nurse on Dr. Goodwin's staff. Abington developed an arrhythmia and his blood pressure fell. The monitor showed ventricular tach with a wide QRS. I'm sorry to have to leave you this message. I tried you a couple times, but I couldn't reach you.”
Carrie felt her own heart start to race. She checked the call log, and sure enough: two missed calls from the VA, including the call where Marianne had left her the voice message.
Carrie muttered to herself, “The haloperidol, dammit.”
She probably should have just given Abington more Valium, since it was already in his system from before. Except she had checked his ECG, and the Q-T interval was not prolonged or anything, and it had calmed him down. She felt physically ill. She had made the call, she had ordered the drug, and Steve Abington in the ICU was on her.
Carrie thought of other ways she could have handled the situation, but kept returning to the haloperidol. He had seemed so crazy, beyond agitated. She had never experienced a post-op patient with symptoms resembling anything like Abington's. His repeating the same phrase, and that look in his eyesâthat was fear and terror she saw. It was different from the confused agitated state or delirium she'd seen time and time again, whether someone was in the throes of DTs, or suffering the consequences of acute stroke, or sepsis, or, well, a host of other medical and surgical disorders. This was something unique, and she did not know what to make of it.
What else could have caused the arrhythmia?
A hemorrhage?
Goodness, that was always a risk after surgery. And Carrie had seen at least one case where a subarachnoid hemorrhage had resulted in a serious arrhythmia. While negative drug reaction remained the most probable event, other considerations besides a hemorrhage dotted her thoughts. It could be an infection. Fever. Perhaps a seizure, or even a stroke. A CT of the brain would be the logical first step.
However, she could do nothing about it now. Abington's welfare was in the hands of the med ICU team. Before she could do anything, Abington needed to be stabilized. His blood pressure, heart rhythm, vital signs in general had to be under control. To go barging in there at this late hour would be counterproductive. They would take all the necessary precautions. She could picture Abington lying in an ICU bed, intubated again and hooked to a ventilator, IV fluids and antiarrhythmic drugs flowing through his veins. Dopamine and other vasopressors keeping his blood pressure up. The baton had been passed; Abington was not a neurosurgical post-op case any longer.
Still, she would go see him first thing in the morning.
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It was dark when the alarm went off. Cocooned in her bed, Carrie thought about hitting the snooze button, but decided to get an early start. Despite the aches in her body and neckâthe result of a buildup of lactic acid and inflammationâshe managed to arrive at the VA a little after seven thirty. She wanted to check on Abington before her day officially started. Even though the med ICU staff was more than capable, she had done the invasive procedure and felt ultimately responsible for his outcome. It could be that all she did was give them her thanks and a pat on the back, but she had to do something. Either way, she had to know the outcome.
Carrie had just flashed her security badge at the front desk when her phone began to vibrate. To her surprise, it was a text message from Dr. Sandra Goodwin, head of neurosurgery.
Come see me as soon as you arrive. I'm in my office now
. The text came across as a bit edgy. Carrie belonged to Dr. Finley, head of neurology and his DBS program, so even though surgery resided under Dr. Goodwin's purview, the line of responsibility to her was a dotted one at most, and thus far Carrie had had little interaction with the woman. Still, Abington could wait. Carrie stopped by the cafeteria for coffee before making her way to Dr. Goodwin's second-floor office.
Seated behind a metal desk that had probably been manufactured in the 1970s, Dr. Goodwin eyed Carrie with contempt. Carrie had not expected to see Dr. Evan Navarro, who ran the residency program, there as well. Navarro sat on one of two uncushioned folding chairs set in front of Dr. Goodwin's desk. The concrete brick walls were painted a sorry shade of yellow, and the low ceiling covered with cheap acoustic tiles made Carrie feel uncomfortably confined. Other than a couple of struggling plants, Dr. Goodwin's home away from home had all the life of a pathology lab.
Dr. Navarro turned the chair next to him slightly and offered it to Carrie. She sat down gingerly, which had more to do with Navarro's hard stare than with her aching knee. Dr. Navarro was shortâCarrie probably had two inches on himâbut he had a reputation for being pugnacious and for bringing residents to tears. His dark hair was gelled back, showing off a prominent widow's peak.
