Murder at Memorial

Louisiana State Attorney General Charles Foti has charged 3 former healthcare workers at Memorial Hospital in New Orleans with murdering four patients by injecting them with lethal doses of morphine in the days following Hurricane Katrina.

A single doctor, Anna Pou, MD, was accused, as well as two nurses, Lori Budo and Cheri Landry. All three have good professional records, as far as we know.

In the medical community in New Orleans, support has generally swung to Dr. Pou, who is well-known otolaryngologist, or ENT (Ears, Nose, & Throat specialist). Most New Orleans doctors I know reacted with anger when the story broke, indignant that the attorney general would accuse people who risked their lives to care for patients in the aftermath of the storm of unethical behavior. By and large, they feel that this process is simply an attempt to scapegoat medical personnel for the failures of the government and of hospital administrators to get all the patients out on a timely basis.

Certainly the decision to prosecute the three women raises many questions.

When a diver plunges to the bottom of an ocean full of fish and only comes up with three guppies, it makes one wonder. There were a dozen hospitals operating in New Orleans during Katrina, and 34 people died at Memorial. Dozens more died in other facilities. Out of all those deaths, and all those hospitals, it perplexes that a 10-month investigation could only come up with 1 doctor, 2 nurses, and 4 patients. Were the rumors totally overblown? Or was there a widespread problem, and is what we have just a trio of scapegoats?

It is possible that in all those hospitals with all those doctors and patients only three exhibited suspicious behavior, but it gives pause to anyone with common sense. We are supposed to think that all the rest of those deaths are on the up and up. That there is no moral difference between a patient euthanized and one abandoned. That someone who stayed behind to care for patients for 5 days in 110 degree heat, with no electricity and no drugs besides morphine, is morally indistinguishable from Jeffrey Dahmer. That no one else bears any responsibility for what happened. Just these three villains.

There are many things about this accusation that should concern us. For one, Pou is an ENT. Not to insult ENTs – all the ENTs I know are fine doctors – but an ENT is a specialist surgeon and someone who would not typically be expected to care for chronically ill patients in a disaster setting. The unevacuated patients at Memorial should have been under the care of an internist, or a cardiologist, or perhaps even an emergency room specialist. Someone trained to handle general medical problems and emergencies. If you were in a hospital during a hurricane, would you think it appropriate that your pneumonia or heart failure was left to a doctor who does sinus surgeries for a living?

Perhaps if  Dr. Pou had been an internist or ICU specialist she would have handled the situation in a different way. There are ways to manage dying patients that lie within the bounds of both law and ethics and nonetheless would have brought the whole thing to the same endpoint without any room for accusation.

How do I put this? She could have finessed it. This may sound like a lawyer’s game, but it is not. In medical ethics, there is a recognized difference between actively killing a patient and allowing him to die. Dr. Pou could have heavily sedated a patient with morphine for the purpose of relieving suffering, and then allowed the underlying disease to run its course.

There nothing ethically objectionable to administering huge doses of morphine to a patient as long as the intent is to relieve pain. Hospice patients die all the time like that. A patient may have terminal cancer, and a doctor will give enough pain medicine to put the patient to sleep. Then the sleeping patient is allowed to expire. Of course, this can only be done if the patient is in pain. But as long as the pain is well documented, there is no absolute limit to the amount of pain medicine the doctor can give.

A doctor well versed in palliative medicine or internal medicine would have understood that. Although some ENTs handle head and neck cancer and trauma patients, it is rare for an ENT to be experienced in acute hospital care or end-of-life issues. It may be that Dr. Pou was out of her depth.

This, however, is just guesswork. Dr. Pou was a medical school professor and a distinguished academic. But it is hard to see why a person of such knowledge and skill would, in her right mind, choose to actively euthanize 4 patients when alternative approaches were possible. That is, unless she was pushed beyond her competency.  Euthanasia is prohibited in Louisiana under any circumstances. She had to have known that.

Of course, proving euthanasia will be a very difficult legal task. Charles Foti claims to have autopsy evidence that all four patients received lethal injections of morphine. If he knows a way to prove such a thing medically, it is news to me.

