Friday night, 11p.m., a phone rings. 

“Hello” 

“This is the Prime Medical Center switchboard.  Dr. Joseph Kae?” 

“Yes.” 

“You are the surgeon on call?” 

“Right.” 

“The Hospitalist wants to speak with you. Go ahead Ma'am.” 

“Hey Dr. Kae, this is MaryBeth.” Mary Beth is the uber competent Nurse Practitioner covering med surg patients for the hospitalist service. Except for the Anesthesiologist staffing OB and the Physician and Nurse Practitioner in the ED, she is the only advanced care practitioner in-house at night. “Are you on call for Dr. Goneaway’s patients?” 

“Yeah, whatcha got?” Dr. Kae knows MaryBeth. He is on call every fourth night and MaryBeth works ten shifts a month. Their schedules frequently overlap. 

“There was a rapid response on one of his patients, Mr. Horrendous Catastrophe.” 

“We”, by which Dr. Kae means the hospital surgeons, “all know that patient. Mr. Catastrophe has been in and out of the hospital with bowel obstructions multiple times since the first of January.” 

“Then you know Dr. Goneaway operated on him? Today is post-op day 3. He does not look good; abdomen distended, guppy breathing. I have him on 100% oxygen by face shield. O2 sat is around 88. I need you to come in and look at him.” 

“You think he might code?” 

“It’s possible. He’s being transferred to the unit now.” 

“I’m at home. I’ll be there as soon as I can; 30 minutes – maybe sooner.” 

“Thanks.” 

When Dr. Kae enters the ICU, Mr. Catastrophe is not difficult to locate. He is in the room emitting a clamor that reverberates throughout the unit. Dr. Kae encounters staff bustling over and around the patient; a respiratory therapist is ventilating the patient with an ambu bag attached to a face mask, the anesthesiologist having been summoned from OB looms over the head of Mr. Catastrophe’s bed with a Mac bladed laryngoscope in hand, a nurse titrates the Levophed drip that runs into a catheter protruding from the right side of Mr. Catastrophe’s neck. MaryBeth stands beside the entrance to the room talking on her cell phone with a floor nurse about a different patient. 

Amid the commotion, Dr. Kae examines Mr. Catastrophe’s abdomen. The abdominal wound is intact and there is no drainage. He notes the amount of abdominal distention and commences internal dialogue. Is this abdomen tight? Not really. Is there rebound? Rigidity? Can’t tell with all this activity. Any bowel sounds? A few tinkles. He glances at the collection bag dangling from the patient’s foley catheter. There are two thin streaks of blood floating in a few ccs of dark yellow urine. Dr. Kae asks the nurse adjusting the Levophed, “Traumatic catheterization?” 

“Went in smoothly. You see the urine? Not much. I didn’t lose enough to chart either.” 

Dr. Kae steps out of the room to talk to MaryBeth, who is off the phone. 

“What do we know?” 

“Chest x ray shows bilateral atelectasis or maybe bilateral pneumonia and a tiny streak of lucency suggestive of pneumoperitoneum. Enlarged stomach. White count is 19,000. Could be aspiration pneumonia, less likely PE. I ordered CT of the chest and abdomen. We haven’t had a chance to get those yet. Too unstable. What do you think about the abdomen?” 

“Not as bad as I feared. I need the additional imaging before I can make a meaningful decision. He’s septic from something. Have you used the medication the FDA recently approved for sepsis?” 

A nurse overheard the conversation and volunteered, “If you are thinking about using StopIt!, you will have to speak directly with the pharmacist. You know a dose of StopIt! costs $500,000 dollars.” 

MaryBeth turns to Dr. Kae and says, “Worth a try don’t you think?” 

“Yes. There was a dispositive paper published in JACS showing when administered to the right patient at the right time StopIt! can reduce mortality by 50%. We can start StopIt! while we wait for the CT scans. I’ll call the pharmacist.” 

“O.K., I’m leaving Mr. Catastrophe to you. A lot has happened on the floor that requires my attention.”  MaryBeth leaves the ICU. 

Dr. Kae sits at the ICU desk, a position from which he can monitor the activity in Mr. Catastrophe’s room.  He picks up the receiver of the landline phone to his right and dials the switchboard operator. 

