“IT’S not that bad.” Mr. Kelly smiled. “I’m not even hurting now.” He was a forty-two-year-old housepainter who’d been having dull, intermittent chest pain for two days. Three wires ran from under his patient gown to the monitor in the corner, where a fine green line bounced with each beat of his heart.
His wife shifted in her chair. A disposal box for contaminated needles jutted from the wall, next to her head. She leaned away from it, as if she wanted to scoot her chair over. A stainless steel supply rack hemmed her in on the other side.
“It was just a nagging little pain.” He gestured toward his chest. His fingernails were square and stubby, trimmed close. They glowed pink against the white paint stuck to his cuticles.
“When you have the pain,” I asked, “how long does it last?”
“I don’t know.” He looked at his wife, then back to me. “About ten, fifteen minutes.”
“Did you tell him about your arm hurting?” The lines on her face showed concern, worry. Mrs. Kelly was a thin woman; she sat with her feet tucked beneath the chair and her hands held tightly together in her lap.
“It didn’t hurt that bad.” He rolled his left shoulder. “I might’a pulled it at work. You know, moving ladders and all.”
Mrs. Kelly shook her head.
I asked him about the cardiac risk factors: he didn’t know his cholesterol, he smoked about a pack a day, and his father had had a heart attack when he was in his late fifties. I wrote orders for the standard chest pain work-up: EKG, cardiac enzymes, chest X-ray, and routine labs. “When the results come back, I’ll come and talk with you.” I gave the chart to the secretary and went to see my next patient.
The EKG was done promptly, and was normal. The results of the blood work came back later, and I went to the dictation booth to review them. They were normal, too. Even so, in the evaluation of chest pain the symptoms and risk factors are more important than the tests. The safest thing to do would be to admit Mr. Kelly overnight to check his cardiac enzymes two more times.
When you have a heart attack, enzymes from the damaged heart tissue leak out into the blood. If we check the cardiac enzymes early in the process, the level might not have gotten over the threshold of “positive.” We check subsequent levels, to catch any rise that may occur over time. That’s why we admit patients for “serial enzymes.”
Mr. Kelly didn’t have a physician, so I called the doctor who was on call for unassigned patients, to arrange for an overnight admission.
In training, interns and residents work incessantly. To a bleary-eyed intern who’s hoping to sneak off and take a nap at three o’clock in the morning, a call from the ER is never good news. It doesn’t mean he has an opportunity to help someone. It doesn’t mean he’s getting a case he can learn from. It just means he’s gotten screwed out of the few hours of sleep he’d hoped to steal.
When a patient needs to be admitted to a university hospital, the senior resident goes to the ER and checks on the patient. If an admission is unavoidable, the senior calls the intern, who comes down to do the history and physical and write the admission orders. If there’s some doubt as to the necessity of an admission, the senior resident may put up a fight with the ER attending, and try to talk him into sending the patient home. Some of the senior residents never question the ER attending. They’re called “sieves,” because they let everyone in. Those who consistently argue against admissions are called “walls.” Sieves are despised by interns. Walls are worshipped: they shield their interns by thinking of fifty different reasons every patient could be discharged. And they just seem smarter than the sieves.
This attitude is understandable when you consider the hallucinatory, sleepless fog of residency and the fact that they’re young, still in training. Most physicians outgrow this attitude. Some though, even years out of training, seem to take pride in being a wall, and sending people home from the ER.
I paged George Packard, the doctor on call for patients without a primary care physician. He’s been in practice for years, and he’s a wall. Proud of it. Has a cocky little walk he does if he discharges a patient the ER doc thought needed to be admitted. When we call him about one of his own patients, he’ll try to talk us into sending them home. When he’s on call for unassigned patients, he argues even more stubbornly. I wasn’t looking forward to the call.
George returned the page, and listened to the history, physical exam, and labs.
“Sounds like he could go home.”
“I don’t know, George.” I stared across the ER at a drunk, who was leaning further and further across the side rail of his stretcher. Blood dripped slowly from a laceration on his forehead. I covered the phone’s mouthpiece. “Someone help that guy in room eight,” I yelled. “He’s about to fall.” One of the health care techs strolled into the room and pushed the drunk back on the stretcher. “The guy has a strong family history and he’s a smoker,” I said into the phone. “Stoic guy, may be in denial. I think he’s real, and he needs to come in.”
