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Since You’re Going To Die Anyway

You know, Doctor that every year I look forward to your Christmas card. It’s always the first to arrive. I wait for it. It starts the season. It’s not politically correct, it’s always something religious. But then you and your brother are really into religion.  That’s why you forgave them. I’m better now, but not quite to forgiveness. Time heals but I’m still waiting. Lets say I understand what they did, and why. It doesn’t surprise me.

Also you sign your name, and put in parenthesis, “Dr. Fredricks, Carmen’s dad.”

Like I could forget you or her? It’s been what? Eighteen years? I think so. Your card makes me realize how important it was to do what we did.  I will never forget you, Carmen, or your brother. I promise.

Your brother was quite the gentleman. He looked like a distinguished figure from the past. His bald-head rimmed with gray hair, wire rim glasses, and his navy blue pin striped three piece suit adorned with the Phi Beta Kappa key.

He went to Howard and was a Tuskegee airman you said.  He got his PhD. in Theology and one of yours was in Theology and the other was in Education or Psychology I can’t remember. You’re quite a pair.

You and your brother would probably have gone to an Ivy League school now.  But I’m not convinced that would have been a good thing. Do I want an Alma Mater to be a school that gave us the Vietnam War, investment bankers and the collapse of the American financial system, medical faculty in the pockets of drug companies, two Bushes and two Clintons? Is that the best we can do? Give me a three-point student from The Big Ten.

The Ivies also gave us the DRG, the diagnostic related group. That’s what hurt Carmen so bad.

I want to explain the DRG to you. It helps me with the why of what they did to Carmen. You see, Doctor, in the mid 1980’s an idea came from some thinkers at Yale. It was the DRG. This was supposed to be the answer to the escalating costs of health care. Health care costs have escalated further, and we still have the DRG’s and fifty million Americans without health insurance.

If health care is so expensive why are hospitals getting all that money to build new buildings they don’t need? That money should go to patients not well connected construction companies.

Anyway a DRG is supposed to work like this: a person comes into the hospital with a medical problem, lets use a heart attack for an example, but it could be anything.  The hospital gets a lump sum to take care of the patient. It is the same amount of money with little attention to extenuating circumstances.  A heart attack in a fifty year old man with strong family support and a blind, elderly, diabetic woman with no family are treated in a similar fashion. The old lady needs more care but the hospital gets the same amount of money, and the same number of days. If the hospital gets the patient out in four days rather than five, the not for profit, tax except hospital, makes a profit. Let the up-coding games begin. I’m sure it’s more refined now but it wasn’t eighteen years ago when Carmen was so sick.

We were pushed to get the patients out. The hospital started to rank us on “financial credentialing.” I kid you not. Not on medical acumen alone. They would have thrown Marcus Welby, Hippocrates, Virchow, Cushing, Osler and House out on their collective asses. The bean counters have prevailed.

To make certain we got the patients out fast, nurses were recruited to review charts and pressure us to send them out quicker and sicker.  They were called Senior Supervisors.  We called them: “SS.”

Hospitals will deny it, but then how come a federal law had to be passed to prevent patients from getting the bum’s rush? Step down hospitals didn’t exist back then.

What they said to her is the cruelest thing I’ve heard someone say to another person.  Especially to a twenty-four year old woman.  If they would have treated my daughter like that I don’t know what I would have done. That’s why I’m not yet to the forgiveness stage.

The Senior Supervisor assigned to Carmen’s case was the worst. Rumor has it that he was a stand out football player and wrestler in college but he hurt his knee and his career ended. He went into nursing and being mean. Now lots of men go into nursing but back then it wasn’t very manly. Maybe that’s why he was such a prick.

Carmen had the worst luck of any patient I knew. First she comes to me at the age of fourteen with juvenile diabetes. We had to teach her how to check her blood sugars and give herself shots of insulin. She was a quick study.

I remember she had a game that she wore like a watch. It was a computerized pet dog. You had to take care of the cyber dog, pay attention to its digital needs: water, food, vaccinations. You and I took care of Carmen, and she took care of that computerized dog. She was so concerned that the dog would get sick. The tasks were set against a timer. This beat the clock and save your pet is supposed to be fun. Then she goes into a diabetic coma and the game sat in her nightstand. The virtual pet got sick or died. Why would they have that happen in a game? She was so upset. It took me a long time to convince her that it was only a silly game and that she was being tricked by the game maker. Nobody could do what they asked.

I was very happy you got her a real puppy.  She loved that dog. She taught that dog so many tricks.  And when she got sick and went into the hospital the puppy did okay.

Then she turns eighteen, accepts the diabetes, but gets lupus. Damn. We went through the same thing again, only we gave her the medication to save her kidney and she went bald. Getting her through that one was tough. She got a bit wild but did okay. Her hair grew back and she developed into a beautiful young lady.

I was so proud when she got accepted to Vanderbilt. I felt so bad when she had to quit school during her sophomore year because the lupus caused her kidneys to fail.

I told her that we could get her a kidney transplant and a pancreas transplant. We could cure both her diabetes and kidney failure. I promised her she would be normal. I know you shouldn’t promise things to patients but your daughter was special. I wanted to believe it too.

She was engaged to that nice young man. Do you still see him? He was so good to Carmen. I told Carmen what a wonderful mother she would be. I kidded her and told her she would be a soccer mom and drive a mini-van. She liked the idea.

