“Gordon Lightfoot’s playing at the Morris Stampede.” Bob said.
“I know you like Gordon Lightfoot. Would you like to take that week call?”
“Sounds great,” I said. Not knowing what I was getting into.
There were dislocations after dislocations after dislocation. I’d a terrific technique of double the standard dose of morphine and lots of Valium. I wanted my patient ‘relaxed’. This did the trick. Even the big cowboys muscles relaxed. Relaxed it was easy to free up the dislocation which was essentially a bone out of place and being held out of place by the hurting muscles. Sometimes just the morphine allowed the dislocation to almost pop back into the right place.
One poor little old lady appeared to have a shoulder dislocation but it wasn’t. The radiology technician was off a fraction on the views. The overlapping due to angle had me believing this was a dislocation. Consequently I was repeating the Kroeker movement and giving her morphine and she was high as a kite. A famous Canadian writer. I just roughed her up a bit and got her stoned out of her gourd and even dragged her about on the floor. She was shouting ‘weeeee’ and having a jolly good time with my stockinged foot in her armpit. The repeated film never improved so I just sent her home after a night to remember. Our films were reviewed by the radiologist next day. He got back to us and taught the radiology tech the ‘technique’ of the proper positioning of the X-ray for this particular presentation of dislocation. She was all apologetic but her speciality was Chemistry which she was really good at and radiology was her subspeciality. She was great in deed. This was a minor gaff and if I was better in radiology I’d have picked it up myself. I called the writer and she said she’d had a great time, though she didn’t remember much of the ‘party’. She had no more pain and her arm worked just fine.
She’d fallen. Most of the other dislocations were cowboys flung miles in the air by raging bulls and bucking bronchos. I’d a few fractures to set too. I really liked setting fractures, legs and arms. I’d done that time in orthopaedics and was good at this. I understood bones and joints. It was a good thing because that’s all I did that week. Plus Lacerations, which I liked for sure, I had a lot of those too. Bar fights and swollen eyes. It was bedlam.
I only heard Gordon Lightfoot through the windows of the hospital. I listened wistfully as I set another fracture. Bob and Mike knew. Neither had figured I’d leave the hospital but neither wanted or liked orthopaedics like I did so it all worked out. Almost no sleep for the week, no going to the concert and watching Gordon Lightfoot, no seeing the actual horses and bulls, just cuts and sprains, and dislocations and fractures, all day and all night. It was a spectacular weekend of medicine.
I could get no further than Morris Hospital for a long list of stories.
My friendship with the Lutheran minister was a blessing. We’d sit up all night drinking coffee when I was on call talking about God and service and the town. One time he and I both showed up for an emergency call for a parishioner who had an MI. He was just making his normal rounds having heard she was going into hospital whereas I was called to emergency.
“Oh no!” She cried, seeing her minister and doctor coming through the door together.
She thought she was dying. She might have but thanks to prayer, digitalis and lasix she lived. His wife was a beautiful blond vivacious American cheerleader who became friends with Maureen. More dinner parties.
Maureen was doing her internship in the city at the time. We’d be together on the weekends mostly. Our call schedules sometimes conflicted and we’d not see each other for a couple of weeks but mostly we were staying in touch though both of us were often thoroughly exhausted. Some weekends she’d join me in Morris.
The case I’m afraid to face is one I’ve written of before. A young athlete had asthma. He’d seen both the other doctors before me. Each of us prescribed theophylline. This Saturday there was a party at his house. Everyone was apparently drinking. He’d woken with difficulty breathing but didn’t want to go to the hospital. He’d not come till the evening.
He and his parents told me that he was taking the theophylline. I could take a blood level and send it to the city but in the country we didn’t have the means to assess the level there and then. I did that. It was critical. Only when it came back days later was it clear that he’d not taken any theophylline, the problem the other doctors had faced. He refused to take his medications and lied about it. The other more important lie even was that he’d just developed problems breathing an hour before coming to the hospital. If I’d known he wasn’t taking his medications I could have loaded him with theophylline and maybe then his lungs would have freed up. If I’d known he was in respiratory distress for more like 12 hours I’d have sent him immediately to the city by ambulance. A young man with respiratory distress has hours of reserve. As it was I treated him as aggressively as I could admitting him and ordering an X-ray.
A malingerer drunk stoner was playing sick in hospital that night because he’d missed work and wanted a chit to say he was ‘sick’. The nurse put the patient in that room and put the lights on which one does with a respiratory patient. He began complaining right away and consequently the lights were dimmed. When the X-ray tech arrived he was blue but she didn’t see it at first.
