The promise keeper


Looking back on my long career in emergency medicine, the one thing I’d tell you: you’re nobody’s friend manning the emergency room.  It’s in the emergency department that the politics of the hospital begin.  The staff of doctors is always unhappy when they receive that call for an admission at three in the morning.  They are the first to find failure in your care and the last to help you out.  It’s always, “Dr. Norris never told me he was this sick,” or “Dr. Norris missed that hairline fracture in the emergency room.”  And the nurses are just as bad.  To them, an empty emergency room is a happy emergency room.  They won’t have to face the family members or lawyers when you miss something in their loved one.  And where the doctors are more direct at going after you, the nurses are slyer as they stab you in the back. 

My wife, Jessie, a family practice physician herself, who worked in a small group of doctors whose office was on the strip that led to the rodeo grounds, was always her own woman.  She had the ego of a surgeon and the common sense of an untethered and unattended jackass.  She soured me on Parkview Hospital when she sought solace and passion in the brass bed of Tom Prebus, a family practice doctor in her small group of practitioners.  Prebus had a ranch on the South Fork of the Shoshone River, while Jessie and I had a small spread on the North Fork.  I first found out about their affair when I drove home after a long twenty-four hour shift in the emergency department, only to find my valuables in suitcases and cardboard boxes on the front porch.  It was her day on call so I couldn’t even confront her on her infidelities until that night.  “You aren’t half the man Tom is,” she told me.  “I never loved you. Get your things out.  My lawyer will get in touch with yours, and we’ll settle the rest.  I can’t believe how dense you are.  This affair has been going on a year and you… you were the last to know.”  The woman had a point, a painful one.  With that, my whole demeanor changed.  I was no longer the cheerful, unflappable person I had been before I married Jessie the day after graduation from Princeton University.  I felt that I had been suddenly cast out of Paradise, that I had fallen into the disfavor of the gods.  I was suddenly sullen, surly, unsociable.  For her lack of common sense, Jessie still managed to secure over half of what we’d accumulated since that fateful day when our futures had been annealed. 

And Prebus, the most arrogant and self-righteous, abrasive and stubborn of the attendings on staff at Parkview, seemed to revel in the whole shake-up.  It was the biggest “fuck you” he had ever pulled off and he enjoyed seeing me squirm, trying hard maintain an even keel when I had to deal with him.  When either he or Jessie came in to admit a patient, I retreated to the call room in the basement of Parkview Hospital.  And the patients got to me as well: they weren’t the passive, pleased patients that I enjoyed taking care of in residency back east.  It was ironic: I’d grown up in western Colorado and always wanted to get back to the mountains.  Now that I was here, my marriage in tatters, the patients intolerable, I should be happy.  All I wanted at that point was to get out. 

Prebus and Jessie and I were all the same age.  It was with a sense of nausea that I watched him climb up the ladder of attendings at Parkview.  Joining the most important committees at the hospital, he was privilege to the underpinnings to how Parkview was run.  First, he was on the Credentials Committee, which established whether a new doctor was sufficiently qualified to work at the hospital.  Secondly, he was on the hospital morbidity and mortality committee, the group that decided (behind closed doors) if any negligence had transpired in a medical misadventure.  Finally, he was on the medical practices committee, the band of doctors who decided what tests were required when a patient with a given cluster of symptoms, would need a certain procedure.  This last committee would mandate certain situations, such as patients who had chest pain, an EKG required.  If that was obvious, there were a myriad of other medical and surgical scenarios generating flow charts in the hospital.  Me, I just shunned the committees and interacting with the staff in general.  Prebus, who always made a dramatic entrance, wearing denim jeans and pearl button cowboy shirts when his patient presented when he was in the emergency room and his office was closed, would make some statement about why something wasn’t done on one his patients.  He brought me up before the morbidity and mortality committee because I didn’t get blood cultures on a young woman with a kidney infection.  Sitting there, in front of the five doctors who availed themselves to sit on the committee, I said, “I did.  I gave the order for a set of blood cultures as they took Ms. Sisk up to her room.  The problem is that it was a verbal order.”  Many hospitals didn’t do blood cultures routinely for such infections.  I was abashed that something as picayune as a set of blood cultures would so trouble Prebus.  “I can’t help it that the nurse forgot to do it.  Besides, it didn’t really impact her care at all, Tom.”

“I beg to differ.”  Prebus’ face was as flushed as a pack of aces.  “I had to keep her in a day longer.”

“Perhaps if you were a better doctor she would have gotten out a day sooner.  I don’t have to take this crap.  More to the point, I don’t have to take it from you.”

“What…” but I was gone, already walking towards the door.

It was not a month later that I called him to admit one of their group’s patients.  Though his EKG was almost normal, the man had too good a history (diabetes, hypertension, hyperlipidemia, family history of heart disease) to go home. 

 “Hell, he doesn’t need to come in.”

“Maybe I didn’t explain myself well”

“I say he doesn’t need to come in.”

“You can explain it to the chief of staff.  If you’re not here within the hour to admit him, I’ll call Holmes (Chadwick Holmes was the chief of staff).  I heard the phone slamming down on the other end. 

It was not long before Prebus was trying to ensure that his longevity was intact, that the gene pool had dried up.  He got my Jessie pregnant.  A year after she delivered a boy, she delivered a little girl.  Though I couldn’t imagine Prebus ever being more proud of himself than he was, the pride now was gushing.  I was a little surprised because I heard he was having trouble on the marital front.  If rumor was to be believed, Jessie was carrying on with the hired help (Prebus ran about a half dozen Arabians and forty-some Hereford on what had once been mine.  Some of the other attendings noted that he seemed a little intoxicated over the past few months and more erratic in his behavior.  To me, he was the same old prick. 

But the day came when Prebus’s ego was aggrieved.  It was like a fortress falling into enemy hands.  After that, Prebus got religion.  But it was more like a smorgasbord of beliefs.  For a few months he was Catholic; for a few months he enjoined the Methodists on Sunday mornings.  Had there been a synagogue, he might have become the Jew for of the month.  Then it was the Promise Keepers.  They were a group of men as nutty as scientologists.  The semi-religion was started by an ex-football coach at the University of Colorado.  The core of the belief was that society and social order was lacking because grown men were not assuming the helm of their family.  Meeting once a year in Boulder, Colorado and there, standing next to them, recount their sins and speak of the times they let their families down.  The first year that Prebus attended the gathering, he was hooked like a rainbow trout caught on a dry fly.  “By God,” he was alleged to have said by a friend who had accompanied him, “I’m taking over when it comes to my family.” 

Upon his return from Boulder, his wife wrote a rambling, accolade on what a wonderful man her husband was for being a good Christian who delighted in the freedom of being a Promise Keeper.  The next month, she was in the ER getting an X-ray to determine if Prebus had broken anything when he struck her.


By Joseph Dylan


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