The screams came from above me. I ran up the trail and into the woods. Red and white smoke billowed across the ground, obscuring everything. I spun around, searching for anything that looked like a patient. The wind shifted, causing a plume of smoke to spiral up into the air, and I saw it. A boot in the dirt. I dove towards it, dropped my aid bag and began evaluating the patient. The sound of machine guns ripped in the distance.
“Hey buddy, are you all right, are you okay?” I hollered. I quickly ran my hands from head to toe, looking and feeling for injuries.
A whistling scream pierced the sky. “Incoming!” a voice yelled in the distance. I leaned over my patient, creating a barrier between him and the metal fragments of the mortar round barreling towards us.
“No, no, no, Goddammit!” Sergeant First Class Genarro yelled as he stomped out of the woods in front of me. “You got to cover your patient, Bess.” He shoved me down onto the practice dummy, forcing my face into the dirt. “You’re a blanket, not an umbrella, son.”
“Yes, sergeant, a blanket,” I yelled.
Sergeant Genarro put his knee into my back and lowered his weight onto me. The air shot out of my lungs as the hard plastic of the mannequin pressed into my ribs.
“You got to cover him completely, Bess. You got to take that blast for your patient. Don’t let him get another wound.”
“Roger, sergeant.” I tried to yell enthusiastically, but my lungs couldn’t manage the effort.
“You feel that patient under your belly, private? You feel his bloody flesh in your face?”
“Is it uncomfortable?”
“Then you know you’re doing it right.” He leaned forward, pressing the mannequin deeper into my chest. “What’s our motto, private?”
“Sergeant,” I paused, trying to think. “Non Pro Nobis…Non Pro Nobis Sed Aliis,”sergeant.”
“And what does it mean, private?”
I thought about the lectures we received about 105th Medical Regiment, the first formation of combat medics during the Mexican-American War, and the legacy and motto they passed on to us.
“Not for ourselves but for others, sergeant!”
He grabbed me by the collar and yanked me to my feet. I didn’t want to look at him, so I watched the last remnants of the smoke grenades wreath around his jungle boots and up his starched uniform. I knew what I’d see if I looked up. The Expert Field Medical Badge on his chest, the 1st Infantry Division combat patch on his shoulder, the disdain in his eyes.
“Don’t you ever let your personal welfare come before your patient.”
“I’m sorry, sergeant.”
“Don’t apologize to me, son. Apologize to the soldier you just killed,” he said giving the dummy a kick to the head.
I looked at the mannequin, dressed in fatigues and covered in fake blood. “Sorry.”
“Medic. Hey medic, wake the fuck up.”
I peeked out from my sleeping bag to see a red flashlight beam painting streaks across the inside of my track.
“Get up, private. We need you at Bulldog Two-One.”
I rolled out of my bag fully dressed, slung on my LBE, and felt for my pistol and protective mask. Check. Grabbing my helmet in one hand and aid bag in the other, I lumbered out of my armored ambulance into the moonless black of another night in the South Korean countryside.
“What’s wrong?” I asked the soldier walking briskly next to me.
“Don’t know. That’s your job, medic.”
Medic. He practically spit the word at me. Here on the line respect was reserved for the killers—tankers, scouts, and infantrymen. Back in the training battalion, seasoned medics like Sergeant Gennaro had warned us that an unproven medic was about as welcome on the line as a case of heat rash. The only way to earn your keep, and the title “Doc,” was by proving yourself, putting your patient’s wellbeing ahead of your own.
I stumbled along, following the flashlight. I’d been in country exactly ten days, assigned to the 2/72 Armor Battalion for seven, and in the field with Bravo company for four. This was my first duty assignment, and I was heading for my very first patient.
“Well, is he bleeding?” I asked.
“No, it’s his stomach.”
I ran through all the things I could remember from my training. Ruptured appendix, appendicitis, pancreatitis. Shit. I had no clue how to diagnose any of those things. I tried to remember which quadrant of the stomach held the pancreas. By the time we reached the tank, all I could remember was that the duodenum was in the upper right quadrant, but I had no idea what its function was or if it was even prone to causing pain. As I climbed up the side of the tank, two soldiers sitting on the back smoking cigarettes hollered towards the turret.
“You’re fucked now, Hurley. They sent the private.”