“You think everyone needs to come in.”
“This guy has a good story.” The drunk had his head over the side rail and was looking at something on the floor.
“You’re saying you think he’s having a heart attack?”
“I’m saying I think he could have a plaque that hasn’t ruptured yet.”
“Didn’t you just tell me he had a normal EKG, and negative enzymes?”
We both knew Mr. Kelly could be having a heart attack and initially have normal studies. That’s why we admit patients for serial tests. “I don’t know what to tell you, George.” I shook my head. “Guy’s dad had an MI in his fifties, he smokes a pack a day, and his pain is typical of ischemia.”
“With a normal EKG, and negative enzymes after two days of pain. If anything was going to be positive, it already would’ve been. You know that.”
“I think he needs to be admitted.” I wished we had an equation we could apply to the problem. So many points for this risk factor, so many points for the other. But there isn’t one. It all gets down to a judgment call, based on a few risk factors and very subjective symptoms. Pain versus pressure, discomfort versus pain. Is the patient exaggerating or minimizing his symptoms?
“I’d be glad to squeeze him in at the office, first thing in the morning. Do an accelerated outpatient work-up.”
“I don’t think he should go home tonight.”
“Do you know how many hundreds of patients with bullshit chest pain we admit for every patient who has real disease? Or have any idea how much we spend, a year, on these worthless admissions? How much ‘covering your ass’ costs a year?”
“I’d love to talk about that sometime, but not right now.” The drunk had given up whatever he’d been trying to do, and lay with his head half off the stretcher, passed out. “And we’re not talking about ‘covering my ass.’ We’re talking about a guy who needs to be admitted to rule out MI.”
“If I come in, I’m just going to send him home.”
“That’ll be your decision.”
“You’re going to make the patient wait another two hours?” George’s voice scaled upward with incredulity. “Just for me to come in and send him home? I’m offering to see him first thing in the morning. That’s only fourteen hours from now.”
Two paramedics stood in the hallway with an asthmatic patient on a stretcher, waiting for the charge nurse to tell them where to put him. The patient leaned forward, struggling with each breath. With the effort, muscles in his neck tightened into cords. His skin was gray, and shiny with sweat.
“George, the guy needs to come in.”
“It’s up to you.” George was probably shrugging on the other end. “I’ll come in, but it sounds like he can go home.”
We didn’t have a bed for the asthmatic and he was too sick to stay in the hall. No point in tying up a bed with Mr. Kelly if George was going to send him home. “You’ll see my guy first thing in the morning?”
“Glad to.” George’s voice warmed up.
“Okay.”
Mr. Kelly and his wife looked at me when I walked back into the cubicle. “Your EKG and labs are normal.”
Mr. Kelly smiled, looked at his wife, then back to me. “That’s great.”
“I think we can let you go home.”
“Great.” Mr. Kelly grinned and nodded. His wife looked down at her hands.
“I’ve spoken with Dr. Packard, the doctor on call. He’ll see you in the morning, in his office.”
His wife didn’t look up. I got the feeling that she wanted her husband to stay, but she didn’t say anything.
“I think you’ll be fine, but if you have any chest pain, come back immediately.” I waited for them to respond. If either of them objected, I could call Packard back and tell him they were balking at going home. Mrs. Kelly didn’t look up. Of course, I could call Packard back anyway and tell him to come to the ER and see the patient. Let him send the guy home.
I didn’t.
Joanne, the charge nurse, had pulled a different patient into the hall, to make room for the asthmatic.
Lisa, one of the other nurses, was slapping the back of the patient’s hand to find a vein in which to start an IV. “The line EMS put in blew.” She didn’t look up from her task. “I went ahead and started another breathing treatment.”
“Good.” I nodded to the patient, then, with my stethoscope, listened to the tight, high-pitched wheezing sounds of air barely moving in and out of his lungs. “You sound tight,” I said to the man.
He nodded.
“Let’s give him Solumedrol,” I said to Lisa.
“Got it in my pocket.” She looked up. “Can you hand me some tape?”
I tore two thin strips of tape and handed them to her.
