Twelve Patients: Life and Death at Bellevue Hospital (37 page)

“Margarita—is it okay if I call you Margarita? If you don’t mind my asking, where are you from?”

“Yes of course, I would prefer that you call me Marga. I am French, from Algeria originally. We moved to the States when Susanne was a teenager. My husband, or ex-husband, is Algerian and teaches at the university on Long Island. I tried to reach him. He is on sabbatical in the Middle East now. I don’t know where exactly.”

“What was going on with Susanne? What made being her mother so hard?”

“I don’t know where to start. The beginning or backward maybe is better.”

“Don’t worry, we can put the pieces together. It doesn’t have to be all right now.”

“Things started to get crazy when we were divorcing. I don’t blame the divorce, but I do think the house was poisoned in ways it took me a long time to ‘own up to,’ as you would say in the States.”

“It can be a pretty painful time for everyone in a family. There can be a lot of wounding as marriages unwind.”

“Her father had wide-open affairs with his students and made nothing of it. I was supposed to watch, suffer in silence, and continue with our suburban pretend family life as if nothing was happening. I refused one day. He went crazy. He ranted, he broke things, he hit me and told me to get out, that I could figure out how to live on my own and could crawl back to clean up his ‘shit.’ ” More left unsaid than you could put in an encyclopedia. The details of domestic dissolution were too painful. Humiliations recycled and introduced with surgical precision. Self-abasement, drop by drop. Extreme stress pried open doors into people’s lives you would never otherwise get an opportunity to enter. It was perhaps the greatest privilege of being a physician. Confession, but face-to-face, not hidden in a wooden box.

“Susanne was a teenager. She got caught up with other kids, her friends, and stopped coming home regularly. I didn’t know because she was split between two homes. A mother who had a studio apartment and spent her days, MetroCard in hand, climbing cement staircases in four boroughs as an itinerant French teacher. I was a backup, a stand-in adjunct for subsistence pay seven days a week. A father who flaunted his new sexual freedom like a teenager, with a twenty-year-old college senior sleeping in my old bed.

“Over the next few years—it is all blurry now, and it doesn’t matter really all of the details, I know that—she tried drugs of all kinds and overdosed a couple of times. One time she was saved by chance. Another addict had a syringe filled with a medicine that brought her around. She had stopped breathing. That close. She got pregnant twice, more crises and abortions with pills and mini surgery.” The tip of dozens of other issues. What could be said hid a lot more that couldn’t. The social workers and the team would have time to tease out what was current and what was history.

“I did what I could. School meetings, therapists, hospital visits, emergency room middle of the night, taxi rides, advice from friends, group sessions for parents who had similar lives. We careened. We didn’t live a life. We were like random planets bouncing from an
exploding star. That was my daughter. That was me.” A phase change. From the outside, it was invisible. Normal family. A trivial incident brought it from liquid to gas like water to steam. A fraction of a degree of difference.

“She stayed away from me. From her father, too. She wouldn’t talk to us. She hated us. I couldn’t understand. I have to say, I stopped looking for her. But more than that I hid myself away in a protective cocoon. I had to do something to hide myself so I did not get damaged beyond repair as she fell apart. Her father never stopped. The good parent, I guess. Or maybe not.” She looked at me, enigmatically.

“Until I got Charles’s call. It all started to flood back again. I had to talk to someone,” she said, looking at me. “I did a terrible thing. I didn’t do anything. I abandoned my daughter.”

“Your husband? Is he involved? Will he care or want to know?” I wasn’t sure which layer of Detroit’s story I was encountering now. It was getting more and more complicated—and I hadn’t even met the patient! The only thing I did know for sure was that I hardly knew anything at all. Medicine is a forensic science. It hardly prepares one for this. This, life that is learned the hard way.

“I really don’t know, to tell you the truth. He is and isn’t involved with Susanne. He can be cold-blooded one minute and generous and warm and outgoing the next moment. He is two people in one. You never know which one will be there with you. It is a sort of terror. Will he be doting father number one or father number two who likes young girls?” Marga was leaning toward me with her elbows on the table. The cords of her neck muscles stood out like cables of the Brooklyn Bridge.