“Hey Hurley, can I have your Playboys when you die?”
Inside the turret, a soldier sat doubled over in the commander’s seat. Multicolored lights shone like a stained glass window behind his head. Below him, in the belly of the tank, Sergeant Riley, whom I had met at the Division in-processing station, sat reading a hot rod magazine. A small Walkman was wired into the tank’s intercom system, reverberating Pearl Jam’s “Evenflow” off the iron walls.
I leaned into the turret and placed my hand on my patient’s shoulder.
“Hey buddy, how you doing?”
“Shit, not good,” he said, turning his head slightly to look at me. “My stomach’s fucking killing me.”
“How long’s it been going on?”
Well, I thought to myself, that rules out trauma.
“Can you point to where it hurts?”
He made a circular motion around his abdomen with his hand and said, “Everywhere.”
Good, I thought, no point tenderness, probably something gastric.
“Can you lean back so I can feel?”
He tried to straighten himself in his seat, and I could tell that it made things worse.
“I don’t want to come off the line,” he said staring at his boots. “I can’t go back to the rear.”
My gut tightened. I squeezed his shoulder.
“Hey, that’s why I’m here. Forward medicine, baby. I’ll take care of you. Get you back in the shit.”
I looked at Hurley, and my heart ached. At that moment I understood my mother’s reason for leaving nursing. She used to always say that she couldn’t stand to see people suffer, that she cared about them too much to know she couldn’t help them. I knew I had to do everything I could for him, so I focused on what I’d been taught.
I felt his abdomen with my left hand. No guarding, no rigidity. I asked a series of direct questions. He’d had worsening diarrhea since he’d been in the field. His head hurt. He was dizzy. He had no other symptoms.
“Can you come back to my track, so I can start an IV? You can rack out for awhile, get some rest.”
He looked at Sergeant Riley, who’d turned to see how he would respond.
“Can’t you do it here?” Sure thing, I told him.
I started an IV and hung it from the whip antennae mounted to the turret.
“Look, you’re dehydrated. You’ve been shitting out your electrolytes. I’m going to run this bag, then see how you’re feeling.” I pulled a bottle of Pepto from my aid bag and gave it to him. “Here, take a big drink of this every four hours starting now. Also, I don’t want you eating the K-rats. That shit’s too greasy. It’ll run right through you. We need to keep some food and fluids in you for a day or two and see what happens. You guys have MREs?”
Sergeant Riley spoke up, “Just this box, four lunches for two days.”
We had hot chow every morning and evening, K-rations, and ate the prepackaged, Meals-Ready-to-Eat for lunch. MREs were well-known for causing constipation, which may have been why the hot food was served so greasy, to even things out. But it wasn’t working for my patient.
“I’ll see if I can get more,” I said.
I walked around our Area of Operations, searching for the mess trailer. Two cooks were getting breakfast ready, but they refused to give me a case of MREs. They had an entire pallet full, but no matter how hard I tried to explain the medical reasoning, they refused to just give out a case to some private.
“If you can get authorization from the First Sergeant,” one of them said, “then we’ll give them to you.”
I walked to the Tactical Operations Center and found the soldier on radio watch. I explained the situation to him, but he said I’d have to come back in the morning, because he had strict orders not to disturb the First Sergeant unless the North Koreans started a war.
I left the TOC and stood in the dark staring at nothing. What the fuck was I supposed to do now? I headed for the mess trailer and snuck around back. I crouched low in the shadows, listening. The two cooks were joking and listening to rap music. The pallet full of MREs was only a few feet away. I thought about Corporal Hurley hunched over in pain. I thought about what would happen if I got caught: loss of rank, loss of pay, months of extra duty. Then I thought about the motto I had been forced to memorize: Not for ourselves but for others. I crawled forward, snatched two cases of MREs, and ran back to Bulldog Two-One.
The soldiers who’d been smoking were now stretched out on the back deck of the tank in their sleeping bags. I left the cases next to them and crawled up to check on Hurley. He was curled up in the cupola, his head propped on his helmet.
“How you feeling, troop?”
“Better, much better.”
“Good,” I took down the empty IV bag and removed the canula from his arm. “Look, I had to swipe some MREs for you. There was no other way. Keep it between us.”