“Thanks.” She taped the IV in place. “There.” She looked to me. “Portable X-ray?”
“Yup.” With good nurses, an ER doc can get a lot done just by saying, “Yup.” I saw Mr. Kelly and his wife walk past, toward the exit. I had an urge to call out, “Wait, let’s check another EKG.” But a repeat EKG would probably be normal too, and I would have felt foolish asking him to stay after I’d discharged him. I’d arranged a follow-up for the next morning. He’d be okay for fourteen hours.
“Paul,” Lisa called. “This guy’s looking sick.”
I turned to the asthmatic, and forgot Mr. Kelly.
The next day when I started my shift, Joe Davidson, one of the other ER docs, was sitting in the dictation room. He was a runner, and looked like it. Tall, bony guy, with broad shoulders and no ass. He looked up from the chart he was working on. “Paul, you remember a guy named Kelly?”
My stomach felt queasy. “Guy with chest pain?”
“Yeah.” Joe looked up from the chart he was holding. “He came back, about four thirty in the morning. Cardiac arrest.”
I sat.
“You okay?”
“Yeah.” I felt prickles in my scalp and down the back of my neck. I glanced at the trash can, afraid I might vomit. “He’d been having chest pain off and on. Didn’t have any while he was here.”
“I worked the code for at least thirty minutes before I called it,” Joe said.
Mr. Kelly was dead.
Joe adjusted the stethoscope draped around his neck. “I looked over his EKG, and labs from when you’d seen him. They were normal.”
“I know.” I’d sent Mr. Kelly home, and now he’s dead.
“It’s gonna happen.” Joe shook his head. “We can’t admit every single chest pain that comes in. I would’ve done the same thing.”
I still wanted to puke. “I had a bad feeling about him when I let him go.”
Joe shrugged. “I sent home a guy last year. Came back a couple of hours later with ST segments like fucking Mount Everest.” He was describing a classic EKG pattern of a heart attack.
“Did your guy make it?”
“Yeah,” Joe said, “but that’s not the point. I’d sent the guy home. I was just lucky.”
He was trying to help me feel better. Every doctor has had a patient die as the result of a wrong judgment call, or a brief lapse of attention. It’s inevitable when fallible people make mortal decisions. There are people who’ll say, “This should never happen.” And they’re absolutely right. It shouldn’t.
I struggled through the shift, oppressed by the knowledge that I’d sent Mr. Kelly home and that he’d died. Maybe if I’d paid attention to his wife, her unease would have prompted me to ask more questions. Maybe she would have told me something that would have made me insist on his admission to the hospital. But I’d looked Mr. Kelly in the eye and told him I thought he’d be okay, even though I had misgivings. There hadn’t been enough hard data to convince George Packard to come in, and I’d not paid enough attention to an intuition, an uneasy feeling. I’d trusted Packard’s judgment over mine.
In lectures, seminars, and magazine articles, malpractice lawyers tell you to never, never, never discuss a potential malpractice case. With anyone. The other side will ask if you’d discussed it, and have you make a list of names. Then they’ll interview everyone, and find someone who remembers your admitting a mistake. In one class I listened to on cassette tape, the speaker told about a doc who’d confided in his wife about a mistake he’d made. Before the case went to court, the doc and his wife went through an acrimonious divorce. In the malpractice trial, his ex-wife took the stand against him with a vengeance. The class had roared with laughter at the poor schmuck’s bad luck. You don’t discuss the case, and you never, ever, apologize. To the malpractice lawyers, “I’m sorry” is just another way to say “I’m guilty.”
The shift moved slowly, like a bad dream. Finally, it was over. I copied Mr. Kelly’s phone number down on a scrap of paper before I left. When I got home, everyone was asleep. I wanted to wake Sally and tell her. But she was sleeping soundly, so I went downstairs and turned on the TV. A tall, handsome attorney with a very good toupee was on the screen. His voice was deep, and caring. “If you, or anyone in your family, has been injured by a doctor or a hospital, call me.” A 1-800 number flashed on the screen. “We’ll get the money you deserve.” He somehow managed to mix enthusiasm with sadness in his voice. I vaguely wondered if Mrs. Kelly was at home alone, watching the same ad.
