CONCUSSION, short story by Blake Prescott

! ! ! ! INTRODUCTION

The basis of this short story emanates from a series of suggestions submitted by the author to a variety of authorities and media over a few years. Here, the material is selected and presented in a more intriguing fashion. The characters in the story are fictitious, the medical facts are real.

Type to enter text

2

! ! ! ! TROUBLED TEA

!
! Disconsolate. What other way could he describe it? He thought that he had anticipated and been prepared. Now, he felt like a fool, an object of derision, no ... worse. His adversaries had actually reined in their criticism. While he had reeled from his series of gaffes, they had delighted in exhibiting their comfort with every detail of the subject, ignoring him. That was hours ago, but he could not be rid of it, or the remorse that accompanied it.

! He sat down on the iron chair, not noticing the crumbs on the seat. The waiter came and asked for his order. "Tea," was his simple response.

! "What kind of tea, sir?"
! "Any kind. You choose."
! He noticed not whether others were there, let alone any discerning quality they might exhibit. He had no idea as to the occupants of the half dozen tables in this sidewalk cafe. The only pertinent thought circulating in his cranium was disquieting. Others might be looking at him, whispering, and none of it complimentary. This was an unfamiliar and unwanted feeling. So he further shuttered his awareness, and sat with his face in his hands.

! It wasn't the tea. It was a woman. "Is this chair taken?"
! "Ah, no."
! "Do you mind?"
! Hardly hearing the question, and certainly not catching its implication, he simply shook his head negatively, being somewhat taken aback when she sat down. She carefully placed her coffee in front of her, reached into the leather trimmed bag at her foot and placed a few neatly clipped papers before her. One hand adjusted her glasses while the other, her left, targeted the first page with a pen.

! "Your tea, sir," the aproned man stated as he set a pot and cup meticulously before his customer. "And here, sir, in these foils, are the teas. You choose."
! The waiter had taken only a few steps, certainly not beyond earshot, when the woman lifted the pen to her lip and noted, "Officious prig!"
! "But, then,” she continued, “there’s no shortage of people who delight in arrogance.” She paused, and with only a fleeting glance directed toward her implausible companion, she continued, "It's refreshing to encounter their opposite. It sets up an interesting ring for sparring.”
! Taken aback, he had absolutely no idea what she was talking about, and certainly had no response.
! She stroked a check mark next to one line of the page before her, put the top of the pen to her lip, and muttered to the paper, until she more clearly stated, "You see," she paused, circled a word with her pen, and then, continued, "or, at least I should hope that you see, you were set up.”

! “What?”
! “They obviously had conspired, taking that abstruse, ridiculous minutiae, and made it look like everyone should be thoroughly acquainted with it. You were a patsy.

3

They wanted to eliminate you, or at least make you seem inconsequential; so they set you up. You were a mark. I hope you don't go to carnivals. You'd be fleeced in the first hour."

! "I'm sorry, I'm not sure I know what you're talking about."
! Resting the pen on the paper, she took off her glasses, looked him straight in the eye, and emphatically asserted, "Of course you do. You're too trusting! They bring up financial details that are phantom figures and dazzle you, and presumably dazzle the audience, and what do you do? You don’t suspect them. You fault yourself. They played you! Arrogant connivers! And they delighted in their little victory. Public servants, no; self serving, yes. They don't deserve to be elected!”

! “And, come on, were you hurt that bad? Sure, it was a back-hander, a foul, but it wasn’t a knockout. You still have your turn. Wait for the opening and savor that sweet, satisfying moment. Instead of fancy footwork, you feint, and pow! Retribution is a mother!"

! "Who are you?"
! "I'm offering you a way back; something they, your gloating opponents, would grab in a twitch. And you ask about the source! You are so naive! But your idealism, your dedication, and your willingness to go toe to toe with the pros, that really is refreshing. You see the need for change, you insist on change, well ... this is how you’re going to get it. You’re a fresh face with no history of losses, and you obviously believe in what you are doing. That’ll pull in a lot of backers. But, you have to show that you can take a round or two. And, make no mistake, this fight is going to go outside the ring as well. You need organization and preparation. You need a couple of Dobermans by your side. We might just throw in a pit bull."

