Pennsylvania's Finest, page 15
“You make me sick,” said Ranier who stormed out of the room slamming a door behind her.
Knight continued to quietly look out the window as Ranier left the room. Physical and mental fatigue was beginning to overtake him. His back hurt from being corkscrewed amidst two oversized passengers on the flight home. He wanted to preserve whatever energy he had for the meeting with Rineman and Barnes. Shaking his head he left the apartment realizing what a delicate situation he had just created with Jennifer Ranier. After leaving the apartment high rise he turned west, walking towards the PGH. The pending trek was two miles in distance.
Per his genetic disposition, Dr. Barnes arrived fifteen minutes ahead of time for the meeting. As usual Dr. Knight was sitting in front of his desk silently. Barnes held back on any sarcastic remarks as he offered a sincere “Good morning” to the troubled surgeon. Barnes then circled in front of the motionless Knight and took a seat in his chair. Looking at Dr. Knight he sensed both fatigue and turmoil in his face.
Barnes then let Knight start the conversation. “What the hell is going on here? Two fatalities at the worst time of the year.”
“Bad luck,” said Barnes, “Just bad luck.”
“Its like I’m cursed,” said Knight. “Why couldn’t they die after the New Year?”
Barnes cocked an eyebrow upwards and looked at the surgeon in front of him. Being a surgeon he knew that a single patient’s death, yet alone two, weighed on one’s mind. When complications occur the thought process for a surgeon can become cloudy. Barnes knew the best remedy for this was to discuss one’s concerns with a trusted colleague. He was one of the few colleagues that Knight trusted.
“They were both doing very well,” said Knight. “I just don’t understand why they should have coded all of a sudden.”
“I’m sure you have looked over every aspect of the first death,” said Barnes. “From what I understand everything was appropriate regarding the care of the second fatality.”
“That’s not what his wife thinks,” said Knight. “I could read her mind over the phone on Friday. There is going to be some litigation out of this case.”
Dr. Barnes also well knew the second issue that blurred a surgeon’s intellect, that being the threat of a lawsuit. He tried to further console Knight saying, “Well that’s out of our hands, we will let legal handle that matter if it occurs.”
“It doesn’t get any easier Mike,” said Knight. “I mean this occupation doesn’t get any easier. In my younger days a death was just part of the whole occupational package. Now they hang on me like an albatross.”
“The faint of heart need not apply for a surgeon’s job,” said Barnes. “I also think you place too much emphasis on this Chronicle article. The public has a short memory, so don’t get too hyped up about it.”
Knight looked up ready to reply when CEO Rineman walked in briskly.
“What’s the emergency?” said Rineman obviously not happy to be in the hospital that Sunday morning.
“Another one of Dr. Knight’s patient’s died,” said Barnes.
“So what,” said Rineman, “This is a hospital, people die every day in the hospital.” Rineman then circled around Knight to stand in front of him.
“Not my people,” said Knight with an elevated tone to his voice. “Not my people.”
Barnes took control of the conversation saying, “Howard, it’s just that the timing is bad. Another fatality slants Richard’s numbers in the wrong direction for the upcoming Chronicle article.”
“For goodness sake, there have only been two deaths,” said Rineman. “It’s not like the plague wiped out your entire hospital census,”
“That’s all it takes,” said Knight sharply. “There are still three months left in the year, another death and I’m sunk.”
“Well what can we do about it?” asked Rineman. “I mean there has to be an answer.”
Five or ten seconds passed in silence between the patriarchs of the PGH that morning. Each man thought of options that their moral compass quickly extinguished.
Barnes then spoke, “The numbers are what they are.” He then continued more bluntly, “We can’t fiddle with the numbers, they are generated from several different entities that we have no control over.”
All three men again sat silently, thankful that no one else pursued this line of thinking.
“There is only one alternative,” said Knight looking up at his compatriots with a smile. “I just crank up my numbers.”
“What do you mean?” asked Rineman quickly.
