Doctor's Orders

On a golden September afternoon, Karl Shipman climbed two rungs up a ladder to trim a tree near the 150-year-old Vermont farmhouse he owned with his wife, Claire. Shipman had grown up near this maple-lined patch of countryside; from the ladder, he could see the cemetery where years ago he'd played hide-and-seek with his kids.

Suddenly the ladder buckled, and Shipman clattered to the ground, instinctively jutting out his hands for protection. He sat up, stunned, but he'd only broken his left wrist--a dime-a-dozen injury, as any doc would know. Any doctor like Karl Shipman, M.D., for example.

When not puttering around his precious acre of Vermont on vacation or skiing at Loveland every chance that he could, Shipman was a well-respected internal-medicine specialist who practiced at Presbyterian/St. Luke's Medical Center in Denver. A fellow with the prestigious American College of Physicians, he'd even served as chief of medicine at Presbyterian Hospital from 1975 to 1977, fifteen years before it merged with St. Luke's. Throughout the 35 years of Shipman's medical career, the hospital had been his second home.

It would also be the place he'd die a gruesome and premature death.
Shipman's fall started a slow-motion plummet toward disaster: Over the next two months, the medical profession to which he'd dedicated his career would collapse just like that ladder beneath the maples, dropping him rung by rung, with no safety net in sight.

After Shipman's accident in early September 1997, surgeons in Vermont fit his wrist with an external fixator, a contraption that holds the bones in place with temporary metal pins about as big around as a household screw. Although it's a common procedure, fixators are associated with a high risk of infection; after the pins are taken out, normal bacteria on the skin can make their way into the holes before the skin has healed.

Wrist immobilized, Shipman wrapped up his month-long vacation and returned to his patients in Denver.

Most mornings, Shipman, a vigorous 64-year-old, would leave his Cherry Hills Village home early--in his typical white shirt and tie, carrying a lunch packed by his wife--to make rounds at Presbyterian/St. Luke's, checking in on any of his patients who might be hospitalized. From there he'd head to his office in Cherry Creek, where he worked with six other physicians in the Denver Internal Medicine Group. As an internist in private practice, Shipman filled the role of long-term "family doc" for adults, performing regular checkups or working on more specific problems: helping patients manage their diabetes, treating their infections, figuring out the source of their aches and pains. If he suspected something life-threatening, such as cancer or a severe heart problem, he would match up the patient with a specialist. Before heading home at night, Shipman would swing by the hospital again for evening rounds.

Twenty days after Shipman's operation, a local orthopedist removed the pins from his wrist. Thinking he was on the mend, Shipman and his wife headed back to Vermont for a couple of weeks to enjoy the fall colors and close up the farmhouse for the winter. But a few days later, Shipman began experiencing severe pain in his neck and shoulder. A physician's assistant attributed the pain to "muscle spasms" resulting from the few minutes Shipman had spent painting a patch of ceiling.

In early October Shipman flew back to Denver and returned to work. Still plagued by pain, he visited two different orthopedists at the same practice where he'd gone for treatment of his broken wrist; each diagnosed muscle spasms and prescribed painkillers and physical therapy. According to medical records, neither doctor did an old-fashioned checkup to measure vital signs: heart and respiratory rate, blood pressure and temperature--which, if high, can point to an infection.

When the orthopedists had removed the fixator from his wrist, they'd told Shipman to expect some swelling. And after the wrist continued to hurt, Shipman chalked it up to overuse and all the suitcase-lugging he'd done on his Vermont trip. Besides, the pain in his back was now so severe that a sore wrist seemed incidental. He told his children he was feeling "lousy"; despite treatments ordered by his specialists, he seemed to be getting worse. But he continued to follow doctor's orders.

He trusted his doctors. "He was a physician himself," says Debra Malone, his daughter, "but when you're a patient, you're a patient."

Shipman's pain became excruciating, disabling; to check on his hospitalized patients, he had to support himself on an office chair on casters that he pushed down the hallways of P/SL. More physical therapy was prescribed.

The doctor's doctors didn't recognize the real problem: A raging staph infection had climbed from Shipman's wrist into his blood and lodged in his spine. If nothing was done, toxins would steal into his organs and kill them off, one by one.

