Angels on the Night Shift

by Robert D. Lesslie, M. D.

  The first time I had met her had been in the ER about two years ago. She had come in during the middle of the night, just like tonight, and complained of shortness of breath. The triage nurse was concerned enough to put her in the cardiac room and then immediately came to find me.

  Lucinda was complaining of right-sided chest pain, shortness of breath, right calf pain, and an episode of nearly blacking out. Her vital signs had all been stable, her oxygen saturation was normal, and clinically she looked fine. The problem was that all of her symptoms pointed to her having a pulmonary embolus—a blood clot in her lung. She was a classic presentation. Her reaction to this news was a little peculiar, though. She had almost smiled when I told her and seemed almost happy I had come to this conclusion. I explained that we would need to do some further testing, including a blood gas, which was a painful procedure. It involves a needle puncture of the radial artery at the wrist, and then aspiration of a small amount of arterial blood. It hurts, and it’s not anything I would want to have done unless absolutely necessary. But it was part of the workup for Lucinda and would provide additional support for this diagnosis.

  She would also need a lung scan, as well as additional blood work and an ultrasound of her right leg.

  “Sounds like I’ll need to be in the hospital,” she had remarked, strangely calm and seeming to be almost relieved at this turn of events. This was a life-threatening problem, and I had done my best to explain the seriousness of her condition to her. Maybe I wasn’t communicating very well.

  A couple of hours later, I had the results of all of her studies in front of me. Everything was completely normal. Now what?

  As I explained these findings to her, her face seemed to cloud over, and she became a little agitated. I had expected her to be happy that things were pointing away from an embolus.

  “Oooh!” she began moaning, clutching her right chest. “I can’t breathe!”

  She was gasping, and I was just standing there looking down at her, when one of our nurses hurried into the room. She had heard the moaning from out in the hallway.

  “Dr. Lesslie, is there anything we need to do?” she had asked me anxiously.

  At that point, I had given up. I talked the pulmonary specialist on call into putting her in the hospital with a diagnosis of “possible pulmonary embolus” and then seeing how things would shake out over the next few days. When I saw him in the ER later on that week, he told me he had sent Lucinda home the next morning.

  “I still don’t know what’s going on with her,” he had told me. “All of her studies stayed normal, and she never ran any fever or had any abnormal vital signs. She didn’t want to leave the hospital, but I told her she had to be discharged. We weren’t doing anything for her here except providing a bed and three meals a day.”

  He had learned a few things from her family doctor, though. She had reported a history of cancer (not true), a recent five-hour plane flight (also not true), and a distant family history of an unusual bleeding problem (how could you ever confirm that?).

  “She seemed to know all the risk factors for an embolus, and she had all of the symptoms. And you know what, Robert? It’s almost as if she wanted to have one. That’s what beats me.”

  I hadn’t felt so bad when I learned she had stumped one of our best pulmonary guys. But Lucinda Banks was puzzling—something I had never run into before.

  The next time I saw her was a few days after Thanksgiving, about a year later. On this occasion she came to the ER in the middle of the afternoon, dressed the same way as before—very professional and very polished.

  She had all the classic symptoms of a heart attack, but with none of the physical or laboratory findings. One of our cardiologists reluctantly put her in the hospital and, as expected, everything turned up normal. She even had a negative heart cath.

  When I saw the cardiologist a few days later, we talked about Lucinda. He mentioned the idea of Munchausen’s and wondered if that might be what was going on with this woman.

  When I got the chance, I looked up this strange malady. The more I read about it, the more it seemed to fit. In fact, it perfectly described Lucinda and explained all of her behavior, all of her lack of objective findings, and all of her expert knowledge of her disease du jour.

  We hadn’t seen Lucinda again after that chest pain visit, not until tonight. I was curious about what her complaint was going to be this time. Based on Jeff’s reaction, it must be something interesting.

  He walked out of her room and over to the nurses’ station.

