Silent Treatment

Chapter1

Harry Corbett was on his fifteenth lap aroundthe indoor track when he first sensed the pain in his chest. The track, abalcony just under an eighth of a mile around, was on the top floor of the GreyBuilding of the Manhattan Medical Center. Ten feet below it was a modestlyequipped gym with weights, the usual machines, heavy bags, and some mats. Thefitness center, unique in the city, was exclusively for the hospital staff andemployees. It had been created through the legacy of Dr. George Pollock, acardiologist who had twice swum the English Channel. Pollock's death, at ageninety, had resulted from his falling off a ladder while cleaning the guttersof his country home.

At the moment of his awareness of thepain, Harry was actually thinking about Pollock and about what it would be liketo live until ninety. He slowed a bit and rotated his shoulders. The painpersisted. It wasn't much — maybe two on the scale of one to ten thatphysicians used. But it was there. Reluctant to stop running, Harry swallowedand massaged his upper abdomen. The discomfort was impossible to localize. Onemoment it seemed to be beneath his breastbone, the next in the middle of hisback. He slowed a bit more, down from an eight-minutes-per-mile pace to aboutten-and-a-half. The ache was in his left chest now. . no, it was gone. .no, not gone, somewhere between his right nipple and clavicle.

He slowed still more. Then, finally, hestopped. He bent forward, his hands on his thighs. It wasn't angina, he toldhimself. Nothing about the character of the pain said cardiac. He understoodhis body, and he certainly understood pain. This pain was no big deal. And ifit wasn't his heart, he really didn't give a damn where it was coming from.

Harry knew his logic was flawed — diagnostic deduction he would never, ever apply to a patient. But like mostphysicians with physical symptoms, his denial was more powerful than any logic.

Steve Josephson, jogging in the oppositedirection, lumbered toward him.

'Hey, you okay?' he asked.

Still staring down at the banked corktrack, Harry took a deep breath. The pain was gone, just like that. Gone. Hewaited a few seconds to be sure. Nothing. The smidgen of remaining doubtdisappeared. Definitely not the ticker, he told himself again.

'Yeah. Yeah, I'm fine, Steve,' he said.'You go ahead and finish.'

'Hey, you're the zealot who goaded me intothis jogging nonsense in the first place,' Josephson said. 'I'll take anyexcuse I can get to stop.'

He was sweating more profusely than Harry,although he had probably run half as far. Like Harry, Steve Josephson was ageneral practitioner — 'family medicine specialists,' the bureaucrats haddecided to name them. They were in solo practice, but shared night and weekendcoverage with four other GPs. It was just after six-thirty in the morning — earlier than usual for their run. But this would be a busy and important day.

At eight, following morning rounds and anemergency meeting of the family medicine department, the entire MMC staff wouldbe convening in the amphitheater. After months of interviews and investigation,the task force charged with determining whether or not to reduce the privilegesof GPs in the hospital was ready to present its findings. From the rumors Harryhad tapped into, the recommendations of the Sidonis committee would be harsh — the professional equivalent of castration.

With a portion of Harry's income and asignificant chunk of his professional respect on the line, the impendingpresentation was reason enough for the ulcers or muscle spasms, or whatever thehell had caused the strange ache. And even the committee report was not theforemost concern on his mind.

'We've been running together three or fourtimes a week for almost a year,' Josephson said, 'and I've never seen you stopbefore your five miles were up.'

'Well, Stephen, it just goes to showthere's a first time for everything.' Harry studied his friend's worriedface and softened. 'Listen, pal, I'd tell you if it was anything. Believe me Iwould. I just don't feel like running today. I've got too much on my mind.'

'I understand. Is Evie going in tomorrow?'

'The day after. Ben Dunleavy's herneurosurgeon. He talks about clipping her cerebral aneurysm as if he wasremoving a wart or something. But I guess it's what he does.'

They moved off the track as the only otherrunners in the gym approached.

'How's she holding up?' Josephson asked.

Harry shrugged. 'All things considered,she seems pretty calm about it. But she can be pretty closed in about herfeelings.'

Closed in. The understatement of the week,Harry mused ruefully. He couldn't recall the last time Evie had shared feelingsof any consequence with him.

'Well, tell her Cindy and I wish her well,and that I'll stop by to see her as soon as that berry is clipped.'

'Thanks,' Harry said. 'I'm sure she'llappreciate hearing that.'