Shipman's skin took on a yellow cast. He couldn't eat. He started acting absentminded, confused. He thought he had the flu, but he'd never been weakened like this before. "He was a very strong man," says Malone. "He hated to be sick."

While Shipman struggled through another round of physical therapy on the morning of October 21, 1997, Claire decided enough was enough: Her husband was going to the hospital. A strong, quiet woman, Claire had been trained as a nurse, although she hadn't worked much since her children were born. Now she called one of her husband's partners, an older man with whom Shipman had practiced medicine for more than three decades. The colleague admitted Shipman to P/SL.

At the hospital, several physicians, a senior resident and an intern went into a diagnostic huddle. About two years earlier, Shipman had undergone surgery for a local cancer in his colon, so their first suspicion was that the cancer had recurred--Shipman's worst fear--and crept into his spine. The doctors sent him for an MRI, but Shipman was in too much pain to lie still and had trouble breathing while prone, the result of fluid in his lungs. They decided to try an MRI again in the morning. According to medical records, his orthopedist made rounds at around 6 p.m., ordered a brace for Shipman and wrote that he was leaving town.

Malone, a registered nurse for thirteen years specializing in critical and recovery-room care, had flown into Denver that evening from Mexico City, where her husband, an American Airlines pilot, was on layover. Earlier, hospital staff had asked the family to have a relative present because Shipman kept trying to climb out of bed. Malone relieved her older sister, Laura Wagner, a mother of three who had taken the first shift.

By 8 p.m., Shipman was "confused and shaky," Malone says. Where was he? In a hospital. What does a doctor do in a hospital? Go to work. "He kept trying to crawl out of bed," she remembers, "saying he needed to make his rounds." Shipman was transferred to the intensive-care unit, partly to allow the nurses to keep a better eye on him.

Many people go to the ICU to die; according to a 1993 survey by the national Society for Critical Care Medicine, more than half of adult critical-care patients are 65 or older. P/SL is up front about the eight deaths a month it averages in its critical-care unit. (That number often doubles after the holiday season, during the months of January and February.) After all, these are the sickest, and often most elderly, patients in the hospital.

But thanks to new technology and advances in medicine, many of the happier ICU cases simply roll in and out again. Open-heart-surgery patients, for example, who ten years ago would have needed ICU care for a week, now spend only a day there before they stabilize and head back to the general ward.

The P/SL ICU unit has several "pods," each specializing in a different sort of crisis care: some for patients who've just come from open-heart surgery, others for infectious-disease cases, a pediatrics unit for children, and so on. Each pod consists of a cluster of glass-walled rooms facing an open area and nurses' station. Individual rooms are equipped with an array of ultra-high-tech equipment, most of it mobile, much of it to pump hearts, assist lungs or monitor the complex circuitry and piping of the human body.

By day, P/SL's intensive-care unit is a bright place, bathed in fluorescent light, where nurses in cheery colored smocks bustle about--or stay riveted to the glowing colored lines of monitors hooked up to a patient's chest. There's no dress code here: Doctors and interns, and sometimes even nurses, might be wearing a short lab coat, or a shirt and tie, or surgical scrubs. Each wears a badge with his name printed large; the job title is listed below in much smaller type.

At night the ICU becomes an eerie place, hushed by sickness and rest. In many rooms, the lights are out or drapes have been drawn; family members wind their bodies into armchairs to catch a few winks near a critically ill loved one.

In the ICU, Shipman was assigned a "float nurse" transferred down from another unit. ICU nurses are highly trained in their specialty--they are the patient's minute-by-minute caregiver as physicians bounce in and out--but the floater was a part-timer who only rarely works at the hospital. He "appeared to be placed in a situation above his level of clinical expertise," Malone would write later in a complaint to the state's nursing board, charging that the nurse failed to analyze changes in her father's heart rate through the night, did not evaluate his lung sounds or assess urine output, and missed giving him a scheduled dose of highly critical antibiotics.

Malone, distraught and fatigued from her trip, says she was in "constant intervention" mode--trying to calm her father, keep him in bed--when a young woman wearing a white lab coat entered the room and introduced herself as a doctor. When she wrote her orders--all the details for the patient's care, to be carried out by the nurse--she signed her name, followed by "M.D."

