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The Short Happy Life of Harjeet S.

2011-07-02

The Short Happy Life of Dr. Harjeet S.

In 1983, I moved to the town of Hazen, North Dakota, to work as a doctor.  Hazen had a population of about three thousand and was the site of a small district hospital, Hazen Memorial Hospital.  It was the county seat and the place where local people came to shop.  Most of the people who lived there were farmers, but some worked at strip mines nearby, digging up the poor-quality anthracite coal that lay in a thin layer about forty feet below ground everywhere around.  The coal was burned in electric plants in the area that supplied most of North Dakota with cheap power.

At the time, there was a construction project going on about thirty miles north of town.  Construction companies were building a coal gasification plant subsidized by the federal government.  It was intended to use the abundant but low quality coal there to produce methane gas, known as “natural” gas.  The project employed a lot of workers who lived in temporary housing near the plant.

I had a scholarship from the federal government that paid for my medical school; in return, I obligated myself to work in a physician shortage area for four years.  Accordingly, when I was in my family practice residency program, I picked an area to work that did not have enough doctors to take care of the people living there.

The doctors already on staff were S, A, G, and M.  Doctor S was a surgeon who had previously worked in cardiac surgery in a hospital in Wisconsin; it was said that he was tired of the frenetic pace of a university hospital and wanted to slow down.  Dr. A was a general practitioner and self-styled radiologist, from a small country in South America.  Dr. G was a general practitioner.  He had been raised locally, but trained as a pathologist and had worked in Los Angeles.  He liked to drink, and I suspected that he had lost his pathology job for that reason.  Dr. M was also from nearby, but he was young and had trained as a family practitioner.  He was, like me, obligated to work in a shortage area in exchange for his federal scholarship.  His practice was based in Beulah, a town about ten miles away that didn’t have a hospital.  Beulah was closer to the project and had many construction workers living in the town.

Dr. S was the only one I respected; he was a gentle man and a wonderful surgeon who as so courteous and affable that I immediately took a liking to him.  Dr. S and Dr. A worked out of the same office, but with totally different schedules, and both used hospital resources a lot, which generated money for everyone.  Dr. S performed all the surgery, especially emergencies, and kept a lot of patients in the hospital.  Dr. A would do anything for money, and he self-referred patients for X-ray procedures for which he could then bill handsomely.

In light of the lack of leadership among the assembled doctors, I was made assistant chief of staff by acclamation.  Dr. S was chief of staff, of course, partly because he spent so much time at the hospital, and partly because he was the only one willing to do it.

In the summer of my first year there, a young man came in to the emergency room with a gunshot wound in his right big toe.  He had been grouse hunting, and had accidentally shot himself while carrying his shotgun with the safety off.  The wound was a neat semicircle punched out of the end of his toe.

I cleaned and debrided the wound thoroughly and left it open, packed with sterile ointment.  After two days, there was no sign of infection, so I called in Dr. S to see if he could close the wound.

I watched as he injected local anesthetic into both sides of the base of the toe, numbing the nerves that entered the toe from the foot.  He was gentle and quick.  Then he made incisions into the flesh on both sides of the wound and neatly turned the healthy tissue around to close the gap.  Within five minutes, he had completely rearranged the skin and tissues to create a nearly normal looking toe.  It was a neat and lovely job.

Since I was the newest doctor on staff, I expected that I would be assigned to work Christmas day the first year and I was.  It turned out to be quiet and uneventful.  That year, North Dakota had an unusually cold spell that lasted a week from Christmas until New Year’s Day.  The temperature dropped to forty degrees below zero every night, one night reaching -47.  During the day, it never got above zero.

The next spring, I was on duty in the emergency room one evening when another young man came in with the sudden onset of excruciating pain in his testicles.  I examined him and found that his right testicle was swollen, hard, and unbearably painful.  I called Dr. S and described the case to him.  He immediately said, “It’s a testicular torsion.  I’ll be right over.”

