Philip’s arms were hurting like they were going to fall off. But his father had preached that a parent’s promise was sacred. And Philip had told Emily and Erin that they would finally have a chance to ride their new bikes down the sidewalk along Kelly Drive, just like the big people. After all, Philip and Dorothy had watched adults and kids having fun on the river drive ever since they had moved back to the city from the Poconos. They had waited patiently until Emily and Erin were old enough to have tricycles that could move along fast enough to stay out of the way of the crazy people who zipped up and down the path that bordered the Schuylkill River. And now the time had come.
Philip and Dorothy had moved out of the city to Narberth, a sweet residential village at the top of the Main Line, complete with a shopping village and playground. It was situated west of the city, only a short drive from Boathouse Row and Kelly Drive. Once they arrived at Kelly Drive, Philip didn’t want the girls to ride in the parking lot or across the few streets they needed to navigate to get to the bike path, so, besides his lunch-laden backpack, he carried their riding equipment, no petty task. Not only did those sturdy tricycles weigh a ton, but he had to carry both with the same arm, leaving his other hand free to hold on to the hounds. Rocky and Meeko strained at their leashes, as excited as the girls to begin their jaunt. Philip was almost prostrate before making it to their starting point. But now, finally, the fun could begin.
And it did, the girls jumping on their pretty pink tricycles and scurrying off much faster than Philip thought possible. He and the dogs were forced to run to keep up as they wove their way around and through the pedestrians, runners, and riders who populated the walkway. But as hectic as it was, Philip had to admit he was having some of his best fun in a long time. And he not-so-secretly enjoyed the adulation of passersby, who had to be jealous of the father of such gorgeous and sweet children who worshipped Philip for being the most wonderful dad in the world.
It was an afternoon of perfection, a day of unusually low humidity with a perfect blue sky dotted with puffy white clouds. But sadly, a day that Dorothy couldn’t share with her family. Though she had vowed to cut back on her work to be with the girls, difficult cases had come across her desk recently that demanded extra time in the office on weekends. As much as Philip hated being without her, he reveled in the opportunity to have the girls all to himself, to carefully lay plans for a splendid day, including a lunch packed with everything they loved to eat. So when the angels had finally tired themselves out, Philip found a place on the lawn next to the river to lay a picnic blanket and begin to unpack the peanut butter and jelly sandwiches, nectarines, dried fruit and nuts, and cupcakes that the girls would scarf up as they recharged their batteries and prepared themselves for the next leg of their mini-adventure. And treats for the dogs, of course, who could never be left out of any culinary adventure.
“This is probably too good to be true,” Philip mused, as he sipped on a juice box and lay back on his elbows, watching the two children who had transformed not only his life but his relationship with Dorothy. Never before had they related so well to each other, ever vying to prove to the other and to themselves that the decisions they had made years ago—to leave their old lives and be with each other—had been necessary to land them where they were at that moment: in love with each other and their girls and their two hounds. Yes, only two now, fourteen-year-old Buffy having died just a few weeks earlier, leaving Dorothy and the rest of the family inconsolable for days. The girls were devastated; Philip and Dorothy were anxious to convince them that Buffy was waiting for them at the Rainbow Bridge and would see them all again one day soon.
But Philip had been right. The moment of perfection couldn’t go on interrupted. His cell phone had to ring at precisely that moment, jolting him back to reality.
“Dr. Sarkis?” started the party at the other end.
“Yes?”
“This is your answering service.”
“That’s nice. But I’m not on call this weekend.”
“I know, Dr. Sarkis. We tried to reach you on your pager several times before we got your cell number from the hospital operator. I apologize, but I have a call from a Dr. Ray Gilbert, and he says it’s urgent that he speak with you.”
Philip grimaced. “I guess I asked for this when I told him I would be there for him whenever he needed me,” he muttered to himself. “Did he give you any details?” Philip asked the operator.
“No, Dr. Sarkis. I’m sorry. He only left a number where you can reach him. He sounded pretty desperate to speak with you, though.”
Now what the hell am I going to do? Philip thought, closing his eyes, anticipating a headache. “Please call Dr. Gilbert back and tell him that I’m in the middle of something and will have to phone him back in about an hour.”
