Texas Medicine

CHAPTER 1

The desk lamp threw a circle of light over the nursing station, the remainder of the half empty ICU shrouded in semi-darkness, the patients resting quietly.  Mrs. June Belton, a patient in her mid-thirties, was propped up in her hospital bed, an IV infusing fluids in her arm, a nasogastric tube protruding from her left nostril, the inflated balloon of a Foley catheter irritating and chafing her bladder wall, a hard plastic endotracheal tube lodged in her throat, connected to a ventilator continuously and methodically pushing oxygen enriched air into her lungs, the collective discomfort greater than the sum of its parts, the ordeal of being an ICU patient. 

The nurses in the unit tended to their routine tasks when the alarm on Mrs. Belton’s ventilator interrupted the quiet.  Her nurse was at her side within seconds.  Mrs. Belton, who had been sleeping, was now wide awake, her labored breathing triggering the ventilator at thirty breaths per minute, the LED on the cardiac monitor displaying a heart rate of 120, eyes wide on her weathered face, beads of perspiration forming on her forehead, her dishwater blond hair matted on her scalp, the look of a person aware that something was going wrong inside her own body.  She frantically gestured to the nurse.

Page the intern and the respiratory tech, the nurse shouted.

Another nurse picked up a telephone receiver and called the page operator.

Dr. Dixon, ICU stat.  Dr. Dixon, ICU stat.  Double O, ICU stat.  Double O, ICU stat.

Within seconds Dr. Dixon and the respiratory technician were in the ICU.

What’s going on?  Dixon asked.

I don’t know, replied the nurse.  She had been resting quietly.  She was doing the best she’s been since she arrived.  Her temp was down to 99.  Her blood pressure and heart rate were stable.  All of a sudden the alarm went off and she began fighting the ventilator.

Dr. Dixon listened to Mrs. Belton’s chest with his stethoscope.  Except for some slightly decreased breath sounds at the right base, everything sounded clear.  He looked at Mrs. Belton.  How do you feel?

Mrs. Belton shook her head.

Are you short of breath?

Mrs. Belton nodded.  The technician disconnected the ventilator from the endotracheal tube.  The ventilator emitted a constant flow of air, hissing into the night.

It’s the pop-off valve, she said.  It won’t shut off.

Let’s get some blood gases and another ventilator.  Dr. Dixon turned to the nurse.  We need a chest x-ray, ABGs, a CBC, and some lytes.  Call Dr. Cummings and tell him I need him to come in.

The nurse handed Dr. Dixon an arterial blood gas kit.  He prepped Mrs. Belton’s wrist with Betadine and inserted the needle of the syringe into her radial artery.  Dusky-red blood filled the syringe, a sure indicator of a lack of oxygen in the blood.  Dr. Dixon withdrew the needle and applied pressure over the puncture site.

The respiratory technician hurried out of the ICU.  Crossing the waiting area, she encountered Mr. Belton.  He had been dozing on a couch, but had been awakened by the page.  Is it my wife?

Her ventilator malfunctioned, she said.  We have to get another one.

The tech disappeared down the hall, returning a few minutes later, pushing another ventilator into the ICU.  Within five minutes Mrs. Belton was attached to the new ventilator.  Every breath distressed, she was sweating profusely.

Dr. Dixon sat down at the nurse’s station and began reading Mrs. Belton’s chart searching for clues to the dilemma.  Still in his twenties, it was his third month of internship.  Mrs. Belton was not his patient.  Because she had been stable, sign off rounds with the other intern regarding her status had been perfunctory.

She was a thirty-five year old female, five feet three inches tall, one hundred seventy-five pounds, and a heavy smoker.  She had two children, ages twelve and four. She had been admitted in respiratory distress with pneumonia.  On the day of admission, she presented to the Emergency Room extremely short of breath.  Her chest x-ray showed diffuse infiltrates.  Her sputum was full of bacteria identified as Hemophilus influenza.  She was immediately admitted to the ICU and started on antibiotics.  Because of her impaired pulmonary status, she was intubated and placed on a ventilator.  The resident had accidentally punctured her lung while putting in a subclavian line, necessitating the placement of a chest tube.

Nonetheless, her condition improved over the next several days.  Her temperature dropped.  Her white blood cell count had come down.  Her arterial oxygen concentration had improved.  She had even been out of bed in a chair yesterday afternoon.  Dr. Dixon continued to read the chart, searching for any information that might have been overlooked. 