I clicked off the TV. I went to the kitchen, got a beer, went out on the front porch, and sat down on the steps. Two large magnolia trees shaded me from the street light. Mrs. Kelly was probably awake, too. Maybe sitting on her front porch looking out into the night, stunned by the emptiness she faced.
The next morning was my day off. After the kids were in school, I told Sally the whole story.
“Paul, there’s no way you could’ve known he was going to die.”
“His story was good enough to buy him an admission.”
“No one’s perfect.” She shook her head. “I know it makes your job scary, but everyone is going to make mistakes.”
“Yeah, but not like this.” I rinsed my coffee cup. “Missing a fracture, or a urinary tract infection, stuff like that, sure, you’re going to miss a few of them. But sending a guy home to die?” I felt the pain continue to build, of all places, in my chest. Maybe if I cried, I’d feel better.
“You didn’t send anyone home to die.” Sally sounded a little irritated. “You evaluated him, and made a decision.” Simple as that. “No one expects you to be perfect.”
“Even if I’d admitted him, he probably would have died.”
“That’s true.” Sally nodded.
I leaned against the kitchen counter, my back to the sun coming through the kitchen window. “Must’ve been a huge MI, to have killed him so quickly.” I needed to believe that Mr. Kelly would’ve died even if I’d admitted him, because nothing in my experience had prepared me for feeling so guilty. Up to the moment I found out Mr. Kelly had died, the possibility I could make an error of that magnitude had remained an abstraction, a theoretical possibility that wasn’t grounded in personal experience. I’d been trained well and I was careful. I thought that if I was vigilant enough, I could practice indefinitely without seriously hurting anyone.
As a resident, I’d been shocked when Dr. Solters joked that he expected each of us to kill three patients in the process of becoming a doctor. At the time, a mistake that big was inconceivable. A few months later, I rotated through the cardiac care unit, and took care of Mrs. Mahoney, a seventy-one-year-old woman who’d had a heart attack. One night when I was on call, her blood pressure dropped precipitously. I was glad Dr. Putman was the cardiology fellow backing me up that night, because he was smart, decisive, and had sound judgment. He supervised us closely, and didn’t resent getting out of bed to give us a hand. Dr. Putman decided that Mrs. Mahoney needed a Swan-Ganz catheter, which would allow us to record pressure readings from different areas inside her heart and lung. I enjoyed doing procedures, and had inserted several Swan-Ganz lines with Dr. Putman. We didn’t anticipate any problems.
Nicole, one of the CCU nurses, helped me into my sterile gown and gloves, and then handed me the sterile equipment I’d be using. She and Dr. Putman watched as I carefully painted Mrs. Mahoney’s upper chest and neck with orange antiseptic, and draped the area with sterile green drapes. I then stuck a long needle through the skin, and advanced it until it hit the collarbone. Mrs. Mahoney grunted in pain. “Sorry,” I said. I withdrew the needle again, and angled it slightly lower. I was aiming for the large vein that runs just under the collarbone. If you angle your needle too steeply, you puncture the lung. The safe way to do it is to “walk” the needle down the collarbone. I advanced the needle again, until it hit bone a second time. She grunted again, and I apologized again. The third time I pushed the needle into her chest, dark red blood filled my syringe. I was where I wanted to be, in the vein. “Don’t move,” I told Mrs. Mahoney, as I threaded a long, softly springy wire through the needle, and into the vein. I withdrew the needle, leaving the wire sticking up through the skin. Using the wire as a guide, I pushed a white plastic tube about the size of a small soda straw through the skin, under the collarbone, and into the vein. I sewed it securely to the skin of her chest, to keep it from being accidentally pulled free. All of these steps went without a hitch. I leaned back, took a deep breath, and let it out. So did Dr. Putman.
“Ready to float the Swan?” he asked.
I nodded to Dr. Putman. “The hard part’s over,” I told Mrs. Mahoney, “but you still need to hold still.”
“Okay,” she said, in a quiet voice.
After Nicole and I calibrated the equipment, I slipped a fine, supple catheter through the white plastic tube and into the vein under her collarbone. I advanced the catheter further, until it was in her heart, and then inflated the tiny balloon at the end of the catheter by injecting air into the appropriate port. The catheter was swept along with the flow of blood, out into the vessels of her lungs. We followed its progress by watching the pressure changes on the monitor screen as the catheter threaded its way through the chambers of the heart and out into the pulmonary arteries.
