By Larry Martin
The TV in Memorial Hospital’s doctor’s lounge was on mute, but CNN’s running headline showed the grim news: May 28, 2020: U.S death toll from Covid-19 passes 100,000.
“No big surprise, there,” said Dr. David Kanter, pointing to the television. He and colleague Dr. Scott Donahue were on a much-needed break from daily rounds.
“Yeah,” replied Donahue, “the way things are going at Memorial, we may reach the 100K mark all by ourselves.”
“It’s not that bad, Scott. We saved two vent patients just this week. Both Covid pneumonias.”
“Great, and how many have died in your ICU?”
“David, you know Administration is going to ask. Greg Wilson is getting hung up on the numbers. The more cases, the more support for his mission.”
“What’s his mission?”
“To retire with the hospital better off financially than when he became its president.”
“He’s been here ten years,” replied David. “You and I have been on staff fifteen years. It was never clear to me why a non-MD was made president in the first place.”
“Were you born yesterday? It’s all about money, or profit. Then comes patient care.”
Dr. Kanter reached for the remote and turned off the TV. “That’s what I really like about this job. We just have to take care of patients, not worry about making a profit.”
“And pray tell, Dr. Head-of-the-ICU, what do you not like about your job?”
“I’ll tell you,” said Kanter. “People dying because we don’t have a vaccine. And none on the horizon. Three months already. When’s it going to end? And, am I going to be the next victim? Or you?”
“Not me. I’m too nasty for this virus. And besides, I’m loaded up on hydroxychloroquine.”
“It’s May, Scott.”
Dr. Kanter’s cell phone buzzed with a text message. When you get a chance, please stop by my office today. Greg.
“Scott, look at this. Speak of the devil.”
“Yeah, he’s probably listening in. If he mentions my name in less than glowing terms, tell him to go to hell. He can find another infectious disease doctor for Memorial.”
“What is it with you two? You’ve never gotten along.”
“Policy differences. Budget issues relating to the microbiology lab. For more detail, wait for my novel.”
“You’re writing a novel?”
“Yeah, in my head. It’s called The Decline and Fall of Memorial Hospital Due to One Specific Ass-hole.”
“Wonderful. I’ve gotta get back to the ICU. And as for you getting fired by Greg, sorry, not
a chance. He couldn’t find a better infectious disease doctor, and he knows it.”
“If you say so. And you’re the best pulmonary specialist. So, why are we bitching?”
“It’s Covid,” Scott. “And it’s driving us all crazy.”
An hour later Dr. Kanter entered Greg Wilson’s plush office, found him sitting at his desk. Kanter took a chair placed a dozen feet in front of the desk. Both men wore face masks.
“Thanks for coming by, David. Hope I’m not pulling you away from the ICU. I know you and your team are super busy. And doing amazing work.”
“Thanks, Greg. Do you wear your mask all day? Or just when visitors enter?”
“Just for visitors. Though the office is big enough we probably could socially distance a dozen people.”
“So, what’s up?”
“I’ll get right to the point. We’re having some issue with our Covid-19 stats. This is something you don’t have to worry about, but as hospital president, I do. It’s insane and I don’t like it, to be honest with you, but Washington is looking at the numbers.”
“Oh, what numbers?”
“How many of our patients die with Covid-19.”
“Really? Why is that important? How about how many live with Covid-19?”
“Medicare pays a higher rate for Covid-19 deaths. The more we have, the more we are reimbursed. It’s that simple. St. Luke’s Hospital across town, which has the same bed capacity as us, had more Covid-19 deaths last month.”
“Well, maybe they serve a much older population. That would explain it.”
“Actually, we serve an older population. Don’t forget, we have a nursing home right across the street.”
“OK, St. Luke’s has more Covid-19 deaths. What’s this got to do with me? Maybe we’re doing a better job?”
Wilson did not answer right away, but shuffled through some papers on his desk, pulling out a manila folder. “This was recently brought to my attention. Before I show you this, let me reassure you I’m not asking you to do anything illegal or immoral. I just want to bring this to your attention.”
“I’m all ears.”
“These are three death certificates you’ve signed in the past two weeks.”
Gregory stood, walked over to David and handed him the folder, then returned to his desk. “You’ll notice, in none of them is the cause of death given as Covid-19.”
Dr. Kanter studied the three documents, then replied, “That’s because they weren’t.”
“David, our Covid Audit Team looked at the full medical records. Two of the patients were positive for Covid-19. The third came from the nursing home with high fever and pneumonia, and apparently died before the Covid test was done. However, two people on his floor at the nursing home are quarantined because they are Covid-positive. So it seems reasonable that the deaths of all three could be attributed to Covid.”
