Fatal Cure

11

Nikki did not have a good night, nor did her parents. Angela was particularly distressed. By the wee hours of morning it was clear that Nikki was becoming progressively more congested. Well before dawn Angela tried the usual postural drainage combined with percussion. When they were through, she listened to Nikki's chest with her stethoscope. She heard rales and rhonchi, sounds that meant Nikki's breathing tubes were becoming clogged with mucus.

Before 8:00 A.M., David and Angela called their respective offices to explain that they would be late. Bundling Nikki in multiple layers of clothing, they took her to see Dr. Pilsner. Initially their reception was not encouraging. The receptionist informed them that Dr. Pilsner had a full schedule. Nikki would have to return the following day.

Angela was not to be denied. She told the receptionist that she was Dr. Wilson from pathology and that she wanted to talk with Dr. Pilsner. The receptionist disappeared into the interior of the office. Dr. Pilsner himself appeared a moment later and apologized.

"My girl thought you folks were just the usual CMV subscriber," Dr. Pilsner explained. "What's the problem?"

Angela told the doctor how a sore throat had led to congestion overnight and that the congestion did not respond to the usual postural drainage. Dr. Pilsner took Nikki into one of the examining rooms and listened to her chest.

"Definitely clogged up," he said, removing the stethoscope from his ears. Then, giving Nikki's cheek a playful pinch, he asked her how she felt.

"I don't feel good," Nikki said. Her breathing was labored.

"She's been doing so well," Angela said.

"We'll have her back to normal in a wink," Dr. Pilsner said, stroking his white beard. "But I think we'd better admit her. I want to start intravenous antibiotics and some intensive respiratory therapy."

"Whatever it takes," David said. He stroked Nikki's hair. He felt guilty for having insisted on the New Hampshire weekend.

Janice Sperling in admissions recognized both David and Angela. She commiserated with them about their daughter.

"We've got a nice room for you," she said to Nikki. "It has a beautiful view of the mountains."

Nikki nodded and allowed Janice to slip on a plastic identification bracelet. David checked it. The room was 204, one that indeed had a particularly pleasant view.

Thanks to Janice, the admitting procedure went smoothly. In only a few minutes they were on their way upstairs. Janice led them to room 204 and opened the door.

"Excuse me," Janice said with confusion. Room 204 was already occupied; there was a patient in the bed.

"Mrs. Kleber," Nikki said with surprise.

"Marjorie?" David questioned. "What on earth are you doing in here?"

"Just my luck," Marjorie said. "The one weekend you go away, I have trouble. But Dr. Markham was very kind."

"I'm so sorry to bother you," Janice said to Marjorie. "I can't understand why the computer gave me room 204 when it was already occupied."

"No trouble," Marjorie said. "I like the company."

David told Marjorie he'd be back shortly. The Wilsons followed Janice to the nurses' station where she phoned admitting.

"I want to apologize for the mix-up," Janice said after the call. "We'll put Nikki in room 212."

Within minutes of their arrival in room 212, a team of nurses and technicians appeared and attended to Nikki. Antibiotics were started, and the respiratory therapist was paged.

When everything was under control, David told Nikki he'd be back to check on her periodically throughout the day. He also told her to do everything the nurses and the technicians asked her to do. He gave Angela a peck on the cheek, Nikki one on the forehead, and was on his way.

David returned directly to Marjorie's room and gazed down at his patient. She'd become one of his favorites over the months. She appeared tiny in the large orthopedic bed. David thought that Nikki would have been dwarfed.

"Okay," David said, feigning anger, "what's the story here?"

"It started on Friday afternoon," Marjorie said. "Problems always start on Friday when you are reluctant to call the doctor. I didn't feel well at all. By Saturday morning my right leg started to hurt. When I called your office they switched me to Dr. Markham. He saw me right away. He said I had phlebitis and that I had to go into the hospital to get antibiotics."

David examined Marjorie and confirmed the diagnosis.