“Yes, Dr. Sarkis. I can do that.”
“Apologize for me, but tell him I can’t talk right now.”
Philip hung up, realizing that whatever he did from that point on, his afternoon had been effectively ruined. He was now under time pressure to get home, and when he arrived, there would be no gradual unwind and pleasant evening preparation but rather a headlong dive into another urgent medical problem. This was what the public didn’t understand about being a doctor. It wasn’t just the long hours he had to spend at work but, even more significant, the personal cost of dealing with problems off hours, problems that literally could mean life or death.
And so, the forced march back to the car with children, dogs, and equipment. The drive back to Narberth was extra-long because of traffic, although the girls clearly enjoyed themselves and had fun with Meeko and Rocky, who always appreciated human attention. It was Philip who was knocked off kilter. But as agitated as he was, he realized that his pique was more his fault than Gilbert’s, even though his former pupil had deigned to infringe on his weekend.
Philip ushered the girls into his bedroom, situated them in bed with some milk and cookies on the bedside table, and turned on Cartoon Network. The girls had become expert in deflecting the hounds, who wanted to know which of the cookies they were entitled to. They giggled as Meeko and Rocky climbed on top of them, eager to pilfer whatever they could of the forbidden treats.
Philip retreated from what he knew would be a chaotic scene to his den, where he dialed the number Gilbert had left for him. He looked at his watch. Two hours had elapsed since his answering service had called him, which meant that Gilbert had been wrestling with his emergency for nearly three hours. Hopefully, he had resolved it.
Gilbert answered, almost instantly, words spilling out quickly. “Philip, thanks for calling back. Sorry to interrupt your weekend. It’s that damn Sterling thing again. Big problem with a patient.”
“OK, Ray, slow down and start from the beginning.”
“Last night, the guys up north sent me another patient who was having frequent shocks from her device. Fifty-five-year-old who had a heart attack about a month ago. Young, but she was a smoker and had a terrible family history. She did fine after they opened her arteries, but she got a defibrillator implant last week. She was readmitted yesterday when she arrived in their ER after getting a bunch of shocks. They weren’t able to get her rate controlled, so they loaded her into our helicopter and flew her here in no time. I told the flight crew to hold on the pad while I got a look at her, suspecting that we were going to have to ship her down to you for an ablation—a real one this time—if she was having VT.”
“Wait a minute, Ray. She shouldn’t have gotten a defibrillator that soon after a heart attack. They’re supposed to wait at least a few weeks to see if her cardiac function comes back.”
“Tell me about it, Philip. I was already pissed off when I found that out, but I was really frosted when I reviewed the electrograms they sent, and I saw the patient. It wasn’t VT, Philip. It was AF with a rapid rate that triggered the device.”
Silence as Philip seethed. The patient had experienced an arrhythmia coming from her upper heart chambers, not the bottom, which would cause her to die suddenly. The defibrillator had sensed a rapid rate and decided to try to shock the rhythm back to normal, which was simply not possible since her shocking electrodes had been placed in the bottom chamber. The device was never intended to stop atrial arrhythmia. A terrible scenario for the patient but one that could usually be handled by simply turning off the device and giving drugs to control the heart rate.
“Thank goodness you figured it out, Ray,” Philip finally said. “You saved the patient a lot of trouble.”
Silence once again, this time as Gilbert gathered himself.
“But if that were all there was to the case, you wouldn’t have put in an urgent call to me, would you?” Philip continued.
“No, Philip. The story doesn’t end there,” Gilbert answered, obviously having a difficult time continuing the conversation.
“Deep breath, Ray.”
“Right, deep breath. OK, so I took the woman off the helicopter and admitted her to our unit, where she proceeded to have several more episodes of rapid AF. By that time, I had turned the damn defibrillator off, but she dropped the crap out of her blood pressure with heart rates that went up to 220. She was on a lot of medication to slow her heart rate, and they weren’t touching her.”
“You’re sure it was coming from the atrium.”
“Yeah, definitely from the top chamber. But then I began to suspect that something else was going on.”
