“The pain is in my heart. I want you to send me to a heart specialist so that I can have an angiogram and have this taken care of right away.”
Stephan’s deep, subdued tones, deliberate cadence, icy eyes, and furrowed forehead made it clear that this 59-year-old black man from Oakland was accustomed to tossing aside the short end of the stick to get what he needed. His lovely younger wife Tamara looked at me anxiously. It was exactly a week before the Thanksgiving holiday.
I cautiously but firmly pushed the area along the left posterior aspect of his neck, which made him grimace. He’d had excruciating knifelike pain in his left upper chest, left neck, and left arm for almost a week now. Two days before coming into the office, he’d had a temperature of almost 105 degrees. This was his first visit to me with this problem.
“Something bad is going on here,” I confirmed. I looked back and forth between their attentive faces. “But the problem’s in your neck, not your heart.”
Stephan didn’t buy it initially, but after ten minutes of explaining why inadequate blood flow to the heart causes intermittent symptoms, without significant fever or focal tenderness, he understood that the problem was in his neck. I could not persuade him, though, that this was an emergency and that he needed to go to the hospital to get an MRI scan of his neck. I knew he was insured through a health maintenance organization. It would be difficult for me to get approval for a prompt MRI, because the next week would be cut short two days due to the holiday. They would, however, allow an urgent MRI to be ordered through the emergency department.
“It’s not my heart, so I’m not going to the hospital to wait for five hours in the emergency room,” he concluded. We wouldn’t be negotiating this any further, despite my contention that he might have a life-threatening cancer or infection affecting the area next to his spinal cord.
I reluctantly wrote out a prescription for oral morphine and for gabapentin, a medicine for nerve pain, to help him get through the night, and they agreed to come back to the office the following day, or to the emergency room before that if anything changed for the worse.
Because I split time between offices in Alameda and Berkeley, I was not in the Berkeley office the next day when he came back, so his appointment was with David, the other family practice physician in our office. When David told him again that this was not a situation where it was safe to wait for insurance authorizations, Stephan grabbed his medical chart from David’s hands and stormed out the door. He was heading to the hospital, just a block from our office.
Carol, our clever, lovable office manager with a mischievous grin that reminds me of my five-year-old daughter, and Kathryn, a high-level administrator in our practice, saw him leave. They devised a plan. They went to the emergency room, where Carol was able to retrieve Stephan’s office chart. They safely delivered it back to its home location, and it seemed our mission had reached a successful conclusion.
Stephan ruined that illusion a short time later when he appeared again in the Berkeley office waiting room, having been thrown out of the emergency room for what had been perceived as belligerent behavior. I wondered why someone couldn’t have seen that extra efforts should have been made to help this man experiencing torture-level pain. Meanwhile, Carol took the time to calm Stephan down enough to escort him back to the emergency room.
Our local emergency department consistently impresses me with the high level of compassionate and competent care they give my patients, but not this time. When to my surprise and horror Stephan surfaced again with his wife Tamara the following Wednesday morning, heavily sedated but otherwise untreated, I knew we would have to assemble our collective machetes and bulldozers. Carol and Reggie, our designated referral chief and premedical student, whose dry sense of humor and fondness for pranks keep us all on our toes, started making phone calls to the MRI facilities listed under Stephan’s independent provider association’s (IPAs) radiology providers, knowing that we needed to find a facility that would squeeze in this one-hour test on the day before Thanksgiving. The IPA informed us that we had to find a facility before they would give us an authorization, while the facilities expected us to give them the authorization number before they would schedule the test.
The closest facility to our office said that their staff would be leaving early, at 3:00 p.m., and they did not have any openings before then. Over the ensuing two hours, we found two facilities that would do the test. But each time, when we called the IPA for authorization, they informed us that, although each facility was on the approved list of providers, they could only do X-rays, ultrasounds, and CT scans for patients in the IPA. They were not covered for MRI scans. The only place we could get an authorized MRI scan turned out to be the one that was closing at 3:00 p.m.
Reggie finished explaining this to me at 2:40. I knew I had only one hope, and that was to call the radiologist at the local facility.
“Jim,” I pleaded, after describing my patient, “I know you all want to go home, but sometimes we have to do what needs to be done, and you are the only person who can help him right now.”
“Can he get here in five minutes?”
I knew Stephan was at a pharmacy just down the street.
“Yes,” I said.
“Send him over.” Reggie called the IPA and got the authorization. Carol called Tamara. Ninety minutes later, Jim paged me.
“He has an eight-centimeter abscess right next to the left side of his lower cervical and upper thoracic spinal cord,” Jim explained. “He needs immediate surgery.”
Jim then walked out to find our patient. He said, “There doesn’t appear to be anyone here.” Apparently, his staff was so determined to get out early that they’d all left the building and told Stephan to leave as well.
I had Tamara’s cell phone number, so I thanked Jim and reassured him that I would locate Stephan. Tamara answered the phone driving home on the freeway. I told her what we had found and said, “You have to turn around and go back to the hospital,” which she did.