“I just operate more, a lot more,” replied Knight. The two men looked at him trying to grasp the concept. “I can ratchet up my number of surgical cases over the next three months. Without any other fatalities my mortality number will naturally drop lower.”
“That’s assuming there are no other deaths,” said Barnes.
“That’s a risk we will have to take,” said an energized Knight.
Rineman wasn’t sold on the idea as he spoke, “How are you going to magically find patient’s who need heart surgery so quickly?”
“Come on,” said Knight. “We are at the helm of the prestigious Philadelphia General Hospital, where more people in the Delaware Valley get their care than any other place. All we need to do is open up the spigot a bit more, convince the patient that the surgical option is a bit more pressing.”
“I’m out,” said Barnes raising both of his hands up in the air and looking in the opposite direction.
“So am I,” said Rineman shaking his head with a look of disbelief. “Do you realize what you are suggesting?”
“Of course,” said Knight. “This isn’t anything illegal or unethical. I’ve got a laundry list of patient’s on hold for surgery. All I need to do is open up another surgery day each week in the OR. That should garner about forty more cases for the year.”
“Again, I don’t want any part of this line of thought,” said Barnes. “I don’t feel comfortable even discussing it.”
“Then don’t,” said Knight with a nervous energy. “Just do me two favors.” Knight had a slightly maniacal twinkle in his eyes as he spoke, “One is to secure me an extra O.R. day every week. Friday’s would be fine. The second is to tell the cardiologists throughout the system that I’m available for all cardiac emergencies, seven days a week.”
Barnes pondered the idea and then spoke as he shrugged his shoulders, “I guess I’m O.K. with that, seems like a benign request.” He then looked over at CEO Rineman.
“I’ll pretend I’ve never heard this conversation,” said Rineman, washing his hands of the whole deal. “If need be I would categorize your decision as an internal surgical department choice based on the best interest of the patients.”
All three men then felt at ease with the select and comfortable wording from their health system’s chief executive officer. Their conversation then turned onto the upcoming surgical rotation changes.
“Who will be my chief resident for the next three months?” asked Knight.
Dr. Barnes shuffled through some papers on his desk while taking out a pair of reading glasses. “The schedule has Dr. Snyder as your chief resident and Dr. Polk as your intern.”
“Snyder!” yelled Knight. “I don’t want that incompetent boob with me down the home stretch.”
Dr. Barnes didn’t speak knowing quite well that chief resident Snyder was the worst resident the program had in a long time. He continued to look at the rotation list as if searching for an answer.
“I’m keeping Pete Larson,” said Knight abruptly. “He is good and knows the system well.”
“You can’t just change the schedule like that,” said a concerned Barnes.
“Why not?” asked Knight. “You just heard our CEO call our motives in the best interest of the patient. Do you think Dr. Snyder represents our best interest?” Knight paused and then looked a bit pitiful at Barnes saying, “Just do it Mike. Try to help me out for once.”
Barnes stared straight ahead thinking for a moment. In his mind he knew the switch was possible at the upper resident level only. “O.K., I’ll let you keep Dr. Larson for another three months. But the surgical intern cannot change.”
“Thank you,” said Knight with a smile. Despite the two fatalities over the past rotation, Dr. Knight thought highly of Larson. He also realized that Larson was already on high alert. “Who is Dr. Polk?” was his next question.
“Dr. Polk is, let me see,” said Barnes then fumbling for a folder in a side drawer. He opened the folder and began to read aloud. “Let’s see, Dr. Polk is a graduate of Hershey Medical School. His dad was a surgeon I believe, that’s right, a urologist. Good intern, quite the entertainer from what I hear.”
“An entertainer, I don’t want an entertainer,” said Knight. “I want a dull, paranoid intern that checks every detail twice a day.”
“I hear he is actually living down in the hole. Stays there seven days a week. Has no actual apartment outside of the hospital,” replied Chairman Barnes.