Since he lived only a block from the hospital, he was there in five minutes.  He quickly evaluated the patient, prescribed intravenous morphine, and ordered the nurse to call in an anesthetist and his surgical team.

Fifteen minutes later we were in surgery.  Watching him work, I was again impressed with his rapid and assured movements.  He opened up the scrotum and delivered the twisted testicle out of the incision.  In a few moments, he had the testicle untwisted and it began to pink up immediately.  Our rapid diagnosis and surgical intervention had saved the man’s testicle from necrosis and destruction.

At medical staff meetings, Dr. A would sit on Dr. S’s left side, chain smoking, while I sat on Dr. S’s right side.  Dr. M sat in the doorway, since he claimed to be allergic to cigarette smoke.  Dr. A was constantly making dirty jokes and double entendres.  He noted that, since I was “vice” chief of staff, I should be responsible for examining all the new nurses.

In fact, I was tasked with examining all the new employees.  The hospital had a policy of performing X-rays of the lumbar spine on all the new staff, a policy of which I was unaware until a young woman, who was three months pregnant and newly hired as a housekeeper, had this done.  I had to talk to her after the X-ray was done and explain that there was a small risk of leukemia in her unborn child because of the routine X-rays.  She had apparently failed to notice the sign on the door of the X-ray room asking her to report to the technicians if she was pregnant.

I think that Dr. A had told the administrator to institute this policy to “protect” the hospital in case an employee complained of back problems after being hired.  I could not determine how this would protect the hospital.

One day I sent in a patient that I knew had spondylolisthesis at her fifth lumbar vertebra for a follow-up X-ray of her lumbar spine.  Dr. A’s report noted the arthritic changes but failed to note the spondylolisthesis that was causing the arthritic changes.

As “vice” chief of staff, I had to chair the Quality Control Committee.  This committee, sort of a post mortem for incident reports, met once a week.  I decided to analyze the hospital logs for who ordered how many X-rays and for what.  The tally for a month indicated that Dr. A ordered almost half of the X-ray procedures, more than twice what his share of hospital admissions would have warranted.

One specific case had generated the analysis, at Dr. S’s request. In that case, one morning when Dr. A was on duty in the Emergency Room, a young man came in with abdominal pain, fever, and a high white blood cell count.  Dr. A ordered a barium enema.  Instead of calling Dr. S immediately with a request to consider an appendectomy, he admitted the teenager to the hospital, gave him painkillers, and left him there all day.  He came back at five in the afternoon and performed the barium enema he had ordered.  The X-rays showed barium spilling out of the colon into the abdominal cavity, indicating a ruptured colon.

Only then did Dr. A call Dr. S, who was forced to clean the barium out of the poor young man’s stomach as well as removing the abscessed appendix and a portion of the colon, leaving him with a colostomy.  A case of appendicitis that could have been easily treated in morning with an appendectomy turned into a surgical nightmare that took all evening to clear up.

I was asked to report my assessment to Dr. S in an open medical staff meeting.  By coincidence, I had just a few weeks before myself admitted a young man with mild right lower quadrant pain, a borderline elevated white blood count, and no fever.  I felt that he must have appendicitis, but the presentation was so mild I couldn’t prove it.  I had him transferred to a large hospital in the capital city.  The surgeons there performed a barium enema (because it was such a doubtful case) before they eventually operated and removed a small, contained, inflamed appendix.

The two cases really showed no resemblance to one another.  The record of the Emergency Room examination of Dr. A’s patient showed his fever and high white blood cell count, and the nursing assessment also made it clear that his patient was quite sick.  The fact that his pain improved after he was admitted to the hospital didn’t make his condition any better.

Not wanting to offend Dr. A to his face, I said, “I would have agreed with you that a barium enema was inappropriate except that it happened to one of my patients recently too.”

During the fall of my second year, I walked in to the hospital one day to find an eerie silence in the front hall.  The corridor doors that were usually open were closed, and there were sheets of paper Scotch-taped to the little windows in the doors.  No one was around.  I went in to the emergency room nurse’s station and found the old nurse in charge sitting there looking sad.  I asked her what had happened.