Mrs. Belton’s blood gas results appeared on the computer printer.  Her oxygen saturation was down again, carbon dioxide level up.  The x-ray technician returned with the film.  Dr. Dixon hung it up on the view box and compared it with a film from the day before.  Her lungs looked no worse.  If anything, they appeared better.  Dr. Dixon instructed the nurse to increase the oxygen and repeat the blood gases in thirty minutes.  Subsequent blood gases showed the oxygen saturation gradually improving.  Mrs. Belton was still uncomfortable, but she was breathing easier. 

Dr. Cummings arrived within a few minutes.  Dixon recounted what had transpired.  Cummings examined Mrs. Belton and asked a few questions which she attempted to answer with gestures.

Dixon and Cummings discussed the situation regarding the ventilator, which the technician had decided had malfunctioned.  It had already been taken to biomedical engineering to be checked.  Before going to talk to her husband, Dr. Cummings went to check on Mrs. Belton once more.

Are you feeling any better?

There was no response.

I said are you feeling any better?

Mrs. Belton stared vacantly off to her left.

Cummings raised his voice, Mrs. Belton, can you hear me?  Oh, no.  He picked up Mrs. Belton’s right arm and let it go.  It flopped down on the bed like a dead fish.  She seemed oblivious to her surroundings. Dixon, this woman is having a stroke.  Call x-ray. I want a stat CT and angiogram.  Get the neurologist on call.

Dixon and the nurse rushed to the telephones while Dr. Cummings walked out of the ICU.  Mr. Belton was hovering in the waiting room.  How is she, doc?

Not good.  Not good at all, he said. She’s had a stroke. I’m afraid she’s paralyzed.  She doesn’t understand, and she’s unable to speak.

Mr. Belton stood silently, his worried face tanned, weathered, and etched by years of ranching in the sun, wind, and heat of the North Texas prairie.  Dr. Cummings had been managing his wife’s care since she arrived in the ICU.  He was the chief of pulmonary medicine and Mr. Belton had full confidence in him, the trust that hardscrabble rural people instinctively held for the educated professional population.  His wife had arrived critically ill, and through Dr. Cummings care, she had gradually improved.  He had even talked about weaning her off the ventilator over the next two days.  What can we do? he finally asked.

I’m not sure.  I’m calling in a neurologist to see if he has any thoughts.  We need to get some studies in x-ray.  I assure you, we’ll do everything we can.

What about the ventilator?  The technician told me that the ventilator malfunctioned.  Is that what caused all this?

I don’t think so, but we’re checking it out.  Cummings paused.  Excuse me.  I need to go back to see how she’s doing.  I wanted to let you know what’s going on, and I’ll keep you posted.

Mr. Belton reached out with his calloused paw and shook Dr. Cummings soft hand, Thank you, doc.  I know you’re doing all you can.

The neurologist arrived and proceeded to examine Mrs. Belton.  Pressing a knuckle into her sternum, she reached for it with her left hand. A light pinch on the left arm caused her to withdraw it, a pinch on the right provoking no response.  The neurologist looked into her eyes with an ophthalmoscope.  He gently touched her corneas with a wisp of cotton.  He checked reflexes in her extremities. He stroked the soles of her feet with the end of his reflex hammer. The toes of the left foot curled slightly.  Those on the right slowly fanned apart as the right first toe dorsiflexed in the classic Babinski sign, a marker of significant brain injury. He concurred that she had occluded her left middle cerebral artery, resulting in a stroke, and that an arteriogram might be helpful.  Two hours later, Dr. Cummings reviewed the CAT scan and the arteriogram with the neurologist and radiologist.  Despite the fact that the stroke was less than three hours old, a faint area of abnormality was already discernable, conforming to the distribution of the left middle cerebral artery, and confirming the presence of an evolving stroke.  The angiogram showed minimal atherosclerotic changes in a few vessels, but the left middle cerebral artery was totally blocked.  They concluded that a clot had broken off from somewhere and lodged in the artery.  The neurologist ordered an echocardiogram, but no clots were visible in the heart or on the valves.