Shipman's family would not learn until three months later that this M.D. was an unlicensed intern fresh out of med school, assigned to P/SL's teaching service.

It was during these otherworldly late-night hours that Malone began to sense that something was going very, very wrong. Her father's heart rate became erratic, his actions more delirious. Malone later surmised that her father had become hypoxic, meaning he didn't have enough oxygen in his blood and thus his brain. But instead of ordering an ABG, a standard test to measure the gases in the blood, the intern wrote orders for the anti-psychotic drug Haldol. Shipman had to sit upright in bed because of fluid in his lungs; the intern, Malone says, ordered too much fluid for his IV, which only compounded the lung problem.

It was a classic case of acute respiratory distress syndrome, says Malone; her father should have been put on a ventilator by midnight so that the machine could take over the job of breathing and let his body rest. "All night long," she recalls, "he struggled to survive."

That night would be the last time that Karl Shipman would ever speak.
By now in tears, the jet-lagged Malone started asking questions. But she'd only worked in smaller ICUs in the mountains; she trusted big-city Presbyterian/St. Luke's to give state-of-the-art care. The nursing staff that night "intimidated" her, she says. Annoyed by Malone's fretting, a nurse insisted that Shipman was stable and urged his daughter to leave the room and rest. Malone tried to nap in a waiting room but returned within two hours.

In retrospect, she says, "it was a lesson in how important it is to stand up for what you believe."

Shipman's hospital chart never mentions a visit that critical night by a senior physician or a senior resident, who is usually responsible for checking on less seasoned staff. "It was," says Malone, "a total system breakdown failure."

Around eight o'clock the next morning, an anesthesiologist arrived to prepare Shipman for another go at an MRI. By then Shipman's heart was pounding frantically because it couldn't effectively pump his blood; his blood pressure was alarmingly low. The anesthesiologist ran for Dr. Steven Weiss, the ICU's head intensivist (a physician who is board-certified in critical-care medicine). Within fifteen minutes Shipman was put on a ventilator and an IV to help regulate his heart rhythm.

From that point on, Malone says, the care given by Weiss, neurosurgeon Dr. Roderick Lamond and the regular ICU nursing staff was "just awesome." But the damage had been done. Shipman was given a 40 percent chance of survival.

Several days later, Shipman's four children, all in their thirties, found themselves back in the house where they had grown up, sitting on their parents' bed, talking about what to do next. The family finally decided to sign a DNR, or "do not resuscitate," order. The hospital was instructed to do everything it could for Shipman's recovery. But once all hope was lost, he was not to be subjected to medical interventions that, says Malone, "would diminish the last shred of peace and dignity at death."

They couldn't believe it had come to this. Their daddy--Karl Shipman, M.D., the family man with a twinkle in his eye and a gentle, mischievous sense of humor, grandfather to five, skier, hiker, athlete--was barely hanging on to life.

"He would occasionally open an eye," Malone recalls. But Shipman couldn't follow simple commands, even a whispered Just try to move your leg or a gentle If you can hear me, squeeze my hand.

Shipman's sedation medicine was occasionally withheld to see if he might awaken or give some sign for hope. "It was horrible," says Malone. When the sedation meds were taken away, "there was a complete grimace and agony on his face."

Over the next two weeks, fellow physicians stopped by to show their concern. Relatives flew into DIA during a legendary snowstorm and made the long--in some cases, ten-hour--trek down I-70 to Presbyterian/St. Luke's. A family friend brought Shipman's 95-year-old mother from her Denver nursing home; she spoke to her son quietly in her native German and from her wheelchair reached across his heart to make the sign of a cross.

Nineteen days after Shipman's admission to the hospital, doctors had no choice but to perform a second surgery on his spine to clean out the infection trapped within. It was a last-ditch effort. Shipman went into "DIC"--a condition in which the blood no longer coagulates but just runs, taking the body's strength with it.

Back in his ICU bed, Shipman's blood seeped into the sheets and his heart rate dropped, dropped, stopped. His last reserves were gone. Karl Shipman was gone.

The 139-word Denver Post obituary written by Lisa Shipman, his youngest daughter, summed up Shipman's major career achievements. But obituaries don't allow room for the stories that really count--like how every summer Shipman, a devoted animal lover, would load up a dozen partridge chicks and, with his wife and kids, head to the Green Mountain State. Shipman's crazy mission: to help rejuvenate Vermont's partridge population.