“Operator, can you get me the pharmacist on call?” 

“It’s Sarah Wright. I’ll call her for you. Standby. 

The phone rings twice before Sarah answers. Dr. Kae identifies himself and says, “A patient I am seeing in the ICU is septic. I want to dose him with that new medication for sepsis, StopIt!. Can you release it for me?” 

“Do you have the Code Blue Causing Protein titer? I can’t release it without knowing the CBCP titer. According to the protocol approved by the Pharmacy and Therapeutics Committee, the titer must be between o.2 and 0.9 mcgs/dl. If the CBCP titer is too low, the patient doesn’t need StopIt!, and if the titer is too high, StopIt! isn't beneficial.” 

“The lab is running Mr. Catastrophe’s bloodwork now. I’ll check with them and call you back.” 

Dr. Kae hangs up with the pharmacist and calls the lab. The phone rings half a dozen times before a harried laboratory technician answers. 

“Laboratory.” 

“This is Dr. Kae. Do you have the results of Mr. Catastrophe’s bloodwork?” 

“What room is he in?” 

“He was on the floor, but he’s been transferred to ICU bed 13.” 

“I found him. The results I have are on the computer. I’m running the rest of the tests now.”  

“Can you tell me the CBCP titer? I don’t see it on Mr. Catastrophe’s profile. If you don’t have it, when will it be ready?” 

“You want a CBCP? I don’t have an order for that. CBCP is a sendoff anyway. We don’t do that assay here. It takes three days to get the result from an outside lab.” 

“Damn! All right, put it in under my name. I’ll enter the order now.” Dr. Kae sees the anesthesiologist leave the unit after successfully intubating Mr. Catastrophe. 

“I’ll set it up for you, but the sample won’t go out until morning.” 

“O.K., if that's the best we can do.” Dr. Kae toggles the phone connection and summons the operator. “Operator, get me the pharmacist again.” 

The phone rings. Sarah promptly answers.  “Dr. Kae? Did you get the CBCP?” 

“It takes three days. You probably knew that. Mr. Catastrophe might die in three days. I might die in three days!” 

“I hope not. Don’t get mad at me. I didn’t know when the CBCP was ordered.  Without that result, I can’t release StopIt!. If you want it right away, I suggest you ask an administrator to override the P&T Committee’s protocol.” 

“I’ll try that.” 

 Dr. Kae ends the call and dials the operator. “Operator, this time, I need the administrator on call.” 

“It will take a few minutes for me to find out who that is. The administrative call list is in a separate file from the regular call list. I’ll have to call you back.” 

Waiting for the operator to call back, Dr. Kae reviews the chest x ray taken after Mr. Catastrophe was intubated. The endotracheal tube is in a good position. Nasogastric tube is coiled in the body of the stomach. The phone rings. Dr. Kae snatches up the receiver. “Hello.” 

 “The administrator on call is Mr. Wagoner. I’m ringing his phone now.” 

“Mr. Wagoner? Who is that? I never heard of him.” 

“The hospital parking lot supervisor. He is on call for administration this week. They take call a week at a time.” 

Dr. Kae hears the phone ringing in the background of his conversation with the operator. After an inordinate number of rings, a man with a deep voice answers the phone. 

“Hello?” 

“This is the switchboard at the Prime Medical Center. I have Dr. Kae on the line for the administrator on call.” 

“Oh yeah. That’s right. I am on call this week.” 

“Go ahead Doctor.” 

“Mr. Wagoner, I don’t believe we have met. I am Dr. Kae, the surgeon on call tonight. The purpose of my call is to urge you to instruct the pharmacist to send medication to the ICU for a patient I am seeing. The patient is septic and the medication might help him survive.” 

“Well sure. What is the problem? Administration usually doesn’t get involved in clinical decision making.” 

“The medication is expensive and there is a certain protocol for its use.” 

“Oh? How expensive is it?” 

“I am hearing $500,000 dollars a dose.” 

“Hmm... that is expensive. Honestly, I ‘m not authorized to approve that kind of expenditure. You will have to discuss it with the CEO on Monday. I will send her an email with your request so she will know to expect your call.” 