! "Miss, or Ms, or whatever, I really am a tad confused. The race isn’t over? You think I’ll even be invited to the next debate? Sorry, but you can't blame me for being doubtful. And, who are you?"
! Now, awaiting her response, he looked at her squarely, studying her features. She was both comely and commanding. Chiseled angles and prominent cheek bones somehow pleasantly blended with a rather wide mouth and prominent teeth to suggest authority. Her confident posture, broad shoulders, and athletic proportions accentuated that impression. Her conservative, tasteful attire described professionalism. There was only minimal makeup and no jewelry adorning impressively large hands. A wide- brimmed hat nearly completely covered her hair and shadowed a cafe? au lait complexion. The additive impression was almost androgynous. She was a handsome, impressive looking woman.
! She had paused, looking back at him without discomfort. Then there was the beginning of a smirk. One eyebrow exerted some independence by elevating briefly as she said, "I'm the one who's going to teach you how to fight."
! She carefully folded the pages lying before her, stood, and handed them to him. As he got up to receive them, he saw that she was nearly equal to his height. He hadn't expected that she would follow that gesture with no word, but, instead, a grasp of her bag, and a turn toward the street.
! "What am I to do with this? You're leaving? How do I contact you? Really, who are you?"

4

! Turning back briefly, she assured him, "My dear Brandon, I shall contact you. Study those pages. That's the first of twelve great punches. It's a stiff left jab. Later, we'll surprise them with a left hook. I do love those left handers! Oh, and as to who I am, read on."

! And a moment later, she was gone.

!!! !!!!

5

! ! ! ! II! PAPER PUZZLE
! As he placed the tea cup on one corner of the papers, an obese, bald man brushed against his hand, spilling tea over much of the page.

! “Sorry,” was mumbled, emanating from the overly ample abdomen which led the man to the street.
! Patting the papers with napkins, he found himself muttering, “Not my day.” The typing was hopefully still legible, but the annotations in ink were dissolving and flowing over their neighbors. “There goes the left jab,” he uttered as he soaked another napkin. Continuing to talk to the only one sympathetic to his plight, “Oh well, let’s see what I can make of this mess.”

! “More tea, sir?” The waiter had returned.
! “No, thank you.”
! “You must have something to occupy the table, sir. Would you like your check?”
! “Bring me a muffin.”
! “We don’t have muffins, sir. Would you care for some toast?”
! “Fine.”
! “What kind of toast, sir?”
! “I don’t care. You choose.”
! She was right. He’s an officious prig. Now, to the papers.
! Squinting, he attempted to read the soggy pages, hoping there would be no further interruption. Going over them the second time, he was able to assimilate nearly all but those written additives in the northeast of each sheet. A circled portion with an exclamation point was illegible. He put his finger to his lips, much as she had done with her pen, trying to decipher, to summarize, to encapsulate ... to understand.

! While not clearly labeled or outlined, unless by way of the pen marks lost in that sea of tea, his unsolicited benefactor had noted a few, precise points. Health care was, as his opponents had established, the central issue of the battle. He, Brandon, had been blinded by his opponents’ shuffling of figures indicating how dollars could be saved simply by “modernizing,” incorporating those efficiencies that worked so well in their very own New England factories and shops. Surgeries in Florida had patients seated on motorized chairways, passing them most efficiently through stages of questions and examinations. An illustration of the future. Why, one of the two candidates had had his cataracts removed in just such an efficient “clinic.” He was playing golf shortly thereafter. They had presented, as his mysterious friend indicated, their “phantom figures of savings” associated with projected alterations that might be instituted right here in Millville. But this misconception, this shell game of shifting figures was devised to convince the public that they, these two pillars of the state, truly were concerned about health care. She thought not. Instead, she saw him, the Greek American, Brandon Asklepios, as having a true caring and a true vision of the larger picture. The tragedy of his mother, and his determination that others should have better, was evidence enough. That part of her “essay” was clear.

6

! “Your toast, sir. On the left is whole wheat, on the right, white. And, your check, sir. The gratuity is automatically included. Do come again.”