Opioid (morphine) overdose is a hard thing to prove without corroborating evidence. People build up tolerance to opioids just as drinkers grow to tolerate alcohol. A 20 mg dose of morphine could be fatal to someone who has never had it before, but many cancer patients take 1000 mg daily and continue to function. Since all four victims in this case were hospitalized patients, the odds are that some or all of them had received painkillers before. Estimating a lethal dose in such a patient is not a simple thing. One of the patients was allegedly close to 400 pounds. This also does a lot to complicate the picture.

As is often true in medical cases criminal or civil, most of the evidence used against the three accused will come from the medical records. That is, what the defendants wrote about themselves will be the main evidence against them. It does not appear that anyone besides the defendants was in the room when the patients died. Unless there is a statement in the patients’ charts that clearly implies that the patients were to be euthanized, it will be very difficult for a jury to distinguish between willful killing and accidental overdose in an honest attempt to relieve pain.

If Dr. Pou was naïve about end-of-life matters, or if she was deranged by the pressures of Katrina, she may have consciously documented an intent to kill. But every doctor I know (even the dumb ones) know enough to never, ever, record anything in the chart that would suggest that a massive morphine injection was intentional. My impression is that Dr. Pou is pretty smart; I doubt a smoking gun will ever be found.

Though I side with most doctors in their feelings of anxiety and regret that these three would be charged with murder, I am not willing to say that the investigation is a sham. If it is possible to find out what happened, it is imperative that we do so. Much of the mayhem that occurred in New Orleans after the storm, specifically looting and lawless behavior, happened because some people thought that the normal rules of behavior were no longer applicable. I would never put Dr. Pou on the same level as a looter. But re-establishing law and order was crucial in reversing a horrendous situation that awful week, and that process is continuing even now. If the three accused broke the law or any ethical standard, this should be known.

I straddle the fence on many things, but euthanasia is not one of them. There are too many ethical ways to assist patients to an easeful death for euthanasia to be even a consideration in the vast majority of patients. Euthanasia is like a magnetic force that distorts the thinking of everyone in its vicinity. Once it is placed on the table it tends bends our thoughts and concerns, often obscuring viable alternatives that would be considered if euthanasia were not an option. The problem with people who fancy euthanasia is that when they are pushed to the wall, it is the first thing they think of. Given this, I think it is important that if anyone was euthanized, a public statement needs to be made and at least a slap on the wrist issued.

I do not understand, however, why the matter could not have been turned over to the Louisiana State Medical Board. A group of doctors and nurses would have been in the best position to judge if rules of ethics were broken. I dismiss the concern that doctors look after their own and would let Dr. Pou off easily. This case is in the national spotlight, and the Medical Board would have been under tremendous pressure to justify its verdict.

Critics of the medical system often point out that doctors are loath to discipline their own. This would be a golden opportunity for the medical profession to prove it can do the job, and do it right. I am a member of the Louisiana State Medical Society, and I have not heard anyone advocating for the Board to take the public lead in this case. That concerns me. The Medical Board should not be in the cleanup position here. It should be first up.

The sad part about this case is that, whether Pou, Budo, and Landry are convicted or not, the unmistakable message is that all three would have been smarter if they had run away. No one is being prosecuted for abandonment. Why didn’t they run? Obviously, because they felt a sense of responsibility to the patients, a sense that no one else seems to have had. Charles Foti wasn’t on a helicopter evacuating patients that week. Neither was Mayor Ray Nagin, or Governor Blanco, or FEMA Director Michael Brown, or Secretary of Homeland Security Michael Chertoff, or President Bush. It is the great travesty of this situation that the people who are really responsible for the conditions at Methodist are still AWOL, just as they were a year ago.

I think if I were Dr. Pou’s attorney, I would subpoena George W. Bush. His testimony is relevant (how could anyone in charge of the Katrina rescue not target hospitals first?), and I cannot see how the case could be any more of a circus than it already is. Maybe New Orleans can finally get the answers it deserves out of the president.

If these four patients were euthanized, Dr. Pou, Ms. Budo, and Ms. Landry should be disciplined. They should not go to jail, though. Given the extremity of their situation, the fact that Dr. Pou is an ENT and therefore should not have been put in the position of caring for chronically ill patients, given that rescuers were inexcusably slow and that the doctors who should have been in charge had all run off, there is no reason for anyone to be charged with murder. Licenses should be suspended, even revoked, fines levied, but no jail.