“Good,” Dr. Putman said. “Let the balloon down and re-wedge it to be sure.”
I nodded. Dr. Putman was meticulous, which is one of the reasons I liked working under his supervision. I let down the balloon. Nicole recorded the pressures, and I gently reinflated the balloon. Nicole nodded. “Yup. They’re the same.”
Dr. Putman grinned. “Good job.”
Nicole said, “Smooth.”
I smiled behind my sterile mask, and began to remove the sterile paper sheet covering Mrs. Mahoney’s chest.
Mrs. Mahoney shuddered, then coughed up a huge mouthful of blood.
“Damn.” Dr. Putman went to the head of the bed. “Mrs. Mahoney?”
She heaved out another gush of blood, then another.
What had I done? I took a small step away from the bed.
“What’s her pressure?” Dr. Putman asked Nicole.
“I palpate it at 50.” She dropped the BP bulb. “You want fluids?”
“Yeah, give her a liter wide open.” He turned to me. “How much resistance did you meet when you inflated the second time?”
“None.” I shook my head rapidly. “It went easy.”
“You must’ve blown open a pulmonary artery.” He frowned and crossed his arms. “But how’d the blood get from her interstitium into her airway?”
I stood without moving.
Mrs. Mahoney chugged out another mouthful of blood.
“We’re going to have to tube her,” Dr. Putman told me. He turned to Nicole. “Call for O-negative blood, and hang Dopamine.”
I went for the airway box. Usually I enjoyed intubating people, but this time blood kept pouring up out of her trachea. My hands shook so much I could barely get the tube in. A respiratory therapist arrived just as I secured the tube in place, and took over squeezing the bag that pushed air into Mrs. Mahoney’s lungs. I stepped away from the stretcher, and stripped off my bloody gloves.
I watched, stunned, as Dr. Putman ran the code. Nicole did chest compressions until she tired out, then another nurse took over. Dr. Putman told me to call Mrs. Mahoney’s husband, and ask him to come in, but not tell him why. We’d explain it when he got there. After about an hour, Dr. Putman told them to stop CPR. Mrs. Mahoney’s husband was in the CCU waiting room.
Dr. Putman did the talking. He said that Mrs. Mahoney had begun to bleed as we were doing a procedure. I sat quietly, glad I wasn’t the one having to tell Mr. Mahoney that his wife was dead. Dr. Putman asked permission to do an autopsy, to see what had caused the bleeding, but Mr. Mahoney said that his wife had been through enough so he refused.
When he said that, I felt my burden begin to lighten. Without an autopsy, who could say for certain that I’d killed Mrs. Mahoney? Maybe she had something else going on, and it was just coincidental that the blood started gushing out right after I reinflated the balloon. And I still couldn’t figure out how that much blood would get from the pulmonary artery into the airways. But even though my brain couldn’t resolve how I’d killed Mrs. Mahoney, my body was certain that I had. My fingers had held the syringe and my thumb had gently pressed the plunger. Fourteen years later, it’s still a visceral memory. But Dr. Putman had walked me, step by step, into the disaster. A teacher I respected and trusted had stood at the bedside with me. If we’d killed Mrs. Mahoney, I could tell myself, it was Dr. Putman’s fault, not mine…
But I was the only one standing at the end of his stretcher when I told Mr. Kelly and his wife that he’d be okay. I’d sent him out and he’d come back dead. I sat at the kitchen table, replaying the scene of Mr. Kelly and his wife shuffling down the hall in the ER, wishing I could rewind it all, call out to them and tell them that I’d changed my mind, that I’d admit him to the hospital.
The phone rang. It was Ken Anderson, one of the guys in our group. He’s been an ER doc for twenty years. He has graying hair, a calm voice, and never seems to hurry. Even when the ER is rocking, Ken looks like he just strolled off the golf course. I don’t know how he does it: each month we get a report on how many patients we see each hour, and Ken’s numbers are consistently good, but he rarely seems perturbed, and I’ve never seen him look rushed. “Paul,” he said, “I was going to drop by if you’re around.”