  “Good luck with this,” he whispered, handing me the chart and glancing back over his shoulder. “I can’t make heads nor tails of it.”

  The buzzer had gone off again and he headed back out to triage.

  He had written multiple complaints—headache, visual changes, kidney failure—on Lucinda’s ER record.

  Kidney failure? I thought. Now that’s something different. How did she come up with that one?

  Another quick glance at her chart informed me that her blood pressure was normal, as were her pulse and temperature. Again.

  “Ms. Banks,” I said to her as I stepped into room 4. “I’m Dr. Lesslie. What can we do for you tonight?”

  “I remember you, Dr. Lesslie,” she replied pleasantly, looking up at me and smoothing the stretcher sheet on either side of her. She was sitting up with her legs dangling from the edge of the bed, crossed at her ankles.

  “I’m just not sure what’s wrong with me,” she sighed, slowly shaking her head and folding her hands in her lap. “I started having this strange numbness in my hands, and then in my feet. And I’ve noticed that my vision isn’t what it should be.”

  She paused and rubbed her eyes, struggling to focus on some object off in the corner of the room.

  “And then all my joints started to hurt, especially my wrists and fingers and hips. I feel like I’ve been run over by a truck!”

  She looked up at me, waiting for a response. I just stood there, nodded my head, and waited for her to go on.

  After a moment, she continued. “And these headaches—they’re awful! Right here at my temples.” She was rubbing the sides of her head now, wincing in terrible pain.

  She didn’t say anything further, and this time I couldn’t wait her out. I finally asked her, “Tell me about this kidney failure. Who diagnosed that, and when did it start?”

  She seemed relieved that we were finally moving down her list of complaints, and she stopped rubbing her head. She looked up at me and sighed.

  “My family doctor was worried it would only be a matter of time,” she informed me. “My urine output has been diminishing over the past few months, and now, my kidneys seem to have shut down completely.”

  She said this with a surety and calmness that rattled me a little. This was a bright woman, and I was having a hard time believing what I was hearing.

  I glanced down at her vital signs again. Most people with kidney failure had an elevated blood pressure. Lucinda’s was 110/78. And her pulse was 70.

  “I haven’t been able to produce any urine in more than 24 hours,” she told me, searching my eyes for the hoped-for alarm.

  I was tempted to have one of the nurses put in a Foley catheter and call her out on this, but something told me that wasn’t the way to handle this. That’s probably what she wanted me to do, as well as get a bunch of lab work. Instead, I just stood there, holding her chart, and meeting her gaze with mine.

  There was a split second where I thought I saw the corners of her mouth turn down. Then there was that smile again, almost condescending. But she was beginning to lose her patience. I wasn’t jumping down this rabbit hole quickly enough.

  “Do you…do you think I could have lupus?” she asked with feigned trepidation.

  “Hmm…” I responded, and started stroking my chin, seemingly struck by this surprising possibility.

  Of course it sounded like lupus. She was describing all of the symptoms of this disease, even stretching things t
o the point of manufacturing the findings of one of the disease’s end-stage complications—kidney failure. But that one was going to be hard for her to validate. Yet…what was the best way to handle this? We had already put her in the hospital twice for imagined maladies, and that was just at Rock Hill General. Who knew how many other places she had been with these complaints? And who knew how many other diseases there were whose symptoms she had manufactured?

  “Dr. Lesslie, do you think lupus could explain this?”

  She leaned toward me, turning one side of her face for me to examine.

  I hadn’t noticed it before in the less than optimal lighting of the exam room, but as she came closer, I could see that her cheeks and forehead were obviously a little more flushed than the rest of her face. It was the classic “butterfly” distribution of the facial rash of lupus—the “red wolf.” She had really done her reading.

  But how had she managed to do this? The rash was in the typically described form and was the appropriate color. I looked closer. It was all I could do not to say something, but there was the answer. It was clear that Lucinda had applied a faint dusting of makeup to her cheeks and forehead. It was very subtle, but it was definitely makeup.