! She was so right, he thought. An arrogant snob, pretending to be a servant.
! Ignoring the toast, he stared at the papers, skimming them for a third and final analysis. It was supposedly simple. Money could be saved, but not through a ridiculous imitation of factories and depersonalization of care. There were to be twelve major steps: steps that would each, most importantly, improve medical care. Almost unbelievably, these steps would also save money. Save lots of money. This was his mantra! What could be better? Instead of the dollar coming first and foremost, it would follow. Nonetheless, while suggesting further measures which would not only follow, but dovetail neatly, here, she emphasized only the first of those steps. It was the ER, the emergency room.

! Local people had complained of the cost of emergency room care, most particularly those folks without insurance. She, in her notes, had indicated this was only the tip of the iceberg. His opponents had used the Florida factory clinic as their focus. He, Brandon, could use another southern state as his example. The average cost of an emergency room visit was, by a recognized authority, $2000.00. In one notorious example, in one southwestern state, one patient had tallied over 100 emergency room visits per year for the past two years! Mind-boggling! He could highlight that case and offer a solution.
! The objective would be that any given emergency room, including their local one, would have an adjacent, urgent care center, and a further, facilitated connection to personal primary care. Emergency rooms are elaborately equipped and carefully staffed to deal with emergencies. They can become exceedingly busy with a need to prioritize care for the most critical. They are not intended to offer continuity of care, follow up care, or treatment of non emergencies. They don’t have the time for patient education, the basis of primary care. There’s little room for compassion, let alone psychological counseling as part of the treatment.
! So, with minimal adjustments, each emergency room, each ER, would be connected to an urgent care center, and that in turn to rotating primary care providers. An ombudsperson would make sure the patient got to the appropriate provider.
! Thus, the 100 plus visitor would not only be shifted from ER to Urgent center, but adopted by the primary care physician on call, gaining continuity and appropriate care and eventually saving hundreds of thousands of dollars. That’s the punch line. Better care and tremendous savings.
! His analysis of the papers was interrupted by a pigeon lighting next to his toast. He couldn’t help himself, and, while speaking softly, he scolded the bird, saying, “You probably won’t tell me your name either.” The bird took a few cautious steps toward the toast. Brandon smiled and whispered, “The whole wheat is on the left, the white on the right.” Then, he was back to summarizing the notes.
! Terminal care is for the dying, for those with less than six months to live, for those searching for some small measure of quality in their remaining life. Prolonging life and prolonging suffering is not the target. Terminal care is not synonymous with emergency care. This is a mismatch. Emergency room staffs are equipped and trained to do all they can to save people. And so they should. Terminal care is different. Do Not Resuscitate, or DNR, is not tattooed on the patient’s forehead. An unrecognized “DNR” patient

7

coming into the ER is saved. This is inappropriate care at great expense. Terminal care should be empathetically delivered, minimizing suffering. The ideal setting for this is home care and hospice, not a jammed and impersonal ER. Then there was the part she had underlined twice: this is a major reason why one third of the cost of any patient is spent in the last few months of life. There’s a point that can make a real impression ... better, more compassionate medicine and great savings.

! One of the scribbled notes fortunately lay in the southwest corner of the pages, free of the fat mans carnage. Clearly decipherable, it had read, “Not to worry. You’ll have two medical expert Dobermans.” Reassured, he moved to the last point, one which touched home.

! What of the patient who presents to the ER with a bag full of medications and an equal number of medical problems? How much time can be spent sorting the medications, analyzing ill effects, side effects, and interactions? Now throw in all the medical problems and multiple presenting complaints. Can we expect an unfamiliar clinician to pick this up in midstream? A personal physician conversant with her case can do this; but that’s not what she’ll get in the ER. She needs continuity of care. This is where third parties have to join the team. Encourage use of and properly reimburse primary care. That’s the road to continuity of care and avoiding disaster.

! That seemed to be the gist of it. A lot of material. It was everything that he championed. Now, how could he present this so others would understand and believe? ! Her pen notes seemed to indicate that this could be done simply. It was the left jab. How to deliver it?!

! “May I take this, sir?”
! “What? Oh, yes, just a moment.” He placed a five dollar bill on the small tray.
! “The bill is seven dollars with the gratuity, sir.”
! He added two more dollars which were whisked away with the tray.
! The waiter must be related to one of his political opponents.

!!!!

