Richard Mabry - Lethal Remedy

Sara was about to enter an exam room when she heard Lillian Goodman call softly, "Sara, hang on a second." She turned and watched Lillian walk swiftly down the hall of the clinic, a chart held at arm's length in front of her like a stick of dynamite about to explode. "I don't think I'd better see this patient. Would you take him?" "Sure. But why-" "Recognize the name on the chart?" Sara looked.

"No. Should I?" "Let's just say it's someone I don't want to establish a professional relationship with." Lillian shook her head. "You know, maybe I should call Don Schaeffer. It would probably be best for the chairman to see him anyway." "Don't be silly." She looked at the history form. Chief complaint: cough and fever. "Probably bronchitis.

I can handle that. And maybe later you can tell me why you didn't want to see him." Without waiting for Lillian to respond, Sara tapped on the door and entered the exam room. A middle-aged man in a Wwell-cut gray pinstripe suit sat in the patient chair in the corner of the small room. His white French cuffshirt was spotless, and she recognized his tie as a Gucci. He rose when she entered the room. "I want to tell you that I'm here despite grave misgivings." His tone was mild, but there was no mistaking the emotion behind the words. "I have severe doubts about this institution in general, but my family doctor is unavailable and both my wife and sister insisted that I would receive good care here." He bowed slightly. "Please don't take that as an indictment of you or your capabilities. I don't know you. But-"

Sara waved offhis comments. "Never mind. You're here, so we'll just move on," she said. "Have a seat and let's talk a bit. What kind of problems are you experiencing?" The story was one she'd heard a lot in recent weeks. An upper respiratory infection that worsened and morphed into a persistent cough productive of green to yellow sputum. Fever and chills. Fatigue and loss of appetite. If the history didn't suggest it, the man's persistent cough and the perspiration on his brow gave her clues to his problem. He shed his coat and shirt when requested to do so, and perched uneasily on the edge of the exam table. When Sara placed her stethoscope on his chest and listened, her clinical suspicion was verified. Crackling rales and diminished breath sounds in both lungs, maybe a little worse on the left. Classic signs of pneumonia. "Just a chest cold, right?" the man asked. "So you can give me something and let me go." "Afraid not," Sara said. "I need to get some lab work and a chest X-ray, but I think you have pneumonia."

"But I don't have time for that. I'm a busy man. Can't you just give me a shot of penicillin or something like that?" She'd heard it all before, heard it so much that her response was almost a set speech.

"This could be something quite simple or very serious. I won't know how to treat you until I see the results of these tests. They won't take long, and there's a very good possibility we'll be able to treat this on an outpatient basis." She looked pointedly at her watch. "And the less we argue about it, the sooner we get the information I need to treat you." He acquiesced, but it was obvious he was used to simply telling doctors what he wanted instead of letting them determine what he needed. Sara hated that attitude, but she'd learned that trying to educate these patients was often an exercise in futility. While the patient donned his shirt, Sara stepped outside and handed the chart to Gloria. "PA and lateral chest. CBC. Sputum culture. And, oh, have them do a smear and Gram stain of the sputum right now. That will help me pick an antibiotic while the culture's working." Almost an hour later, Sara was leaving an exam room when Gloria motioned to her. "Got the lab on your patient." She handed a chart to Sara, then fanned out three Post-It notes like a card player considering what she'd been dealt. "CBC showed a high white count with left shift." Sara nodded.

She'd expected this, evidence of a bacterial infection. Gloria shifted to the second note. "You may want to look at the films yourself, but the radiologist read them as bilateral bronchopneumonia, almost total consolidation of both lower lobes, with a small pleural effusion on the left." Sara breathed a silent thanks to John Ramsey, who'd taught her and hundreds of other medical students the art of physical diagnosis. I made that diagnosis with my stethoscope. Gloria moved to the third note. "Saved the worst for last. The chief microbiology technician did a sputum smear. Grampositive cocci, clusters, and chains. She says it looks a lot like Staph luciferus." Sara took a moment to collect her thoughts. There was no way this patient was going home. She needed to admit him to University Hospital for pulmonary treatments, supportive care, and antibiotics. That raised the big question. Consider Jandramycin therapy immediately, or wait until the culture and sensitivity studies were back? That would take at least two days, maybe three, and if this was really Staph luciferus, the man could be almost dead by then. But if this turned out to be another type of Staph, even MRSA, Jandramycin would be the wrong antibiotic. And the final kicker-Jandramycin would put the patient at risk for a late autoimmune complication, possibly a lethal one. Ask Jack to consult? Not with what she knew about him now. There was one person whose opinion she trusted. She'd consult him. "Please page Dr. Pearson and ask him to call me back as soon as possible,"

Sara said to Gloria. "Then get the papers ready to admit Mr.-" She found the name on the chart Gloria had handed her: Randall Moore.

"Admit Mr. Moore to University Hospital with a diagnosis of bilateral bronchopneumonia."

"Mr. Moore, I'm Dr. Pearson. Dr. Miles asked me to consult on your case." Moore glared at Rip. "I don't need a bunch of doctors poking around on me and running up a big bill. I told-" He doubled over with a paroxysm of coughing and took a moment to recover his breath. "I told that woman I just had a bad chest cold. I think I'll leave and go to an emergency clinic somewhere. They'll give me a shot of penicillin, and I'll be fine." Rip took a deep breath and tried to get his emotions in check. Maybe the best thing would be to let this guy sign himself out against medical advice. No, Rip remembered the oath he'd taken. Some members of his medical school graduating class had laughed at the process of repeating the Physician's Oath, an updated version of the old Hippocratic oath. But he had sworn to abide by these words: "The health of my patient will be my first consideration." "Mr. Moore, look at this X-ray." Rip pointed with his pen. "Your lungs are operating at about half-capacity because of the infection. Fluid is already building up in them. If we don't do something about it, you'll die. And it won't be pleasant. You'll suffocate." Maybe a little drastic, but judging by the expression on Moore's face, effective. "So what do you need to do?" "Admit you to the hospital. Give you breathing treatments. Control your fever. And pump you full of strong antibiotics." "How long do I have to stay?"

Good question, and one to which Rip had no answer. "As long as it takes to get the infection under control and make sure your lungs are clearing." He forced a smile. "Believe me, we'll get you out of here as quickly as we can." "Well… " Rip fired his last possible shot.

"I'll have the chairman of our department look in on you later today.

And I can ask the head of our infectious disease division to take over your case if you'd like." Rip was surprised when Moore shook his head.

"Not necessary. I want you and that woman doctor to take care of me."

"Why?" Rip blurted. "Because you didn't let me bully you. Usually my money and position in the community get me whatever I demand. You didn't give in." "I'm sorry, Mr. Moore, but I was unaware of both of those. I treat everyone the same, whether they live in Highland Park or under a bridge." "I'll bet you do," Moore said. "But there's another thing. Both of you seem genuinely interested in treating me, even though… I don't know if I should even mention it." "Mention what?" "That I'm currently suing the medical center and a number of its doctors for several million dollars."