"You think it was necessary for me to come into the hospital?" Marjorie asked.

"Absolutely," David assured her. "We don't like to take chances with phlebitis. Inflammation of veins goes hand in hand with blood clots. But it's looking good. I'd guess it's already improved."

"There's no doubt it's improved," Marjorie said. "It feels twenty times better than it did when I came in on Saturday."

Although he was already late getting to the office, David spent another ten minutes talking with Marjorie about her phlebitis to be sure she understood the problem. When he was finished he went to the nurses' station and read her chart. All was in order.

Next he called Dudley Markham to thank him for covering for him over the weekend and for seeing Marjorie.

"No problem," Dudley said. "I enjoyed Marjorie. We got to reminisce. She had my oldest in the second grade."

Before leaving the nurses' station David asked the head nurse, Janet Colburn, why Marjorie was in an orthopedic bed.

"No reason," Janet said. "It just happened to be in there. At the moment, it's not needed elsewhere. She's better off in that one, believe me. The electronic controls to raise and lower the head and feet never break down, something I can't say about our regular beds."

David wrote a short note in Marjorie's chart to make it official that he was assuming responsibility for her care; then he checked in on Nikki. She was already doing much better, even though the respiratory therapist had yet to arrive. Her improvement was probably due to hydration from her IV.

Finally, David headed over to the professional building to start seeing his patients. He was almost an hour late.

Susan was upset when David arrived. She had tried to juggle the patients' appointments and cancel those that she could, but there were still a number waiting. David calmed her as he slipped into his office to put on his white coat. She followed him like a hound, ticking off phone messages and consult requests.

With his white jacket half on, David abruptly stopped moving. Susan halted in mid-sentence, seeing David's face go pale.

"What's the matter?" Susan asked with alarm.

David didn't move or speak. He was staring at the wall behind his desk. To his tired, sleep-deprived eyes, the wall was covered with blood.

"Dr. Wilson!" Susan called. "What is it?"

David blinked and the disturbing image disappeared. Stepping over to the wall, he ran his hand over its smooth surface to reassure himself it had been a fleeting visual hallucination.

David sighed, marveling at how suggestible he'd become. He turned from the wall and apologized to Susan. "I think maybe I watched too many horror pictures when I was a kid," he said. "My imagination is working overtime."

"I think we better start seeing patients," Susan said.

"I agree."

Launching into work with gusto, David made up for lost time. By midmorning he was caught up. He took a brief time-out from seeing patients in order to return some of the phone calls. The first person he tried was Charles Kelley.

"I was wondering when you would call," Kelley said. His voice was unusually businesslike. "I have a visitor in my office. His name is Neal Harper. He's from CMV utilization in Burlington. I'm afraid there's something we have to go over with you."

"In the middle of my office hours?"

"This won't take long," Kelley said. "I'm afraid I must insist. Could you please come over?"

David slowly put the receiver down. Although he didn't know why, he felt immediately anxious, as if he were a teenager being asked to come to the principal's office.

After telling Susan where he was going, David left. As he arrived at the CMV offices, the receptionist told him to go right in.

Kelley got up from behind his desk, appearing tall and tan as usual. But his manner was different. He was serious, almost dour, a far cry from his usual ebullient self. He introduced Neal Harper, a thin, precise man with pale skin and a small amount of acne. To David he appeared the apotheosis of the bureaucrat who'd been forever locked in his office, filling out his forms.

They all sat down. Kelley picked up a pencil and played with it with both hands.

"The statistics are in for your first quarter," Kelley said in a somber tone. "And they are not good."

David looked back and forth between the two men, feeling increasingly anxious.

"Your productivity is not satisfactory," Kelley continued. "You are in the lowest percentile in the whole CMV organization according to the number of patient visits per hour. Obviously you are spending entirely too much time with each patient. To make matters worse, you are in the highest percentile in ordering laboratory tests per patient from the CMV lab. As far as ordering consults from outside the CMV community, you're completely off the graph."

"I didn't know these statistics were gathered," David said lamely.