8

! ! ! ! III! STOREFRONT
! The light played tricks with him as he faced the storefront, one moment revealing the interior, the next, changing to a mirror. Inside, he saw equipment carefully displayed so as to indicate a family campsite. It even included a somewhat convincing fire so that the coffee pot overhanging might be expected to boil over any moment. With the ax imbedded in a stump, fishing gear leaning against the tent, and backpack opened, one expected a family camper to appear at any moment. Surely, the equipment was more elaborate than any he had had; nonetheless it was a fond reminder of his childhood days when his parents shared their love of nature with him, where biology became a passion at an early age, and where he treasured those few years with his father.

! Then the light changed, and his reflection replaced the campsite. Instead of the boy with his family, he saw a receding hairline and graying temples. His father was in his face. The prominent chin, the more than ample nose, the thin lips, and one tooth seemingly somewhat awry could have been his father. Yet mixed with this, and recessed, as if hiding his maternal, Nordic background, were those stark blue eyes. Not blue, but a light blue-green with a dark blue surround; that was his mother looking back at him.

! Then the light shifted once more. Reassuringly, the coffee had not boiled over. But this interior encounter was most brief; and, when the light left the campsite, he saw another figure next to him.

! “Planning on trying to escape to the woods?”
! “I didn’t know if I would see you again.”
! “I told you that I’d find you. You needed time to stop feeling sorry for yourself.”
! “Well, I think I could have improved more quickly if I had shot the waiter. I did read your notes. Well, almost all.”

! “You couldn’t read my scribbled additions.”
! “It’s a long story, involving a very fat man, tea, and a pile of napkins.”
! “I’m almost beginning to like you. Now, about the notes. You do know that Pattingale, your long legged, superior, strutting peacock accompanied his niece to the emergency room when she had a cut that a boy scout could have taken care of. Are you aware that their visit there was a disaster? You do realize that, in the end, he read the riot act to everyone within earshot, indicating that he would show them how emergency rooms should be run. I fully expect that this will be high on his agenda for the next debate.”

! “No, I didn’t know that.”
! “Well, there are two other things that happened that are feeding right into our strategy. Oh, yes, you are going to be invited to the next debate. So, it’s the left jab, ER reform, with allusions as to how you’ll fight in future rounds. Oh, this is going to be such fun!”

! “Do you have a name?”

9

! “You can call me Cynthia. If I get to like you a little more, you can call me Cindy. Now, here are a few sheets of homework. I’ll make it easier for you this time in case you run into another fat man. Here’s the first zinger. It’s about summary cards and flag sheets. These list allergies, ongoing problems, current meds, special notes, ... you know, like DNR, medic alert, or religious aversion to certain treatments,” she paused and showed him a sample on one page, “like this. See how simple it is? No one should leave home without it. It should be the first thing to hit your eye. Outpatient, inpatient, office patient, any patient. Think of the hospital patient with a chart two inches thick. Who’s going to go through all that? They’ll do well just to weigh it! You need a flag sheet that’s always kept up to date. Just like this one.” She pointed to another example. “It’s the same idea as the card. You’ll see how that plays into Pattingale’s disaster at the end of my notes.”

! She turned to the next page, put her finger in the middle and said, “It gets better. You get to bait them. Oh, you’re going to love this. Talk about retribution! This page is the part about needing time, and dealing with the whole patient. Wait ‘till you see how that hits home.”

! “Why are you doing this?”
! “We don’t have time to go into all that now. Your skeleton crew has been paid their arrears. Our backers are willing to extend themselves that far and a tad more while they wait to see how you do in this next debate. Their motives are honorable, I can assure you. They have the same idealistic goals that you do. They see you as someone who has been knocked down with a really foul punch, someone the public will root for. They feel that you’re a candidate, ... no, the candidate that can get their message, which is your message, across.”

! “Our backers?”
! “Yes, our backers. Now, all that will come out later. First you have the next debate. If you do well, all sorts of things will become evident. I know you can do it. That’s my job. Now, look at page three.”

! “Why me?”
! “Just full of questions, aren’t you. Trust me. We probably know more about you than you do. You’re the ideal guy for the health care message. Now here,” she pointed to an underlined portion of the notes, “these italicized parts refer to the punches to come. You’re going to end up with twelve great shots. Left jab, left hook, right cross. Timing is everything. You bait Pattingale to get the opening, then boom! Read it. Study it. Then we’ll talk again.”