When brain cells die, they begin to swell.  If enough cells die at the same time, the enlarging cells will compress surrounding structures further compromising the blood supply.  This results in further cell death and further swelling.  The vicious cycle had already begun in Mrs. Belton’s brain.  Over the next three days, despite the best efforts of Dr. Cummings and his colleagues, Mrs. Belton’s brain continued to swell until it had crushed itself and her life out of existence.  For almost three more weeks her heart continued to beat, her kidneys continued to filter blood and her lungs continued to expand and contract by ventilatory support.  For almost three weeks Mr. Belton agonized over what to do.  He had two young children to consider.  He had not been emotionally prepared for what was happening.  He spoke with Dr.  Cummings every day, but Cummings could offer little more than sympathy and reassurance to take as much time as he needed to make a decision.  Finally, Mr. Belton resigned himself to the fact that his wife was not going to recover, and allowed the ventilator to be turned off.  Deprived of oxygen, her heart stopped beating after twenty minutes, and she was pronounced dead.

CHAPTER 2

B. J. Milam slammed the solid oak door to his office suite as he entered.  His staff had been on the job for an hour.  A cup of hot coffee steamed on his desk in anticipation of his arrival.  Despite the commotion, no one in the office looked up.  B. J. tyrannized the people who worked for him.  He had chewed out and fired employees with no apparent provocation.  It could be an article of clothing, a look, a comment, or merely being the first person to enter his field of vision.  No one knew what was on his mind.  The employees had learned to keep a low profile, especially when B. J. first came in.

Actually, B. J. was in a good mood.  He had the world – or at least Texas by the tail.  Just yesterday, he had won his fifth multi-million dollar lawsuit in three years.  B. J. had come a long way from his early years in the Texas panhandle.  His father had owned a small ranch outside Childress which he had tried to maintain against all odds.  Finally, the big drought in the fifties had wiped him out.  To support his family, B. J.’s father worked doing odd jobs around town.  In the evenings he would come home and drink to ease the physical pain of his labor and the emotional pain of having failed his family.  At these times Mr. Milam would be prone to drunken outbursts.  B. J. was terrified of his father and tried to keep his distance. 

At school, things were no better.  The other students taunted him.  His father had gained the reputation as the town drunk.  In addition, the Milam’s were the poorest family in a town where poverty was the norm.  It seemed almost every day B. J. was in a fight.  The first time, he ran away, but when his father found out, he beat B. J. even worse.  After that, B. J. never ran, knowing that it would be worse if he did.  Through the haze of time, it seemed that B. J.’s pre-adolescence was a continuum of fights in which he was always on the short end.

The turning point came one day when B. J. got in a fight with Bubba Archer.  Bubba had beaten B. J. at least a dozen times before.  Maybe it was the rage, or the frustration, or the overwhelming feeling of helplessness.  Maybe this time B. J. had finally had enough.  On this day, B. J. fought harder than he ever had before.  This time he landed an effective punch.  He could feel Bubba’s nose collapsing under his fist.  It wasn’t clear who was more surprised; B. J., Bubba, or the friends who stood cheering Bubba on.  For an instant, everyone froze watching the blood and snot flowing from Bubba’s nose.  In that instant B. J. knew what to do.  With fists flailing, he tore into Bubba Archer with all the fury that had been building up over years.  Blow after blow landed on Bubba.  When he fell, B. J. jerked him up from the dusty ground and pummeled him some more until Bubba’s stunned cronies finally pulled him away.  B. J. and the boys stared at each other, the only sound being the gurgling noise coming from Bubba’s throat.  The feeling of helplessness was gone.

The fights continued for a while, but now Bubba inflicted pain on his opponents even when he lost, and the losses became less frequent until he was known as the best fighter in school.  No one picked on him anymore.  He still wasn’t liked, but he had gained respect.

As time passed, it became apparent that B. J. had inherited his father’s genes for size.  By the age of sixteen, he was over six feet tall and weighed two hundred and twenty pounds.  In Childress there was only one place for a teenager that size . . . the football field.  B. J. had never been interested in football, but his gym teacher, who was also the football coach, took him into his office and told B. J. he was on the team or else.  B. J. became a middle linebacker and fell in love with the position.  He loved to hurt people and inflict pain.  In two seasons B. J. earned the reputation as being the meanest, hardest hitting linebacker in the panhandle.  By his senior year he totally intimidated opposing ball carriers.  On Friday nights in the Texas autumn, the residents of Childress turned out to cheer for B. J. whoops of delight filling the cool night air whenever B. J. punished the runner given the unenviable task of trying to move the ball against him.

