Heartburn, Insomnia, and the Byword for Recklessness

Dr Adam Able liked to think that, had his house-cum-hospital possessed a working EKG machine, then Nicolas Pfeiffer may have still been alive. 

The generous part of him acknowledged that, even if he did have access to the gold standard diagnostic tool for detecting myocardial infarctions, he wouldn’t have had the ability to provide definitive management of such pathology. After all, thanks to the post-apocalyptic world he now lived in, cardiac catheterization labs were as hard to find as the trained interventional cardiologists needed to use to equipment in those labs to navigate a person’s coronary arteries under fluoroscopy. 

Dr Able was a general surgeon by training and was living in the small settlement of Cain Township, home to about three hundred survivors of the zombie apocalypse. He figured it went without saying that he lacked access to both catheterization lab and interventional cardiology colleagues. 

He therefore knew that Mr Pfeiffer’s death was unpreventable. Even before the end of the world, Dr Able had maintained a reputation among his colleagues and patients as being ruthlessly practical and realistic. He firmly believed that, if he had done everything in his power to provide the best care possible, then the outcome didn’t matter. Plenty of his patients had died in the past—perhaps even fewer than those of his other surgical colleagues—but when he had worked in pre-apocalyptic times, he had been able to sleep easily knowing that he had given each patient the best care he could have given. 

Working as hard as he could during the day was exhausting, but it ensured that his conscience was clear enough and his body was tired enough to allow him to fall asleep quickly and sleep soundly.

And sleep was something Able prioritized.

It was also something that, in these post-apocalyptic times, was constantly in jeopardy.

Being the only trained physician in the township had destroyed any semblance of work-life separation that he had previously enjoyed. He did have his share of nights on call before the end of the world, but he also had time off. He was allowed spurts of time safe from work encroachment: time that was his and his alone.

Now? Now he essentially ran a twenty-four-seven clinic/urgent care center/hospital with only the help of someone who had been a zookeeper in their pre-apocalypse life. 

To say that his job was exhausting was an understatement. 

It didn’t help that Cain Township had precisely zero surgery capabilities—no operating room, no surgical tools, no ability to effectively sterilize surgical tools even if he had them, no ventilator, no anesthesiologist to manage the vent settings even if he had one, no scrub tech to assist him…

This list of lacking was a long one.

Of all the medical specialties, surgery was the one that he had started to suspect was the least useful in his current situation. 

Therefore, having to learn how to be a general medicine practitioner while engaging in such practice left him more stressed, tired, and overwhelmed than he had been at any point in his career, including intern year of residency. 

But at least he still had no trouble sleeping at night.

And then Mr Pfeiffer died. 

————————————————————— 

“You’re admitting Lindsay?” Tim asked, hovering in the doorway to Able’s office as he busied himself documenting her symptoms and his treatment plan.

“Yes.”

“For…?”

“For a UTI.”

“A UTI.” Able didn’t have to look up from his writing to detect Tim’s dubiety. 

“Problem?”

“No, it’s just…she seems to get a UTI every couple of months and she doesn’t look sick and you’ve never admitted anyone for a simple UTI before. What changed?”

Able kept writing. “You’re telling me you’re confident that the infection won’t go up to her kidneys?”

“Well…no. But…UTI’s don’t usually seem to do that? And, she can always come back if she gets sicker, right?”

Able ignored the vicious inner voice that agreed fervently with Tim's logic. “Do you really want to take that chance?”

“I…no. I don’t.” 

“Good. Neither do I. You can put her in the main ward.”

—————————————————————

“Did you really just request that Mr Vanderbilt come see you in clinic tomorrow?”

“I have three patients waiting for me and he had more problems than we were able to get to today.”

“But…he always has symptoms that he wants to talk to you about and I distinctly remember you telling him last week that he can only come see you in clinic if the symptom is new, lasting, severe, and possibly deadly.”

“And you pulled me aside afterwards to lecture me on my lack of bedside manner.”

“Which is completely besides the point.”

“I’m not sure what your point is.”

“My point is that I’m just wondering why you’re taking him seriously now. Especially when your clinic schedule is the busiest I’ve ever seen it.”

“Just…just pencil him in for tomorrow, please.”

“….fine.”

—————————————————————

“Mr Tobin wants to speak with you.”

“Put him in an exam room and I’ll be right there.”

“What? No, he’s not a patient.”

“Then why is he here at…” Able forced his tired eyes to focus on the clock across the ward from where he was doing one final sweep of his patients before he turned in for the evening. “…ten at night?”

“Because you put his daughter under quarantine.”

“So?”