She explained to me that a man had been brought in with a gunshot wound to the abdomen, and he had died despite everything Dr. S had done.  She described a chaotic scene, with people running around and bystanders trying to force their way into the emergency room.  The police had been called in to keep all the spectators out in the front hallway.

She told me that Dr. S had been groping around inside the wound with his bare hands, trying to find and close off the patient’s abdominal aorta.  Within twenty minutes, despite all his efforts, the patient had died.  She said the wound had looked very small on the outside, just a little hole in the patient’s lower back; in front the hole was somewhat larger, but Dr. S had still been forced to make an incision to enlarge the wound in order to reach inside.

I could imagine in my mind’s eye the destruction that a deer hunting bullet had wrought within the man’s abdomen.  I was surprised that he had lived long enough to reach the hospital.

I offered her my condolences.  She looked as if her confidence had been shattered.  I explained to her that sporting firearms used expanding bullets that were designed to inflict maximum internal damage to their victims, in contrast to military rifles that used full metal jacketed bullets that do not expand and cause much  less damage.

Apparently the man had been hunting deer with his friends and had been shot by one of them at a hundred yards distance when a deer had run behind him.  I couldn’t really see how a careful hunter could make such a terrible mistake, but hunters are not known for their caution.

A few months later, I was on duty in the ER when one of Dr. A’s patients was brought in.  This was a two month old baby that he had delivered.  The mother lived on the nearby Indian reservation, and she had five or six other small children.  She told me that the infant had been having some diarrhea and vomiting for the last couple of days but she didn’t seem to think it was too bad.

However, when I examined the infant, I discovered that she had not gained any weight since birth and looked listless and malnourished.  I ordered the infant admitted with a diagnosis of “failure to thrive,” that is, a lack of expected growth and weight gain.

My understanding was that this usually caused by neglect, but may be caused by chronic intestinal infections such as giardiasis (which is common on Indian reservations.)  I wanted to run stool cultures and keep the patient under observation to see if it would gain weight in the hospital.  However, as I was writing the admitting orders, Dr. A showed up.  According to protocol, I turned the patient over to him.

This two month old baby thrived dramatically during a week in the hospital.  She gained at least two pounds, never had any diarrhea, and took all of her feedings greedily.  The cultures I ordered came out negative.  After a week the mother showed up and wanted to take the baby home.  Dr. A obligingly discharged her immediately to her mother’s care.  The nurses apparently wanted to call Child Protective Services, but Dr. A seemed uninterested.

A couple of months later the mother brought the same baby back to the ER, but this time she was dead.  An autopsy showed dehydration and malnutrition.

The nurses complained to the local district attorney, and he charged Dr. A with “failure to report child abuse or neglect.”  When the case went to trial, the prosecutor told me to come to the court at 1 PM to testify.

I accordingly spent the morning seeing patients in my office and showed up at the appointed time.  By the time I arrived, the prosecutor had already rested his case and didn’t want my testimony.  Apparently, the judge was in a hurry and couldn’t wait for me to show up; he thought I was supposed to be waiting at the courthouse when court convened in the morning.

Unfortunately, no one told me that I needed to show up early, and no one called me at my office to ask me to come in when they were ready for me.  The jury found Dr. A not guilty of “intentional” failure to report and questioned why the prosecutor had not charged me as well.

Not only had the prosecutor failed to use my testimony to explain the causes of “failure to thrive” to the jury, but he had allowed them to think that I was equally at fault for not reporting the case.  It seemed that the prosecutor was as incompetent as the doctor.

Several patients sued Dr. A for malpractice; the malpractice insurance company was forced to settle out of court in each case.  One man had a renal carcinoma that Dr. A failed to notice even after he ordered, and personally performed, an intravenous pyelogram.  He had done the pyelogram because the man had blood in his urine.  The carcinoma had appeared as a suspicious open space between the renal calyces outlined by the radio-opaque dye as it was excreted from the kidney.  The patient’s blood tests showed highly elevated alkaline phosphatase levels, suggesting that he already had metastases to the bone.

