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Cardiac Event

By Richard L. Mabry, MD

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Dr. Cliff Hamilton watched the bright green lines of the EKG dance across the monitor screen. It wasn’t until the tracing had remained normal for several minutes that he allowed himself to relax. I think that second shock did it. He took a deep breath and felt some of the tension turn loose.

The patient, Matthew Gaines, was an older male with known coronary artery disease and increasing symptoms. Heart specialist Dr. Kirk Martin had admitted him to Sommers General Hospital for further testing and treatment. When Gaines reached the cardiac unit and was hooked up to a monitor, Nurse Anna Scott noticed the man’s heart rhythm becoming more and more erratic and his rate increasing beyond acceptable limits. The heart rate sped up quickly until Gaines was in full-blown ventricular tachycardia, the beats coming at a rate of more than two hundred per minute, and the nurse knew she had to do something.

“I need some help here,” Anna called. Her voice, only slightly above conversational level, was still loud enough to get Dr. Hamilton’s attention as he passed by the room.

Now both doctor and nurse were bathed in perspiration. Gaines was pale, but his heart ticked along in a normal rate and rhythm. Despite the stress of the past few minutes, Hamilton felt the elation that went with snatching another patient from death.

“Mr. Gaines,” Hamilton said. “Your heart acted up for a while there, but I think it’s under control now.”
Gaines’s eyelids flickered but did not fully open. His lips parted, but no sound emerged. He nodded slightly, made one movement as though to sit up, held there for a few seconds, then fell back onto the pillow. His breathing deepened, and he seemed to relax.

“Do you want me to page Dr. Martin and tell him what’s going on?” Anna asked.

“That won’t be necessary.” The voice from the doorway was quiet, but the tone was measured and biting. “Cliff, what are you doing with my patient?”

“Saving his life, Kirk,” Hamilton replied coolly. He turned away from the cardiac monitor for a moment and inclined his head toward the hallway. “Ms. Scott, please keep an eye on the patient. Dr. Martin and I will be right outside if you need us.”

The corridor wasn’t deserted, but the doctors, nurses, orderlies, technicians, and visitors passing by seemed more interested in their own destinations and activities than in the conversation between two doctors. Hamilton leaned against the wall beside the door of Gaines’s room. A drop of sweat dripped into his eye, and he blinked it away. He resisted the temptation to pull out his handkerchief and mop his brow. He wasn’t ready to let anyone—especially Dr. Martin—know what the past few minutes had done to him.
He hadn’t performed badly for a late-fifties family practitioner. Hamilton was pleased that he could still do a cardioversion, remembering what he’d learned over twenty years ago. He wasn’t ready to be put out to pasture—not by a long shot. And doing a bit of cardiology gave him a rush that family practice didn’t.

“So, what happened?” Martin asked.

“Nurse Scott hooked up your patient to a monitor and noticed he was throwing PVCs and extra systoles.”

“Abnormal heart beats happen, Cliff.”

“True. But his arrhythmia quickly turned into v tach,” he said. “Rate got up to over 200 and Anna—Nurse Scott—knew the next stage could be ventricular fibrillation and death. So she called out for help. I was passing by, and I responded.”

“And…”

“We gave Mr. Gaines the usual meds—procainamide, amiodarone, a beta-blocker—but his rate didn’t improve. So I did a cardioversion. After I shocked him a couple of times, he reverted to a normal sinus rhythm.” Hamilton rolled his shoulders to relax the muscles. He took a deep breath and held it for a moment, hoping the tightness in his chest would ease. “He’s all yours now.”

Martin frowned. “Cliff, you know you don’t have privileges for cardioversion. You should have called me.”

“This was an emergency, Kirk. The man needed the procedure immediately, not later, and I have some training in performing it.”

“Yeah, you rotated through cardiology for a short time over two decades ago. Things change over time, Cliff. That’s why you should have called me.”

“If we’d taken the time to call you, Mr. Gaines could be dead by now. I see nothing different here than my putting on a tourniquet to prevent an accident victim from bleeding to death.”

“There’s no way you can compare this to giving first aid. You administered extremely potent drugs, then you gave an electrical shock to the patient’s heart.” Martin shook his head. “You saved the patient, but you could have killed him.”

“Kirk—”

“I’ve tried to look the other way, but I’m afraid it’s time the chief of staff heard about the way you repeatedly exceed your hospital privileges here.”

