Although it was Friday after five o’clock, I walked out into the clinic waiting room. Checking to make sure there were no more patients was a force of habit.
To my surprise, I saw a tall man sitting in the corner. He was leaning forward clutching his chest. His ashen color and pained expression gave him the unmistakable look of an impending heart attack.
I took him into my room and reflexively gave him nitroglycerin and oxygen. How could they have left a sick patient in the clinic, I wondered.
Suddenly, he grabbed my arm. “Am I going to die?” His hand was cool and clammy. His eyes looked plaintive and fatigued. Streaks of grey ran through his mostly brown hair. He was clean but not well groomed.
“Not if we can help it.”
He shook his head at me, but didn’t seem well enough to talk more.
“Just take it easy.” I said.
After a brief time, he was doing better and I was able to get some information. Satisfied that he was stable for the moment, I began to think about getting him to the emergency room. I stepped out of the door.
“Hey,” a voice called out behind me at the other end of the hallway. “Where are you off to in such a hurry? Wait up!”
Without looking I knew it had to be Dr. Carlos Santini. Always upbeat and positive, Santini loved cracking jokes with everyone. He was handsome with a type A personality, quick wit, and always enjoying being the center of attention. He missed his calling and should have been an actor, but I respected him as a physician.
“I’ve got to tell you this joke,” he said with a crescendo of animation.
“Come over here,” I said. “I’ve got a late walk-in patient. Can you eyeball him for me?”
“Do I look like a glutton for punishment?” Santini retorted playfully.
“I need you in here now,” I insisted.
“Did we have a little too much coffee today?” he bantered.
“He’s got chest pain,” I said, ignoring his remarks. “He looks acute. There are no medical records here and everyone seems to have left the office, including the secretary.”
Santini’s smile evaporated. We stood just outside my room, so I could keep my eye on the patient. “Okay, so what do you know about him?”
The brief history I could get is that he was climbing the stairs out of the subway and felt as if a ton of bricks landed on his chest. The pain was squeezing and radiating down his left arm. He claims he has never had this kind of pain before, never been seen at our clinic, and is on no medications. He’s roughly fifty pounds overweight, smokes two packs
of cigarettes a day over thirty years, and he puts away a six-pack or two of beer on the
weekends.”
“And what have you done so far?” Santini asked.
“I hooked him up to oxygen by nasal cannula at two liters per minute but his lips remain cyanotic. I gave him a sublingual nitro- glycerin tablet. I didn’t feel there was time for an EKG the way he looked. I wanted to get this guy to the ER stat but he was too unstable to transport by wheelchair.”
“Let’s go see him.”
Mr. Gary Boone looked like a different man as he sat on the examining table. Only a little short of breath, he was pinker and more relaxed. “Doc,” he said to me, “I feel better since you put this thing in my nose and that pill under my tongue, but wow— what a headache, just like you said.” He got off the table and started getting dressed.
“Where are you going?” I asked in bewilderment.
“I’ve got to leave.”
“You’re not ready to leave.”
“Oh, I don’t want to bother you people, so if you just get me unhooked I’ll be on my way. Thanks a lot.”
Santini gave me a puzzled look as he introduced himself to the patient. “Mr. Boone, do you have a plane to catch?” he said, trying to inject some levity. “Seriously, though, I must ask you a few questions. I am responsible for your care today.”
Boone sat down again. “Okay, but please hurry.”
Santini questioned him about previous episodes of chest pain. Boone’s answers were vague. Santini keep hammering at the point. Mr. Boone, now looked down at the floor sheepishly and then at me. My intuition told me he was about to confess to something troublesome. Boone returned Santini’s gaze. “Sure, I‘ve had chest pains before, just not this bad.”
“Why didn’t you mention this?” Santini asked.
“I don’t know. Look, I have to be honest with you. I don’t want to waste any more of your time. It comes down to this. I’m not a great husband to my wife. I’ve beaten her when I was drunk and only knew it by the bruises left on her face the next day. I know the ticker is giving out but I hope to redeem myself in my wife’s eyes with the $750,000 dollar life insurance policy I have. I deserve this pain. Lord knows I’ve caused her years of heartache. I just came by to pick up my wife from her appointment and got a little lost. I came into this clinic, thinking no one was here and I would finally die. This nice lady saw I was hurting and helped me out. But that’s as far as it goes.” He proceeded to take off the nasal cannula, stood up, and buttoned his shirt. “I’d gotta get going. My wife will wonder what happened to me. Can you tell me how to get to the kidney clinic? She has bad kidneys, you know.”