“What?” said Howard Rineman. “Living in the hospital. I’ll charge him room and board for that.” The three men then burst into hearty laughter appreciating some levity from the executive officer.
“That brings me to another intern that we all know,” said Barnes. “That being Dr. Frederick Riles.” Barnes paused looking around the room aware that everyone knew intern Riles’ father quite well.
“Apparently Frederick junior is having a tough go at it already,” said Barnes. “His father has been calling me every other week to complain.”
“Like father like son,” quipped Knight. “Frederick Riles senior couldn’t operate his way out of a paper bag.”
“Now, now Richard, we had some good times together back in the day,” said Barnes.
“I don’t remember good times,” replied Knight. “All is remember is his incompetence and covering his lazy behind. Remember that case he botched and we all got sued as residents?”
“I didn’t think they had lawsuits back then,” said Rineman, now looking at his watch and getting ready to leave.
“Back then you had to really screw up to get sued,” barked Knight. “And old man Riles really did. Killed a patient as far as I’m concerned.” Knight’s face was starting to turn beet red as he continued, “Then he blamed everyone except himself. Real team player,” was his final line.
“Richard, Richard, easy. You are going back thirty years,” said Barnes calming the discussion. “Apparently Fred junior isn’t meshing well with the upper level residents. All I ask it that you don’t make it any harder on him. Apparently he is quite the sensitive kid.”
“Yea, whatever,” said Knight not committing on taking it easy on the younger Frederick Riles. Knight had much larger issues on his mind as opposed to the happiness of an intern.
“Richard, I need assurance that you won’t lean on Fred junior,” said Barnes pressing the issue. “I’ve given you my word to open up another day in the O.R. Please help me out.”
“O.K., O.K.,” said Knight while waving his hand casually in the direction of the chairman. “You have my word.”
“How was L.A.?” asked Rineman to Dr. Knight as he changed the subject and began moving towards the door.
“Bankrupt and overrun by illegal immigrants,” said Knight. “That’s it in a nutshell. Wouldn’t want to live there,” was his next comment as the three men began to walk out of the office.
Rineman then slapped Knight on the back saying, “I saw you and the wife at the Russian ballet the other night, she looks fantastic. Absolutely fantastic.”
“Thank you,” said Knight with a smile. “She is a great woman, great woman, really takes care of herself.”
“You’re a lucky man,” said Rineman in return with a smile. “A very lucky man.”
CHAPTER 15 M and M Rounds
Morbidity and Mortality rounds were held once a month in the department of surgery at the Philadelphia General Hospital. The tradition dated back well over one hundred years. Called M and M rounds by the residents, the meeting represented a gathering of many levels of academia. The purpose of M and M rounds was to discuss in detail a death that occurred recently in the hospital including a review of the disease process, medical management and effect on future patient care. M and M rounds started at 9 A.M. on the third Thursday of each month.
The gathering occurred in the cramped conference room located in the Kirby building. Attendance was mandatory for all interns and residents, and encouraged among all attending physicians. A good turnout was the rule and all attendees filed in according to rank and stature. First to arrive were the confused looking medical students who filtered to the rear of the room. These students were on their surgical rotations in a variety of fields. Medical students were only allowed to wear white coats that came to their waist level, which made their attendance obvious. The students did not speak as a rule during M and M rounds. In the middle of the conference room sat the interns and junior residents. These physicians were allowed to wear the traditional long white coat, which extended towards the knee level. At ten minutes to nine Phil Drummer, Rick Polk, Cathy Finley and Frederick Riles walked in together. They sat side by side throughout the meeting. Several minutes before the hour the chief residents entered the room. They were allowed to have the honorable row behind the attending physicians. Unfortunately the chief residents had to present the cases to the crowd. The task of presenting a case in which someone died was never coveted.