“Did she have normal thyroid tests, Ray?” Philip asked, hoping that Gilbert hadn’t forgotten that high thyroid levels could accelerate the heart rate with atrial arrhythmias and be resistant to drugs.
“Normal T4 and TSH.”
“Good,” Philip said, trying hard not to sound relieved. “What drugs did you have her on?”
“The kitchen sink, including amiodarone, but they were knocking the hell out of her blood pressure without touching her heart rate. I was beginning to think that she had another problem.”
“Pre-excitation, I’ll bet,” Philip concluded. A congenital heart condition in which impulses from the top heart chamber go directly to the bottom of the heart, driving it to dangerously high heart rates that could be lethal.
“Right, a bypass tract!” Gilbert answered excitedly. “Thank goodness you came to the same diagnosis. Otherwise, I wouldn’t be able to live with myself.”
“What next, Ray?” Philip said through clenched teeth, anxious to find out what had happened to the poor patient.
“I decided to take her to the lab to find out if she had a bypass tract. It was going to have to be pretty close to the septum to give her a narrow QRS, but she already had a pacemaker device so I didn’t have to worry about interfering with her normal conduction system.”
“Good,” Philip confirmed. He suspected that Gilbert would have had a hard time burning an abnormal fiber without damaging the wires that sent normal impulses to the bottom chamber. “So were you successful.”
“Yes, but I perforated her heart.”
“You did what?”
“Come on, Philip. You have to know how nuts the situation was. The woman was crashing, and I couldn’t make her heart rate go down. I was so focused on finding and ablating the pathway that I lost track of one of my pacing catheters, and it ended up in her pericardium.”
“Damn. Not good, Ray.”
“I know, I know. The pathway was a bitch. It was right next to the His bundle, and it was a miracle I didn’t cause heart block. Anyhow, I recognized the perforation right away and drained the effusion, and she’s fine. She wasn’t on any blood thinners so the bleeding sealed up pretty quick. Her heart rate and blood pressure are perfect now, and she’s waking up nicely from the anesthesia. So all’s well that ends well, I guess.”
“I’m sorry I didn’t call you back sooner, Ray. But I doubt I would have told you to do anything different.”
“I was calling mainly for hand holding. There was no time to send any recordings, and the patient was definitely not going to survive a transfer.”
“I agree. You handled it well, Ray.”
“Thanks, Philip. I appreciate that. But it does bring up the same problem we talked about a few weeks ago.”
“Yes, it does.”
“Not only was the device put in too early, but the implant had to have had something to do with provoking that bypass tract to become active. They damn near killed her, Philip. What do you think we should do?”
“Not sure, Ray. I do agree that you have to do something if patients are getting hurt.”
“That’s what I think.”
“But you can’t come down on the docs up there too hard, or they’ll just blow you off.”
“I understand that, Philip. I’ve been racking my brain and can’t come up with a reasonable solution.”
“Tell you what, Ray. Let me talk to Dorothy. She knows a lot about issues like this and has a lot of common sense and excellent judgment. I would love to hear what she has to say. How about if I get back to you on Monday?”
“Philip, that would be great. I really appreciate your help with this.”
After they hung up, Philip put into play the late-afternoon ritual of pet care and childcare that was now a regular part of his existence, being especially attentive to the details so when Dorothy came home, they would have time for brain picking over their favorite cocktails.
The dogs heard the garage door go up long before Philip, who had just parked his butt on one of the kitchen stools at the island that had rapidly become the center of their family life. The marble counter was their first destination whenever they returned home and the place all family members and visitors placed their belongings on arrival, before they had a chance to distribute them or put them away. Philip, the neatnik, struggled to keep the counter in order, while Dorothy and the girls seemed hell-bent on recluttering the space at every opportunity. So Philip wasn’t surprised when Dorothy staggered into the kitchen and began to throw the many bags she had lugged in from her car onto the surface, the contents spewing this way and that. His head shaking, Philip began to sort through the stuff, all the while exhorting Rocky, counter-surfer extraordinaire, to keep his paws down and his nose out of the fragrant food bags.