Hamilton pushed away from the wall and straightened his white coat. “You do what you need to do.” He jerked a thumb at the room behind him, where the patient lay. “But I suggest you take care of Mr. Gaines first.” He looked at his watch. “While you’re doing that, I’ll write up a progress note detailing what I did. That way, you’ll have all the evidence you need when you take this to Dr. Bardwell.”

Hamilton waited until he was around the corner and out of Kirk’s sight before he dug into his pocket. When he felt the little bottle, he relaxed a bit. Relief was moments away.

* * *

As Kirk hurried down the hall he almost ran over Dr. Jack Burnett, who was coming in the other direction talking on his cell phone.

At the last minute, Burnett looked up and averted the impending collision by stepping to one side. He told the person on the phone, “I’ll call you later,” and smiled sheepishly at Kirk.

“You look like a man on a mission,” Jack said.

“Sort of,” Kirk replied. “I’ve just had another run-in with Cliff Hamilton.”

“Let me guess. He’s working outside his privileges, probably in a cardiac situation, and in so doing, he’s stepped on your toes again.”

His colleague was probably right, although Kirk might not have framed it in exactly those terms. He described the current situation, and Jack nodded his understanding.

“I’m going to the chief of staff,” Kirk said. “This time, something has to be done.”

“Are you sure this isn’t simply an opportunity for you to get back at Hamilton because he’s done something you think should be the province of your specialty?” Jack said. He grinned, obviously trying to take any sting out of his remark.

But Kirk recognized there was some truth in what Jack said. And he valued the opinion of his colleague. Jack had a way of seeing beneath the externals that was sometimes uncomfortable for Kirk.

The two men had known each other since their years together in medical school. They’d both done their residency training at the same medical center—his in internal medicine, Burnett’s in surgery. When he completed his cardiology fellowship, Kirk was both surprised and delighted to find Jack already in practice here at Sommers General. They didn’t see each other often, but when they did, the encounter always brought a smile to Kirk’s face.

When Kirk asked Jack about setting up his practice in Sommers, Texas, his friend told him that his wife’s opinion of the city played a large part in their decision. It was large enough to have the things she wanted, small enough to retain a bit of “country” feel, and close enough to Dallas to make occasional shopping trips and evenings at the symphony possible. Jack figured that Sommers General was a nice mid-sized hospital where his surgical talents could flourish, and he’d been right so far.

They hadn’t seen each other a lot recently, but in med school Jack’s advice had been good—even when it hurt. Could Jack be right? Was this fueled by Kirk’s attitude and not by a concern for the patient’s welfare?
Kirk hesitated in the hall and thought about turning back. Then he decided—or perhaps convinced himself—he wasn’t just out to get Hamilton because the family practitioner had done a bit of cardiology. This wasn’t an instance of professional jealousy. Something needed to be done about Hamilton before his tendency to exceed his privileges ended up causing a patient’s death. He hurried toward the office where Ed Bardwell sat.

* * *

Dr. Ed Bardwell ran his hand through his thinning, mouse-colored hair and frowned. He didn’t need the aggravation that went with this job as hospital chief of staff. Bardwell’s specialty was general surgery. He enjoyed it. He was good at it. When he was in the operating room, he was the person in charge. But here, in the office where he now sat, he dealt with frequent, sometimes daily challenges presented by people who walked through the door or the pieces of paper crossing his desk.

He looked up at the young doctor sitting across from him. “Weller, I’ve had another complaint from Dr. Hamilton about your handling of a patient.”

Dr. Herbert Weller sighed and shook his head. “What did the old curmudgeon find to complain about this time?”

“I hardly think that’s the way to talk about one of our senior staff members,” Bardwell said. Even if the description is accurate. “He has filed a complaint that alleges you were rude and insolent to Mrs. Watersby when she presented to the emergency room with abdominal discomfort.”

“I remember that lady. Actually, she had a classic case of gastroenteritis. I made the diagnosis, suggested some over-the-counter loperamide, instructed her in a clear liquid diet, and discharged her home to bed rest.”

Bardwell held up a printed email. “According to what she reported to Dr. Hamilton, who is her primary care physician, you gave her the diagnosis in rather scatological terms, told her to go to a drugstore and get some pills for it, recommended she stop eating rich food, and told her to see Hamilton the next day but not to bother either you or him again that night.”

