William Kienzle - Deathbed

“Now, there are code blues all over this place. Shoot, people have been known to arrest out in the lobby while they’re waiting to register. But you’ll find you’re going to be summoned for codes down to the OR and ER more often than anywhere else. So I thought it would be good if we got to know each other better. And if you got to know this place and some of its personnel better.”

“But I’ve already had orientation—”

“To be a chaplain—a temporary one at that. There are things going on here besides the care of souls that are going to concern you—ready or not. Are you game to learn in the school of hard knocks?”

Koesler nodded. He felt the question was rhetorical.

“Right,” Scott affirmed. “First, how about some dessert?”

“No, thanks.” Koesler found it difficult to believe that Scott had finished all the food on his tray. But he had.

“Coffee?”

“Sure.”

When Scott returned, his tray contained two cups of coffee and one huge banana split. Koesler felt awe at Scott’s appetite.

“Okay,” Scott said, “let’s start with the boss lady.”

“Sister Eileen Monahan.”

“The same. She is unique—and I do not use the term lightly. She, and she alone, is the reason St. Vincent’s continues to sputter along. It long ago passed the point at which it should have been shut down. It is a financial disaster that is getting worse rather than better.

“Even in the brief time you’ve been here you must have noticed there are very few well-to-do, well-educated patients—white or black—occupying our beds. They’re mostly indigent blacks. And precious few Catholics.”

Koesler nodded. Making his rounds this day, he had not met a single patient, white or black, who would have fit socially or financially into Koesler’s Dearborn Heights parish.

Scott continued. “Lots of patients who come here not only can’t pay anything, they’re not covered by anyone—neither their own resources nor medical insurance. But by decree of Sister Eileen, not one of them is turned away. Somehow the hospital is expected to swallow their costs. As you can imagine, the hospital regularly gags on their expenses.

“Then, there are a goodly number who can’t pay their own costs—well, who can?—but, while they have no private insurance, they are covered by Medicare, Medicaid. Then things get complicated. What with DRGs—that’s diagnostically related groups—we can have the patient hospitalized for only a limited time and we can collect from the government only a set minimum fee. Not only is that extremely restrictive to the patient, the hospital is not going to get rich. Indeed, since the hospital cannot tuck administrative costs or any future planning in the bill, it begins a slow fiscal retreat.

“These are the kinds of odds facing Sister Eileen.”

“I see.” Koesler shook his head. “But then even more so now than when I asked Sister this afternoon, I find it difficult to understand why she bothers trying to keep St. Vincent’s afloat. Especially here in the core city.” Koesler’s hands were wrapped around the cup with its untasted coffee. He preferred warm hands to a warm stomach.

“She’s trying to bring the ideals of service of St. Vincent de Paul to Detroit’s inner city,” Scott explained. “And I’ll be damned if she doesn’t almost carry it off. And it’s all her, too. No doubt about it, St. Vincent’s Hospital and Sister Eileen Monahan are almost identical. They’ve been together so long they have become inseparable. She’s always here. She’s always available to everyone. She inspires a special spirit in everyone, from the orderlies to the volunteers to the head nurses.”

“Do I detect an omission of the doctors?”

“Oh, yes, you do. But as far as the doctors go, Sister Eileen has written the book on the care and feeding of doctors. It’s not that she can’t be firm with them when necessary. It’s more that she has a magical touch when it comes to the little things, the infinitesimal perks that are so dear to doctors. Things like—you know—‘Dr. So-and-So wants this special instrument in the OR’ or, ‘Dr. So-and-So wants the charts kept in this special way.’ Then, along comes Sister Eileen to say that Dr. So-and-So really ought to have that instrument. Or, without offending the nurse in charge, Eileen will see to it that an exception is made for Dr. So-and-So and that the floor nurses will keep his charts in his own peculiar way.

“But those doctors, generally, are the ones who have made a conscious and rather generous decision to stick with the core city. And in doing so they have made the not inconsiderable sacrifice of giving up great wealth and prestige patients. Outside of these, many of the other doctors on staff here simply could not ever be accredited to the swankier hospitals. But . . . they are all we’ve got. “

“I see.”

“Take for example Dr. Lee Kim.”

“The one who was working with you in the emergency unit.”

“Right.”

“He’s not a good doctor?”

“On the contrary, he’s quite good. He just can’t quite figure out what he’s doing here at St. Vincent’s. This is not in his timetable at all.”

“I don’t understand.” Koesler tasted the coffee. It was tepid. He shuddered and set it aside.

“He came here from Korea. Not unlike many other doctors. And, like many other foreign doctors, his progress has been arrested at an inner-city hospital. He makes no bones about it: He wants to be affiliated with the affluent suburbs.”

“And in this, I take it, he is not alone.”

“No, that’s true. But his ambition causes him to take a rather casual attitude toward some of his work here.”

“Casual?”

“Uh . . . for instance, suppose we have a terminal case. Somebody whose life system can be supported by mechanical means alone. Well, rather than waste half an hour of his valuable time, he will go to the family and say, ‘Do you want us to do everything?’”

“‘Everything’?”

“It becomes a rhetorical question. The point is, he could spend some time with the relatives, the next of kin, and talk about the quality of life this patient is not going to have in a coma and plugged into machines that will breathe for him, keep his heart going, filter his waste. Dr. Kim doesn’t want to spend a lot of time explaining the choices the family has. And the easiest way of getting out of that chore in a hurry is to ask the family simply, ‘Do you want us to do everything?’ Few families will have the gumption or the knowledge to ask about alternatives. They will say, ‘Of course, do everything.’ At that point, Dr. Kim will put in an order to plug in the life-support systems, and leave the patient to vegetate.”

“I see.” Koesler thought he did. “But what does conduct like that have to do with the hospital—or Sister Eileen?”

“For one thing, it drives costs up, most of the time needlessly. Instead of spending a lot of money on systems that keep essential body functions going, the patient should be allowed to die with some dignity. But doctors like Kim never quite give dignity a chance. So it’s that much more difficult to balance a budget.”

“I see.”

“Now, Dr. Kim is by no means alone in his approach to terminal patients. Where he could have a problem, that could cause the rest of us to have a concomitant problem, is in the clinic. Has anyone told you much about the clinic?”

“I know where it is. You treat outpatients there. You even have outpatient surgery.”

“Right. It’s also where we have some of our more pressing ethics problems.”

“Oh?”

“Normally, they’re not problems for most doctors. Certainly they’re not problems for other hospitals. But they’re very definitely problems for Catholic hospitals.”