“Sure,” I said. “You know our address?”
“Yeah,” he said, “I’m about a block away.”
“Okay.” I hung up. “That was Ken,” I told Sally. “He’s coming over.”
“It’ll be good to talk with him,” she said. “Why don’t I go work in the yard some, give you guys some space.” She stepped forward for a quick hug, then walked out the back door.
I went to the bathroom, then peered at my face in the mirror, hoping I didn’t look as vulnerable as I felt. I also hoped I wasn’t in trouble with the hospital, or the group of ER docs I worked with. I felt vaguely nauseated again.
Ken knocked on the door, and I let him in. He followed me back to the kitchen.
“I was just about to make a pot of coffee,” I said.
“Sounds good.” He sat in the chair at the end of the kitchen table.
“Are you here about Mr. Kelly?” I rinsed the basket of the coffeemaker, and put in a clean filter.
“Yeah.”
I turned to look at Ken. “I feel terrible.”
“You should,” he said. “The man died.”
I turned back around, hoping I hadn’t outwardly flinched. Neither of us spoke as I silently counted the scoops of coffee. I dropped the scoop back into the coffee jar, and closed it.
“And good doctors,” Ken continued, “are bothered when one of their patients dies.”
Ken still thought I was a good doctor? I felt a wave of gratitude and relief. I put the coffeepot under the basket and punched the button to start the brewing. “I feel like I killed the guy.”
“Whoa,” Ken said. “Back up a minute. You didn’t kill anybody. You’re not even sure of the cause of death.”
“Guy comes in with chest pain, comes back dead?” I turned to face Ken. “Doesn’t seem like rocket science to me.”
“Okay, say the man died of a heart attack. No matter how careful, how smart, or how compulsive you are, eventually you’re going to make a mistake.”
“Yeah, I know.” I sat down in the chair at the other end of the table. “Missing something really obscure, or something so rare no one else would’ve picked it up either.” I shrugged. “To me, that wouldn’t be so hard to live with. But sending home a patient who’s having a heart attack?”
“Paul, we can’t admit every single patient who comes in with chest pain.” Ken shook his head. “It’s impossible. The hospital wouldn’t hold them all.” He looked over his shoulder at the coffeepot. “I think it’s ready.”
I got up and poured us each a cup.
“I’m just glad it was you, and not me.”
“Thanks, pal.” I tried to chuckle.
“What can I say?” He sipped his coffee. “Luck of the draw who picks up what chart.”
“Ken, have you ever sent someone home and they came back dead?”
He carefully set his cup down, and gently rapped the table with his knuckles. “Knock on wood.”
I wrapped my hands around the mug of coffee to feel the warmth.
“But, Paul,” he said, “it’s going to happen. It’s like driving a car. No matter how careful you are, someday you’re going to glance down at the radio to change stations, look up, and there’s a car right in front of you. You’ve had a clean driving record for thirty years, you’re a model citizen, and boom. You’ve plowed into some little old lady’s Cadillac.” He shook his head. “I’m not saying you made a mistake with this guy, but even good drivers have accidents.”
“How do you do it?”
“Do what?”
“Keep on making life and death decisions, knowing that you’re fallible.”
“Paul, I don’t make life and death decisions.” He carefully put his coffee cup on the table. “I make medical decisions.” He gave a slight shrug. “I work as carefully as I can, but it’s not up to me who lives and who dies.”
I stared at Ken’s face.
“That’s God’s department.”
Okay.
“Do you know what happens when a patient dies?”
“Yeah,” I said. “The doc feels like shit.”
“That’s not what I mean.” Ken looked away, then back at me. “We know a lot about how cells live. And we can describe, down at the molecular level, what happens when a cell dies: membranes break down, oxidative phosphorylation fails, hydrogen ions accumulate in the cytoplasm, all that stuff. But do we really know why people die?”
I couldn’t see what he was getting at.
“Say someone comes in with a pulmonary embolism. We understand the pathophysiology: hypoxia, hypotension, acidosis, et cetera.” He paused. “And we know how to intervene.”
I nodded.