A 99 was eventually called. I arrived and called for the crash cart. The crash cart hadn’t been used for a year or two. The only intubation tray was a noodle tube without the director. Someone had removed that. The staff hadn’t kept up with cardio pulmonary resuscitations. The medications weren’t up to date on the crash cart. I ‘d initiate training and all that after this case. I was only in the hospital a couple of months when young man crashed. I’d got the patient upright when his breathing stopped and got the ‘noodle’ in on the third try. I’d asked the nurse for D5W or Ringer’s Lactate but she’d not known that these were universal fluids and instead of grabbing anything in the stock began looking specifically for these units and was gone. I was trapped behind the head of the bed and bagging couldn’t get out to manage the heart as well. I asked the respiratory tech to call everyone. I needed hands.
Maureen arrived first. She was staying the night. She got the lines and I asked her to put in the epinephrine but that had to brought from ER. Bob and the head nurse arrived. Maureen was doing compressions. We didn’t have a heart rate then. I was dialing up on meds bagging and ordering more epinephrine. Bob in Bob’s ‘do something’ mode began to shock the patient with me screaming, ‘no’ but Maureen was still doing cardiac compressions and almost got shocked I don’t think she ever forgave Bob that. She was very protective. You yell ‘clear’ for a reasons. She was horrified at the chaos. It really was chaos. Eventually I had more fluids because the head nurse went to get more , finding the other nurse still looking for Ringer’s. It was labelled something else or some generic was there.
Suffice it to say we had a heart going and I was still bagging and we got the ambulance and I accompanied the boy to the city emergency. I handed him off. He lived for 4 days more before dying of brain stem asphyxiation. (Coning ).With Status Asthmaticus he needed a respirator to push open the lungs. I’d done my best but it wasn’t enough.
I had collapsed too after handing off the patient to the ICU doctor collapsing in a corner in the kneeling fetal position and crying. Anurse came kneeled down and put her hand on my shoulder.
“Are you alright/“
“Yes (no)”
I got back to hospital and my life had changed for ever. I’d had my first death where I felt I was solely responsible.
I would bring the crash cart to modern standards. Get the hospital nurses to check the medications. Make a booklet of what was there and insist that it be reviewed every 6 months to ensure medications hadn’t expired.
Bob has just been surviving when his partner had left and when the surgeon had left another doctor had left the previous year. He was doing the work of three doctors and h OR buses that had maintained things had left. There still was the problem of the administrator and head nurse. I could say the death was caused by the firing of the surgeons or by the ‘fate’. I did my best against all odds and happened to have more training up to date in ICU than any other doctor in the rural area a He time. . IT was apparent that keeping skills fresh was nearly impossible in the country with so many demands and so few such emergencies. I trained the nurses and introduced a training review.
Maureen cried. I’ll neve he horror in her eyes. She was appalled. “I’ve never seen such chaos. I couldn’t believe it when I came in and you were alone bagging the patient and there was no nurse. She just left. She never came back. Bob almost killed me. There were no meds in the crash cart....”...she was crying and went on....she was a mess when I got back.
She’d never leave the centre of the centre of the centre of the university hospital ever again. “I could never work like you do with people who don’t know what they’re doing. How can you stand it? I need a team. I really need a team Bill. I need a good team.”
“I know. I know.” A
I soothed.
“Will he live? “
“I don’t think so.”
“He was blue. Blue. Bill”
I know.
“When I stared heart compression he still had a pulse.”
“But the blood wasn’t getting to the lungs because they were ceased.”
We’d talk round and round and round.
I’d have this case haunt me over and over and over again. I still haunts me.
“I should have checked the ICU. I should have checked the crash cart. I should have checked if the IV fluids were stocked. I should have made sure they had inflexible intubation kits. I’d get them in. I ‘d change everything. We’d save more lives in the years to come. His death was’t wasted. The family were angry but by then the blood work came back and a nurse who had been at the party told me that he’d been sick since the morning. The family were angry but they’d lied to my face. But he’d lied to them. Their guilt. Their loss. A miracle hadn’t happened. I’d done all that was humanly possible.”
I kept thinking what if I’d given a massive dose of steroids but it sounded like pneumonia. I’d ordered the X-ray before doing that. Today I’d have given a massive dose of steroids but I doubt anything I did would have worked short of having a respirator because his diaphragmatic muscles were exhausted from wheezing and struggling to breathe all day.
“I could never work in the country like that. I couldn’t work with people who don’t know what they’re doing. “ She said. She was frightened. She was hard.
I saw Africa flying away on angel wings. I saw my country home evaporating. She had new found respect for our country physician friends but she was never going to be herself in the wilderness. It’s what I’d live to do.
I tried to argue with her that this is where doctors are needed. But she went on about law suits and wasted expertise. “I need a team. I can save lives with nurses and equipment that’s up to date. I need colleagues who know what to do and are doing it. I need people who are in practice. I don’t want to be bumbling about with people whose last procedure was a year or two before. I don’t want to be working with people who do medicine as a job on the side like it’s a position at the grocery store. I need a team Bill. I like doing the A team things.”