Every Easter the Shipman kids would awaken to a new assortment of pets--bunnies, chicks, ducklings. Big white Duck-Duck, Shipman's favorite and the winner for fowl longevity, trotted alongside the family collie for years, greeting Shipman each evening when he came home from work. Each morning Shipman would go outside to feed the wild birds; after he once hit a squirrel while trying to chase it away from the bird feed, he had a change of heart and began feeding the squirrels, too.

Raised by immigrant parents, Shipman had decided as a young man that he didn't want to become an acclaimed chef like his stepfather; instead, he considered veterinary school and then medicine. He met his young bride while she was in nurse's training. On a road trip west, Shipman fell in love with something else, too: the Rocky Mountains. His entire medical career was based in Colorado.

In the eulogy for her father, Malone, herself an accomplished skier, recalled that "Daddy used to say, 'There is no utopia,' but a good day of skiing followed by a good meal with friends and family came pretty close."

He was a devoted dad, but "we had to share him with his patients," Wagner recalls. Life was full of late-night emergencies, house calls and even a few Christmases away from home to tend to a sick patient. After Shipman's death, his family came across letters from grateful patients. "Dear Dr. Shipman," one begins. "Thank you for saving my life."

"It's frustrating," Wagner says, "to think of a physician taking care of patients all of his life--and when he needs assistance, the system isn't in place for him."

The Shipman family has a much greater understanding of medicine than most people, she points out. What about families who are less familiar with hospital care, who will never know why a loved one died before their eyes?

Karl Shipman had practiced at Presbyterian/St. Luke's for more than half of his life, but after his death his family received no acknowledgment, no flowers, no words of condolence from the hospital--just "a bill for $250,000," says Malone.

A month after her husband's passing, Claire Shipman wrote to Presbyterian/ St. Luke's to obtain his hospital records. When Malone started combing through them, she was shocked. The records upheld every frantic fear she'd had the night of October 21. "I was livid," she says, "that I had been invalidated all that time and that no one advocated for my father all night, so he didn't get adequate care."

Among other things, Malone learned that the woman she'd thought was an experienced doctor was just an intern (specializing in internal medicine, Shipman's own field). According to P/SL's own "Adult Critical Care Medical Rules & Regulations," the hospital's interns and residents "will function under the direct supervision of an attending physician." Yet "here was an intern six months out of medical school," says Malone, "making these decisions in an intensive-care unit."

Students earn the "M.D." behind their names the day they graduate from medical school, but only residents who successfully take the two-day U.S. Medical Licensing Exam will be licensed by the Colorado Board of Medical Examiners. And although the board maintains licensing and disciplinary power over these young physicians, as well as all other licensed doctors in the state, it has no jurisdiction over unlicensed interns and residents.

Malone complained to the hospital about her father's care but received no reply until November 1998, when P/SL patient representative Patty Boyd responded. "We have investigated," Boyd wrote, "and feel that the care your father received was not substandard."

Malone wrote again. In January, she also filed formal complaints with the Colorado Board of Medical Examiners about her father's last orthopedist and the intern; the Colorado Department of Public Health and Environment, which monitors hospitals; and the state nursing board.

In February, fifteen months after her father's death, Malone received a terse note of acknowledgment of her complaint from the University of Colorado Health Sciences Center (UCHSC), which oversees the state's residency programs. That same day, she received a letter from P/SL president and CEO Kevin J. Gross, extending "our deepest sympathy" and assuring Malone that "the issues you raised surrounding your father's care are being investigated."

Presbyterian/St. Luke's Medical Center has endured its own share of grief lately; earlier this month, it became public knowledge that the U.S. Health Care Financing Administration is investigating the hospital following the February 3 death of Mary Catherine Heidenreich. The 78-year-old Denver woman, admitted to the hospital for knee surgery, died after morphine was given to her intravenously instead of into a muscle, as ordered. If PS/L fails to correct any deficiencies uncovered by HCFA, the hospital could lose more than an estimated $100 million in federal Medicare funds. HCFA's report is expected by the end of the month.