“Greg, I don’t want to seem rude, but aren’t you a little out of line here. Practicing medicine without, you know, a—”
“A license. Look, David, I told you I’m not asking you to change these death certificates. It’s actually too late for that, anyway. All I’m asking is that you be more aware of the potential cause of death as being from the Covid virus, and put it down when you sign these certificates.”
“OK, but for the record, let me just recap these three, who I remember well. Mrs. Schwartz was 85 and had end-stage pancreatic cancer. She should never have been in the ICU. She had a positive Covid-19 test but didn’t die from the virus. She died from terminal cancer.
“Mr. Brandon-Smith was similar. He had lung cancer, and was in fact on hospice care, not expected to live more than a few weeks. The ED didn’t know the full story when they sent him up to the ICU. Once we realized he was a hospice patient, we transferred him out and he died within 24 hours. I had to sign the death certificate only because the new attending said he didn’t know the patient. To label his death from Covid makes no sense.
“When people with terminal cancer die, there is often an intervening event, some infection perhaps. If we never put down the real cause, that is, the cancer, you would have no idea how many cancer deaths there were. So that’s a medical rebuttal, if one is even needed.”
“Covid is not ‘some infection’, David. It’s a pandemic. One hundred thousand dead to this point, and they are projecting another one hundred thousand deaths by October. Yes, I’ll admit it’s somewhat a political situation. But I don’t see any downside for diagnosing Covid when there’s any possibility.”
Dr. Katz held up the third certificate. “As for the last patient, age 80, he didn’t get the Covid test. How am I supposed to infer his death was from the virus? I missed that.”
“David, David, we’re in this together. I called you here just to sensitize you to the reality of what we’re dealing with. My hunch is, St. Luke’s is labeling these types of patients as Covid deaths. Look, no one appreciates the work you do more than me. I’m retiring in a year, so this isn’t about me.”
“You’re retiring? You don’t look a day over fifty-five.”
“Thanks. Flattery will get you promoted to high places. In fact I’m sixty-seven. I’m in good health, but it’s time to retire, let someone younger run the hospital. Are you interested?”
“Me? Greg, do you do stand-up comedy? Let me rephrase that. Do you do General Sherman?”
“You know, the Civil War General. ‘If nominated I will not run, if elected I will not serve.’”
“OK, spoiler alert. You’re not in the running for hospital president. Your reaction shows you understand how unpalatable this job can be sometimes. I have nothing personally to gain by making these deaths Covid-related. But the reality is that we’re always compared against St. Luke’s, and Washington pays more for a Covid death than your garden-variety terminal cancer. You’re the head of the ICU. Who else am I going to talk to?”
“How about Scott Donahue?”
“Scott? Why Scott?”
“Well, he’s head of Infectious Disease. See what he thinks.”
“Now who’s doing stand-up? I appreciate your sense of humor. You know damn well Scott and I don’t get along. Besides, he never signs death certificates.”
At home that night David had dinner with his wife Betsy. Both kids were home from college, upstairs in their bedrooms.
“I sense another tough day,” said Betsy, in between bites of tilapia.
“More of the same. We’re averaging five to six Covid-ventilator patients at a time. And I don’t see an end to the pandemic any time soon. The country passed the 100,000 death mark today.”
“I know. I was watching the news before you came home. I hope you’re being damn careful. You’re going to be fifty this year.”
“Oh? I didn’t know. Of course I’m careful. Masks, face shields, gowns, hand washing with each breath. So far none of my ICU staff has caught the virus, which is a miracle in itself. How are the kids doing?”
“Doing? Thank goodness for Zoom. Both colleges are now fully online. Of course, don’t expect a break in tuition. No such luck. God knows what’ll happen in the fall.”
“Can’t blame them,” said David. “Your elementary school isn’t going back so fast, either.”
“My pupils are eight years old. Kids that age don’t get sick from the virus, or they rarely do. Problem is, they can transmit it. So no, I’m not rushing back either, until we get a vaccine. My third graders are really losing out, though. Have you ever tried to teach an eight-year-old math via Zoom? It’s crazy. They won’t even stay in front of the screen unless an adult is with them at home. But at least it’s not life and death work. Like yours.”
“Well, I am careful. It’s one thing to take care of these patients, to risk my own life. But then you have to deal with administrators like Gregory Wilson.”
“Memorial’s president? What are you talking about?”
“Oh, he called me in today, to discuss how I fill out death certificates …”
In the ED’s cubicle 9 he met Dr. Harwood, at that moment examining a middle-aged male who lay supine in bed, intubated. The bedside ventilator made a quiet whoosh-whoosh sound. Two IV lines entered the man’s arms. The patient was Gregory Wilson.
“What the hell happened?” asked Kanter.
“He apparently had a fever for two or three days, thought it was the flu,” explained Harwood. “His wife insisted he come get checked, but she says he refused. He was dizzy this morning, almost fainted, and she called 9-1-1. When he arrived his O2 sat was 85% and he was in distress. Went downhill rapidly. We intubated him just before I called you. I’m willing to bet it’s Covid.”