In fact, he doubted that she would. Aswarm, bright, and caring as Steve Josephson was, Evie could never get past hisobesity.

'Did you ever listen to him breathe?' shehad once asked as Harry was extolling his virtues as a physician. 'I felt likeI was trying to converse with a bull in heat. And those white, narrow-strappedtees he wears beneath his white dress shirts — pulleese …'

'So, then,' Josephson said as they enteredthe locker room, 'before we shower, why don't you tell me what really happenedout there.'

'I already — '

'Harry, I was halfway around the trackfrom you and I could see the color drain from your face.'

'It was nothing.'

'You know, I spent years learning how toask non-leading questions. Don't make me regress.'

For the purpose of insurance applicationforms or the occasional prescription, Harry and Josephson served as oneanother's physician. And although each persistently urged the other to schedulea complete physical, neither of them had. The closest they had come was anagreement made just after Harry's forty-ninth birthday. Harry, alreadyobsessive about diet and exercise, had promised to get a checkup and a cardiacstress test. Steve, six years younger but fifty pounds heavier, had agreed tohave a physical, start jogging, and join Weight Watchers. But except forJosephson's grudging sessions on the track, neither had followed through.

'I had a little indigestion,' Harryconceded. 'That's all. It came. It bothered me for a minute. It left.'

'Indigestion, huh. By indigestion do youperhaps mean chest pain?'

'Steve, I'd tell you if I had chest pain.You know I would.'

'Slight correction. I know you wouldn't.How many men did you lug back to that chopper?'

Although Harry rarely talked about it,over the years almost everyone at the hospital had heard some version of theevents at Nha-trang, or had actually composed one themselves. In the stories,the number of wounded he had saved before being severely wounded himself hadranged from three — which was in fact the number for which he had beendecorated — to twenty. He once even overheard a patient boast that his doctorhad killed a hundred Vietcong while rescuing an equal number of GIs.

'Stephen, I am no hero. Far from it. If Ithought the pain was anything, anything at all, I'd tell you.' Josephson wasunconvinced.

'You owe me a stress test. When do youturn fifty?'

'Two weeks.'

'And when's the date of that familycurse?'

'Oh, come on.'

'Harry, you're the one who told me aboutit. Now, when is it?'

'September. September first.'

'You've got four weeks.'

'I … Okay, okay. As soon as Evie'ssituation is straightened out I'll set one up with the exercise lab. Promise.'

'I'm serious.'

'You know, in spite of what everyone saysabout you, I always thought that.'

Harry stripped and headed for the showers.He knew that Steve Josephson, in spite of himself, was staring at the patchworkof scars on his back. Thirty-one pieces of shrapnel, half a kidney, and a rib.The design left by their removal would have blended into the pages of a RandMcNally road atlas. Harry flashed on the incredible sensation of Evie'sbreasts gliding slowly over the healed wounds in what she used to call herpatriotic duty to a war hero. When was the last time? That, heacknowledged sadly, he couldn't remember.

He cranked up the hot water until he wasenveloped in steam. Two weeks until fifty. Fifty! He had neverexperienced any sort of midlife crisis that he could think of. But maybe thedeep funk he had been in lately was it. By now the pieces of his life shouldhave fallen into place. Instead, the choices he had made seemed to be underalmost constant attack. And crumbling.

He thought about the day halfway throughhis convalescence when he had made the decision to withdraw from his residencyin surgery and devote his professional life to general practice. Something hadhappened to him over his year and a half in Nam. He no longer had any desire tobe center stage. Not that he minded the drama and intensity of the operatingroom. In fact, even now he truly enjoyed his time there. But in the end, he hadrealized, he simply wanted to be a family doc. Simply. If there was oneword that was most descriptive of the life Harry had chosen for himself, simplymight well be it. Get up in the morning, do what seems right, try to help afew people along the way, develop an interest or two outside of work, andsooner or later, things would make sense. Sooner or later, the big questionswould be answered.

Well, lately things weren't making muchsense at all. The big answers were just as elusive as ever. More so. Hismarriage was shaky. The kids he had always wanted just never happened. Thefinancial security that he had expected would gradually develop over the yearswas tied to a brand of medicine he was not willing to practice. He neverallowed his office to become a medical mill. He never sent a collection agencyafter anyone. He never refused anyone care because the patient couldn't pay. Henever moved to the suburbs. He never went back for the training that would havemade him a sub-specialist. The result was a car that was seven years old and aretirement fund that would last indefinitely — as long as he didn't try toretire.