Dr. Goodwin looked every bit her fifty-five years. She wore her hair in a bob that called attention to her face's sharp features, and nothing warm or fuzzy showed in her hazel eyes. She was all business and all about maximizing every minute in her day. Wearing a white lab coat over a set of blue scrubs, her clothing implied she would touch a scalpel at some point in the day, which Carrie highly doubted. Dr. Goodwin was an administrator. But maybe she liked looking the part of a surgeon.
Dr. Goodwin spoke bluntly. “I heard you went to see Steve Abington in the neuro recovery floor yesterday.”
No “Hello.” No “How are you adjusting to the new job.” No “I heard you almost got killed.” Dr. Goodwin was as efficient with her words as she was with her time.
“I did.” Carrie did not know what else to say.
Dr. Goodwin's glowering expression said that the chief of neurosurgery did not approve. “Yes, I see,” Dr. Goodwin replied. “I heard about yesterday, and I'm aware of the circumstance. I'm sorry that happened, though I do believe Dr. Finley expressed to you beforehand that the PTSD patients should never be seen without accompaniment.”
Carrie felt a bit ashamed by the accusation, but she bristled. It sounded like victim-blaming.
“I guess I didn't fully appreciate the need for the warning,” Carrie said.
“That may be,” Dr. Goodwin replied coldly, “and because of the extenuating circumstances here, Evan and I thought it would be appropriate to review our department policies with you with respect to post-op care, among other things.”
“That's the job of the residents,” Navarro said in a sharp tone. “You may think of yourself as one of the gang, but you're not.”
Dr. Goodwin shot Navarro an admonishing look, perhaps to call back her attack dog. “What Evan is trying to say, Carrie, is that you are basically an employee of Dr. Finley. Your situation here is highly unique. Unusual, is the word I would choose to describe it. To be blunt, the hospital has a well-organized residency program, and you're not part of it. Surely you understand that we have procedures in place for patient care, and a hierarchy for addressing emergent situations. You show your face and nurses don't know who to call if there's a problem. Do they call you? You're not even insured here if something does go wrong. You expose this program to added risk by this behavior.”
Carrie's face felt hot. “I was simply curious to see how my first DBS patient was doing.”
“That's understandable,” Dr. Goodwin said. “Which is why we're having a friendly chat about it.”
Doesn't feel friendly,
Carrie thought.
“If the residents think you're undermining them, it will throw my entire program into disarray,” Navarro said.
“It was certainly not my intention.”
“Yes, well, our best intentions may have unintended consequences.”
“Well, how is Abington doing?” Carrie asked. “All I know is that he was moved to medical ICU.”
“And that's all you need to know,” Navarro answered curtly.
Dr. Goodwin held up her hand again. Navarro apparently needed an even shorter leash.
“I guess I'm a bit confused,” Carrie said. “I just wanted to see how my patient was doing after
my
surgery.”
Dr. Goodwin's intense expression ticked up a few notches. “Let me take a moment to clarify your role here,” she said. “You are the DBS surgeon. Period. You did your surgery just fine. Dr. Finley brought you on board exclusively for that purpose. And I, for one, did not support your appointment.”
No kidding
.
“I would have preferred we bring in somebody who had gone through a formal residency program
successfully
,” Dr. Goodwin continued. “But Dr. Finley is the one who has the funds, and he insisted your skills as a surgeon trumped any concerns we may have had regarding your ⦠unfortunate history.”
Carrie tensed at the reference, and in doing so caused a stab of pain in her aching knee.
“Your job is to do the DBS installations, and that's it,” Dr. Goodwin said.
“And the next link in that chain is me,” Navarro added.
Carrie felt like she had just been body-slammed.
“So you see, Carrie, you're here because the DBS surgeries are lengthy and do require a dedicated resource. You're quite simply a hired hand, and it's best if you keep your involvement to that.”