“But when a patient dies, what happens?” He raised his eyebrows. “I mean, one moment they’re alive, and the next, they’re not. You’ve felt it. We all have. Something’s happened, and we don’t know what it is. Sure, we can trace out the failures of the circulatory system, and we can get EEGs for brain activity.” Ken shook his head. “But the fundamental thing of death itself it something we still don’t understand.”
“So?” I said.
“So, I look at each EKG as carefully as I can, and interview each patient as carefully as I can, and I make decisions as carefully as I can. Then I do my job and I let God do his.” Ken held his hands out, palms up. “How can we possibly claim the credit for success, or take the blame for failure, in a process we don’t really understand?”
I shrugged.
“Paul, you and I both know that you did your best for that man.” Ken shook his head. “That’s all any of us can do.”
When I’d first started working in Durham, I’d been surprised by how much I liked talking with Ken. In so many ways, we’re polar opposites: He’s a conservative Republican. He wears knit shirts and khaki pants on his days off. He belongs to two country clubs, one here in Durham, one at his beach house. He thinks Rush Limbaugh is smart. I’d always thought of Ken as someone with useful answers to questions about buying stocks or avoiding taxes, but I hadn’t thought he’d be the one to say something that would help me deal with Mr. Kelly’s death.
Ken stood, and took his coffee mug to the kitchen counter. “Give my love to Sally.”
“I will. Tell Barbara I said hey.”
Ken rinsed his cup, and left it in the sink. “You’re going to feel bad for a while,” he said. “That’s okay. Just keep feeling bad. You’ll eventually feel better.”
We walked to the front door.
“When do you work again?”
“Day after tomorrow.”
“See you then.” He stuck out his hand. “Paul, you’re a good doctor.”
“Thanks.” We shook hands, and he left. I felt my eyes fill, and hoped Ken hadn’t noticed. It must have been awkward for him to come by and talk with me, and I didn’t want to go all gushy on him. I felt as though being a good father, or a good husband, or a good man, was a hollow success if I wasn’t a good doctor as well. I was glad that Ken thought I was a good doctor. I just wished I felt that way.
After Ken drove away, I walked outside. It was a bright, sunny day. I sat in a wicker chair, and wondered if prayer would offer some relief. I prayed silently, but felt a need for something more physical and real than closing my eyes and thinking about God. My palms were sweaty. I wiped my hands on my jeans, and looked out at the street. The sun was still bright, the porch was still in the shade. A woman walked past, a dog tugging on the leash. I closed my eyes. “God, forgive me. And be with Mrs. Kelly, and their kids, if they have any.” I took a deep breath. “Comfort them. And let them know I did the best I could, and I’m sorry.” I opened my eyes. No change.
Maybe I should talk with Karen, or James. They’re our pastors, at the Pilgrim United Church of Christ. Sally grew up in that denomination and a pastor from her parents’ church had performed the ceremony when we’d gotten married. When Sally and I had kids, we started going to the Pilgrim UCC in Durham. The folks there seem like Unitarians, only less embarrassed to be called Christians. We went to Sunday School and church almost every Sunday I was off duty. I went to the Adult Bible Study Class. Matthew, my Sunday School teacher, was a law professor at Duke. Worked with Janet Reno on some legal stuff, worked with Al Gore on the problem about the use of the telephone at the White House. I felt lucky to discuss Christianity with such a smart crowd. So much of Christianity in the South seems anti-intellectual: TV preachers sputtering about sin and pleading for money, telephone numbers flashing on the screen. I’ve always felt like a second-rate Christian, insufficiently saved, with inadequate fervor. At the same time, I feel the Bible drawing me back, particularly the four Gospels. I believe there are answers there. And a model of grace. A model of how I can live.
I went inside and called Karen. She said I could come right over. I changed jeans, splashed my face, and drove to our church, a brick building that’s mostly roofline, tucked in among a thick stand of trees that shields it from the traffic on the street.
I knocked on her office door and Karen let me in. The bookshelves lining the wall were filled with paperbacks, probably texts from divinity school. Light filtered in through windows looking out into woods. She got up from behind her desk, and gestured to an upholstered chair. Another chair faced mine. She pulled it toward mine a little, and sat. “Are you okay?”
