Comfort Zone

Chapter 20

Miriam poured a cup of coffee in the doctors' lounge, sat down at a computer and waited for the cardiologist, using the time to brush up on pacemakers, searching articles and internet-based textbooks. Miriam barely remembered the last time she'd dragged out a hefty tome to look things up, or visited the hospital library. Getting medical information is so much easier and faster these days, she thought. At least until the computer freezes.

Not that all the information led to real knowledge, though. Sometimes it was like the extra-long electronic notes everyone was writing--so-called note bloat--an avalanche of facts, details and repetition, but just try finding one useful sentence!

Fortunately, Miriam was able to find many useful sentences on the different types of temporary pacemakers. When the paramedics first got to Ms. Fielding, they had used the transcutaneous kind. Two patches were slapped on her chest, and an electrical current passed through her skin to stimulate her heart to beat. The type she had now, more stable and comfortable, was called transvenous. Across a vein. Miriam brought up a video on insertion, and watched as the pacing wire was passed through the internal jugular vein in the neck and floated into the right ventricle. It lodged there, conducting impulses from the pacer generator box that kept the heart beating.

Next, complications. Both permanent and temporary pacemakers are intricate pieces of medical equipment, she read. Though generally reliable, they can fail for a number of reasons. Failure to pace occurs with temporary pacemakers, most commonly due to displacement or accidental removal of the lead wire, or a loose cable connection. Patient morbidity and mortality can thus ensue...

Miriam clicked out of the screen, and conjured up the motif on the Kennedy Space Center decal that was propped on her office bookcase.

Failure is not an option.

Her next job was to access the hospital EHR again and scour over Lilly Fielding's admission forms. Since she'd been brought in by the paramedics comatose, she wasn't able to name a health care surrogate, but she had done so on a recent ER visit for a sprained ankle.

Marilyn Fielding, she'd written in a neat hand next to the surrogate line. Relationship – daughter. Damn!

In one way, emergency care for an unknown, unconscious patient is easy, Doug Allen had once said. Keep the patient alive, do whatever it takes. Needs surgery? Make the cut. Low in blood? Pump it in.

But when the patient wakes up, things get more complicated. He'll assert his autonomy, tell you he's a Jehovah's Witness and refuse the blood transfusion or other care you want to give.

Harder still is when the patient doesn't wake up and a family member appears and tells you what to do, Doug had concluded. Family. Sometimes loving, sometimes even reasonable, but always filled with baggage that affected medical decisions.

Besides being her daughter, Marilyn Fielding had of course also been chosen as the surrogate, or health care proxy as it's sometimes called. She had the right and responsibility to decide all medical issues while her mother was unresponsive, including giving or refusing permission for a permanent pacemaker.

Miriam thought about the as yet unwritten DNR order, and took a closer look at her new patient's medical records. The chart showed that Ms. Fielding had high blood pressure, high cholesterol, borderline diabetes, bunions, and a successful bout with breast cancer a decade earlier. In short, nothing deadly, just typical history for an eighty year old. If her cancer returned with a vengeance, that could be grounds for a DNR, but the history Miriam found showed nothing that would kill her in the foreseeable future besides a malignant daughter.

On the other hand, her heart had just quit beating in Publix. That certainly would have knocked her off without emergency treatment. She now had a condition that, while easily fixed, was likely deadly without treatment.

Did that qualify as terminal? The transition from fairly healthy to end-stage seemed too abrupt; most loving families would need more time to accept it. Miriam needed more time. Why didn't the daughter? This wasn't like Ms. V, Miriam thought, who'd been spiraling down for a very long time. A pacemaker wasn't an impediment to good life. Who could object to a little implanted maestro, conducting a beautiful, life-prolonging symphony of lub dubs in your chest?

At any rate, few sane, self-protective cardiologists would put in a pacemaker, or do any other non-urgent procedure, without signed consent, and that signature would have to come from the daughter.

Unless of course Lilly Fielding woke up.

Miriam checked the time. Saturday evening already. This case was a bonafide ethical emergency. She knew she couldn't do a consult on her own case, but thought about calling Edna Boyle, her ethics partner, to talk it over with. But what could Edna do at this hour? Maybe she should give her a break for date night. On the other hand, maybe Edna could think of an angle that had escaped her.

Fear ran through Miriam as she thought about a pacemaker malfunction, or the thin wires slipping out. She suddenly envisioned the ties of her patient's hospital gown snaking around the flimsy pacer wires, the transporter crashing into a wall and bang! The pacer is ripped out, the weak heart stops beating, the daughter is standing there and shoves away the code team even though there's no DNR order on the chart.

The resuscitation team, made up of new doctors, might indeed be the mighty know-it-all force they often were, pushing Marilyn Fielding away and calling security to restrain her if necessary. Miriam briefly reveled in the picture of security wrestling the younger Fielding to the floor.

Or they might be too timid, she worried. It was July after all. True, a senior resident headed them, but the team of newbies might get distracted and in the confusion, the patient could expire. Marilyn wouldn't throw herself over her mother's body and prevent resuscitation, would she?

Edna was a social worker, and likely knew additional methods of persuasion, gentle and not. She might even be able to find other family members or friends who could influence the daughter, or at least shed light on the situation.

Miriam dialed the number and got a recorded message. She left a hesitant message, thinking that Edna, a married grandmother, was probably out celebrating some happy occasion, not sitting and drinking bitter coffee, fretting over dreadful scenarios.

Miriam's cell went off. The cardiologist was in the ER.