“She’s out in the waiting area. She doesn’t know he’s intubated. Just happened. You want to talk to her? He’s all yours now. I think he’s safe to transport to the ICU.”
“Thanks much. You’ve made my day. I’ll go talk to her. His vitals are stable?”
“For now, yes.” Dr. Harwood pointed to the heart monitor. “We’ve got his sat up to 95%, on 100% O2.”
Mrs. Wilson related the possible source of the virus, a family party for their grandson’s high school graduation. The graduation ceremony was virtual, but the party was real. Just “eight or nine friends, all young people. We just didn’t think …” One of the young people at the party soon tested positive for Covid-19. Fortunately, she and their grandson tested negative.
“And Mr. Wilson?” asked Dr. Kanter.
“At the time he wasn’t sick, and would not go for the test.”
Kanter learned that the party came after his meeting in Wilson’s office. I wonder how many hospital personnel he might have infected later.
Wilson was placed in ICU Room 3. At age 67, and otherwise healthy, he had about a 50% chance of dying from the infection. While ICU nurses connected him to a vital signs monitor, and the respiratory therapist checked the ventilator settings, Kanter put in a call to Scott Donohue. After the “You’re kidding,” and “I’ll be damned,” comments, Donahue said he’d be right up.
Hospital-based doctors like Kanter and Donahue pride themselves on giving world-class care to any and all classes. Insured or uninsured, homeless drifter or mayor, it didn’t matter. Everyone got the same care, albeit with a heightened level of anxiety when the patient was a VIP.
As for Mrs. Wilson, she stayed calm. Dr. Kanter discerned she was oblivious of hospital politics, which was a good thing. Another good thing, perversely, was that her husband’s Covid status solved the problem of visitors. None. Not their grown children, not the Board of Trustees, not the mayor. She was allowed into the ICU to view her husband through a glass door, but not to enter the room. Too risky.
“I trust the doctors,” she told Dr. Kanter. She also said this to Dr. Donahue, who replied, “I assure you he’s getting the best care possible. And you have your husband to thank for that. He’s never scrimped on providing the best care for our patients.”
Shortly after admission Mr. Wilson’s blood test returned positive for Covid-19.
“No surprise there,” said Donahue, viewing the just-completed chest CT scan with his colleague. “I put him on Remdesivir, and dexamethasone.”
“Good, I thought you would,” replied Kanter. He pointed to areas of the scan showing multiple white blotches against a background of lung tissue. “Bilateral pneumonia. Classic case of Covid-19.”
Day one passed with no improvement in the patient’s respiratory failure. He was now on 60% oxygen, lying in the prone position, fully sedated to make it easier for the ventilator to do its work.
Day two, still no significant change. “Scott, just so you know,” said Dr. Kanter, “the chairman of the board called me. Mrs. Wilson gave me permission to talk to him, and he seems satisfied with our care. He asked who the other doctors were, and I gave him your name. You might get a call.”
“Hope not,” said Donahue. “Anyway, don’t know him. Nice guy?”
“Businessman. Car dealerships, I think. He seems reasonable.”
The morning of day three, with no improvement in Wilson’s condition, Donahue burst into the ICU and pulled Kanter aside. “Great news, David. I got approval to use Covid-convalescent plasma. Going to start it now. Experimental, but some good theory why it should help. Contains Covid antibodies.
“How’d you get it?”
“I’ve been trying for a month, for other patients. None available, they said. Now it is. Just arrived from Johns Hopkins. They’ve used it twice already.”
“That is great news. I lie awake at night worrying about losing him. And last night I had a nightmare.”
“Nightmare? Do I need to hear it?”
“Yes,” said Kanter. “In my nightmare, we lost him, and I was handed his death certificate to sign. He’s dead in my dream, but his ghost is standing beside me, waiting for me to sign the paper.”
“Have you been drinking, David?”
“No, listen. It’s weird. I look down at the death certificate and write, under Cause of Death,
‘Covid-19’, and Gregory is now smiling, and says to me: ‘Thank you, Dr. Kanter. That will help.’ Then I woke up in a sweat.”
“OK, crazy dream, David. File it. We are not going to lose him. Not on our watch.”
“Thanks, Scott. Let’s start the plasma.”
Lawrence Martin is a retired physician from Cleveland, where I practiced pulmonary medicine for 39 years. He retired in 2015 and, with his wife, moved to The Villages, Florida.
During his medical career he wrote mostly medical books, for both doctors and a lay audience. In retirement he has also turned to writing fiction.
Two novels and several short stories have won Florida Writers Association’s Royal Palm Literary Awards. In 2017 he was president of the Writers League of The Villages, and since then has served on the Board of WLOV and been the WLOV Newsletter editor.
He may be contacted at firstname.lastname@example.org