“We all do Maureen. I love the A team. I ‘ve been the A team.”
“Come back to Winnipeg. Go back to Surgery. The pediatric department wants you. Everyone wants you. You don’t need to be out in the country with a corrupt administrator and doctors not having the help they deserve. The government doesn’t care for doctors in the city but they sure don’t care about rural doctors. Some of the equipment out here is turn of the century. You can’t like working in third world conditions.” She said wiping tears.
“I do. That’s where we are needed. Anybody can work with a great team. The interns and residents do well in the hospital but it’s out in the country where the need is. Bob and Mike and I are making a difference. We save lives every day. Bob’s fighting all the time to get the local government to get the equipment up to date.”
It helped a little bit when I got a call from the ICU head who told me he’d never seen a ‘status asthmaticus’ survive coming in from the country. He said they only succeeded with respirators and that I’d done a good job getting the boy in with his heart and lungs still working but it was just a tragedy that he had coned. He was very kind to call me. I have over the years had some of the finest colleagues. I think the ICU doctors and staff are some of the finest people because they deal with reality, life and death on a daily basis and don’t get distracted by the nonsense so easily.
The parents loved their son. A parent never gets over the death of a child. All they can do is try to move on.
Maureen and I would talk round and round. I just saw that THE GREATEST NEED was where doctors needed to be. I ‘d go work further and further out there and she’d get closer and closer to the centre, safe in the pack.
She was never coming to the country. She was certainly not going to the third world. She liked clean and order way to much. She was pretty OCD. She liked luxury. A princess, a queen, a goddess. A city girl all the way. I loved her and I had to think about what I was going to do in the city. I couldn’t see being a general practitioner because a city gp often was a glorified Triage Nurse. There were niches like the one my friend Frank found , working as a surgical assistant half time. There were other possibilities.
But I was interested in why this young man had’t taken his medication and why he lied to the doctors. I was interested even more why the parents lied. I was becoming more interested in why our hospital administrator wasn’t rquisitioning the equipment Bob was asking for, like some of the stuff missing on that crash cart and where the money was going to. I began to study ‘non compliance’ and it was like finding the ‘greatest secret’ hidden in the centre of the room like a proverbial elephant. I’d spend the next 20 years of my life fascinated by it.
At the end of the day I was the doctor. I was responsible. If I had been a better doctor I might have saved his life. It is always a dance between patient and disease so if he wanted life even more maybe he would have saved his life. I’d yet come to learn even further that the ‘bullet has your name on it’. A WWI vet would teach me that one. I’d also come to know that ‘every GI surgeon has his fistula”. That was my case. This was the one that haunted me. Nightmares and dreams. I’ve played that case over and over in my mind. There’s nothing I would have done different. I’d never known status asthmaticus, rare. I’ve saved countless asthmatics since. I’ve resuscitated hundreds. If the drug addict wasn’t in the room demanding the lights off, if the technician and nurses had seen the initial duskiness when they were in his room. He was pink when I admitted him. Even admitting him was done against his will. He wanted to go home. “Just give me some meds and I’ll be fine. I just need another puffer.”
I’ve been crying writing this. I can’t think of it without choking up. I didn’t know the kid hardly at all but he was a great boy and his poor family and what a waste. What possibilities he had. Now I know so many possibilities. Now I’ve worked through suicide epidemics and aids epidemics and I’m still working in the fentanyl epidemic. I’ve worked without anything and been alone and afraid more times than I can remember trying to keep some body alive, trying to convince someone to live.
I’ve had people die in my hands. I’ve watched premature babies die unable to breathe. I’ve extracted dead babies to save the life of a mother. But it’s this first one I think of and the horror on Maureen’s face and the terror in the room and everyone doing the best they could, everyone wanting the boy to live and everyone wishing they had a city ICU. I could play the blame game. It s so easy but now I know death isn’t simple. On tv or in court it’s Perry Mason but in medicine it’s rarely black and white, at best hands of grey.
I think it recurs as much for me because it’s when my marriage began to pull apart. I had a whole differernt view of medicine. Maureen was a great doctor. Really one of the very best. I admired her skills and mind but she did as she said ‘need an A team’. I was going whereever the greatest need was and always glad to have good people around but I wanted to help the patients who needed help the most.
This spiritual thing would affect me and ultimately decide me to go into psychiatry because it was a wilderness. The patients had the greatest need as did others who were isolated and stigmatized. I never left the country hospital. It just took on a different shape. I’ve always worked in the wilderness even in the core city.
The Baby Incubator would be another turning point.
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