A football scholarship to the University of Texas led the way out of Childress.  B. J. played with determination, but he knew he would not be able to play football all of his life.  Late in his freshman year, B. J. decided he wanted to be doctor.  At first the pre-med courses overwhelmed him, but the coaches arranged for tutoring so that B. J. could maintain his grades and not lose his eligibility.  By his junior year, B. J. was doing well enough that he did not need the tutors.  He had become a star with the academic faculty with grades good enough to gain admission to one of the state medical schools.

B. J. actually found medical school easier than college, and had he not gotten the dean’s seventeen year old daughter pregnant during his fourth year, he would have been practicing medicine on this day.  B. J. wasn’t a football star anymore, and the dean wasn’t interested in having B. J. for a son-in-law. An abortion was quietly arranged and B. J. was dismissed from school. 

Soon after, he entered law school.  It was the perfect profession for him.  His clients provided him the opportunity to get back at the world for his poverty, the degradation, the beatings, and the humiliation of being thrown out of medical school.  His early desire an obsession for revenge, over the years his success provided consolation.  The intensity of his feelings muted.  Nonetheless, he continued to obtain immense satisfaction every time he won a malpractice suit.  Still basking in the glow of success from yesterday’s verdict, B. J. sat down and propped his boots on the hassock next to his desk.  He was glancing through the mail when his receptionist opened the door.

Your ten o’clock appointment is here, she said.  A Mr. Belton.

CHAPTER 3

Scott Michaels heard the front door open.  He looked up to see Sukey Parker walking into his apartment. She was wearing a sheer blouse with a camisole visible underneath and a skirt that reached just above her knees, her long blond hair full and luxuriant.  Her nails perfectly

manicured.

Hi darlin’.  Been waiting for me? she asked.

You know it, he said.  What’d you tell your husband?

I told him I was visiting a friend in Dallas.  Sukey sat down on the couch next to Scott.

You think he bought it?

He’s more interested in his properties, than he is in me.  I’m just his trophy bride.

Scott stood up and went into the kitchen and prepared two bourbons on the rocks.  He returned with the tumblers, handed one to Sukey and sat down.  I don’t get it.  He took a swallow of the bourbon, the liquid creating a warm glow as it flowed into his stomach.  I don’t understand this trophy bride stuff.

I don’t understand why your wife left you . . . for another woman, no less.

Scott took another swallow of bourbon.  The emotional wound was still raw.  Scott, the fair haired local boy, born and raised in Ft. Worth, college at TCU, medical school at Baylor, and internist to the social elite in the city, awakened one morning to discover his wife had run off with Betsy Morrison, the leading money winner of the LPGA.  He had no inkling his wife had developed a sexual preference for women.  He had no idea how long she had been involved with Morrison.  Now he was living in a unit of the Live Oaks apartment complex recovering from his divorce.

I guess that makes us even. he said.

Sukey nursed her drink as she gazed at Scott.  Scott still had the physique of the college athlete he had been.  His broad chest and muscled arms filled the polo shirt he was wearing.  He had a full head of thick sandy brown hair and pale blue eyes.  He looked considerably younger than his early forties. 

It’s her loss and my gain, she said.

You really think so?  I’m having trouble dealing with the idea of my wife leaving me for a woman.  Leaving me for a man would have been bad enough. But a woman?  Somehow, it makes me wonder about . . . Scott stopped in mid-sentence groping for the words to describe his feelings.

Your own sexuality?

Sort of.  My sexuality.  My manhood.  My identity. The whole situation has left me feeling like there’s something missing, but I can’t figure out what.

I don’t have any doubts about you, and I’m here to help you any way I can.  Sukey moved close to Scott on the couch.

You’ve been wonderful, but I worry about our being involved while you’re married.

I know. I’m not cut out for having affairs either.  I’ve decided I’m going to leave J.C.

Steve sat up straighter.  Serious?

Our marriage is sterile.  I don’t love him, and I know he doesn’t love me.  I was enamored with his wealth and power, but marrying him was a mistake.  I know better now. Sukey leaned over and kissed Scott.  I know what real love is.

Aren’t you worried about what he might do?

I don’t think he’ll do much of anything.  I don’t want his money, so he won’t care if I leave.  Sukey stood and pulled Scott by the hand, C’mon, sugar.  I need some loving. 