Carrie's cheeks flushed. She could feel her anger starting to percolate. Digging deep, she mustered restraint. “I understand.” She directed her attention to Navarro. “Would you mind giving me an update on Abington's condition? I understand he's been moved to the medical ICU. I did the procedure. I feel a responsibility for the patient outcome. I think I deserve that professional courtesy.”
Dr. Goodwin and Navarro exchanged an inscrutable look.
“Let's make sure we got this clear, Carrie,” Dr. Goodwin said. “You do the surgery and you're done. The residents and Dr. Navarro will do the post-op care. If a patient is moved to another unit, that patient becomes the responsibility of others. Not us. We take care of our responsibilities as they apply to neurosurgery, and do not go chasing after patients when they become the province of a different department. This is the way our organization is effectively maintained. Do I make myself clear?”
Carrie was shocked. She could not believe the tone Dr. Goodwin was using with her, the utter disdain. It was as if Carrie, by acting in a thoughtful and caring manner toward a patient, had violated some sacred oath and thereby single-handedly put the entire system in a state of dysfunctional disrepair.
Carrie knew all about “turfing,” the idea that a patient who was moved off one floor and brought to another became OPP, other people's problem. But she had never worked in an environment where the hush-hush practice was so openly supported and, in fact, endorsed. The notion made Carrie sick to her stomach. This was not what she had signed up for, and she had every intention of making her feelings known to Dr. Finley.
For now, the best, most politically expedient strategy for this meeting was to appear compliant and retreat.
Never poke an angry bear
.
“You've made yourself clear,” Carrie said. “So if I'm not scheduled to do any DBS surgeries, what then?”
“As long as you respect our procedures, that is not my concern. You do what you feel is best for you and your career, Carrie,” Dr. Goodwin said.
Dr. Goodwin's smile held all the warmth of a snow cone. Carrie didn't have to be told to stand; this meeting was clearly adjourned.
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Carrie spent fifteen minutes in her cramped, windowless office trying to decompress. Her blood pressure had settled, but she was having enormous trouble concentrating on her DBS research. She was halfway through a difficult paper on dysarthria in Parkinson's disease, but the words jumbled on the page.
She was ruminating on that contentious conversationâambush was more like itâwith Drs. Goodwin and Navarro. The insinuations were absolutely infuriating. Carrie had not taken the job just to be a surgical tool. A hammer for a nail, so to speak. Dr. Finley had told her she'd be part of the team, and that was how she'd envisioned her role.
I would have preferred we bring in somebody who had gone through a formal residency program
successfully
.
Dr. Goodwin's words bit hard.
Out of frustration, Carrie balled up the printout she'd been reading and threw it against the wall. That woman had been cutting, disparaging, and downright offensive. Something odd had happened with Steve Abington, something potentially related to his DBS treatment. It was more than the agitated state the duty nurse had described. This was somethingâbut what? She was focused mostly on his strange response. In her mind, she could still hear him muttering the same phrase over again, repeating what she had said.
Follow my light ⦠follow my light â¦
Abington seemed to experience some form of auditory hallucination. It was unusual, not the type she had seen in schizophrenics where disturbing voices outside the head seemed to speak directly to victims. She was keen to try and understand. Even if she were prohibited from seeing Abington, her time was her own, and Carrie could still work his case.
Take that, Dr. Goodwin!
Carrie squeezed into the crowded elevator. Her finger hovered over the button to the medical ICU floor before she resisted the temptation. It was one thing to do some research in the library on a “turfed” patient, but she couldn't flagrantly ignore Dr. Goodwin's instructions minutes after they had been issued. It was best for now to keep her investigation academic.
The library at the VA was located on the first floor, just off the lobby, and it did not look like it got much use. The floor was covered with a threadbare carpet, and though it had a few wooden carrels, none had a chair. Unlike the gift shop, which was staffed by volunteers dressed in brightly colored smocks adorned with patriotic pins, the library reception desk was unattended. In place of a human, a sign in an acrylic holder provided instructions on how to obtain a password to access the computer and navigate to the home page. Some of the more recent medical journalsâwhat limited print supply was on handâwere stuffed haphazardly into a standing magazine rack, but the library's shelves were notably barren.