No: this is my patient. Part II: My Hercule Poirot moment
Continued from Part 1: The gathering storm.
I was pissed that he would write that on an official medical document. I stood up, ripped off my gloves and ran into the nursing station where Dr. Simoo was sitting.
“He has a subhyaloid hemorrhage (a flame-shaped red streak on his retina indicating bleeding into the eye) and needs an LP”
“I saw him. He doesn’t have any such thing. He just has a concussion. LP is contraindicated”
“I think that is what I saw. I need to rule out a subarachnoid bleed”
“You are just a GP. I am the specialist and I am going to admit him to the ICU under me.”
This statement was galling for many reasons. The arrogant tone and condescending posture was intimidating. Yes, I could just back off and wash my hands of this case. But that just is not the best care of this patient. It didn’t help the situation that he did this in front of Roberta and other nurses in the nursing station, undermining my position and putting them in a conflict position of whose order to follow.
There was also sub-text: Dr. Simoo had a well-earned reputation for churning the system, going through the hospital writing “consults” on most patients (and billing for them) without being asked for his opinion (which the law requires). When he saw patients without being consulted he went on the offensive and warned the doctors that whatever the condition of the patient was, always required a medical consultation.
To her credit, Roberta showed her loyalty: “What would you like me to do, Dr. Fisher?”
“Roberta. Are the ambulance drivers still here? OK, ask them to go to River Street and bring me the bike.”
About 15 minutes later the ambulance drivers burst through the ER door with a stretcher, with a bicycle covered by a blanket and one of the boys blowing air on the handlebars with a self-inflating bag.
It was very funny. I got it. But my guts were in knots.
River St. was about 100 m long and had a steep slope. I walked up that slope every day to Aaron Street, where my apartment was. I ran over to the stretcher and pulled off the blanket to uncover the bike. I said “Was it pointing toward Aaron Street?”
“Yes. How did you know?”
I had my diagnosis.
“Roberta, lets turn Mr. Dube on the side again. I am doing the LP.” We sent upstairs for the trephine (a drill used to drill into the skull if the patient began to cone). Dr. Salgado was already in the nursing station waiting. Dr. Simoo stomped out of the room.
The first drops from the end of the LP needle were…clear. I had a visceral sick cramp in the pit of my gut. In the event of a subarachnoid bleed, there should be some blood in the cerebrospinal fluid (CSF). I collected 3 small ampules as per protocol and pulled out the needle. Roberta labelled them with a 1, 2, and 3 and sent them up to the lab. An eternity later, the pathologist phoned down from the lab: there were about 7,000 red blood cells per high power field in the third tube. Indeed, Mr. Dube did have a subarachnoid bleed.
Mr. Dube was transferred to Moncton by air a few hours later.
The next morning I was in Mrs. Hunter’s office, as I described at the beginning. She, the hospital lawyer, and Dr. Simoo, and the Board of Directors wanted to know why my privileges to practice in the hospital should not be revoked. “Dr. Fisher,”, Mrs. Hunter continued, “the outcome of the case, and the fact that the patient did indeed have a subarachnoid haemorrhage and his transfer to Moncton could be life saving I grant you, but it is totally irrelevant. Dr. Simoo is a specialist and Chief of Staff here at Soldier’s Memorial. He had rendered an opinion in the best interest of the patient. You are just a GP here and for the overall wellbeing of our patients, for better or for worse, you must follow the specialist’s advice.”
Most times in life one walks out of such a meeting and over time can think of many rejoinders and arguments one should have made, but by then it is too late to recoup. Once in a while—not often, mind you—despite being caught totally off guard, intimidated by the CEO, Chief of Staff, the hospital lawyer, and the Board, all of whom have made up their mind to fry your grits, standing alone without an ally, the youngest in the room, one happens to find one’s voice.
“Mrs. Hunter,” I addressed her as she was the one who asked the question “first, let me say, Mr. Dube was my patient. When he came into the hospital the family called my office because they wanted me (emphasis) to look after him. He was admitted under me (emphasis) and I (emphasis) was responsible for his care. Dr. Simoo was not consulted by me to advise regarding the patient’s care. It is totally against Medicare rules for a specialist to see and bill for a patient without a direct request for consultation.” I worried that this was a low blow or like his being a specialist, was not mitigating in this case. Glancing around the table I could see that the postures on the people was changing subtly and their eyes were now mostly on the paper in front of them instead of riveting into my eyes. I let the previous statement float out there, surely some of them knew of his reputation, and then went in for the kill. “As a consultant, and not an admitting doctor, Dr. Simoo can provide advice but he cannot direct care. I am the patient’s doctor. I take into account the various lab tests and specialist’s advice and I advise the patient and the family . The patient and the family then decide on the care. Not me, and certainly not Dr. Simoo.”
Silence. Mrs. Hunter turned to the hospital lawyer. He said “We need to review the case further.” They motioned for me to leave. I went home. When I closed the front door behind me, I noticed I was shaking.
Denouement
So, why did I call for the bicycle, and how did it help make the diagnosis? Mr. Dube was very tall and weighed, I would say, easily 250 lb, if not more. All muscle. If he was riding downhill and lost control, and fell into the ditch at speed, the bike would crumple like cardboard. Going uphill, of course, would require great effort in pedalling to lift the bulk of Mr. Dube up the slope. This would cause him to strain, a classic precipitation of bursting a blood vessel in the brain. When the vessel bursts, he would get a tremendous headache, get off the bike, maybe become dizzy, and fall into the ditch, and his bike would simply fall over. When the bike came in, it was pristine. The examination of Mr. Dube showed no trauma. He basically lay down on his own.
That evening I phoned to Toronto to gather information about which residency is appropriate for someone interested in critical care (there were no critical care residencies then). I was told I could do Internal Medicine, but it was highly recommended that I take at least one year of Anesthesiology.
The patient was treated appropriately in Moncton. I didn’t hear any more about my privileges. I continued to look after my patients.
After making appropriate arrangements, I began to wind down my practice, and in good time, said good bye to the close friends Sarah and I made in Campbelton. I gathered my wife and baby, and headed back to Toronto, where I entered an Anesthesiology residency in July 1977 at Toronto Western Hospital. After that year of Anesthesiology training, I planned to return to finish my Internal Medicine training. Some time later, I heard Dr. Simoo was also leaving Campbelton and returning to India. I hope it wasn’t something I said.