"And that's not all," Kelley said. "Too many of your patients have been seen in the Bartlet Community Hospital emergency room rather than in your office."

"That's understandable," David said. "I'm fully booked out for two weeks plus. When someone calls with an obviously acute problem needing immediate attention, I send them to the ER."

"Wrong!" Kelley snapped. "You don't send patients to the ER. You see them in your office provided they're not about to croak."

"But such disruptions throw my schedule into a turmoil," David said. "If I take time out to deal with emergencies, I can't see my scheduled patients."

"Then so be it," Kelley said. "Or make the so-called emergency patients wait until you've seen the people with appointments. It's your call, but whatever you decide, don't use the ER."

"Then what's the ER for?" David asked.

"Don't try to be a wiseass with me, Dr. Wilson," Kelley said. "You know damn well what the ER is for. It's for life-and-death emergencies. And that reminds me. Don't suggest that your patients call an ambulance. CMV will not pay for an ambulance unless there is pre-approval and pre-approval is only granted in cases that are truly life-threatening."

"Some of my patients live alone," David said. "If they're ill…"

"Let's not make this more difficult than it need be," Kelley interrupted. "CMV doesn't operate a bus service. All this is pretty simple. Let me spell it out for you. You must seriously increase your productivity, you must lower your use of laboratory tests drastically, you must reduce, or better yet stop, using consults outside the CMV family, and you must keep your patients out of the ER. That's all there is to it. Understand?"

David stumbled out of the CMV office. He was flabbergasted. He'd never considered himself extravagant in the use of medical resources. He'd prided himself on always keeping the patient's needs to the fore. Kelley's tirade was unnerving to say the least.

Reaching his office suite, David limped inside. He caught sight of Kevin disappearing behind a closed door with a patient and remembered his prophecy about the utilization evaluation. Kevin had been right on target; it had been devastating. What also bothered David was that Kelley had not made a single reference to quality or patient approval.

"You'd better get hopping," Susan said the instant she saw him. "You're getting behind again."

Midmorning Angela ducked out of the lab and went to check on Nikki. She was pleased to find her doing as well as she was. The fact that she wasn't running a fever was particularly encouraging. There was also a definite subjective decrease in Nikki's congestion following a prolonged visit by the respiratory therapist. Angela used a nurse's stethoscope to listen to Nikki's chest. There were still sounds of excessive mucus, but not nearly as much as there had been that morning.

"When can I go home?" Nikki asked.

"You just got here," Angela said, giving Nikki's hair a tousle. "But if you continue to improve the way you've been going, I'm sure Dr. Pilsner won't want to keep you long."

Returning to the lab, Angela went to the microbiology section to check on Nikki's sputum swab; she wanted to make certain it had been plated. It was crucial to determine the mix of bacteria in Nikki's respiratory tract. The technician assured her it had been done.

Returning to her office, Angela hung up her white coat in preparation to read a series of hematology slides. Just before she sat down she noticed the connecting door between her office and Wadley's was ajar.

Angela went over to the door and peeked in. Wadley was sitting at a double-headed teaching microscope. He caught sight of her and waved for her to come over.

"This is something I want you to see," Wadley said.

Angela stepped over to the 'scope and sat opposite her mentor. Their knees almost touched beneath the table. She put her eyes to the eyepiece and peered in. Immediately she recognized the specimen as a sample of breast tissue.

"This is a tricky case," Wadley said. "The patient is only twenty-two years old. We have to make a diagnosis, and we have to be right. So take your time." To make his point, he reached under the table and grasped Angela's thigh just above the knee. "Don't be too impulsive about your impression. Look carefully at all the ducts."

Angela's trained eye began to scan the slide in an orderly fashion, but her concentration faltered. Wadley's hand had remained on her thigh. He continued talking, explaining what he thought were the key points for making the diagnosis. Angela had trouble listening. The weight of his hand made her feel acutely uncomfortable.