“Marga, are you saying what I think you’re saying?” I didn’t know what to believe. I had seen so many stories turn into their opposite.

“I don’t know what I’m saying.” She looked away.

“You emailed him?”

“Yes, I sent him a message. I called his department. He is in Europe and then to the Middle East. North Africa, his life’s work.”

“Marga, what about your daughter and Reed? You talked about a teenager in trouble.”

She paused a moment to take a couple of breaths. “She has gone through a few partners including a marriage to a guy who wanted a green card from a
gringa
. That lasted until the paperwork came through and then he was packed and gone. He was too young, too tattooed, too much into marijuana, beer, and uppers and downers. Stoned all the time and played the guitar all night long. Not a bad person, not vicious or violent. Zero motivation. Zero reason to get out of bed. But one day he was gone.”

“It sounds like Susanne doesn’t know who she is.”

“Doctor, I really don’t know myself. I was hoping you could help me while she is here, I mean help her. She is like a wounded bird and I think she found another wounded bird to look after. He is a nice person—don’t get me wrong. I mean he has been through terrible injuries.”

“So maybe that is not so bad, if they can help each other? There aren’t a lot of opportunities for caring and loving out there in the cold.”

We had patients, deeply wounded souls, who had stories of betrayal of the most intimate kind. Fathers preying on their daughters, selling them to strangers and watching television while they were being violated with broomsticks. We sewed them up, re-operated half a dozen times, and tried to figure out the puzzle of why and how. How could someone stay with anyone so evil without repeating the cycles of violence? Many of the stories, we couldn’t understand at all. We were at a loss.

“Did something happen to your daughter when she was a kid? Is there something you are trying to tell me?” I had no idea if I was way out there, even becoming inappropriate, thirty minutes into a family meeting. I rationalized that Marga had opened the door, kicked it open in fact.

“That’s what I don’t know. Precisely. I mean precisely what I don’t know. I have been terrified that I was there and it was happening in front of me but I didn’t see it or want to see it. He had me in some kind of a grip. A fog or something. I was afraid of him. Totally afraid. I anticipated everything so as not to trigger something that might set him off into that other person that lurked inside the one I had married. I must be confusing. You would think I had married two men.”

I had never jumped out of a plane. At that moment I felt I had been pushed out of one.

It took a few days to get our review team together. Susanne was out of the PACU and into the surgical unit and doing very well. For a woman who had been bled nearly to empty, she was in good spirits and liked the nearly full-time attention of the care team that fluttered around her bed. She was in a chair when I went to see her again for a few minutes by herself.

“Hey, Susanne, not bad now. Up and moving around. Impressive.”

“Doctor, I am doing okay. I just spent another hour with Marion. She walked me through the events. It was like talking about someone else. I was out on the street corner, there was yelling, and then nothing.” She had a slight hint of a French accent and spoke Arabic with one of her doctors from Baghdad.

“The good news is that your body goes into a complete survival mode and in the process wipes most of the memory banks clean. Pieces may come back, but overall it will be about recovery and getting back to your life.” Here I was on less firm ground, but I held my voice firm.

“The doctors have come by several times to go over the transfusion mistakes. I don’t really know what to say. I am okay. Evidently nothing bad happened to me. So in the scheme of things I guess I got great care and a big dose of luck.”

“We are going through what happened to make sure it cannot happen again. I will let you know what we put in place,” I added.

“I know they feel terrible about what happened. But they did save my life. My husband was hit and burned and he was evaced to a military hospital. Did he tell you about the medication combination that gave him a very high temperature, something-malignant syndrome? His legs get burned and he survives and then nearly dies from medication side effects that burn him up to a temperature of nearly 107!”

“No, I had no idea, but I’m not surprised unfortunately. The combinations of medications can be pretty nasty.” Just then Reed walked in and I said good-bye, promising, as always, to come back. He bent over her and gave her a warm smile, and a warmer kiss.