I evaluated her for the kidney transplant but found a tumor. A cancer in her thigh. A sarcoma. I sent her to four different cancer centers. There was nothing they could do for this aggressive tumor. Her kidneys fail and she has to go on dialysis.

This was the worst, Doctor. It sounds like I’m making this up. So, she is back in my hospital and she is too sick to go home and there is nothing we can do for her cancer, her lupus, or her kidney failure. That nurse can’t get her out. The meter’s running. He started to put the pressure on me.

She was young and terminal. She had more bad luck than any patient I had taken care of before or since.

I asked Carmen, if, given all her problems, she would like to stay on dialysis or go to hospice. She wanted to stay on dialysis. She said she had some things she wanted to get done.

“You are not telling her the truth,” the senior supervisor said. “You have to tell her she is terminal.”

“She knows. I want her to die gently. Have some compassion,” I said.

“I’m going to call Dr. Hatcher. He’ll make you stop her dialysis.”

“That will never happen.”

I went to the office and returned to the hospital to make evening rounds. I stopped to see Carmen. She sat up in bed, crying, hyperventilating, gasping.

“I know I’m going to die,” she said. “I know they want my bed. But I want to live as long as I can. They told me that since I’m going to die anyway why don’t I stop dialysis?”

“Who told you that?”

“The male nurse. The one with all the muscles,” she said. “I told him I want to live as long as I can.”

I went to the bedside and held Carmen. She was pretty thin by that time. I had to hold her gently because bones filled with cancer are painful and break easily. I asked her to take a Valium.  She was crying and could not talk because of her gagging and hyperventilating. I’ve never seen some one cry like that. The tears welled up and seemed to pulsate from her eyes with each heartbeat. I held her for a long time until she calmed down. The front of my white coat was wet.

She went to sleep. I hoped she dreamed of her life before the diabetes, the lupus and the cancer. When her mother was still alive.

Then Doctor, I made a mistake. I went to the nurse’s station and announced, “Whomever told my patient to stop her dialysis treatments because she was going to die anyway, tell that bastard to stay out of her room.”

I knew it was the male nurse that said it. He turned all shades of red and looked at me but did nothing. I did some amateur boxing, but this guy had about fifty pounds on me and the killer instinct. He could have taken me apart. But he flexed his muscles and walked out.

After that happened your brother came in. He was so soft spoken but was concerned about the nurse telling his niece that, “since she was going to die anyway she should stop dialysis.” I told him that I thought it was more than harsh and apologized for the hospital. I told her not to worry. She would be treated well.

That’s when he told me he was the president of the African-American Christian Ministries and that if I had a problem he would come and speak to the head of the hospital and explain what was said to his niece. I told him I didn’t think that would be necessary. Your brother understood hospital politics better than I did.

Two weeks later she got pneumonia. You agreed to make her a NO CPR, and she died gently. Thank you for not making me put her on the breathing machine, or giving her electric shocks, and compressing her chest. It’s too violent. Like I said, bones filled with cancer break easily. It’s a horrible sound.

I hope Carmen realized that there are nice people in the world, and we did care about her, and that there was still grace, and mercy. Her life was so difficult. I wanted her to leave this world with some nice memories. Something good she could take with her where ever she was going. Heaven I suppose.

After her death I got calls from the administration. A registered letter saying I was a “problem physician” and that I called that nurse “a bastard.”

I admitted it, but I said that “bastard” was too nice a word. I realize now you should never admit anything. Deny, deny, deny.

Another registered letter came and stated I would have to meet with the vice-president of the hospital.

I met with the vice-president of the hospital I told him what was said to Carmen. He told me I was a ‘liar, big mouth, and a troublemaker.’ Well, I could have caused him a lot more trouble. For the past year his wife had been sending me letters suggesting we rendezvous. I am not kidding. My lawyer has them in his office just in case.

You see Doctor, I’m in solo practice, and if I was suspended my colleagues would steal and devour my practice like sharks at a feeding frenzy.

I got suspended.

I went to the president of the hospital. Got pretty much the same thing. His wife didn’t send me any love letters though.  I told him about your brother’s position in the black Christian organization, and that he had offered to help me. They didn’t think I would pull the trigger, I guess. So the suspension stood.

I took it to the CEO. I explained to him what had happened. I also explained your brother’s offer to help me. I told him that I would call him. The CEO thought I was bluffing.

It was quite a sight when your brother pulled into valet parking with five church busses and your congregation filed out. They loved Carmen, too. The lobby was filled. Security came and they brought the dog but they were out numbered. Things got real quiet then your choir started to sing and calmed everybody down, even the dog.

The television stations showed up, all three of the local networks. I bet your brother called them. He has friends everywhere.

The fat, little, CEO was scurrying around the lobby like a bug. He kept telling me to “stop this, stop this.” Then your brother met him, and told him he didn’t like what had been said to his niece and that if he didn’t apologize and lift my suspension the issue would be pursued and perhaps the could bring in the Feds.

He lifted my suspension.

We went to your church and prayed.

You have to fight fire with fire and brimstone sometimes.

So, Doctor, thanks for your annual Christmas card. And you don’t have to qualify it with, “Carmen’s dad.”

I can’t forget.

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