As a former member of the New Orleans medical community I confess that we were not prepared for Katrina. Many doctors abandoned patients. Many facilities (including the Lifecare unit at Methodist) did not arrange in advance for appropriate physician coverage. Many hospitals, especially the one I worked at, Chalmette Medical Center, should have been evacuated. There should have been advance planning to ensure every doctor knew who was evacuating and who was staying and that no patient was abandoned.  Arrangements should have been made to get medical personnel back to occupied hospitals as soon as the storm winds died down. This did not happen.

In 2004, a catagory 4 storm named Hurricane Ivan grazed the Louisiana coast on its way to a devastating strike on Pensicola, Florida. The near-miss produced a temporary upheaval that should have been a warning to every hospital and doctor in the New Orleans area. At Chalmette Medical Center, the hospital administration complained that too many doctors evacuated, leaving inpatients without responsible physicians. A few rules in the hospital bylaws were tweaked, but nothing comprehensive was done. After Ivan, all hospitals should have set up an emergency plan that would ensure that every patient stranded in the hospital would have a doctor of the appropriate specialty available at all times. Either that, or there needed to be a plan to evacuate everyone. Most hospitals did neither, and that was not Dr. Pou’s fault.

I still have uncomfortable feelings when I reflect that I left. I was in a 3-person medical practice. My two partners told me the day prior to Katrina's landfall that they both intended to stay. Since I had two children under the age of 5, and thought it was foolish for all three of us to stay, I elected to evacuate. At least I arranged coverage for my patients. A lot of people did not.

That is why I would prefer to see Pou, Budo, and Landry dealt with by their professional societies rather than by the law. The professional societies can distinguish between unethical behavior and actions that rise to the level of true crime. The courts cannot; they must render a strict verdict, murder or no murder. Moreover, if we are going to prosecute the people truly responsible for the conditions at Memorial hospital that led to murder, we will have defendants numbering in the hundreds, if not the thousands.

The Case of the Relatively Young Man

Recently I admitted a relatively young man to the hospital for cellulitis. Cellulitis is a bacterial skin infection that resides in the space between the skin and the tissue just below it. Imagine it as the layer of dirt between your carpet and the floor. Once bacteria gets into that warm, wet area, it can spread in almost any direction with little resistance; if you are a staph or strep bacterium, that little compartment is heaven on earth. Cellulitis, left untreated, can cause horrific injury in days or even hours, leading to a burn-like destruction of skin, loss of limb, or even death if the infection enters the bloodstream.

Unfortunately this relatively young man had no insurance. When he arrived in the emergency room, the doctor there started him on two antibiotics, clindamycin ($$$) and levofloxicin ($$$$). I was not sure I understood the choice of these two, or why he picked two instead of one. Perhaps he was acting on personal experience of what has worked or not worked in the past, or maybe he had performed a lot of cultures recently on patients and felt, based on what he was seeing in the community, that this combination was necessary.

His choice certainly worked. By the time I saw Relatively Young Man on the floor his infection had already improved. I decided not to change anything, in accordance with my Prime Directive of Medicine: Don’t change a patient’s medications if they are working. The last thing I needed to do was simplify his regimen and watch him get sicker. Call it defensive or even chickenhearted medicine, but I was not about to put myself in the position of having to explain to a patient who had suddenly gotten sicker why I changed an antibiotic regimen that was initially working.

But I knew what was coming. This guy had no insurance, and his two antibiotics were expensive. When the time came for discharge, I would be writing him two very expensive prescriptions to continue at home. I warned him long before he left the hospital that this would be the case. He nodded in understanding, or perhaps that head bob was triggered by momentary disturbances in the earth’s magnetic field.

Anyway, in 5 days the cellulitis was almost gone and there had been no fever for 36 hours. His blood work was normal, and all his cultures were negative. Since I had no positive cultures to go on (cultures allow us to tailor antibiotic regimens more precisely and eliminate expensive medications), I had to stick with what was working when I discharged him. I wrote him a prescription of both levofloxicin and clindamycin. To keep the price of the meds down I abbreviated the antibiotic course to only 5 days.

A weekend passed, then two days after that, and I got a call from a pharmacy about Relatively Young Man. He had shown up with the two scrips I had written, but complained that he couldn’t afford to buy them. After a few seconds of quiet, frustrated breathing I cancelled both scrips and put him on a third, cheaper medication that I thought would work. Though I was guessing.