Now, his professional stature was beinghauled up on the block, his wife was facing a neurosurgeon's scalpel, and justfour weeks from the first of September, his fifty-first year, he hadexperienced pain in his chest.

The hastily called family medicinedepartmental meeting accomplished little. Each physician who spoke during theemotional forty-five-minute session seemed to have different information aboutwhat the findings of the Sidonis committee were going to be. In the end, nomotions were passed, no actions of protest approved. Aside from presenting aunified front at the amphitheater, there was nothing to do until the specificsof the task force's recommendations were known.

'Harry, you didn't say a word in there,'Steve Josephson said as they left.

'There was nothing to say.'

'Sidonis and his vigilantes are on a witchhunt, and you know it. Everyone's scared. You could have calmed them down.You're. . you're sort of the leader of the pack. The unofficial kahuna.'

'A kind way of saying I'm older than mostof the others.'

'That's hardly what I mean. I deliverbabies. Sandy Porter strips veins and does other stuff in the OR. The Kornetskybrothers are better in the CCU than most of the cardiologists. Almost every oneof us does some procedure or activity that might be taken away today. You'reabout the only one who does all of them.'

'So? Steve, what are we going to do?Challenge the specialists to a medical Olympics?'

'Oh, this is crazy. Harry, I don't knowwhat's come over you lately. I just hope it's not permanent.'

Harry started to respond that he didn'tknow what Josephson was talking about. Instead, he mumbled an apology. He hadnever been a fiery orator, but over the years his directness and commonsenseapproach to resolving conflicts had earned him respect in the hospital. And hecertainly had never backed away from a fight. He could have — should have- said something. Members of the department, especially the younger ones, weregenuinely worried about their futures.

The crisis at MMC was the direct result ofthe hospital being named as codefendant in three successive malpractice suitsover a period of a few months. All three suits involved GPs. Harry felt theepidemic of litigation was nothing more than coincidence. In the new medicalorder of sue first, ask questions later, similar numbers could probably beproduced to show that specialists were equally vulnerable. But the medicalstaff had panicked and the Committee on Non-Specialty Practice had beencreated. Caspar Sidonis, a charismatic, widely known cardiac surgeon, had beenmade its chairman.

Sidonis and Harry had never hit it off,although Harry never really understood why. Now they were on opposite sides ofthe table, playing a high-stakes game for a pot that was of value only to theGPs. And Sidonis held all the cards.

'Steve, I'm sorry,' Harry said again asthey turned down the passageway that cut through the emergency room, 'I guess Ihave been down lately. And I really don't know why. Malemenopause or something. I feel like maybe I need — I don't know, some sort ofwindmill to charge.'

The corridor, a shortcut from the roomwhere their meeting was held to the amphitheater, was closed to the public butnot to hospital staff. Today, the ER was humming. The rooms to either side ofthem were all occupied. Major surgery, minor surgery, orthopedics, ENT,pediatrics, minor medical, major medical, cardiac.

'Each one a story,' Harry said as theywalked through.

'Yeah,' Steve mumbled. 'Well, after todaywe better get used to having to read the Cliffs Notes.'

A nurse rushed past them from behind andinto one of the two cardiac rooms.

'Give him another three of morphine,' theyheard a resident say as they neared the room.

'How much Lasix has he gotten?'

'Eighty, Doctor

'This is V. tach. I'm almost certain ofit.'

'His pressure's dropping, Doctor.'

'Dammit! Someone was supposed to havecalled cardiology.'

'I put a page in for them. They haven'tanswered.'

The two GPs stopped at the doorway. Thepatient, a husky black man, probably in his early seventies, was in extremis,sitting nearly upright on the litter, gasping for breath. Loud gurgling wellingup from within his chest accompanied each inhalation. His heart rate was nearlyone hundred and seventy. The young resident managing the case was a decentenough doctor, but he had developed a reputation for losing his cool indifficult situations.

'What is his pressure?' he asked.

'Maybe seventy, Doctor. It's quite hard tohear.'

There was undisguised urgency in thenurse's voice.

Her repeated use of the resident's titlewas a demand that

he do something.

'We can't wait for cardiology,' he said.'Get ready to shock him. Someone please page cardiology again. Janice, I wantthree hundred joules.'

Steve Josephson, his eyes wide, lookedover at Harry.

'Pulmonary edema,' Josephson said.

'Right you are,' Harry replied.

'But that's not V. tach on the monitor.'