Sergeant Riley shot me a hard look.
He turned back to his magazine without a word.
“Stay away from those K-rations, corporal, and come see me tomorrow afternoon. Okay?”
The next morning, before I was out of my sleeping bag, Sergeant Riley showed up at my track. He was carrying a tray of scrambled eggs, grits, toast, sausage, and two cartons of milk.
“Here you go, Doc,” he said, setting the tray on the floor of my ambulance.
“What’s this for?”
“For taking care of Hurley last night,” he said, seemingly surprised that I would ask.
“How is he?”
“He’s doing good. We’re letting him sleep a bit. But he hasn’t run off to the woods to shit once since you left.”
“Good. That’s good.”
“You need anything else, Doc?”
I thought for a second about the things I could use at that moment—a hot shower, a cup of fresh coffee, a letter from home—then I pictured Hurley sleeping soundly for the first time in days.
“Nope, I think I’ve got everything I need. Thanks.”
It was another quiet night in our little E.R. at Keller Army Community Hospital, the only 24-hour facility at the US Military Academy. Two of my medics were stretched out in the trauma room, sleeping. The PA was upstairs in the call room, sleeping. And I was at the front desk, playing solitaire and surfing the web for cheap apartments back home, some place to start my conversion back to civilian life after six years in uniform. I wanted to be sleeping too. But I had to stay awake; somebody had to listen for the radio or be alert if a patient rolled in the door, and I was a Staff Sergeant, the second-highest ranking NCO in the Emergency Room. It was my job to take care of my soldiers, to let them sleep. So I played another round of solitaire and thought about growing a beard when I got out.
“Keller base, State Patrol.” The radio snapped to life next to my head. I jumped a little in my chair and took the call.
Flipping on the trauma room lights, I yelled “We got a call!” as both medics hopped to their feet.
“What is it?” asked PFC Brice, a tall, lanky twenty-year-old.
“Unconscious male on the highway.”
“Not Tommy Baldridge?” the other asked.
I looked at him, Sergeant Anthony Fischer, a solid medic and good NCO who’d just come to us from the 101st Airborne division. “Don’t know who it is, but we got the call.”
Brice was already on his way out the door as I handed Fischer my notes from the call. “He’s just outside Washington Gate, whoever it is.”
“It better not be Baldridge,” he said, putting on his hat and heading out into the dark morning. “I’ll kick his fucking ass.”
The United States Military Academy sits on its own military reservation in New York. But part of that reservation, a stretch a little less than a mile long, crosses over State Road 218. We called it the Miracle Mile. If you got in a wreck anywhere in that stretch, our medics could respond and bring you straight to our ER, two minutes away. Wreck anywhere else and you had to wait for the volunteer services from Highland Falls to roll out of bed, get to the firehouse, then drive the fifteen minutes to come and get you.
Occasionally, a certain Thomas Baldridge would park his car on the shoulder of 218 and drink until he passed out. Eventually, the Rockland County Sheriff’s office or state police would find him, and because he’d claim some medical problem or another, they’d forget about taking him to the drunk tank and call us instead. He was a pleasant drunk, though. In fact, he liked coming to Keller.
I had just finished changing the bed paper in the trauma room when the ambulance rolled in. I decided not to wake the PA on duty. Mr. Baldridge was no drunker than usual, just complaining that his foot hurt. We had a pretty standard protocol for him: blood alcohol level, CBC, Chem 7, and IVs TKO.
Sergeant Fischer sat at the computer ordering the lab tests. “I don’t see why we do all these tests. He doesn’t have insurance. He can’t pay for them.”
“We can’t refuse him service. His liver could be shot. He could have pneumonia. We’ll check him out just to be sure.”
I informed Mr. Baldridge that we would be running some tests and that he’d feel a pinch. He lay placid as Brice drew his blood and started an IV.
“Hey Tommy,” Fischer hollered across the trauma room. “We’re gonna put a tube in your dick so you don’t piss all over our floor again.”
“Use a condom cath,” I said. There was no need to use an invasive and painful procedure on a simple drunk.
“Brice, put a condom cath on this guy,” Fischer ordered.
“Why don’t you do it?” Brice demanded. “I just drew his blood.”