Four days. He went home and walked around without antibiotics for four days because he couldn’t afford them. I concede that the two prescriptions together probably cost about $200, but he could have easily lost his leg. If I could pay $200 to save my leg, I would. And he couldn’t argue that he didn’t understand the severity of his situation. He had come into the Emergency Room a week earlier with a leg the size of an elephant’s, in excruciating pain, and with a fever of 104. He knew what could happen.

If he couldn’t afford $200, he could have called me at any time and I would have tried changing the meds. But he waited, and took his chances in a very serious situation. He was very, very lucky the infection did not come storming back and land him in the hospital all over again.

Maybe I am showing the blindness of affluence, but I cannot understand why a person in the United States could not come up with $200 in an emergency. Maybe he didn’t have it, but all his friends, family, and neighbors, or local church couldn’t help him out? No one likes to borrow money, but it beats living with one leg. He had a job. And this was a one-time treatment, so there was no concern about ongoing costs.

I have two theories about why he waited 4 days at considerable medical risk to do something. Either may be true, or a little of each, but both have sobering implications for the future of health care in the United States.

The first theory is that he figured he could always go back to the emergency room if things got bad. A lot of uninsured patients think this way. ERs are required by law to treat all comers, and this leads many of the uninsured to think of the ER as their health care provider of last resort. This approach, while convenient, is also the most expensive solution possible for society. From a taxpayer’s point of view, anything would be better than waiting for a patient to advance to the brink of death before the public steps in. Besides being inhumane, it is, from a cost-effectiveness standpoint, flat-out stupid.

The second theory is that he felt better and thought he might be able to do without the antibiotics. He did not know me prior to being admitted and may have been afraid that if he called me I would not react kindly to a request for cheaper medication. So he took his chances. Perhaps if he had been my patient before and knew me personally he would have spoken up. If this is true then his treatment failure was a primary care access problem. Since he didn’t know that I would have worked with him, he didn’t ask.

Of course, the problem with both of these theories (and any additional ones the reader may supply) is that Relatively Young Man bypassed every opportunity to act. Rather than trying to work the healthcare system in some way, he chose to do nothing but wait for the system to come to him. He could have borrowed the money. He could have called me for a different prescription. He could have filled the prescription for the cheaper of the two antibiotics and left the other unfilled. Instead, he did nothing.

If the infection had come roaring back, he would have landed back in the hospital, back on my service, again probably on the taxpayer’s dime. He already had one hospital bill he probably can never hope to pay, and he was bucking for a second.

It should make no difference to the average American whether Relatively Young Man was dumb, smart, shy, foolish, reckless, oblivious, or if there was a doctor-patient communications problem. What should make a difference is that this scenario is playing out right now in every city in our country, and billions of dollars are on the line. There is a Relatively Young Man in your town right this moment, nursing a festering medical problem that will erupt into a major one in a few days if he does not find a doctor who will treat him for a very low cost. A certain percentage of Relatively Young Men will crash and burn, landing in the E.R. a septic mess, sucking a little more of the lifeblood out of the system you are hoping will be there for you when you get old. All for $200 worth of pills.

A lot of people (doctors included) huff that Relatively Young Man could have paid the money if he really wanted to. He could have cancelled his cable TV or turned in his cell phone, quit smoking or skipped a month of fast food visits to save the money. Probably true. However, and this is personal experience talking here, he won’t. He will sit at home, watching cable TV, puffing on a $4-a-pack cigarette, pulling at his third Bud Lite wondering why he can’t afford medical treatment. This is just the way things are. We may not like it, but the fact that he cannot cope with his financial situation will not change reality. He is on a deadly collision course with a $30,000 hospital stay at public expense, and he is not going to do anything about it.

At least Relatively Young Man eventually called my office. He is now on a much cheaper medication, though there is no guarantee it will work. Hopefully it will work. I never found out; he has not kept his follow-up appointment with me.

It is my belief that our broken-down medical system cannot be fixed without a major overhaul. But since there is not a single politician in the United States with the guts to do what needs to be done, I would like to propose a low-cost remedy to the problem of the Relatively Young Man.

Since Relatively Young Man will always be around, and will likely never change, it is up to us to do the changing. No, it is not fair. This is not about fair. It is about saving your medical system for yourself.