'I agree. Plain old garden variety sinustachycardia, I would say. Due to the stress of the situation.'

'We can't let him shock that.'

Harry hesitated for just a moment, thennodded. The two of them moved to the bedside.

'Sam, that's sinus tach.' Harry whispered softlyenough so that no one but the resident could hear. 'Try to shock that and youmight kill him.'

The resident looked first at the monitorand then at the nurses and technicians surrounding his patient. In seconds hisexpression went from confusion to anger to embarrassment, and finally torelief.

'You want to take over?' he askedsuddenly. 'Please, go ahead.'

Without answering. Harry picked up a toweland dried the perspiration that was pouring off the patient's brow. He glancedat the plastic identification bracelet.

'Mr. Miller, I'm Dr. Corbett. Squeeze myhand if you understand. Good. You're going to be okay, but you've got to tryand breathe slower. I know it's hard and I know you're frightened right now,but you can do it. We're going to help you. EKG, Steve?'

'Maybe a small anterior MI,' Josephsonsaid. 'He's beating too fast to tell for sure.'

'Hematocrit?'

'Fifty percent. If he's not a smoker, hisblood is concentrated big time.'

They looked over at the resident, whoshook his head. 'Lifetime nonsmoker,' he said. 'But what's his red blood cellconcentration got to do with all this?'

Harry's exam disclosed no ankle swellingand no other signs of excessive fluid. Heart failure, from whatever cause, wasproducing back pressure throughout the pulmonary circulation. Serum, thenoncellular part of blood, was being forced through the blood vessel walls andinto the man's lungs. As a result of the serum shift, the red blood cells, toolarge to pass through the vessel walls, were becoming sludge. Harry checked theman's pupils for the constriction that would signal marked narcotic effect. Thepupils were small, but not yet pinpoint.

'Three more of morphine,' he said. 'Pleaseget me a phlebotomy bag. We're going to take some blood off him. Get ready tointubate him if we have to.' He toweled the man off again. 'Mr. Miller, you'redoing great. Try to slow it down just a little bit more.'

'Excuse me,' the resident whispered,astonished, 'but you're going to take blood off him?'

'We are.'

'But. . but nobody does that anymore.'

'You're doing better and better, Mr.Miller,' Harry said. He turned to the resident. 'No one does this anymore, huh?Well, we do, Sam,' he said. 'Especially when someone's hematocrit is aselevated as this man's. Just because a method's not high-tech doesn't mean itsuseless. Trying to get fluid off him with diuretics often isn't as effective aswhat we're about to do. And in someone whose blood is already thisconcentrated, diuretics are quite a bit more dangerous. Any fluid you get offwith diuretics will just concentrate his red cells even more. If those redcells get thick enough, sooner or later a vessel could clot off. Pressure,please?'

'Holding at eighty. Easier to hear,' thenurse said.

Harry nodded to Steve Josephson, who insertedthe large phlebotomy needle into a vein with a dexterity belied by his thickfingers. Instantly, a column of blood glided down the tubing and began to fillthe plastic collection bottle.

The reversal of Clayton Miller's pulmonaryedema was spectacular.

'I … I'm breathing … a … little.. better. .,' he managed after just a minute or so.

'What do you think, Steve? Another hundredcc's?'

'If his pressure stays up, I would saymaybe even two hundred.'

Harry adjusted the needle slightly, andthe flow of blood increased. For another minute, there was only silence.

'Oh my God,' Miller said suddenly, fillinghis lungs with a long, grateful swallow. 'Oh my God, I'm better. . muchbetter.'

He was still breathless, but much less so.The cardiac pattern on the monitor had slowed to one hundred. The shape of thecomplexes now appeared quite normal. Two nurses exchanged looks of exuberantrelief. The resident stepped between the two GPs.

'This is incredible,' he said. 'I don'tknow what to say. Mr. Miller, Dr. Corbett and Dr. Josephson really came throughfor you — for me, too.'

The older man managed a weak thumbs up.'Listen,' the resident went on, 'I heard about that committee they formed toalter your privileges. If you need me to write them about what went on herethis morning, I'll be happy to.'

'It may be a little late for that,' Harrysaid, 'but why don't you drop Dr. Sidonis a note just the same. He mightactually read it, as long as it starts with the greeting "YourGrace."'

There was a soft noise behind them. Thethree of them looked toward the doorway just as a stony-faced Caspar Sidonisturned and stalked off toward the amphitheater.