“That’s ‘Why don’t you do it, sergeant?’ And the answer is because I’m doing the paperwork. You’ve got penis duty, private. Enjoy.”
Mr. Baldridge was moved to an exam room, where he promptly fell asleep. When the labs were sent off and the ambulance cleaned, Fischer and Brice resumed their naps in the trauma room. I stayed up, read the labs, changed the IV bag, and played more solitaire. Around five in the morning, Sergeant Fischer rolled out of bed.
“Did you take a look at homey’s foot?”
I looked up from the computer. “Nope, totally forgot about it.”
“Think we should? Just to make sure he doesn’t have diabetes or something.”
“Yeah, sounds good.”
Sergeant Fischer stepped into the exam room and turned on a small table lamp. I could hear him talking softly to Mr. Baldridge, but couldn’t make out what he was saying. In a few minutes he returned.
“He’s got an ingrown toenail. It’s not infected yet, but it’s getting there.”
“You going to take it out?” I asked while I hunted for a red nine.
“Sure, might as well, or he’ll just come back next week when he’s spewing pus.”
“Cool. Take Brice.”
By the time the morning shift came in, Sergeant Fischer had walked Brice through the procedure. He was heading upstairs to grab breakfast from the hospital cafeteria as I finished up the chart note for the PA to sign when he woke up.
“I wonder what that would have cost him at St. Luke’s,” Fischer asked, grabbing a hand-held radio and turning it on.
“Probably five hundred bucks, easy,” I said as I got up to join him.
“How much will we charge him?”
“Probably bill him two hundred at the most. Those toenail kits only cost us, like, eighteen dollars. Doesn’t matter, he won’t pay.”
“You know that’s why he comes here.”
“Everyone knows it. But we can’t deny him service.”
“True, but we could have just sobered him up and ignored his foot.”
“Where’s the fun in that?” I asked as we climbed the stairs to the second floor.
“All I’m saying is that we always take it in the ass for this guy. Our hospital loses money every time we help him.”
“It’s not about us. You know that. Non Pro Nobis, right?”
“If you say so, sergeant.”
After we paid for breakfast and were heading back downstairs, Sergeant Fischer stuck his head in the kitchen door and came out with a patient tray.
“Can’t send the bastard home hungry,” he said.
When I left the Army, I struggled to find work in the medical field. While the Army had trained me in a slew of invasive procedures from chest tubes to venous cutdowns and given me the run of my own E.R., the civilian world required licensing I didn’t have just to change bedpans. Eventually, my experience reading lab reports allowed me to take a job at the Cardiac Care Center. Well, it wasn’t really called the Cardiac Care Center, and none of the employee names I give you are real either. But to tell you the truth of what I saw there, I have to keep those things to myself. CCC was the largest cardiology practice in the state, with eighteen physicians and satellite clinics in seven different towns. They even had their own Heart Hospital with state-of-the-art diagnostic facilities.
I ran the lipid clinic—ordering, reading, and reporting lab values for our patients’ cholesterol levels and managing their prescriptions. One winter morning, I was leaning back in my office chair with the phone to my ear, staring at the ceiling.
“No, I’m sorry, Mrs. Segura, I haven’t heard back from Dr. Roberts yet. He’s been in surgery all week and has only been able to come by the office on his lunch breaks.” I waited, listening. “No, ma’am, your husband’s LDL is fine. It’s his HDL, the good cholesterol, I’m worried about. That’s why I asked Dr. Roberts to change his medication.”
I leaned forward and fiddled with my mouse, checking my email account, as she read off her husband’s medications.
“I don’t want Mr. Segura to run out of medication either,” I replied. “Tell you what, I’ll leave you a month’s supply of Lescol at the front desk. When I get your husband’s chart back from Dr. Roberts, I’ll call in the new prescription to your pharmacy, okay?”
I opened Mr. Segura’s history in my lipid management database. He’d been on the same cholesterol meds for years. Lescol was one of the older statins on the market and wasn’t as effective in raising HDL as others. This wasn’t an isolated incident, and Lescol wasn’t the only drug. I routinely received orders from a handful of our physicians that didn’t fit current best practice. They could be counted on to order specific drugs almost regardless of the patient’s particulars.