Wadley had touched her often in the past, and she had had occasion to touch him as well. But it had always been within acceptable social bounds, such as contact on an arm, or a pat on the back, or an exuberant hug. They had even done several "high fives" during the softball game at the Labor Day picnic. There had never been any implication of intimacy until now, when his hand remained rooted to her leg with his thumb on the inside of her thigh.

Angela wanted to move away or remove his hand, but she did neither. She kept hoping that Wadley would suddenly realize how uncomfortable she felt and withdraw. But it didn't happen. His hand stayed on her thigh throughout a long explanation about why the biopsy had to be considered positive for cancer.

Finally Angela got up. She knew she was trembling. She bit her tongue and turned back toward her office.

"I'll be ready to review those hematology slides as soon as you are through with them," Wadley called after her.

Closing the connecting door between the offices, Angela went over to her desk and sank into her chair. Near tears, she cradled her face in her hands as a flood of thoughts cascaded through her mind. Going over the course of events of the previous months, she recalled all the episodes when Wadley offered to stay late to go over slides, and all the times he appeared when she had a few free moments. If she ever went to the coffee shop he appeared and always took the seat next to her. And as far as touching was concerned, now that she thought about it, he never passed up an opportunity.

All at once the mentor-like effort and demonstrative affection Wadley had been expending had a different, less generous, more unpleasant connotation. Even the recent talk of attending a pathology meeting in Miami during the next month made her feel uneasy.

Lowering her hands Angela stared ahead. She wondered if she was overreacting. Maybe she was blowing this episode way out of proportion, getting herself all worked up. After all, David was forever accusing her of being overly dramatic. Maybe Wadley hadn't been aware. Maybe he'd been so engrossed in his didactic role, he didn't realize what he was doing.

She angrily shook her head. Deep down she knew she wasn't overreacting. She was still grateful for Wadley's time and effort, but she could not forget how it felt to have his hand on her thigh. It was so inappropriate. He had to have known. It had to have been deliberate. The question was what she could do to put an end to his unwanted familiarity. After all, he was her boss.

At the end of his office hours, David walked over to the central hospital building to check on Marjorie Kleber and a few other patients. Once he determined that all were doing well, he stopped by to see Nikki.

His daughter was feeling fine thanks to a judicious combination of antibiotics, mucolytic agents, bronchodilators, hydration, and physical therapy. She was leaning back against a pile of pillows with a TV remote in her hand. She was watching a game show, a pastime frowned upon at home.

"Well, well," David said. "If it isn't a true woman of leisure."

"Come on, Dad," Nikki said. "I haven't watched much TV. Mrs. Kleber came to my room, and I even had to do some school-work."

"That's terrible," David said with improvised dismay. "How's the breathing?"

After so many sojourns in the hospital, Nikki was truly experienced at assessing her condition. Pediatricians had learned to listen to her evaluations.

"Good," Nikki said. "It's still a little tight, but it's definitely better."

Angela appeared at the doorway. "Looks like I'm just in time for a family reunion," she said. She came in and gave both Nikki and David a hug. With Angela sitting on one side of the bed and David on the other, they talked with Nikki for half an hour.

"I want to go home," Nikki whined when David and Angela got up to go.

"I'm sure you do," Angela said. "And we want you home, but we have to follow Dr. Pilsner's orders. We'll talk to him in the morning."

After waving goodbye and watching her parents disappear down the hall, Nikki wiped a tear from the corner of her eye and reached for the TV remote. She was accustomed to being in the hospital, but she still didn't like it. The only good thing about it was that she could watch as much TV as she wanted and any type of programming-something she definitely couldn't get away with at home.

David and Angela didn't talk until they were outside under the awning covering the hospital's rear entrance. Even then the conversation was minimal. David merely said that it was silly for both of them to get wet and then ran to get the car.

On the way home there was no conversation. The only noise was the repetitive and lugubrious sound of the windshield wipers. David and Angela both thought the other was responding to a combination of Nikki's hospitalization, the disappointing weekend, and the incessant rain.