Suppose doctors had the ability to write vouchers for free prescriptions. Each doctor could have an annual budget of, say, $5,000, which he could disburse to any patient to pay for medications. The money could only be used for medications, nothing else, and its purpose would be to keep patients out of the hospital. If I had such a resource at my disposal in this case I could have written a voucher for $200. The voucher would have only been good for 24 hours, which would light a fire under Relatively Young Man to get the prescription filled quickly and start his treatment on at timely basis. Such a system could save thousands of ER visits and possibly prevent many hospital admissions or re-admissions. The savings go right into your pocket, my friend.

The great flaw in government-managed solutions is that they are necessarily bureaucratic. With all the rules and regulations, there is no guarantee that money will get to the right person at the critical time. (I could cite Hurricane Katrina as a classic example but let’s not get off on tangents and tirades.) This is where doctors come in. As a doctor, I know my patients and am in the best possible position to judge when a $200 disbursement might keep someone out of serious trouble. No government or charity office could ever hope to consistently do that.

Every doctor knows at least one Relatively Young Man. With a little money, and without changing the health care system as we know it at all, it may be possible to save huge amounts in the long run. Does anyone have the courage to try, or will we allow the infection to continue to spread?

The Blistering: Chapter III

To start this serial suspense novel from the beginning, go here.

The Second Escape

 

Thirty minutes out of jail and Cardinal was already a prisoner. And once again, it was the government taking him down. Leave it to the law to make sure a guy never breathes free.

Edward Mokley sat at the other end of the table in the interrogation room, staring furiously at him. He wore an FBI cap and a military-style shirt with a patch that read "Special Operations" on the short sleeve. Special Ed, Cardinal had always called him.

"We didn't want to do this by force," he drawled. "But we had no choice. You would not cooperate and national security is at risk."

"Funny way to defend freedom," Cardinal said, "by taking away somebody's rights."

"Have you been sleeping with your defense attorney again?" Special Ed asked. "Sounds like you have learned something from Marcia's pillow talk." He laughed, held his cigar aloft and looked around at the guards for supportive levity. No one peeped. Apparently Special Ops guards don't get paid enough to laugh with their superiors. Or maybe it was the lousy health benefits.

"Yeah," Cardinal answered, "we used to talk about habeas corpus while she tied me up."

"Shut up, smart guy." Special Ed's amusement was gone. "We killed your mother once. We can do it again."

"Don't butter me up."

Special Ed lept up from his chair and pounded his fist on the table. He didn't have to do that. He just liked the cliché. "Dammit, Cardinal, you are going to help us in this mission or you will never, ever, get out of this place!"

Cardinal looked past the patch on Special Ed's shoulder and out the window behind him. In the distance, he saw a heat-seeking missle headed straight for the back of the compound they were in.

"Yeah?"

HSAs, Part III

A gentleman named Michael F. Cannon offered this response to my recent comments about HSAs. Mr. Cannon works at the Cato Institute and obviously has devoted a lot of time and thought to Health Savings Accounts. His viewpoints are well thought out and worth reviewing.

As I have tried to emphasize before, I am not morally opposed to HSAs. I just do not think they will improve health care in the United States. But as a doctor, I am above all an empiricist, and so I am willing to let the facts prove me wrong. I do not think they will, though.

There is one point Mr. Cannon makes I have to take issue with: He suggests that primary care medicine may not be cost effective. He sites an article in the New York Times as his only evidence. This article, which discusses research I am well aware of, says that annual medical checkups may be a waste of money.

I have never been an advocate of the annual physical, especially in healthy adults. The only routine testing a healthy young adult needs is occasional blood pressure measurement, a cholesterol check, and, for women. a Pap smear. Obviously none of these screenings necessarily require a primary care doctor -- a nurse may be sufficient. No, the annual physical is not the reason to have a primary care doctor.

Primary care doctors are needed because medicine is getting more and more complicated, and specialists are becoming more and more compartmentalized. A primary care doctor is like a financial advisor -- he is someone who can help you navigate all your options efficiently. Most people do not need to see a financial advisior every year (though some do), but having someone on hand who can help you identify your needs at key times is very important.

Everyone complains that health care is getting increasingly expensive. What is more cost effective if you have more than one medical problem, say, diabetes and high blood pressure, and you develop poison ivy -- to go to an endocrinologist, a cardiologist, and a dermatologist, or to go to a single doctor who can handle all three? Doctors who can address multiple medical problems at one office visit will certainly be more valuable to health cost control than those who specialize and are thus unable to address more than one thing. 