HCFA also stepped in to investigate in 1995, after the hospital was hammered by a string of medical errors: a nineteen-year-old admitted for surgery on a benign brain tumor died when the breathing tube in her throat became disconnected; a 34-year-old Florida man was given the wrong blood type and died; an infant was burned by a heat lamp; a failed heart-lung machine apparently caused the death of a transplant patient. The hospital escaped losing its Medicare dollars that year only after making changes demanded by HCFA.

The complaint Malone filed in January with the state health department is among those being investigated by HCFA. The department fields all sorts of patient gripes--109 complaints last year about 53 Colorado hospitals--ranging from "'The food was lousy' to 'They left a knife inside me when they operated,'" says spokeswoman Jackie Starr-Bocian.

But Malone sees wider gaps in the system. Had the hospital enforced its policy, she says, her father would never have been left in the care of an inexperienced intern. Despite P/SL's written regulations, Malone says, the intern never contacted the on-call physician; he was at home in bed, asleep.

Other than nurses, most of the medical personnel a patient sees during a stay at a teaching hospital such as Presbyterian/St. Luke's belong to the "housestaff" and hang off the early end of the learning curve. These are residents and interns (often referred to as "first-year residents") who exchange their labor for a modest stipend and on-the-job training in the art of healing.

These trainees are expected to introduce themselves--and explain their status--when they meet a patient or a patient's family. Still, lowly interns "are not required to tell the family that," says Pennie Clor, an attorney and former critical-care nurse familiar with the Shipman case. "They wear a white coat and look like a doctor and call themselves Dr. So-and-So."

As the state's sole medical school, UCHSC oversees the logistics of some 800 interns, residents and fellows in close to fifty specialty training programs lasting three years or more. Only about half of Colorado's medical-school graduates remain in the state for residency; the 144 residents in UCHSC's internal-medicine training program, for example, come from 55 different medical schools. Colorado tends to favor the "mature student," drawing residents in their thirties who have some life and career experience behind them. Last year the internal-medicine program alone drew 1,450 applications to fill 51 slots.

"We attract smart, talented, good people," says Dr. William Kaehny, director of the residency program for internal medicine. Kaehny's first-year interns perform seven to nine month-long "rotations"--working a maximum of eighty hours a week--in six Denver hospitals: P/SL, University, the VA hospital, Rose, Denver Health and National Jewish Center. Presbyterian/ St. Luke's joined the university program only three years ago after running, and then discontinuing, its own in-house training program.

The UCHSC program is built on a strict hierarchy. At the top is the hospital's clinical director, followed by the chief medical resident, followed by a "team": the attending physician (a patient's private doctor or a faculty member), a senior or junior resident, one or two interns and one or two junior medical students. At P/SL, more than a dozen residents might be assigned to the ICU for any one month, according to the unit's patient-care director. Chief residents stick around for a whole quarter.

"The intern is like the detail person. They do the nitty-gritty things," Kaehny says. "They don't make truly independent decisions."

Under standards set by the Chicago-based Accreditation Council for Graduate Medical Education and echoed by many local hospitals, teaching institutions must supply "sufficient oversight to assure that residents are appropriately supervised" and give them "progressively increasing responsibility according to their level of education, ability and experience."

Long before they move onto the hospital floor--often in their first year of medical school--the state's would-be doctors begin their observation of docs at work and learn new communication skills, says Nancy Nelson, associate dean for student affairs at UCHSC. "It is said that a physician is only half done when they graduate from medical school. A physician is supposed to continue learning all through life."

It's common practice at P/SL--and at most teaching hospitals--for attending physicians to admit their patients to the teaching service, says Dr. Julie Rifkin, who oversees the P/SL house-staff. But interns are expected to call in a senior resident or the attending physician "if they're faced with a difficult situation or it's something they don't understand."

At P/SL's daily "morning report," Rifkin or another faculty member meets for an hour with the residents for an in-depth discussion of two of the twelve "teaching" cases the housestaff handled the previous night. If a house officer ever performs sloppy work or "fails to meet their professional responsibility," Kaehny adds, he and other university authorities become involved and can decide to give the resident a notice of admonition, a formal warning or even probation--a mark that stays on the young doctor's record.