CHAPTER 4

Steve Marcus poured a cup of cold coffee left over from yesterday and beamed it up in the microwave. He sipped the stale brew, a bitter taste lingering in his mouth.  Over the years his medical practice had ebbed and flowed, but for the last two or three weeks, it had occupied almost every waking minute.  He had finally crawled into bed after midnight.  It was 6:30, and if there was any chance of keeping up with the work, he had to leave home now.  He stepped outside with his cup of coffee and was greeted by the din of hundreds of cicadas, their timbals causing their bodies to resonate loudly throughout the neighborhood, several hideous cast-off exoskeletons visible on nearby tree trunks, recently shed by the large primitive green insects as they had emerged from the ground.  A lizard stared coldly at Steve from the edge of the driveway. A cicada, as large as a hummingbird, buzzed past his face, causing Steve to flinch.  The summer heat had been relentless.  The leaves on the live oaks in the yard were dry and leathery, their glossy surface forming a waxy barrier against the evaporation of precious water.  The sun had been up for an hour, and it wouldn’t be long before the pleasant warmth of early morning was replaced by the brain frying heat of Texas in July.  There was no movement in the air, not a hint of a breeze, total stillness.

Steve was not looking forward to the day.  He was spread thin.  Not only did he have his own patients to take care of, but he was also covering for his friend and fellow neurologist Ken Tucker. Several patients were terminally ill.  Steve was in his early forties. His black hair, slightly graying at the temples, was cut military style as an obligation to the Navy Reserves.  As further obligation to the Reserves, he remained relatively fit to meet the modest physical requirements that included the ability to do push-ups, sit-ups, and run.  Since he was required to maintain these standards, he was determined that his performance remained outstanding. A jagged scar was faintly visible over his right eye.

Steve got behind the wheel of his Mercedes 560 SL convertible. The opening notes of Texas Trilogy flowed from the radio speakers followed by the rich baritone of Steve Fromholz.

"Six o’clock silence of a new day beginning

Is heard in a small Texas town.

Like a signal from nowhere,

The people who live there

Are up and they’re movin’ around.

‘Cause there’s bacon to fry,

And there’s biscuits to bake

On a stove that the Salvation Army won’t take

And you open the windows and turn on the fan

‘Cause it’s hotter ‘n hell when the sun hits the land."[*]

On his way to the hospital, he went over rounds in his mind.  There were eighteen patients in three hospitals plus office hours.  Steve went to St. Vincent’s first.  All his critically ill patients were there, and they might consume the entire morning.

Arriving at St. Vincent’s, Steve took the elevator to the sixth floor, walked to the nurse’s station, and removed Mr. Williams’ chart from the rack.  Two nurses and a social worker worked on patient charts. As Steve riffed through the chart noting vital signs and lab data he asked Jane Houlihan, the nurse, how Mr. Williams was doing.

Bad, Jane replied.  He’s become less responsive over the night.  His pressure’s been falling, and he has little urine output.

Steve shook his head.  Mr. Williams had been in the hospital for a month.  He had presented with seizures, and his work-up had uncovered a malignant melanoma with multiple brain metastases.  The original tumor had been resected twelve years earlier.  Despite conventional treatment with radiation and chemotherapy, Mr. Williams had gone relentlessly downhill.  The oncologist had dropped off the case leaving Steve, who had admitted the patient, with the task of managing his demise and consoling his soon to be widow.  Steve was already depressed and fatigued, the lack of a full night’s sleeping having its undesired effect.  He couldn’t believe Mr. Williams had survived this long, but his vital signs indicated the end was nearing.  He walked into Mr. Williams’ room accompanied by the nurse.  Mrs. Williams was sitting beside the bed gazing at her husband, his eyes glazed over, his breathing loud and labored.  An IV bag hung from a pole, tubing coming out of the bottom and snaking its way under the sheet, a larger tube emerging from near the foot of the bed with a few ccs. of amber colored urine visible at the bottom of a bag attached to the tube.

Steve turned to Mrs. Williams.  How are you doing?

The Williams had been married over forty-five years.  The thought of her impending loss moved Steve.  She looked anxious.  I’m okay, under the circumstances.

Steve examined Mr. Williams, primarily because it helped to soothe his wife, the ritual exam a vestige of earlier simpler days of medicine, before high tech and miracle drugs, but not really providing any new information.  Mr. Williams’ melanoma had taken the high tech and exotic pharmaceuticals, chewed them up, and spit them out with impunity. After he finished looking at pupils, listening to lungs, and palpating the abdomen, he stepped over