Daniel Smith
One man had died a miserable death and the other barely hung on to life. Death and dying were common events in the ER but the cases this night were unsettling to Peter Henley, chairman of the department. To the veteran physician it appeared that the two men who had shared little in life had been afflicted by a similar illness that remained nameless and puzzling to Henley.
George Carpenter, the feisty Chief of Anatomic Pathology, established the definitive diagnosis at autopsy, a diagnosis that certainly had been unsuspected by Henley. Whereas the interest in most cases ended with the post-mortem exam, this autopsy thrust Henley into a controversy that within weeks invaded his home life, threatened his career, and brought his hospital to its knees.
Metro Medical Center, long the premier health-care institution in the area, was caught between the controversy originating in Henley's department and the managed care organizations seeking to do business in western Massachusetts. The evolving crisis, initially confined to MMC, now became a regional and national health issue requiring the intervention and input from the CDC. Teamed with Fred Harris, a young intern in the ER, and Marcia Kramer, Director of Laboratories, Henley sought the cause of the illness afflicting his patients while the administration desperately shuffled plans for its future and that of its employees and patients. The issues facing MMC, when compounded with the whirlwind of change in health care economics sweeping the country, made rational decisions on planning for the hospital's future an impossibility.
At an administrative meeting in beautiful Woodstock, Vermont, organized to plot the hospital's uncertain course, Peter Henley faced his greatest crisis and his previously unknown adversary on a snowbound February night.
The author attended medical school and completed his post-graduate training in the Boston area until moving to the western part of Massachusetts in 1979. He has practiced emergency medicine for his entire career and over the past decade has been actively involved in the education of students and young physicians training in emergency medicine.
Now living in a semi-rural area of New England he and his wife are raising four children; girls 21 and 15, and twin boys, now five years old.
His leisure time is generally spent with the family, perhaps fishing or swimming on Cape Cod or skiing in the hills of New England, quite close to his home.
Daniel C. Smith, M.D.
Tuesday, January 25, 2000
Before heading to the parking lot, Henley decided to go to the ICU. He walked down the two flights of stairs and through the double doors into the eighteen bed ICU. The time of day was inapparent here. The monitors kept beeping and the ventilators kept hissing around the clock. The ICU waiting area always held worried family members, a few now asleep on the chairs and sofa. Henley saw Paul Dean at the desk and walked over to him. 'What do you think is going on with Mr. Stanlowski? Did you see his spinal fluid results?'
'It's hard to know what to make of it. The AFB stain was negative as was the cryptococcal antigen. He's got some form of aseptic meningitis, but I don't know what's causing it.'
Henley walked into Stanlowski's room and nodded to the nurse. He picked up the chart and flow sheet. Things looked very bleak for the patient before him. In addition to the tubes placed in the ER, Stanlowski now had an arterial line in the right radial artery and a Swan Ganz line in the right internal jugular vein. The pressure readouts on the screen suggested that little had improved despite these measures. He had put out essentially no urine since arriving in the ICU. His acidosis had worsened and his blood pressure had failed to stabilize on the dopamine. He had been switched to Levophed, referred to as 'Leave-'em dead,' in a last ditch effort to maintain an adequate pressure. Looking at the monitor which read 68/48, it was obviously not working.
Henley left the room and walked out of the ICU. He took the stairs down and exited the hospital into the cold night air feeling unsettled as he considered the events of the evening. Did Ricardo Lopez have to die that night? Had the distraction of another critically ill patient taken Henley from the bedside of a patient he could have saved?
One of the things Henley taught his students over and over again, was that it would usually be obvious what was wrong with the sickest patients they would care for. On this night that rule had little application. One man had died for reasons that remained unclear to him, and Henley now settled into his car still not having any idea what was causing Stanlowski's meningitis. All he knew was that Mr. Stanlowski would also likely be dead within hours.