As if to confirm David's suspicions Angela broke the silence as they pulled into their driveway by telling David that a preliminary look at Nikki's sputum culture suggested pseudomonas aeruginosa. "That's not a good sign," Angela continued. "When that type of bacteria gets established in someone with cystic fibrosis it usually stays."

"You don't have to tell me," David said.

Dinner was a stifled affair without Nikki's presence. They ate at the kitchen table as the rain pelted the windows. Finally, after they'd finished eating, Angela found the emotional strength and the words to describe what had happened between herself and Wadley.

David's mouth had slowly opened as the story unfolded. By the time Angela was finished his mouth was gaping in astonishment. "That bastard!" David said. He slammed his palm down onto the table and angrily shook his head. "There were a couple of times it passed through my mind he was acting a bit too enamored, like the day at the hospital picnic. But then I convinced myself I was being ridiculously jealous. But it sounds like my intuition was right."

"I don't know for sure," Angela said. "Which is partly why I hesitated to tell you. I don't want us to jump to conclusions. It's confusing as much as it is aggravating. It's so unfair that we women have to deal with this kind of problem."

"It's an old problem," David said. "Sexual harassment has been around forever, especially since women joined the work force. It's been part of medicine for a long time, especially back when all doctors were men and all nurses were women."

"And it's still around despite the rapid increase in the number of women physicians," Angela said. "You remember some of the bullcrap I had to put up with from some of the medical school instructors."

David nodded. "I'm sorry this has happened," he said. "I know how pleased you'd been with Dr. Wadley. If you'd like I'll get in the car, drive over to his house, and punch him in the nose."

Angela smiled. "Thanks for the support."

"I thought you were being quiet tonight because you were worried about Nikki," David said. "Either that or angry about the weekend."

"The weekend is history," Angela said. "And Nikki is doing fine."

"I had a bad day too," David finally admitted. He got himself a beer from the refrigerator, took a long drink, and then told Angela about his utilization review with Kelley and the CMV man from Burlington.

"That's outrageous!" Angela said when David was finished. "What nerve to talk to you like that. Especially with the kind of positive response you've been getting from your patients."

"Apparently that's not a high priority," David said despondently.

"Are you serious? Everyone knows that doctor-patient relationships are the cornerstone of good medical care."

"Maybe that's passe," David said. "The current reality is determined by people like Charles Kelley. He's part of a new army of medical bureaucrats being created by government intervention. All of a sudden economics and politics have reached the ascendancy in the medical arena. I'm afraid the major concern is the bottom line on the balance sheet, not patient care."

Angela shook her head.

"The problem is Washington," David said. "Every time the government gets seriously involved in medical care they seem to screw things up. They try to please everybody and end up pleasing no one. Look at Medicare and Medicaid; they're both a mess and both have had a disastrous effect on medicine in general."

"What are you going to do?" Angela asked.

"I don't know," David said. "I'll try to compromise somehow. I guess I'll just take it a day at a time and see what happens. What about you?"

"I don't know either," Angela said. "I keep hoping that I was wrong, that I'm overreacting."

"It's possible, I suppose," David said gently. "After all, this is the first time you've felt this way. And all along Wadley's been a touchy-feely kind of guy. Since you never said anything up to this point, maybe he doesn't think you mind being touched."

"What exactly are you implying?" Angela demanded sharply.

"Nothing really," David said quickly. "I was just responding to what you said."

"Are you saying I brought this on myself?"

David reached across the table and grasped Angela's arm. "Hold on!" he said. "Calm down! I'm on your side. I don't think for a second that you are to blame."

Angela's sudden anger abated. She realized that she was overreacting, reflecting her own uncertainties. There was the possibility that she had been unknowingly encouraging Wadley. After all, she'd wanted to please the man as any student might, especially since she felt a debt to him for all the time and effort he'd expended on her behalf.

"I'm sorry," Angela said. "I'm just stressed out."

"Me too," David said. "Let's go to bed."