I nodded. “Yeah, basically.” I told her the story. “I feel so bad. So guilty.” I looked at the floor, then back to Karen. “You know, in the Bible, it says if we want God to forgive us for something we did to someone else, we should first ask that person’s forgiveness? Something about leaving the gift on the altar, straightening out the problem, then coming back.”
Karen nodded.
“I want to call Mrs. Kelly and tell her I’m sorry.”
“It’ll be a tough call to make.” Karen was looking me in the eyes.
“Not as hard as walking around feeling as bad as I do now.”
“Maybe.”
“I don’t know if I’m wanting to call Mrs. Kelly to make her feel better, or to make myself feel better.”
“And?”
“It’s probably a little of both.”
Karen waited.
“Do I have the right to call Mrs. Kelly, just to make myself feel better?”
“Paul,” Karen’s voice scaled down several tones. “It’s all right for you to want forgiveness.” She shook her head. “God doesn’t want you to carry guilt and pain around every step of your life.”
I didn’t feel anything in my chest loosen up or any burden lighten. But I caught a glimmer of the possibility. I thanked her.
When I got home, I looked at the phone number on the scrap of paper.
Sally walked into the kitchen. She was sweaty, from mowing the yard. “How did it go with Karen?”
“I’d hoped I would feel better.”
Sally smiled. “You look a little better.”
“I think I’ll call Mrs. Kelly.” I walked to the sink and got a glass of water. “Tell her I’m sorry.”
Sally hugged me from behind. I could feel the damp of her shirt.
“If I call Mrs. Kelly, and it goes to court, they’ll make a big deal about me calling her to apologize.”
Sally shrugged.
“If the award goes past my malpractice coverage, it could come out of our pockets.”
“So what. It’ll probably never happen.” She shrugged again. “And if it does: Fuck ’em.”
If nothing else, I’d married well.
Sally pulled back to look at me. “You should call her. You may feel better.” She hugged me again. “I’ll be on the front porch.”
Mrs. Kelly picked up the phone on the third ring.
“This is Paul Austin, I’m the doctor who took care of your husband the first time he came to the emergency room.”
“Oh.”
“I’m calling to say I’m sorry.” I paused. “I’m sorry your husband died.”
She didn’t answer.
“Mrs. Kelly?”
“I’m here.”
I waited. “If you have any questions, or concerns…”
There was another pause. “Why did you send my husband home?”
The question thumbed me in the chest. “I thought he would be okay.” I took a breath. “I was wrong. And I’m sorry.”
She didn’t answer.
I waited.
She didn’t say anything.
I looked down at the crumbs on the floor. “If there’s anything you want to say to me…” I winced at the accusations she might unleash, but held a glimmer of hope she’d say she forgave me.
“I’ve got nothing to say to you right now.”
I gave her my home phone number, and told her if she ever had anything to say, or any other questions, I’d be glad to talk with her.
We hung up.
I didn’t feel any better. And it seemed that Mrs. Kelly didn’t feel any better, either. But at least I’d said I was sorry.
I walked out to the front porch.
Sally looked up from her novel. “How did it go?”
I sat in the chair next to her. “She didn’t have anything to say to me.”
Sally closed her novel, keeping her place with her finger.
“I didn’t really expect her to flat-out forgive me, but I’d hoped for something.” Glints of sunlight reflected off the hard, waxy leaves of the magnolia tree in front of the porch. I could barely make out the pitted gray bark of the trunk through the dark openings between the leaves. “Some human contact.”
“It’s early.” Sally patted my knee.
“Did I call too soon?” I felt my dismay grow heavier. Had I added to Mrs. Kelly’s pain, just to ease my own?
“Probably not.” Sally shook her head. “But who knows when you should’ve called? She might’ve been sitting at her kitchen table just now, wondering why the ER doctor hadn’t even bothered to call.” Sally turned in her chair to face me. “At least now she knows her husband was important to the doctor. Paul, you’ve done everything you could—you saw the guy, did all the tests, thought about it, and told him to come back if he had more pain.” She held up a finger with each point. “Nobody’s perfect.”
I nodded that I’d heard, and I understood what she was saying. But I wanted relief from the guilt I felt, to somehow snap out of it—to learn my lesson and move on. It’s hard to know how guilty one should feel if, in good faith, one harms another. How does one “get over” a mistake that cost another person’s life?