“So, he wants to know why you think she’s going to turn into a zombie.”

“I don’t.”

“Then why did you put her in quarantine?”

“Because she just got back from a scouting trip.”

“And did she have any bite marks?”

“No.”

“Did she have any physical exam findings that would make you think that she was at risk of turning into a zombie?”

“No.”

Silence.

“Look,” Able snapped, the pointed weight of Tim’s silence prodding sharply into his last nerve, “She just got back from outside our walls. It’s my job to make sure that our runners don’t make any zombies happen inside our walls.”

“If she didn’t have any bite marks when you examined her, then what makes you think that she’s at risk of turning into a zombie?”

“Because she just came from a place where zombies roam freely!” Able didn’t throw his hands up in exasperation, but it was a near thing. “What if she was bitten and I just happened to miss the bite mark? Or…or what if there are other methods by which a person can become infected with whatever virus it is that kills people and then turns their corpses into ambulatory, hungry, dead things?”

Tim actually quirked an eyebrow in pointed disbelief. Able didn’t know he could do that. “Really?”

“I will not have people in other settlements use my name as the byword for recklessness when they discuss the horrible fate of Cain Township. If we all die because the infestation got within our walls, I want to go to my shamble-y death with a clear conscience!”

He wasn’t sure if it was his (admittedly shaky) logic, his fervor, or the fact that he finally lost his impulse-control and flailed his arms in exasperation that convinced Tim to drop the argument and leave.

He felt vaguely ashamed of himself in the silence that followed, but this sentiment quickly receded and ire took its place as a storm-faced Mr Tobin strode into the wards, clearly on a mission and likely—Able couldn’t help but think—given passage into their small ward by a passive-aggressive Tim.

—————————————————————

“She doesn’t need surgery,” Tim said, flatly. Able continued rooting through one of their storage spaces, looking for something that could reasonably be used as a pair of hemostats.

“And why do you say that, Doctor?” Able asked, ignoring the twinge of guilt at how viciously sarcastic he sounded.

“Because her abdominal pain is gone. It went away as soon as she had a bowel movement.” Tim’s voice stayed level, not rising to the bait, but there was a note of clearly unimpressed flatness to it.

Able stopped his rifling. “What?”

“Yeah.”

“Oh.”

“Uh-huh.”

“So it wasn’t appendicitis after all, I suppose.”

“Nope.”

A thought hit him. “I…I guess I used the last of our metronidazole for nothing, then.”

“Yup,” The reply came from down the hall. Tim obviously felt that he had made his point.

——————————————————

“Okay. That’s it. This needs to stop.”

Able, making some notes at his desk, looked up to see Tim, obviously angry, standing in his office doorway. 

Able had never seen Tim obviously angry before.

He wasn’t certain what Tim was referring to, but he sensed that now was not the time for dismissive glibness. He put his pen down and folded his hands calmly before him. “I’m listening.”

This calm response seemed to surprise Tim a bit. He uncrossed his arms and placed his hands into his trouser pockets. “You’re about to admit Mr Vanderbilt.”

“….and.”

“For a heart palpitation.”

“…yes?”

“A single palpitation.”

“…Uh-huh.”

“That happened last week.”

“…I don’t think I see your—“

“Yes, you do!” Tim interrupted, raising his voice. “I don’t know what’s gotten into you lately, but you’re being ridiculous! I’ll be honest, in my opinion, you used to be too indifferent and cavalier when people came in for evaluation, but now you’ve swung to the other extreme! Lately, it seems like you’re treating every person who comes through our doors as if they might die at any second and I just--I just can’t! I can’t keep up with this! We’ve admitted more patients this week than we did in the entire month before!”

Able stared at Tim in shock. He had never heard Tim speak like this. He looked at his nurse more closely. He looked agitated and flushed, but beneath such galvanizing emotion, Able noted a slouched posture, red-rimmed eyes, slightly greasy hair, and a good amount of scruff on the man’s typically clean-shaven face.

Able didn’t need a medical degree to diagnose Tim with exhaustion. 

He absently wondered if his appearance was similar. He couldn’t recall when he last looked in a mirror. Or when he had last had a conscience-clean good night’s sleep.

It was one thing to work himself into the ground, but Tim? The one person he depended on and trusted the most in this new world of theirs? Tim deserved better. 

“I’m sorry, Tim,” Able sighed, leaning forward slightly to rub at his eyes. “You’re right. You should take the rest of the night off. I’ll get Vanderbilt settled in and see to the rest of the patients tonight.”

Tim huffed out an impatient breath. “That’s not what I want.”

Able felt his own temper flare. “Then clearly you’re going to have to dumb it down for me.”