My office wasn’t big enough for the meeting, but it was serviceable.
The people involved in Trauma Detroit were squeezed around the table, ready to discuss what had happened. The mortality from mistakes in the five thousand hospitals around the country is equivalent to a 747 going down every other day. What industry had this as a business model? Or a permissive attitude: “That’s the way it is,” a variation on “shit happens.” The feds were finally coming out with
Never Events
. They finally refused to pay for avoidable complications ranging from pressure ulcers acquired during a hospitalization to infections from contaminated poorly maintained intravenous lines. Unless quality and safety standards were hardwired into the regulatory and payment rules of engagement for medicine, it would take decades more for the profession to adopt them. The awkward truth was that medicine was slow to come around to embracing safe practices, from hand washing to standardizing equipment.

“Thanks for being here,” I started. “I want us to go over the case and get down to the underlying issues right away, before the trail gets cold and events become blurry. We have the written details of the case, and you have talked to everyone involved. Ozal first, please.”

“The error occurred in my department,” she said. “Senior attending who knows what to do and made the mistake. We have been over the procedures and processes again and again. They are crystal clear, there is no ambiguity here about hanging blood.” We were a long way from the days of heat-seeking missiles looking for the single person to blame and shame. In my day, I recalled, similar discussions had felt like group initiation rites, obligatory rituals of cutting and bloodletting.

Our senior surgeon chief, Greg, jumped in. White hair and beard, permanent blue scrubs, forty years of experience, and he still had a sense of humor. “Things get really complicated in the operating room, and many of us are pure adrenaline junkies. I am not joking, really.” He looked at all of us and made sure we were paying attention. “Life-threatening trauma activates everyone around here at a gut level. Even good doctors lose their common sense. It’s contagious.” I think he got it just right. Technically everyone was a black belt. In a moment of extreme stress I wasn’t so sure. These were known, competent people, and they still made a major mistake.

“So,” I said, “we have these policies and procedures in nice shiny red vinyl binders and online. What do we do?”

“The irony,” Saul the head of trauma put in, “is that the traumas are way down. The big stuff, I mean. Yeah, the orthopedic guys get motor vehicle traumas but real trauma, the stuff we grew up on, is down. People just don’t see enough of it. You take that plus the residents having to leave in the middle of a procedure, who will see enough trauma cases? It doesn’t come in on a schedule like your dentist’s office.” He was rabidly opposed to the new work hour rules for interns and residents that prohibited them from working more than a specified number of hours a week. Yes, exhaustion would cause certain mistakes, but the many handoffs during procedures caused other mistakes. The young medical staff did not get to see a case through from beginning to end, and so wouldn’t get a sense of ownership and responsibility. “It will take ten years to train a surgeon,” he continued, “just so they see enough cases.”

“We need to practice and video everyone in mock traumas,” Greg said. “We play it back and debrief. It is part of training and competency. Period, done. That’s the only viable alternative, short of sending all surgeons-in-training for a tour in Kandahar. We are a long way from see one, do one, teach one. The way I learned medicine.”

We’d covered a lot of territory by the end of the long meeting. The airline industry had cleaned up its safety record by standardizing its procedures, putting all of its pilots through extensive simulations, and developing a system for pilots to report in problems and errors that created a database mined regularly for improvements. We all knew the practice of medicine was a complex ballet, and every patient had his or her own vagaries and responses. But we also knew that the profession had hid behind “My patient is different” for too long. It had delayed our ability to respond to the overwhelming similarity of patients. The journey was long, complex, and only partially under way.

My office was a mess strewn with coffee cups and half-eaten cheese Danish. My cell phone went off with an unknown number.

“It’s me, Marion.”

“Hi, what’s up?”

“Eric, you have to come upstairs right away. We have a real problem.” She was not prone to exaggeration. Zero alarm fatigue.

“What is happening and who are you talking about, Marion?” We were following several patients together throughout the house.