It was the best of care. It was the worst of care. It was acts of wisdom; it was acts of foolishness. It was an epoch of evidence; it was an epoch of anecdotes. The patients were full code; they were DNR. It was the summer of safety and the winter of sentinel events. In short it was a hospital so like all others.
It was a slow day when Charles Darnay hit the admission office of Tellson General Hospital. Lucie sat at the terminal, glad for the distraction. She entered his information: DOB 04/21/29/Dr. Defarge/RTKA/Iodine Allergy/Regular Diet/Semi-Private/Regular Diet. Lucie was unsuccessfully trying to place a red seven on a black nine when the phone rang with a direct admit: Darren Charles/Dr. Mannette/DVT/NKDA/ Private/Diabetic Diet.
Darren Charles was not happy to be hospitalized. The CEO of an international fast food chain, he had been flying back from a business trip to London when his leg started to ache. He went to the emergency department where a right femoral vein thrombosis was observed on ultrasound. With a serum glucose of 380, he was incarcerated. The mattress was hard, the pillows starchy, and the cable selection poor. He knew this wasn’t a hotel, but he expected better service. He was tired of finger sticks, blood draws, and IVs already.
Inside Charles Darnay’s right knee joint, cartilage rubbed against cartilage. It was a wheelchair or surgery. He was adopted and a bachelor and the thought of a long lonely rehab left him cold. Dr. Defarge made it sound like it would be a breeze.
Syd Carton was the first physician’s assistant to work at Tellson General. She loved her job and had become very efficient over the last three years. She had started as an orthopedic PA, but switched to Dr. Mannette’s general medicine service to get a wider variety of cases. She took Mr. Darnay’s history. DVT post-airplane flight, with diabetes poorly controlled and dietary noncompliance. His glycohemoglobin was 12. He was high maintenance; she could live without taking care of VIPs.
Jerry Cruncher, the orthopedic intern on Dr. Defarge’s service, was fried. He’d been up all night on the graveyard shift, and it was now 1 p.m. His wife would not tolerate him coming home late again. She was likely to become a whistle blower and sink the whole residency program if he went over his allotted hours again. He loved orthopedics, but working for the infamous Dr. Defarge was a challenge. She was a great surgeon and sewed beautifully, but was mythically unpleasant. The slightest medical problem with a patient and she would bellow, “Off of my service.” It had better happen that way or it would be Intern Cruncher’s head. At any rate he was almost done—just an order or two to write and he’d be in his nice warm bed, with his nice warm wife.
PA Carton received a stat page. Mr. Charles’ oxygen saturation had dropped acutely, and he was complaining of shortness of breath. A fragment of thrombus had broken off from the expanding mass of platelets and protein in his leg and had gone for a wild ride through his circulatory system. A larger strand of thrombus fluttered precariously in the current of his femoral venous flow. Why did the VIPs always have complications?
PA Carton checked Mr. Charles’ PTT, therapeutic. His INR was coming up nicely with warfarin, but it sounded like he’d flipped a clot. She checked his vital signs: He was moderately tachycardic, but not hypotensive. His O2 sat was 84, and only came up to 91 with 4 liters nasal cannula oxygen. She ordered an EKG, troponin levels, and a CT angio. His renal function was normal, but he was on metformin. She held that drug, and called the radiologist. It took a bit of persuasion, but they would do the procedure that day.