! “What about the other opponent? What about Goldsmith?”
! “I believe you’ll see him drop out after the next debate. Maybe sooner. It’s complicated. He never intended to run the distance. He’ll be backing Pattingale.”

! He took the pages and flipped through them. One page had a lot of those familiar scribble marks, circles, annotations, and exclamation points. He looked up at the window. It was a mirror again, and she was but a shadow fading in the distance.
! Her head half-turned, she shouted, “You don’t have time to go camping. Too much homework.”

10

! ! ! ! IV! THEREFEREE
! Well, it was over. It wasn’t at all what he had expected. Goldsmith’s short speech endorsing Pattingale, Pattingale’s tirade about emergency rooms, insurance companies, and invasion of privacy, the sad plight of his niece and Pattingale’s revelation about her drug problem, all this seemed bizarre.

! He started collecting his things.
! “Well done! Well done, Brandon! May I call you Brandon?” Not waiting for an answer, he continued, “I love the way you held back, spoke softly, and then, bang! You let old Pattingale rant into overtime and then you offered solutions. Solutions first; solutions show the problems and fix ‘em. Brilliant!”

! “Thank you.”
! He was half a head taller than Brandon with a chest that made him look both massive and formidable. Balding but with a lower, wild shock of hair to state otherwise, his neck was like a tree trunk with ears that were hidden stubs of branches. And his voice, certainly not softly spoken, was more like gravel coming out of a chute.

! “Sayin’ if only that niece of his had one of them summary cards, she wouldn’t have got that shot. You came off caring more than he did, buddy. I liked how you said if only they chose to go to her primary care doc, he would’ve known better and would’ve cared for her drug problems. An’ Pattingale’s sayin’ that the insurance covered the emergency room but not her old, out of plan GP, it was great! You waited and he baited himself. Well done, Brandon! Yeah, I love the way you tied it all together with that fancy diagram. You showed insurance enables wrong use of ERs. Enables. Nice word. I’d call it cahoots. How did you put it? ‘Patient first,’ And what was it? ‘What’s best for patients don’t cost more, it saves dollars.’ Somethin’ like that. She said you could do it and she was right.”

! “She?”
! “Yeah, Cindy. She said you were the man for the job. She’s a smart one. We don’t want some politician owin’ favors to all kinds of people. We want a young, fresh face. You’re the guy!”

! “I’m not so young.”
! “Yeah, you are,” he patted him on the back, “you’re just right.”
! Evidently there had been a fair measure of success. While not agreeing with all that noted by his tree stump friend, he was rather proud of his diagram. That was extemporaneous. The black board had saved him. He had put the ER in the center and then illustrated with arrows how insurance companies promoted overuse and dollars were wasted; first arrow on target. Then the second shot, urgent care and primary care needing to be intricately allied, but weren’t. Into the quiver for another, shooting terminal care into the right flank. That arrow gave him special satisfaction since he had accompanied it with his impromptu remark, “... emergency room and terminal care were not synonyms, they were antonyms. Next arrow. In a busy ER, as Pattingale had experienced, psychological care went wanting. Then, emptying the quiver, he shot time

11

into the heart of procedure. Time was the forsaken orphan and procedures reigned in a busy ER, multiplying costs. Those arrows did it. They saved lots of words. He was proud of it but, did it get across to the audience? They had clapped ... a little. The tree trunk liked it. He moved quickly for such a big man. He had left as briskly as he had come.

! The last papers were stuffed into his old school briefcase. His mother had given that to him, costing her more than she could afford. He wondered how she would have felt about the debate. It was for her that he was doing much of this. Hopefully, others wouldn’t have to suffer as she did.

12

! ! V! SURPRISE COUNTERPUNCH
! Paper under his arm, he walked through the small park. A premature, chilling breath of fall was in the air, and the park lacked its usual quota of visitors. He aimed for a distant bench. He wished he hadn’t read the paper.