Dr. Roberts’ small office was overflowing with papers and charts. A half-eaten chicken sandwich and fries sat on the corner of his desk. The wilted, brown lettuce told me it had been there for a few days. Dr. Roberts was leaning over his desk, talking on the phone, and taking sips from his “I’d rather be fishing” coffee cup. I waited, staring at the row of snapshots taped to the bookshelf above his desk. A few pictures of his twin daughters. A shot of him in front of a mountain stream, decked out in hip waders, flannel shirt, and scruffy beard, holding a large fish. On his head was a beat up Novartis baseball hat. Next to this was a post-it note written on Novartis stationary. A bold, flowery hand had written, “Dr. Rob—How was Canada? Hope you enjoyed the trip. Vicki.”
I knew Vicki. She was the Novartis pharmaceutical rep, one of the many from various companies who were always hanging around the office chatting up the docs.
When Dr. Roberts hung up the phone, I walked up to him and said good morning.
“Oh, hey John,” he said. His rusty hair was matted to his head, and the wrinkled scrubs peaking through his crisp lab coat told me he’d been in the cath lab all night. I tried to minimize the typical, ex-military, too much coffee, let’s get it done tone of my voice.
“Do you happen to have Johnny Segura’s chart?”
He looked through the piles on his desk and pulled it out. There on the top were the prescriptions I had written. It was common practice for techs to write out prescriptions so all the doctors had to do was sign if they agreed. I had provided Dr. Roberts the two top therapeutic choices for Mr. Segura’s condition. Above them was my own hand written post-it note in the cryptic short hand of our practice.
HDL<39, LDL 88 on current Rx. ∆ to Tricor 160mg qd? Lipitor/Niaspan?
Dr. Roberts looked at the recent lipid test clipped to the chart, then scrawled the following prescription change next to it: Gemfib 600/Lescol 40 bid.
“Here you go,” he said, handing me the file and tossing my prescriptions in the shredder.
I read his note and held a finger up as if I could stop time for a moment while I thought about his decision. “Do you really think this is the best choice?”
“But numerous studies have shown Tricor to be the most effective course of treatment for ACH patients with low HDL.”
“Really?” he said. He spun in his chair to face me. “Remind me again which medical school you went to?”
“Never mind,” I said. “Lescol it is.”
I walked to the storeroom, seething. I couldn’t help feeling that we were screwing Mr. Segura over by not giving him the best meds possible. I began filling a plastic bag with sample packs of Lescol and pamphlets on managing cholesterol. I pulled a pen and blue post-it pad out of my lab coat, scribbled Mr. Segura’s name, and placed it on the distorted CCC logo emblazoned across the bulging package. As I was putting the pad back in my pocket, I noticed the large Tambocor (3M) logo across the top. Every writing utensil, magnet, and day planner in our office was from some pharmaceutical company or another. It was just part of working in a civilian medical practice, so much so I never thought much about it. I realized that in the Army we gave the cheapest, most effective drug available, generic if possible. The docs at CCC rarely prescribed generics.
I opened Mr. Segura’s bag and cocked my head to read the side of a Lescol box. Manufactured by Novartis. My cheek twitched. I felt my jaw tighten. I finally understood: Not for others but for ourselves.
I’d like to tell you that I marched upstairs and filed a complaint, that I exposed this travesty to the world. But I did nothing. I knew a patient’s health was being compromised for some grand fishing expedition, yet I did nothing. To this day I’m not exactly sure why. I had gone into the medical field to help people, and I felt like I was making a difference. But at that moment, I learned that medicine was not inherently about helping others. For the first time, I saw the medical field from the practice’s perspective, from the perspective of pharmaceutical companies and others for whom it was a money-making opportunity. Maybe I’d been idealistic. Maybe I’d been naïve. But now I was just disillusioned. Worse, by not saying anything, I was complicit. My silence may have harmed Mr. Segura. It surely didn’t help. I made the decision to just do my job—answer the phones, fill prescriptions—and something inside me, some bit of the great pride I felt as a caretaker of my fellow man, vanished.
Six months later the entire nursing staff was gathered in the Cardiac Care Center’s conference room. We were seated around a huge, oval table facing a bounty of coffee and doughnuts. We were all there but one: Maggie Shea, our senior nurse. She’d been let go the week before. The rest of the nursing office, we were told, would take up her duties. We would do more with less.