  That was enough. Now I knew what I had to do.

  “Lucinda, this is very concerning,” I told her truthfully. “I’m going to make a few phone calls and we’re going to get you some help.”

  Relieved at last, she leaned back on the stretcher and said, “Thank you, Dr. Lesslie. Thank you so much.”

  When I got to the nurses’ station, I slumped into one of the chairs. Susan looked over at me, puzzled.

  “Do we need to do anything for the woman in 4?” she asked.

  “Would you call up to the behavioral med unit and see if one of the psych doctors is up there?” It was a long shot at this time of the morning, but we might get lucky.

  A few minutes later, I was talking with Martin Childress, the on-call psychiatrist. He had happened to be upstairs handling a problem patient when Susan had called.

  I told him about Lucinda Banks, hoping desperately that he might be willing to take a look at her.

  When I finished describing her case, there was a long pause on the other end of the phone. I was trying to think of my next step, when Martin said, “Robert, that sounds fascinating. Let me finish up here with this patient, and I’ll be down and talk with Ms. Banks. Thirty minutes okay?”

  “That would be great,” I said gratefully. “She’ll be right here in room 4.”

  I hung up the phone, relieved and thankful for the help. And I was thankful that Lucinda Banks was going to get some help. She didn’t have lupus, or heart disease, or a blood clot in her lungs. She needed psychiatric help and not another lengthy and futile workup.

  When Martin Childress came down the hallway a little while later, I picked up the chart for room 4 and handed it to him.

  “Thanks again for seeing her,” I told him.

  “No problem,” he responded, studying the front sheet of her record. “I’ll let you know what I find.”

  He walked over to room 4, stepped in, and pulled the curtain closed behind him. I sat there, watching and listening for some explosion, some outburst from Lucinda. But the room remained quiet.

  “Here,” Jeff said, sliding the chart of room 3 over to me. “Bobby Craddock. Eight-year-old with a sore throat and temp of 102.”

  I picked up the chart, read his name, noted the complaint and the boy’s temp, and thought—A sore throat. Thank you, Bobby Craddock.

  8

  Out of Death Comes Life

  Friday, 7:45 a.m. Virginia Granger had been in her office with the door closed for the past half hour. That wasn’t anything unusual. What was unusual was that she had been meeting all this time with Walter Stevens, one of the hospital’s VP’s. I couldn’t remember what he was VP of, but I knew he was young and hadn’t been on the job for very long.

  They must be discussing the department’s missing medication. Nothing had turned up to explain the inconsistent narcotics count, and now the administration was involved. That certainly didn’t thrill Virginia.

  Her door opened and she stepped partway out.

  “Dr. Lesslie,” she called, getting my attention as I stepped out of the medication room. I had been washing my hands, looking out the window into the parking lot. I’d been watching a young mother herd her four young children toward the ER entrance and thinking that none of them seemed very ill. Maybe they were just visiting.

  Virginia caught my eye, then motioned with her hand for me to join her.

  I finished drying my hands, tossed the paper towel in the trash can at the nurses’ station, and walked over to her office.

  She was just sitting down behind her desk when I entered. I closed the door behind me and walked over.

  “Have a seat, Robert,” she said, motioning to the remaining chair in front of her desk. In the other chair sat Walter Stevens. He had on a long-sleeved white shirt and wore a bright-red bow-tie. In one of his hands was a legal pad filled with scribbled notes. When he noticed me looking down at it, he quickly flipped it over in his lap.

  “Dr. Lesslie,” he intoned with an air of gravity. “It’s good to see you.”

  He held out his hand and I shook it. I was struck once again by the damp weakness of his handshake. I had met the twenty-eight-year-old when he had first arrived at Rock Hill General. He had just finished his MBA program at some small school in eastern Kentucky and had struck me then as being a little too sure of himself, and a little too smug. Nothing seemed to have changed.