“What’s going on? You’ve been off for the past week. What happened that—“ Tim broke off suddenly, eyes going distant. “Nicolas Pfieffer. That’s…that’s what happened, isn’t it?”

Able felt cold anger well up. “‘What happened?’” he snarled. “I sent a man home to die from a massive heart attack that I had assumed was merely heartburn! He came to me three times for help and I just…dismissed him every time!”

Tim met his gaze and held it. “Yeah. You did.”

“What?”

“You made a mistake. An error in judgement. It happens.”

“‘It happens?’ Well, I’m sure his widow would love to hear such a reassuring sentiment.”

“Stop it.” Tim was still holding his gaze and his voice was firm but level. “I’m not going to help you punish yourself. A man died. I’m sure you don’t need me to tell you that, even if you had made the correct diagnosis, the outcome wouldn’t have been different.”

“Yeah, but I could have listened better and treated his pain more aggressively and told him and his wife what to expect!”

“Sure. I’m not saying that you shouldn’t care. And I definitely think that you can learn from this mistake. But it doesn’t look like you’ve learned the right lesson here. Just because one person died doesn’t mean that everyone who comes to you for help will, too.”

“I know that," Able snapped, "But…but if I keep them where I can watch over them, then I’ll be able to pick up on the first signs that something dangerous is happening.”

Tim was silent for a second, as if waiting for Able to evaluate his own words. Irritatingly, as Able did so, he noted how absurd his rationale sounded.

“I don’t know what else I can do,” Able conceded, more softly.

Tim sighed and approached Able’s desk, taking a seat in the chair opposite from him. “I think you do. I think it’s obvious. Start listening to your patients more carefully. Keep an open mind about the diagnosis and don’t…what’s the word you use?…anchor. Don't anchor. And…if we need to admit more people because doing these things makes you start to worry more about them, then that’s fine. But we can’t keep working at this pace. You look exhausted and you’re starting to make mistakes.”

“What? No I’m not.”

“You told me to give 750 milligrams of levothyroxine to Mr Ellis today.”

“What? I did?” Able was struck by a thought. “You gave him levofloxacin instead, right?”

“Yes. And you’re welcome. I figured a case of thyrotoxicosis was not something you wanted to deal with today.”

“Or ever,” Able added. He suddenly felt the full weight of his exhaustion settle on his shoulders. 

“You have to let it go,” Tim said, softly. “You made a mistake and I can’t imagine how hard Mr Pfeiffer’s death hit you. But if you keep doing what you’re doing, someone else is going to die.” He smiled slightly—just an upward quirk at the corner of his mouth—and added, “And, at the rate I’m going, it’ll probably be me.”

Able rubbed his face again. “No, you’re…you’re right. I’m sorry. I’ll…I’ll try to do better.”

“You know, if it helps…” Tim trailed off, sounding slightly nervous.

“If it helps…” Able prompted.

“I can help out? You can run your cases by me and if something sounds fishy or if I feel you’re being too dismissive, I can let you know?”

“Tim, you’re a zookeeper.”

“And you’re a surgeon. How often did you treat diabetes before the zombies ruined the world?”

“Point taken.”

“And, well, I’ve been trying to read as much as I can about medicine. I like to think that I’m at least better than nothing?”

Able smiled slightly. He honestly hadn’t paid much attention, but now that he considered this, he realized that Tim seemed to have grown much more competent in his role as a nurse over the past few months. In fact, he had met several trained nurses in pre-apocalyptic times who would have failed to note his earlier error regarding levofloxacin. 

“You are so much better than nothing, Tim,” he said gently, feeling slightly warm and almost uncomfortable at making such a sincere statement. 

Tim smiled. It was a genuine, bright thing. “Thanks, Doc.” Then, he groaned slightly as he stood stiffly. “I’ll go admit Mr Vanderbilt. Just…think about what I said, yeah?”

“Tim, wait,” Able sighed, standing as well. “I don’t think we need to admit Mr Vanderbilt.”

Tim looked hopeful. “Yeah?”

“Yeah. You’re absolutely right. He can go home and come back in if his symptoms return.”

“Huh. That was a lot easier than I thought.”

“Yeah, well, don’t get used to it.” Able did his best to suffuse his voice with as much long-suffering grumbling as he could.

“I won’t,” Tim replied. Most of his typical cheer seemed to have returned.

“And Tim?”

“Yeah?”

“Thanks. I…I really appreciate it.”

“No problem.”

They walked into the hall together.

The silence was broken after a couple of steps.

“Oh, and Doc? I’ll let you break the news to Mr Vanderbilt.”