This was the mantra of Mike Spinogle, the fellow aiming a laser pointer at the screen in front of us. Several smaller cardiology practices in the region had merged and were literally giving us a run for our money. So the partners had brought Mike in from some big east-coast practice to make us more profitable.
It was his idea to fire Maggie. It was also his idea to stop our free prescriptions for indigenous patients. My officemate, Tom Keeley, who ran the indigenous patient program, was promptly let go as well. Everyone in the nursing office wondered who was next. People were dusting off their resumes and preparing arguments for their own necessity within CCC. It was this tense bunch that sat before Mike eating doughnuts and drinking coffee, because that’s what you do when you’re a team player. You eat the doughnuts. You drink the coffee. And you keep your mouth shut.
Mike was striding back and forth in front of the screen. He reminded me of George C. Scott in the intro to Patton, except Mike had Italian leather loafers instead of jack boots, a laser pointer instead of a riding crop.
“Everyone gets the tunnel,” he said, referring to the imaging tunnel of the CT scan. “We’ve got studies upon studies that allow us to order MRIs or CTs on every patient. Congenital Heart Disease?” he paused for effect and turned on his heel. “MRI.” He looked at me and pointed, “High lipids?”
“Bingo!” He snapped his hand back and pumped his fist. “Nurses, if you think someone needs an echocardiogram, order a function MRI.” He hit a button on his laptop, and his Power Point screen changed to show a list of prices. “Insurance only pays $178 for an echo, but they’ll give us $312 for an MRI. So we’re phasing out our echo lab. We’re going to create two new exam rooms to increase our patient flow. An extra hundred patients a month will allow us to generate unprecedented revenue for the practice.”
I left the meeting feeling like I’d just been subjected to a fast food training film. Would you like an angiogram with your Coronary Artery Disease? Super Size that EKG?
I retreated to my office and listened to my voicemails. Half of them were for Tom. The operators didn’t know what to do with the frustrated patients now that Tom and his program were gone, so they were sending them to me. I wrote down the names and phone numbers and began calling them back. The first number I dialed was for an elderly patient living on the Navajo reservation. I held my breath while the phone rang and sighed deeply when her answering machine picked up.
“Hello, Mrs. Yazzie? This is John Bess from the Cardiac Care Center returning your call.” Mike was passing by my office and stopped in my doorway. He leaned on my doorjamb, waiting. “In regards to the free medications you were receiving, I’m sorry to inform you that our practice will no longer be offering that service. You can apply for help directly from the manufacturers, and if you’d like, I can help you get those forms filled out.”
Mike leaned in over my monitor, whispering. “Don’t forget the CT.”
“I’d also like to tell you that we are now offering cardiac imaging, both CT and MRI, exclusively to our patients. Feel free to call us if you’d like to set up an appointment.”
Mike gave me a thumb’s up and a healthy nod as I hung up the phone. “Good work. Hey, I heard you had some extra room in here,” he said looking around my office. “Yeah, this will do. We’re going to move you over to the records room, set you up a phone and computer there. We can get another exam room in here, increase our flow. How’s that sound?”
“Sounds great, Mike.”
I wanted to tell him what it really sounded like—one more plan to shaft the patients in order to make a buck. I wanted to tell him how I had come to despise the healthcare system. I wanted to tell him that I couldn’t look myself in the eye anymore. But I knew my words were pointless. There was money to be made, and somewhere along the line, some people would be helped. But some would be lied to. Some would die. All I could do was make sure it was never again a result of something I did, or, as in Johnny Segura’s case, failed to do.
As Mike walked away, I picked up my stethoscope and left my office. I wandered around the building for a while. I slowly headed towards the administrative offices. No one was around, and all the doors were locked. I pulled out my heart-shaped Plavix post-its, scribbled a letter of resignation, and slapped it on Human Resources’ door. I packed up my office and, without fanfare or explanation, walked away from medicine for good.
John D. Bess received his MFA from the University of New Mexico, where he still teaches various writing courses. He is finishing his first book, an essay cycle about his tumultuous relationship with his father, titled Still Life with Guns, and researching his second, an historical novel about the Colfax County War. He lives in Albuquerque with his son, Jacob, two German Shepherds, and a vast array of guitars.