I looked at Santini in disbelief and was about to say something to Mr. Boone when Santini cut me off. His face was uncharacteristically stern. “Mr. Boone, I strongly advise
you to be fully evaluated. It goes against medical advice to let you go, knowing you’re bound to have a massive heart attack soon based on today’s symptoms. I really think you’re doing the wrong thing by not going to the emergency room now.”
“I don’t want to stay and you can’t make me,” Boone said emphatically.
“No, that’s true, I can’t,” Santini replied. A look of resignation came over his bright face like a shadow. He turned to me. “Do you have any paperwork on Mr. Boone?
“No.”
“Why not?” Santini replied.
“It turns out he never got registered. He looked so ill and in so much pain, I just assumed he was a walk-in. Otherwise, I would have sent him straight to the ER.” I felt rather embarrassed.
“Well, let’s stamp up some papers on him, write down his information and what was done here.” Addressing the patient, Santini said officiously, “I’m going to ask you to sign your name to acknowledge that we advised you to stay and to have a full cardiac work-up. You can take a copy of this with you. Is that agreeable?”
Boone nodded.
“Then, I’ll have the nurse practitioner take your vital signs again and write you out a prescription for nitroglycerin tablets. Put one under your tongue when you get that chest pain, and if the pain doesn’t subside in ten minutes, take another one. If the pain is still bad, call 911. The nurse practitioner will write those instructions on your discharge copy. Do you have any questions?”
“Nope.”
Dr. Santini left.
As I handed the patient the prescription and papers, I asked him seriously to reconsider. Torn over how much more I should presume to say, I decided to take the plunge.
“Mr. Boone, look, you obviously have regrets about your drinking and the way you treat your wife. Have you thought about other options? You could get counseling, join alcoholics anonymous, or go through an alcohol rehabilitation program. It doesn’t have to be this way.”
He looked up at me blankly.
Mr. Boone seemed like he was considering what I had just said. Then he smiled slowly and said, “I’ll think it over. Give me your business card.”
I escorted Mr. Boone to the main hallway of the medical building and told him where to find the nephrology clinic. I advised him to use the elevators and avoid stairwells at all cost. I reassured myself that he had heeded my words by taking his prescription.
When I returned, Santini was back in my office. In a serious tone, he said, “Now, if you think that patient is going to count as a number on the clinic revenue ledger, you’re sadly mistaken. Remember, register the patient first, and then see the patient.”
“But —.”
Santini burst out laughing and held up his hand defensively. “I’m joking, I’m joking.
But really — lighten up. You look so serious. You can’t save the world. You have got to stop trying to save patients who don’t want to be saved. Help those who ask for your help.”
“Is that why you didn’t fight harder to make him stay?” I asked.
“You mean rant and rave and make a big scene?”
I nodded.
“I would have if I thought it would have done any good. He’s an adult. I’m not a parent. He’s made up his mind. I’ve met many Mr. Boone’s before. You can’t change them.”
I had no reply. Inwardly, I thought he was wrong.
As I was walking through the hospital lobby on my way out of the building, I caught sight of Mr. Boone and a woman I presumed was his wife. They were walking ahead of me. Although I didn’t get a look at her face she seemed like an average middle-aged woman. The thought occurred to me that she might not be his wife. Maybe he was having an affair, felt guilty about it, and wanted to leave his wife the money. That seemed awfully involved. My suspicions broadened. Had he taken something to induce a heart attack? My mind was running away with me.
Should I try to meet the woman? Should I run up and urge Mr. Boone to fill his prescription? I couldn’t believe he was prepared to go through with his plan. If he didn’t fill the prescription, the die was cast. I imagined him dying somewhere from a massive heart attack. I’d give you maybe two months, Mr. Boone— less if you use the stairs or run for a bus.
I watched as he stopped near the exit and pulled out my business card and prescription. He paused a moment, then nonchalantly tore them up and tossed them in the trash can. Catching up with his wife outside the door, he disappeared down the street. She never looked behind.