The hospital won't disclose whether Shipman's care was the subject of a "morning report" discussion. And while Kaehny says he can't discuss details of the Shipman case because of patient confidentiality, he adds that he trusts his colleagues at P/SL to decide if any care was substandard.

Kaehny describes the intern on duty at the ICU that night as a promising young doctor who shouldn't be singled out. "I do protect my house officers," says Kaehny, who strives to be a "father figure" to his students. Residents work hard, fill an essential role and dread the physician's nightmare: a patient experiencing the breakdown of whole organ systems, not responding to usual treatment, failing, failing. "It's really hard on these young people, who are pretty idealistic," he notes.

But he says he also understands that Malone is "uncomfortable with some of the treatment" given her father. "It's a hard thing for someone who's very close," says Kaehny, who remembers the pain of his own brother's death--and the haunting questions about how he might have been saved.

In a statement faxed to Westword on March 5, Presbyterian/St. Luke's officials say, "We have concluded that the care and treatment provided to Dr. Shipman was appropriate and did not cause his death...Within certain parameters, the hospital relies on the attending physician's judgment in admitting a patient to the teaching service. The hospital also relies on the treating intern's and resident's judgment in determining when they may need to discuss a problem, or seek help in caring for a patient, with the attending physician or any of the specialists on staff at P/SL."

When "a concern is raised in regard to medical care," the case is subject to peer review, the hospital officials add. But that internal process and any disciplinary actions subsequently meted out to staff are confidential under Colorado law.

"Before this all happened, I was happy being a nurse and skiing. I had my life in la-la land," says Malone, a lively woman with an effervescent laugh. "If this tragedy had to happen, we want something good to come out of it."

For starters, she would like more oversight of unlicensed young physicians, who are not accountable to the Board of Medical Examiners. "If you have a medical intern or resident, there's very little you can do" as far as filing a complaint with the state, she says. "They may have just killed your loved one."

And while interns are fulfilling the terms of their residencies, they are technically state employees, protected against lawsuits by Colorado's governmental immunity act. (UCHSC furnishes the residents' malpractice insurance; hospitals pay the university to cover the residents' salaries.) The law, which requires civil suits against state workers to be filed within 180 days, caps damages at $150,000 per individual or $400,000 total. Shipman's family was not aware of this law until after the six-month deadline.

In the next six weeks, they will decide whether to file suit against any parties in the case, including the Denver orthopedists who treated their father. When Shipman visited those doctors, he had "clinical evidence of renal failure, liver failure and sepsis," Malone says, and "no lab work or tests were ordered."

While they contemplate legal action--and worry about the emotional and financial toll it could take--Shipman's family is focusing on mending holes in the patient safety net, starting with the intensive-care unit. They want to see any patient admitted to an ICU immediately assigned an intensivist, such as Dr. Weiss, who came into their father's case too late.

And so Malone has joined a growing national campaign promoting intensivists. The Society for Critical Care Medicine envisions a coordinated, intensivist-led "team approach" in large ICUs rather than the patchwork of care often provided by a patient's attending physician and an assortment of specialists, each of whom is treating a separate part of the body.

"The intensivist looks at the whole patient," explains Maurene A. Harvey, treasurer of the 10,000-member SCCM. Yet 75 percent of U.S. hospitals don't have intensivists. The only staffers who might follow a patient throughout a stay in those ICUs are not even doctors.

"If the secret gets out, we'll all know that nurses are doing intensive-care medicine," says Harvey. "The doctors kind of walk in and out. The nurses and the respiratory therapists in our ICUs are taking care of the sickest people in this country."

Critical care is extremely costly; 1 percent of the entire U.S. gross national product is spent on this single wedge of health care. Big insurers are starting to look at the way intensivists can help improve the bottom line. "Managed care is going to end up helping us with this," says Harvey, "and for the wrong reasons."

"Obviously, there's incentive and pressure there to get the biggest bang for your buck," agrees Bill Kinnard, one of two full-time intensivists employed at Exempla-St. Joseph's Hospital by Kaiser Permanente, the nation's largest nonprofit HMO. Yet intensivists, many of whom are board-certified in pulmonary medicine, may help streamline costs because they provide more efficient care and can mend patients faster. "The old-fashioned ICU had all kinds of doctors doing their thing, but no one was looking at the big picture," explains Kinnard. "Along with the care of individual patients, it's our job to make the ICU better as a whole. We actually have the time, interest and resources to step back and look at how we're doing."