“This shouldn’t wait until Monday. The sooner the patient gets dosed, the better his prognosis.” 

“I have a special contact number for the CEO. The operator doesn’t have it. If I am able to get the CEO on the phone, I will have her call you. I suppose the operator knows how to reach you?” 

“She does. I am on call the entire weekend.” 

After speaking with Mr. Wagoner, Dr. Kae pokes his head in Mr. Catastrophe’s room. Two nurses are bundling up the wires and connections extending from Mr. Catastrophe and his bed in preparation for transporting him to the CT scanner. 

Dr. Kae asks, “Is he doing better?” 

The older, she appears to be about 28 years old, more experienced, nurse responds, “Yes, the intubation really helped. And the sedation.” 

“Still on Levophed?” 

“8 mcgs.” 

Dr. Kae helps the nurses push the heavy hospital bed out of the room and through the corridors. When they arrive at the elevators, he peels off saying, “I’ll be in the doctor’s lounge waiting for the CT results.”  

In the Doctor’s lounge, Dr. Kae brews a cup of coffee using the Keurig machine on the counter by the sink. After that, he sits at a workstation and logs on to the computer. Every few minutes, he checks the x ray tab to see if Mr. Catastrophe’s CT images are posted. When the scans appear, he scrolls through the images. Then, he calls MaryBeth. 

 “We got the CT scans. “ 

“Good, then he is stable?” 

“For now. Last I checked he was on 8 mcgs of Levophed.” 

“What do the scans show?” 

“Lines are in position. The bases of both lungs are junked up. Your diagnosis of pneumonia appears right. There are a few tiny, worrisome droplets of air around the porta and in the mesentery. Only a couple. I don’t know what that means on POD 3, but I would feel much better if they weren’t there.” 

“You’re not planning to explore him tonight?” 

“No, let’s keep doing what we are doing. I have a call out to the CEO to see if we can start StopIt!. It’s a complicated story. I’ll tell you about it later. If I get her approval to use it, I will let you know. I’m going home now. I’ll reevaluate Mr. Catastrophe on rounds in the morning.”  

“Hope you rest. I’ll call if I need you.” 

“Thanks.” 

That night, Dr. Kae ruminates over the droplets of air seen on Mr. Catastrophe’s abdominal CT scan. He sleeps fitfully. When morning comes, the day being Saturday, he rolls into the hospital an hour later than usual. Once there, he goes to a computer terminal, logs on, and opens his patient list. Mr. Catastrophe is not on the list. Dr. Kae prints out his list, logs off the computer, and goes straight to the ICU. In comparison to the night before, the unit is brilliantly illuminated. A few doctors wander about unhurriedly examining patients; others gaze at computer monitors that show patient results. The nurses are absorbed in the care of their assigned patients. Dr. Kae sees none of the urgent, frantic activities that were apparent in Mr. Catastrophe’s room the night before. He interrupts a nurse and asks, “Where is Mr. Catastrophe?” 

Sotto voce the nurse says, “He coded and died at shift change this morning. MaryBeth said not to bother you because you would be rounding soon enough. She spoke with the family.” 

“He didn’t get StopIt! did he?” 

“I don’t think so.” 

After completing tasks at the hospital, Dr. Kae arrives home. It is late afternoon. He comes upon her sitting at the desk in the home office; an interior decorator might describe the room as a study or library. She is filling in a ledger or compiling a list of some sort. A bone-China teacup embellished with images of pink cherry blossoms and containing jasmine organic tea rests on a stone coaster by her right hand. She looks at him through the lenses of her glasses. Without rising from her chair, she comments, “You look tired.” And then a bit more perceptively she asks, “Is something the matter?” 

“Everything and nothing. Driving home, I was thinking about that poem Hope by Emily Dickinson. Do you know it?” 

“No.” A pause ensues, then “What do you want to do for dinner tonight?” 

Bruce Harris MD FACS is a retired General Surgeon who practiced in North Carolina. Dr. Harris earned a BS in Physics at Harvey Mudd College in 1977, and is a graduate of the University of Missouri-Columbia School of Medicine in 1981. He enjoys running, reading, writing, snowboarding, and rafting.