! It certainly hadn’t been expected. Just when he was starting to think that he had been successful, bam! Where did that come from? The newspaper had used his egregious overuse of the ER example with evident delight. They had tallied figures to indicate that a modest urgent care center could have been built needing no more than the money spent on that single patient – the one with over 200 visits to the ER in two years. But now, that same newspaper was condemning him. Where did it come from? They were implying that he was a crook! The bursary that he had enjoyed was not something that had to be paid back. They likened it to stealing. The timing couldn’t have been worse.
! It was after he had delivered his speech at the local medical school. He had simply suggested that medical schools, including the local one, consider a closer town affinity where student debt would be traded for later service, helping the needy, caring for the poor – all for a minimal, subsistence salary and forgiveness of student loan. It was debt traded for needed service, not indenture. Indeed, he had combined that suggestion with so many other proposals, like eliminating summer vacations in order to churn out more doctors and nurses, setting up clinics run by the school emphasizing preventative medicine, and ... well, all that and more, which seemed logical and innocent. He had suggested using their ancillary expertise in dietetics and exercise physiology to teach cooking classes and guide exercise programs for diabetics and cardiac patients, especially using the undergraduate language departments. This was an obvious need of their small Chinese population where American diets just weren’t understood. But it was that one part, the student loans, and his student loan. The paper had isolated that and accused him of being a hypocrite. The rest of his message was lost.
! He sat down, pulled out the paper, and muttered to himself, “Well, at least it wasn’t on the first page.”

! “Welcome to dirty politics.” The voice was behind him. It was Cynthia.
! She came around, carefully seated herself, and, looking at the nearby bushes continued, “Didn’t you think they would hit back? If you’re going to throw punches, you’d better be able to take a few.”

! “But my bursary wasn’t a loan, it was a scholarship. It was based on need and performance.”
! “Of course, and they know that too. But now the public will wonder just how honest and dedicated you really are. You have to put it to your advantage and do it quickly. Duck and jab. Your family didn’t have money like Pattingale. Old pedigree Pattingale. Your grades were great and the school believed in you. You had lost your father. The school understood and gave that bursary to you and you are forever thankful. Send a brief, factual letter to the paper; post those grades which resulted in your getting that scholarship, that bursary, along with just how much, no, how little,

13

money you had then. You do that to show young folks that hard work pays off – even when surrounded by adversity. You suggest that Pattingale release similar information about his college days. He partied his way through school, you know. Jab, jab, jab. Enjoy it!”

! “I’m not sure I was cut out for this.”
! “You’re feeling sorry for yourself again.”
! “OK. I’ll take care of it.”
! “Next round, Brandon. This is a big one. You know Pattingale is capable of fighting dirty. You keep it clean but make an opening, and then take it. Bam! We’re going to get the city folk on our side.”

! “The city folk.”
! “Yep. City folk need doctors too. But urbanites pay more. Want to explain why?”
! “Sure, office rents are higher, help costs more, living expenses are higher.”
! “I love it. That’s just how you’ll bait old peacock. You agree with him, and then right cross! You mention that there is one other factor that we might consider.”

! “OK. I’m Pattingale,” Brandon stated, standing tall with an exaggerated and condescending smile, “I’ve taken my time showing how I love the city and know the various expenses so well. For him it would be the cab fares, bar tabs, club dues, and entertaining, but he won’t admit to those. Still, he’ll want to show that he knows the city and how it does cost more to live here.”
! “Right. Let him dance around you, jabbing in the air. You affirmatively nod. You show admiration and respect for his exposition on the city.”

! “Then it’s my turn.” Brandon sat down.
! “Oh yeah, oh yeah! Then, you point out that, much to your surprise, – be humble, you’re good at that, yes, much to your surprise, in your research, you found an unexpected disparity in the city compared to the town and country: a big difference in malpractice premiums. A really big one. Doctors in the biggest cities pay the highest premiums. Around 2004 in Miami, some internists were paying over $65,000.00, general surgeons over $225,000.00, and OB/GYNs nearly a cool quarter million. That’s every year! That was their premium that was due at the beginning of every year. Who pays in the end? The patient, of course. Then you flash the other city figures on the screen, ending with those for our own native metropolis. You leave enough time to point out that this caused a revolt in Florida. Doctors left or threatened to leave. But there was an answer. Then you show how the Floridians took the first big step toward tort reform. So much for your opponent’s Floridian factory example. Right cross!”