I accumulated a long list of Dr. A’s misdeeds, which I decided to bring to the attention of the North Dakota Medical Board.  I sent them a letter with the details, and they asked me to come to the capital city to testify in person.

One night, in the middle of a snowstorm, I drove the seventy miles down to Bismarck to attend a meeting with a group of doctors from the Board.  I gave them the case histories in detail.  They said that they couldn’t do anything.  I think they didn’t feel he was bad enough to stick their necks out by doing anything.  They had recently been sued by a doctor that they had tried to discipline and they found the prospect of lawsuits daunting even when the doctor involved was obviously incompetent.

At any rate, I had come to the completion of my obligated term of service.  After I had gotten a job in Los Angeles, I wrote a letter to the Medical Board telling them that I didn’t want to renew my North Dakota license because of their inaction.   The following December, I drove away from Hazen in near-zero weather.  I remember thinking the road looked suspiciously icy.  I stopped my car and got out for a closer look.  The road was covered with an inch of solid ice.  It wasn’t particularly slippery because it was so cold.

After I left, I heard from a friend there that one evening Dr. S had apparently had enough and  punched Dr. A in the nose in front of a dozen hospital employees.  Every one of the witnesses denied to police that Dr. S had thrown any punch.  Dr. A was unable to force the police to arrest Dr. S or charge him with battery.

I wondered whether it had really happened.  It sounded too neat, like something you would see in a movie.  Maybe I got it wrong; after all, it was told to me by someone who heard it from one of the employees.

I do know that the hospital administrator took sides against Dr. A.  In retaliation, Dr. A had a private investigator dig up dirt on the administrator.  It turned out that his degree in hospital administration was phony, which forced the hospital governing board to fire him.

Dr. A fled the town of Hazen and tried to take a job in Arizona.  The Arizona Medical Board wouldn’t give him a license “because of derogatory information in his file” at the North Dakota Board.  That information was my complaint to them about the cases that he had mishandled.

After punching Dr. A, Dr. Singh retired (he was only fifty- five) and went to Europe for a tour with his family.  He was killed instantly when he stepped off the curb in front of a taxi on the street in Venice, Italy.

4 Comments leave one →
  1. Jack zeller permalink
    2012-03-12 12:19 AM

    Not many taxis in Venice, though. Really bad luck, if true.

    Like

    • 2012-03-12 5:40 PM

      Actually the town was probably Rome. I’m not sure. I could look it up, but then it’s not a commercial (i.e. finished) piece. As far as I know, it’s true.

      Like

  2. JudyH permalink
    2012-03-12 2:33 AM

    Dr. Singh sounds like a prince of a guy who deserved much better than he got from life. And thank goodness you made your official complaints about Dr. A even though the North Dakota board refused to take action. Some community in Arizona was saved from the substandard ministrations of Dr. A. I am originally from Arizona, so it could have been someone I know who was spared an ordeal. It takes some guts to report a malefactor when one is fairly new on the job, so I commend you for your strength of character.

    There is a huge range in the quality of medical care in the United States despite efforts to maintain minimal standards. A friend of mine is a newly-minted anesthesiologist and I am amazed at the amount of continuing education and refresher courses he has to take. (Although I must say that some of it sounds not very rigorous. One of his stories in particular is funny but not confidence-inspiring.) I expect standards are higher now than when you started (since you mention being retired now), but weaknesses are built into the system, as they are into any system. Those who gain by these weaknesses resist reform.

    Thanks.

    Like

  3. SonOfLilit permalink
    2012-08-25 10:33 AM

    I enjoyed reading this very much.

    Despite its chaotic narrative, despite my complete lack of interest in medical practice (probably the only subject in the world I don’t find interesting), the piece held so much raw truth in it that I feel a better man for having read it.

    Like

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