It is also worth noting that PCPs are able to provide a lost art in medicine -- watchful waiting. Sometimes the best way to handle a medical problem is to observe it rather than take aggressive action. Treatment can be worse than the disease. Primary docs charge half or less of what specialists do and thus are in a position to perform serial evaluations of patients and look for changes in a patient's medical condition that warrant further workup.

It used to be that observation was one of the mainstays of medicine. Now everything is scanned, biopsied, and aggressively worked up because specialists find it easier to bill for expensive procedures than for recurring office visits. This shift away from observation towards aggression runs the risk of hurting patients, and is one of the casualties of the microspecialist system. 

Witness

Herbert showed up unannounced on my patient list one morning. He had casually dropped in on the ER the night before, dizzy, blacking out, unable to answer any questions. He had rheumatoid arthritis, and had been taking anti-inflammatories for decades. All of that medication had probably eaten a hole in his stomach wall, and Herbert was slowly bleeding to death. Or maybe not so slowly. That is the problem with intestinal bleeds – they cannot be seen, so the rate of blood loss is only a matter of conjecture.

The ER doc checked Herbert’s blood count before commending him to my inpatient service, and it was low, bad low, hanging-by-a-thread low. Since Herbert was almost to the point of unresponsiveness by the time the labs got back, the ER doc had to ask Herbert’s wife permission for a blood transfusion.

“No,” his wife answered. “We are Jehovah’s Witnesses.”

Jehovah’s Witnesses. Now, I have a faith of my own and I try to be as tolerant of others’ beliefs as I possibly can, but it tests the patience of Job not to exhibit at least a fig’s leaf of consternation about religious groups that refuse transfusions. The problem is that a Jehovah’s Witness will typically assent to any kind of medical treatment except blood transfusions. This singular restriction has the potential to become the nightmare of convergence: a patient who will let you use every trick in the book to keep him from crossing the threshold into the hereafter except the exact treatment most likely to make a major difference.

This difficult situation brought to mind my pediatric residency days at Children’s Hospital in New Orleans. Every once in a long while we would get a child whose parents refused transfusion. Some of these kids were getting chemotherapy for leukemia. It was an impossible situation, and usually the attending doctors would resort to petitioning a judge for a court order to force the transfusion. The court order was usually granted. In the U.S., doctors can get a court mandate for medical treatment for a child if the treatment requested is emergent and life-saving.

The surprising thing is that many of the parents of these children would take the court order in stride. Though they opposed the transfusions morally, usually they were scared to death and relieved when someone else took on the responsibility of treatment. The court order forced them into a happy, if uncomfortable, medium. They could avoid the guilt of having permitted the death of their child, and yet they could answer their God and their pastor with “the transfusion was forced on us; we had no choice.”

Unfortunately, the law does not work that way for adults. We have to abide by the patient’s refusal in almost all circumstances, the lone exception being a patient who is not mentally competent and has no next-of-kin.

Herbert ended up in the ICU. He might have gone to the regular floor if we could have ordered a transfusion from the very first, but this was not to be. His serum hemoglobin, a measurement of the amount of blood in his body, stood at 7.2. Normal is 15, and anything below 8.0 is considered serious.

I gave Herbert the once-over in the ICU, and asked a stomach specialist to take a look. The stomach man dropped a scope down his throat the next morning, found a bleeding ulcer in the proximal small intestine and cauterized it. Herbert stabilized a bit, but because we couldn’t give him blood he was very weak. He held out for a few days and then developed pneumonia. He had probably aspirated (breathed in) some of his own secretions when he initially collapsed, and it had taken a few days for the infection to take hold.

The lung infection made its way into the circulation and before long Herbert’s blood pressure had dropped dangerously low. He was placed on a respirator and we started drips to prop up the pressure. Again, I try not to look demeaningly upon any person’s faith, but this no-transfusion ethos had maneuvered us into an absurd situation. We were applying maximal life support measures but still were forbidden to address the underlying problem.

Back in those days I was overworked and crazy and I usually saw Herbert at about 10 at night. He was all wires and tubing. Almost everything in the room was a sterile white including his gown and my lab coat and the only contrast was the shadow from the 24-hour fluorescent light. With every conceivable tube and wire coming out of him he looked like a swamp creature rising from the water in a black-and-white movie.

