Arthur Hailey - Strong Medicine

As the administrator put down the phone he grimaced wearily, then his manner softened.”This is a bad day, Andrew. For all of us, and for the hospital. But I know you've done what you felt you had to.”

Andrew nodded dully.”What happens next?" "The executive committee will meet in a few minutes. You'll be called in. Meanwhile wait here.”

Somewhere outside a noontime whistle sounded. Time. Wait. Waiting. Andrew mused dejectedly: Waiting was what he had done too much of. He had waited too long. Waited-until a patient-a young patient, who should have lived for many more years-had died.

After his discovery, four years and eight months earlier, that Noah Townsend was a drug addict, Andrew had kept watch as best he could on the older physician-the objective being to ensure that no medical mishap or crucial misjudgment occurred. And while there were limits, obviously, to the closeness of Andrew's scrutiny, he was satisfied that no serious malpractice problem had existed. As if recognizing and accepting his colleague's concern, Noah would often discuss his difficult cases, and it was evident that, drugs or not, the elderly doctor's diagnostic skills were continuing to function. On the other hand, Dr. Townsend became noticeably more careless about taking drugs, not bothering with the concealment from Andrew he had practiced earlier, and showing increasing signs of the drugs' effects-glazed eyes, slurred speech and shaky hands, both at the office and St. Bede's. He left dozens of sample bottles of prescription drugs lying around in his office, not even taking the trouble to put them out of sight, and he would dip into them occasionally when Andrew was with him-as if they contained candy. Sometimes Andrew wondered how Townsend could continue to be a drug addict, yet function as well as he appeared to. Then Andrew reasoned: habit died hard, and so did instincts. Noah had been practicing medicine for so many years that much of what he did-including diagnoses which could be difficult for others-came easily to him. In a way, Andrew thought, Noah was like a flawed machine which goes on running of its own momentum. But a question was: How long would the momentum last? Still, at St. Bede's, no one else appeared to share Andrew's concern. However, in 1961-a year after Andrew's discovery about Noah and the first, abortive session with Leonard Sweeting-Noah Townsend did step down as chief of medicine, also quitting the hospital's medical board. Whether the changes were Townsend's own idea or the result of a quiet suggestion, Andrew never found out. Also, from then on, Townsend led a less active social fife, staying at home more than in the past. And at the office he eased up on his patient load, mostly referring new patients to Andrew and a new young doctor, Oscar Aarons, who had joined their practice. From time to time Andrew still worried about Noah and patients, but because there seemed no major problem, Andrew had as he saw it now-simply drifted along, doing nothing, waiting for something to happen, yet nurturing a wishful belief it never would. Until this week. The climax, when it came, arrived with shattering suddenness.

At first Andrew had only partial, disconnected information. But soon afterward, because of his suspicions and inquiries, he was able to piece events together in their proper sequence. They began on Tuesday afternoon. A twenty-nine-year-old man, Kurt Wyrazik, appeared in Dr. Townsend's office complaining of a sore throat, nausea, persistent coughing and feeling feverish. An examination showed his throat to be inflamed; temperature was 102 and respiration rapid. Through his stethoscope, Noah Townsend's clinical notes revealed, he heard suppressed breath sounds, lung rales, and a pleural friction rub. He diagnosed pneumonia and instructed Wyrazik to go to St. Bede's Hospital where he would be admitted immediately and where Townsend would see him again, later in the day. Wyrazik was not a new patient. He had been in the office several times before, beginning three years earlier. On that first occasion he had also had an inflamed throat and Townsend had given him, there and then, a shot of penicillin. In the days that followed the injection, Wyrazik's throat returned to normal but he developed an itchy body rash. The rash indicated that he was hypersensitive to penicillin; therefore that particular drug should not be given him again because future side effects might be severe or even catastrophic. Dr. Townsend made a prominent, red-starred note of this in the patient's medical record. Wyrazik had not, until that time, known about his allergy to penicillin.

On a second occasion, when Wyrazik arrived with a minor ailmtnt, Noah Townsend was away and Andrew saw him. Reading the patient's file, Andrew observed the warning about penicillin. At that point it did not apply, since Andrew prescribed no medication. That-about a year and a half earlier-was the last time Andrew saw VVyrazik alive. After Noah Townsend sent Wyrazik to St. Bede's, Wyrazik was installed in a hospital room where there were three other patients. Soon afterward he was given a normal workup by an intern who took a medical history. This was routine. One of the questions the intern asked was, "Are you allergic to anything?" Wyrazik replied, "Yes-to penicillin.”

The question and answer were recorded on the patient's hospital chart. Dr. Townsend kept his promise to see Wyrazik later at the hospital, but before that he telephoned St. Bede's, instructing that the patient be given the drug erythromycin. The intern complied with the order. Since, with most patients, it was normal to use penicillin to treat pneumonia, it appeared that Townsend had either read the allergy warning in his file, or had remembered it-perhaps both. That same day, when he visited Wyrazik in the hospital, Townsend would have-or should have-read the intern's notes, thus receiving a further reminder about the penicillin allergy. The patient's own background had some relevance to what happened, or failed to happen, later. Kurt Wyrazik was a mild, unobtrusive person, unmarried and without close friends. Employed as a shipping clerk, he lived alone and was in every sense a "loner.”

No one visited him while he was in the hospital. Wyrazik was American-born; his parents had been Polish immigrants. His mother was dead. His father lived in a small town in Kansas with Kurt's older sister, also unmarried. The two were the only people in the world with whom Kurt Wyrazik had close ties. However, he did not inform them that he was ill and in St. Bede's. Thus the situation remained until the second day of Wyrazik's stay in the hospital. On the evening of that second day, around 8 p.m., he was seen again by Dr. Townsend. At this point also, Andrew had some indirect connection with the case. Noah Townsend, of late, had taken to visiting his hospital patients at unorthodox hours. As Andrew and others reasoned afterward, he may have done so to avoid meeting medical colleagues in the daytime, or it may have been his general disorientation due to drugs. It so happened that Andrew was also at St. Bede's that evening, dealing with an emergency for which he had been called from home. Andrew was about to leave the hospital as Townsend arrived, and they spoke briefly. Andrew knew at once from Noah Townsend's demeanor and speech that the older physician was under the influence of drugs and had probably taken some quite recently. Andrew hesitated but, since he had been living with the situation for so long, reasoned that nothing harmful would happen; therefore he did nothing. Later Andrew would blame himself bitterly for that omission. As Andrew drove away, Townsend took an elevator to the medical floor where he saw several patients. The young man, Wyrazik, was the last. What went on in Townsend's mind at that point could only be guessed at. What was known was that Wyrazik's condition, while not critical, had worsened slightly, with his temperature higher and breathing difficult. It seemed likely that Townsend, in his befuddled state, decided the earlier medication he had prescribed was not working and should be changed. He wrote out new orders and, leaving Wyrazik, delivered them personally to the nursing station. The new orders were for six hundred thousand units of penicillin every six hours, injected intramuscularly, with the first injection to be given at once. Because of the absence, through illness, of a senior nurse, the night nurse on duty was junior and new. She was also busy.