Critical-care medicine is only as old as the 1960s, and intensivists are an even newer breed. The job requires a knack for building good rapport with the staff and using a bit of political savvy, says P/SL ICU patient-care director Margie Haas. In an "open" system like P/SL's, where the admitting physician has the option of bringing in a critical-care specialist, the intensivist must convey the message to other doctors that he or she is not "taking over a case, but 'consulting,'" says Haas.

But Weiss says he's never had a conflict with other doctors. "When physicians know they're in over their head, they're used to calling in another specialist," he says.

Families can be harder to convince. "I don't think [the intensivist concept] is commonly known to John Q. Public," says Debra Behling, a nurse for 24 years, 13 of those in P/SL's ICU. "A family might be upset that their family doctor is not there treating his patient--who he might have known for twenty years. What they don't know is that the patient is probably getting even better care from a critical-care specialist."

With 676 total beds and 643 active physicians, Presbyterian/St. Luke's is the state's largest hospital, drawing most of its ICU patients from smaller communities outside Denver as well as from Nebraska, Wyoming and Kansas. Since 1995 it has employed seven intensivists--who also have outside private practices--to provide 24-hour coverage in the facility. While on duty, the intensivist might tend to patients in the 24-bed ICU, respond to emergencies or catch a few minutes of rest in a "sleeping room" in the hospital's A tower.

"The art of critical care is being prepared for those crises at any given moment," says Margie Haas. "You get an adrenaline rush. When you can help save someone, it's about the most gratifying thing you can do."

But before the intensivist can jump into action, he has to be alerted that there's a problem. It's not enough for a hospital to have intensivists, Malone says.

Critical-care technology has made amazing advancements over the past two decades; now it's time to look at the people-driven part of the system, she insists. One study shows that the intensivist-led team approach can boost patient survival rates by 17 percent. Malone thinks her father could have been one of the fortunate ones--if only an intensivist had been brought in early.

"I could just go on and on about how great Dr. Weiss was when he came to the scene," says Malone. "He knew immediately what was going on. There was no second-guessing."

Which makes it all the more tragic that no one alerted Weiss that crucial night when an intern and a floater nurse guarded Shipman's tenuous grip on life. At Presbyterian/St. Luke's, it is up to the attending physician to pull an intensivist in on a case, but Weiss was never contacted. In this well-equipped ICU, Shipman was "in the right spot, at the right time, with the wrong outcome," says Malone.

The changes that Malone is pushing for "are not going to benefit me," she says. Nor can they bring back Karl Shipman, whose ashes rest in the cemetery near his beloved Vermont farmhouse, in the shade of those maple trees.

Malone still doesn't understand how nurses taking his pulse could have missed the pronounced swelling above his left hand, or why doctors didn't open up his wrist and immediately put him on a strong course of antibiotics. If Shipman had been properly treated before he "crashed," she says, "he still would have been a very sick man, but his chances of survival would have been much greater."

Of course, his chances would have been better yet had Shipman's infection been caught weeks earlier. In the treatment of Dr. Karl Shipman, almost anything that could have gone wrong did. Rung by rung, the medical hierachy failed him.

If only the ICU had automatically assigned an intensivist to Shipman's case.
If only a more experienced doctor had checked on the intern.
If only the intern had asked for more qualified help.
If only the nurse had had more ICU experience.

If only the admitting physician--Shipman's longtime partner--had examined him further before admitting him to the hospital.

If only the Denver orthopedists had diagnosed Shipman's real ailment.
If only Shipman's family members, several of them medical professionals, had recognized the source of his problems.

If only Shipman had never climbed that ladder.
If only the physician could have healed himself.
No one recognized the complexity of medicine more than Karl Shipman--or realized just how long it would take would-be doctors to learn what they were doing.

In a 1975 letter published in the Annals of Internal Medicine, Shipman warned against the trend to squeeze medical residencies into fewer years. "After the year of rotating internship, a physician [begins] to emerge," he wrote. "And, after three years of residency, a solidly based general internist [is] developed...Four years of medical school does not produce a physician."

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