The neurosurgeon operated on Stephan the following morning, removing a section of bone from several consecutive vertebral bones (a laminectomy) and cleaning out the pus-filled abscess. When I went to see him later in his sixth-floor room with a sweeping view of San Francisco Bay and the Golden Gate Bridge, he was asleep, but Tamara met me in the hall, gave me a long bone-crushing hug, and thanked me. She had dark sleep-deprivation raccoon rings around her eyes but assured me she was okay. “I know I’m overdue for an appointment with you, but I’ll see you soon.”
The next day I found Stephan sitting upright in the company of friends and enjoying the view. He introduced me and said to his friends, “I have to give the doctor his props. He was the one guy who right from the beginning knew where the problem was. I gave him a bad time, but he was right.”
I asked Stephan how he felt. “The pain is almost gone,” he said. He pointed to his surgical wound, a vertical line down the back of his neck to shoulder level, with a gentle indentation in the space that the spinous processes of his vertebral bones had formerly occupied. “I can deal with this.” The sense of relief he projected exceeded mine, but not by much. I allowed myself a wide smile. “I’m so glad” was all I could say.
A few days later, he stopped by the Berkeley office. Previously, he’d never shown us any face other than pride and anger. He shocked us all with hugs for everyone in the office, calling Carol his “angel” while weeping in gratitude, prompting her to pull me aside to confirm that “This is what makes all that we do worth it.”
Almost a month later, with Christmas just a few days away, Stephan came back for a follow-up appointment, during which he shook me firmly by the hand and informed me that he now was almost pain free without any medication and that he had full strength in his left arm and hand. He had even resumed lifting weights.
While he was in the hospital, Stephan had opened discussions with his surgeon and with me about where the abscess had come from. “Shooters,” what physicians call people who use intravenous drugs, get spinal abscesses from the bacteria they unintentionally inject into their bloodstream, but these abscesses are otherwise rare. “The neurosurgeon said it probably came from some dental work I had done a month ago,” he’d told me when I came to see him in the hospital. Deep cleanings and procedures involving injury to the gums can cause some of the hordes of bacteria living in the mouth to disseminate into the bloodstream and cause infections in other parts of the body. The chances of an otherwise healthy person getting a spinal infection from a dental procedure, however, are similar to the probability of lightning striking one’s spinal cord. Perhaps the stab wound to his chest so many years ago had left some scar or pocket that the bacteria had invaded. In any case, this was one of those “bad things happen for no good reason” scenarios that we see often in my line of work, and I was thrilled to see that he had made a complete recovery.
“I want to make you aware of something so you’re not caught off guard,” he began, and I sensed the end of the happy part of our conversation. “I have consulted three attorneys, and I just want to warn you that they want to see your records. They don’t want anything having to do with my colonoscopy or matters like that. They want any records that might show a delay in diagnosis so they can sue you. I want to sue the dentist, but the attorneys want to look over what you did also. I’ve told them, ‘I think that all you’ll find is that he was the guy who found the problem and ordered the MRI so that I could see the surgeon.’ You are the reason I am standing here today, the reason I’m not dead. I do not want you to be named in the lawsuit.”
I thumbed through the chart, gathering my thoughts to come up with a careful answer. His words surprised me only a little, and I chuckled inside the way one does after locating a lost wallet only to find it empty. This is our world, and I have been around long enough to know that pulling out all the stops to save a life does not mean you won’t later have to face lawyers.
I said, “I have to tell you that to me this would be an extreme miscarriage of justice. Especially when you look at what everyone here did for you.”
He acknowledged that. “I don’t want you to be involved, but the attorneys said that they have to review your records. I told the attorney about how you even saw me when I did not have an appointment, during your break when you were going to go to your other office.” Thanks, I had forgotten that, but malpractice attorneys do not have any interest in whatever beneficence a potential physician defendant might have shown; it is their goal to make as much money as possible, and the more professionals they can name in a lawsuit, the more money they stand to make.
“You realize that if you sue me, I cannot continue to be your physician, or Tamara’s physician.”
“I know. I don’t want this to happen. But you need to understand. While this was going on and days were passing and I was in so much pain…” He cringed with the memory. “I own a .44 Magnum and I took it out and put it up to my mouth several times.” He said this slowly, looking me in the eye with his left thumb up and left index finger directed between his lips. “Because I would have done anything to end the pain.”
Someone had to pay for the pain, even if it had to be the innocent dentist and me. I assumed at that point that his attorneys had told him they would not accept his case unless I were included, so I shook his hand, thanked him for the “heads up,” and notified Marc, our practice administrator.
He said, “Jim, you need to sit down right now and write down everything that you can remember of what happened and what he said to you.” I knew this already and that I would be submitting this to our malpractice carrier to prepare for what might come, so I sat down at the computer and did as I was told.
“I’m fried!” was Carol’s reaction. “How can he possibly do that?”
My boss likes to remind me that no good deed goes unpunished, but this seemed over the top to me. In the end, Stephan reached the same conclusion. One month later, at the end of his follow-up appointment, he declared, “I decided not to go ahead with the suit. It was not anyone’s fault, and everyone here has been nothing but good to me.”