Weller opened his mouth, but Dr. Bardwell stopped him. “I’ve had complaints from patients about your bedside manner, or lack thereof, but I’ve let them ride because it’s not that easy finding doctors who are willing to work as emergency room physicians at this hospital. But unless you straighten up, I’ll have no choice but to bring this before the Executive Committee and recommend your termination.”

The younger doctor was silent for a moment, then said in a low voice, “I’ll watch it.” Weller brightened.
“The program where I want to do a radiology residency will have an opening on July 1, and they’ve agreed to give me first consideration. If you’d write a letter of recommendation, they’ve almost guaranteed me that slot. Wouldn’t that be a win-win situation?”

“For you and for the hospital, possibly. For patients whose X-rays you’ll be reading, maybe not. Send me the information, but I’m not promising anything.”

The doctor left, and Bardwell picked up another stack of forms to sign. He reached for his pen, but stopped when his assistant opened the door of his office and announced, “Sir, Dr. Martin would like a moment of your time.”

“I’m due in the OR in half an hour, and I still haven’t finished signing these forms. Can it wait?”

Before the woman could speak, Kirk Martin strode through the open door. “Ed, I won’t take much of your time, but you need to hear about this one.”

Dr. Bardwell sighed and carefully laid his pen on top of the forms. He took off his horn-rimmed glasses and used them to motion his assistant back to the outer office. “Lydia, close the door behind you. And if the operating room calls, let me know—even if you have to interrupt us.”

“Look, Ed,” Kirk said, after Lydia was gone, “I know you don’t want to be chief of staff, even on a temporary basis. No one does, which is why we rotate the position. But we’ve been kicking this can down the road for too long. It’s time to deal with the problem, so that’s what I’m asking you to do.”

Bardwell motioned his colleague to a chair. “I presume you’re talking about Cliff Hamilton…again.” One way or another, almost half the problems coming to the chief of staff seemed to involve Dr. Hamilton. “What has he done to upset you this time?”

“The same thing he’s always doing. He’s performing procedures for which he doesn’t have privileges—dangerous procedures. This time it was a cardioversion.” Kirk took a deep breath, and it was obvious he was trying hard to control his emotions. “Hamilton’s a family practitioner, but that little bit of training in internal medicine he had during his residency apparently makes him think he can do anything he wants—including stopping a man’s heart by running an electrical current through it.”

Bardwell looked at his watch, making no effort to hide the gesture. “Tell me about it…briefly.”

Kirk related the latest incident in which Hamilton had intervened. “He claims there was no time to notify me,” he said as he ended the story. “When the man’s ventricular tachycardia didn’t respond to medication, Hamilton shocked him a couple of times before he converted back to a normal rhythm.”

“Was the treatment appropriate?”

“Yes,” Martin admitted.

“How about the patient?” Bardwell asked.

“I think he’ll be okay,” Kirk said. “I saw him after things had settled down. A previous myocardial infarction seems to have left the man with an abnormal electrical focus in his heart. I changed his medicine a bit and plan to monitor his rate and rhythm. If he has more trouble, I’ll either do an electrical ablation to regulate his rhythm or implant a pacemaker. I’ll look in on him again later today.”

“Are you upset because Hamilton overstepped his privileges, even though it probably saved the patient’s life at the time, or are you frustrated that a family doctor did something you’re supposed to be doing?”

“What are you saying?” Kirk asked, although he recognized what was behind Bardwell’s question. It was essentially the same one his friend Jack had posed just moments ago.

“I mean, is this concern for the patient’s welfare or is it professional jealousy?” the chief of staff said. “Sounds like this is a case of no harm, no foul. So what do you want me to do?”

“I want you to put a stop to what he’s doing before he kills someone.”

Bardwell shook his head. “Kirk, I’m supposed to help the administrator with the nuts and bolts stuff that requires a doctor’s oversight or signature,” he said. “I don’t think this warrants an action like suspension of privileges. Even if it did, I don’t have the power to do it. That would have to come from the Executive Committee, and frankly, I’d vote against you there.”

“Then issue a warning,” Kirk said. “Tell Hamilton it’s the last one. But we have to do something. If not—”

A metallic voice from the intercom interrupted their conversation. “Excuse me, but Dr. Martin is needed in the cardiac unit—stat!”

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