“Philip, I really need a glass of wine,” Dorothy said, while planting a light kiss on his cheek as encouragement.
Enjoying being manipulated by his partner, Philip smiled, pulled an opened bottle of Chardonnay from the refrigerator, and poured a generous portion into a wine glass, engraved with the profile of a Portuguese water dog.
“It was tough being at work today. I wish I could have been outside. Did you guys have fun at the river?”
“We did. The kids had a blast, and the doggies were well exercised. They should sleep well, especially after all the food they scarfed up for dinner.”
“Good.”
“We did have a minor interruption that I need to talk to you about.”
“Something bad happen to the girls?” was Dorothy’s first thought.
“No, they’re fine, and so are the hounds. It was a phone call from Ray Gilbert.”
“Who?”
“Remember a few weeks ago I had to go into the hospital to help Marwan with a helicopter transfer?”
“Yeah. Gilbert is the guy who rode with the patient in the chopper?”
“Right. I told you he was worried about some patients up in the Carbon County area getting defibrillators inappropriately.”
“Vaguely. You told him to cool it, right?”
“Yeah, and to clean up his private life.”
“So he called you today. Why? You told me you weren’t on call.”
“Yes. He called to ask my advice and to hear that he had done the right thing with one of his patients.”
“And had he?”
“I guess so, although his procedure very nearly bumped her off.”
“So what did he want from you?”
“This woman came from the same area, and her device was unnecessary too, according to him. He wanted advice about how to deal with it.”
“Without pissing off the universe.”
“Especially the people who send him cases from up there.”
“But he feels like he has to do something to ease his conscience,” Dorothy surmised.
“Precisely. I love problem-solving with you. You cut to the chase aster than anyone.”
“Stop buttering me up. Let me think on it while the wine seeps into my brain, and we get our dinner ready.”
Philip readily agreed, confident that Dorothy would do exactly as she said. However, he began to wonder when Dorothy still hadn’t returned to the subject through dinner prep and consumption, cleanup, and the protracted childcare necessary to get “E squared,” as they referred collectively to the two girls, properly prepared for bed. It wasn’t until they had both landed in bed themselves, switched on their bedside lamps, and prepared to pursue their customary reading that Dorothy finally returned to the Gilbert conundrum.
“When we’ve had problems with people who refer to our firm, we’ve been most successful with the education thing.”
“How do you do that?”
“Frame it carefully, and look for the proper venue. Maybe you and Gilbert can make yourselves available to do a symposium of some kind.”
“They love case conferences.”
“Perfect. The great Dr. Sarkis agrees to do a seminar where you’ll discuss complex cases. Gilbert can be the host, and you and he will pick cases that illustrate the issues you’re most concerned about.”
“Without identifying any of them, so none of the docs who attend will be embarrassed.”
“Exactly. He’ll have to be careful to disguise the perpetrators, but the facts will be clear.”
“And I’ll present treatment options.”
“Based on the best science and guideline recommendations, of course.”
“Brilliant,” Philip concluded.
“Maybe. Depends on how well Gilbert sells it and how receptive the docs up there might be.”
“Ray’s pretty savvy and knows the territory well. I’m sure he can slant this well to get the right people in the room and in a receptive mood.”
“Pick a good restaurant, and don’t spare the alcohol. You’ll be surprised how much easier that will make your task.”
“Done. I’ll call Ray on Monday and lay this all out for him.”
“That’s fine. Let him take the lead, but stay hands-on, Philip, if you want to make sure this will work and not waste your time.”
“Good advice.”
“And now, this oracle is closed for business. I want to read the next installment of Outlander. Jamie and Claire are on a new adventure, and I have to see how it works out.”
“Wait a minute. I’ve seen that series with you. I thought you only watched it for the soft porn.”
“And what’s wrong with that? Might give me some new ideas.”
“If only,” Philip teased, opening his Hamilton tome, finally starting to feel relaxed. Rocky and Meeko jumped on the bed and spun around two or three times before stretching out at the bottom, obliterating any free space there had been for Philip’s legs. “I guess it’s all about the hounds,” he said, not expecting any reply from Dorothy, now escaped from reality and fully immersed in her own personal time machine.