Lastly at 8:58 A.M. sharp a side door to the conference room opened and the grand entrance of the attending staff occurred. The procession was ushered by the department chairman, Dr. Michael Barnes, who walked towards the podium. Behind him was a collection of middle-aged men and women in long white coats. Some were old and some were young, many carried a cup of coffee in their hands. Dr. Knight was third in line, and with a regal aura about his step, marched towards a front row seat. His coat was heavily starched and ironed to perfection. The stage and podium was directly in front on him. The entire spectacle was an awe-inspiring event, as the crème de la crème of the Philadelphia General Hospital entered. The medical students from the rear of the room craned their necks forward trying to connect a famous surgeon’s name to a face in front of them. Then at exactly 9 A.M. Dr. Barnes spoke.
“Good morning everyone,” said Barnes, “And welcome to Morbidity and Mortality rounds.”
At that very moment a hospital switchboard operator could be heard over the public address system stating, “Morbidity and Mortality rounds have begun in the department of surgery conference room on the sixth floor of the Kirby building.”
Barnes continued, “I have a few housekeeping items before we begin. First off, thanks to everyone involved in the chief resident rotation shift.” Barnes paused, looking up at the second row filled with chief residents. “As you know the shift was necessary to satisfy certain educational criteria that recently came to the attention of the residency director, that being me. I would like to compliment the mature manner in which the news was processed by all.”
Phil looked at chief resident Larson who had a look of disgust on his face. The residents were well aware of Dr. Snyder’s incompetence and sensed Knight was behind the decision.
Barnes continued, “Secondly, until further notice the chief resident on trauma and cardiothoracic surgery will be required to spend their call night in the hospital.” Barnes again looked up at the group of residents in front of him. A look of displeasure was common among all the residents peering back at him. This mandate was passed down to the chief residents two days earlier and had not been well received. The “improvement of patient care” guise was the superficial reasoning for the decision. Keeping Dr. Knight’s paranoia of another fatality in check was the true reason. A punitive maneuver to keep the trauma chief resident in house was a smoke screen to balance off the muse. Barnes justified the action in his mind by realizing that in three months it would be reversed.
“Lastly I would like to introduce our esteemed visiting professor for the day,” said Barnes with a smile. He motioned to a stately looking physician with a well-groomed manor and shiny white teeth sitting next to the chairman’s vacant seat. “Doctor Frederick Riles is a well know colleague of ours, having completed his general surgery training here at the PGH. He currently is a professor in general surgery at the Massachusetts General Hospital. Doctor Riles is well known for his work in liver disease and associated small bowel disorders. He recently published the lead article in Lancet this past month and we are honored to have him here.” Dr. Barnes then extended his arm towards Dr. Riles. A polite round of applause followed as the more senior Dr. Riles stood and smiled to the crowd, being quite comfortable in the limelight. Barnes then concluded the introduction with “Welcome Doctor Riles, it’s truly a pleasure to have you here for the day.”
Barnes continued to smile and clap at Dr. Riles while the guest sat down with a look of content. Barnes paused momentarily to allow a restoration of protocol and then continued, “Now our first case will be presented by chief resident Peter Larson,” he motioned to Dr. Larson saying, “Pete.” Dr. Barnes then left the podium taking one step down to the first row and sat next to visiting professor Riles. Riles gently slapped him on the thigh and the two friends laughed and whispered to each other as chief resident Larson approached the podium.
Peter Larson then neared the podium with the medical records of Mr. William Brown in his hands. Despite being in the hospital for less than 48 hours, the chart of Mr. Brown was thick with data. The records contained every scrap of medical information generated by the hospital after the collapse of Mr. Brown directly in front of the hospital. Larson positioned the microphone to his height, opened the immense chart and began his medical presentation.
“The first case is that of a 57 year old black male with a history of uncontrolled diabetes mellitus, hypertension and alcoholism, who was followed by the medical residents in the community outreach program.” Larson paused and looked up at the room, he had just described the classic staffer patient at the PGH. “He presented to the emergency room unresponsive after collapsing on the front sidewalk of PGH. His vital signs upon presentation were…”