The swamp creature would not die. He floundered on, his hemoglobin lurking just below 8.0. Most of the time he was unresponsive. We revisited the issue of the transfusion with his wife several times, but the answer was always no. Three weeks shuffled by, nothing changing.

A rumor circulated among the ICU staff that the wife was a far more committed Jehovah’s Witness than her husband. A visiting family member suggested that Herbert would have consented to the transfusion, that it was his wife who was against it. Unfortunately, the way the law worked, this fact meant little. For all practical purposes, the word of the next-of-kin was the rule.

In theory, though, the rumor suggested that Herbert’s wife was violating the intent of the law. Ethically, a person who serves as the decision maker is supposed to make the decision as the incapacitated person’s proxy – in other words, Herbert’s wife was supposed make decisions according to her husband’s wishes as best as she knew them, and not according to her own. In my personal experience, I have often felt that family members fail to make that distinction.

Things went along like that, in a hopeless standoff, and I began to despair that three weeks of work to keep Herbert with us was amounting to nothing more than a prolonged, expensive form of death by torture. Until a break unexpectedly came.

One late night I came by and noticed that Herbert’s eyes were open. He was still on the respirator and couldn’t talk with the tube in his throat, but when I questioned him, he nodded yes and no appropriately. A lucid moment! I decided to test the rumor that Herbert was not a Jehovah’s Witness right then.

I introduced myself as his doctor and then explained to him that he was severely anemic. That he was in intensive care and near dying. That I felt the only way he could be saved was with a blood transfusion.

“Your wife has declined to let us give you a transfusion,” I said. “But the decision is not really hers, it is yours. If you want one, I will give it.”

He nodded yes.

“You are certain? You understand what I am asking? I want to give you blood.”

He nodded yes again.

To make certain, I called Herbert’s nurse, Todd, into the room. He was the perfect nurse for the case. I knew Todd as a very pragmatic, hard-edged personality. It could have been the effect of many years of working in an inner city hospital, but I think it was just him. Todd was always good for a rant about patients that didn’t take care of themselves at home and then would come into the ER falling apart. He hated the money wasted in ICUs. If Herbert was saying yes to a transfusion, I knew Todd would have the blood running in thirty minutes. He, like me, was tired of the waste and the stalemate. If I decided to go full speed ahead against the wishes of Herbert’s wife, there would be no resistance from Todd.

Todd had spent many years working with the elderly, who are frequently hard of hearing. His habit was to shout at poorly responsive patients. I am certain he thundered in poor Herbert’s ears. “WE WANT TO GIVE YOU BLOOD! ARE YOU CONSENTING TO A BLOOD TRANFUSION RIGHT NOW! IF YOU DON’T GET IT YOU COULD DIE!”

Herbert nodded again. There was no question in my mind he was saying yes.

We stuffed the blood into him, three units by 7 am. True to his word, Todd got the transfusion done before anyone could come in the next morning and say anything. Yes, we were being sneaky. But this guy had been in intensive care for the better part of a month, no doubt suffering greatly, and I had no intention of dithering if I could get him out of this deadlock.

Herbert turned around almost immediately. The blood raised his hemoglobin to over 10. In less than 24 hours he was off all his drips, and in two days he was off the ventilator and breathing on his own. The tentacles were falling off the swamp monster. There was a man inside.

I never spoke to Herbert’s wife about the transfusion. I am not even sure she knew. Herbert knew, though, and was fine with it. Which was all I needed anyway.

As soon as Herbert was off the respirator and stable, I got a call from the powers above – powers more absolute than those of Jehovah himself – Herbert’s HMO. The almighty HMO wanted Herbert moved to a network hospital now that he was stable. My hospital wanted the transfer too, because if the transfer were not made, the HMO would cut off any further payment, no matter how sick Herbert became. Since he was nowhere near out of trouble yet, this denial could cost my facility hundreds of thousands.

After a microsecond of consideration I approved the request and Herbert was gone like swamp vapor in the morning light. Just like that, the next day ICU bed 17 was empty, a fresh sheet spread tightly across it, waiting for the next Herbert.

Herbert was gone, and I never heard a word from or about him again. The only time I ever saw his name in print after that was in a letter I received from the HMO. It denied payment for the entire 4 week hospital stay because, the auditors said, the same level of care could have been delivered in “an alternative setting, such as a nursing home.”

I looked at the letter, and wished I could have had some of what they were drinking. Chivas Regal didn’t take the edge off those long stressful days like it used to.