  “Walter, good morning,” I told him, sitting down and turning to face Virginia. “What’s going on?” I asked the two of them.

  The head nurse put her palms down on the desk in front of her and leaned toward the two of us.

  “Walter and I have been discussing the matter of the missing narcotics,” she began. “And I think he may have some ideas.”

  There was little enthusiasm in her face, and less in her eyes.

  “What makes you sure they’re missing?” I asked. “I had hoped this was simply an oversight. Has there not been some simple explanation?”

  “There is an explanation, to be sure,” Walter intoned. “But it is not simple.”

  Virginia turned in her chair, reached behind her, and picked up a small box from the bookshelf behind her.

  “Take a look at this,” she said, sliding the plastic-wrapped container over to me.

  I recognized it immediately. It was a medication container—a two-and-a-half-inch cube shrink-wrapped in plastic. It contained 25 glass vials of some type of medication, arranged neatly in five rows of five vials each. The tops of the vials were all that was visible, the rest being surrounded by a paper box. Each vial was protected from the others by a thin, cross-hatched insert. One side of the container read Demerol—100 mg. I turned the box over in my hands, examining each side. It looked to be brand-new and unopened.

  I thought Virginia might be testing me, and I thought of something. Looking down once more, I checked the expiration date. It was still current.

  Putting the box down on her desk, I said, “Looks like a box of unopened Demerol to me, Virginia. Is there something important here?”

  “You didn’t look quite closely enough, Dr. Lesslie,” Walter Stevens said, snatching up the box of medicine and holding it in front of me. He oriented the cube so that the bottom of it was right under my nose.

  The guy was starting to get on my nerves, but when I glanced over at Virginia, she gave me a brief nod of her head.

  Reluctantly, I looked once more at the Demerol, this time focusing more intently on the bottom of the box. Again, it looked fine to me, with the plastic perfectly in place. There didn’t seem to be any evidence of tampering, or of someone trying to open it.

  Wait a minute.

  “Let me hold that a second,” I said to Stevens, taking the box out of his hand and moving it around in the light.

  There, just t
o the right of dead center. I looked closer, not wanting to believe this and needing to be sure.

  But there it was—a small hole, almost invisible. And there was another one, about half an inch away. And another. I counted six holes in the bottom of the box. I flipped it over and examined the vials that were sitting above these holes, looking at them closely. Just what I was afraid of—they were empty.

  I lowered my hand to the desk and looked up at Virginia. She was studying my eyes, waiting for my response, waiting for me to say something.

  Looking down at the Demerol again, I said, “Very clever.”

  Someone had taken a small needle and syringe and deftly sucked the Demerol out of six of the vials, spacing the punctures so the box still seemed balanced and full. And with a small enough needle, they wouldn’t have drawn any broken glass into their syringe.

  “Very clever,” I mused again.

  “Not clever, Dr. Lesslie,” Stevens said, once again taking the box from my hand and placing it on the table. “This is criminal.”

  Cleverly criminal, I wanted to say, having to bite my tongue to remain silent.

  But he was right—this was serious business. We had a problem in the department, and it was bigger than I had thought.

  “Have we checked the other medications?” I asked Virginia, fearing the worst.

  “It seems this is the first one,” she answered quietly. “No other evidence of any tampering. But whoever did this has an intensity of purpose and will likely go to extremes to get what they’re after.”

  “And we’ve narrowed our list of possible suspects to just a few people,” Walter added, leaning back in the chair and bridging his fingers, spiderlike. “Just a few,” he repeated for emphasis. He studied my eyes for some response, then looked up at the ceiling, apparently absorbed in a moment of obvious self-satisfaction.

  I looked away and once more focused on the package of Demerol. It had to be someone with access to the narcotics cabinet, so that did narrow the number of possible suspects. But still, that would be a dozen or more nurses. The narcotics keys were handed off at the beginning and end of each shift, so there was an opportunity there for someone to put his or her hand on them. But the nurses were always careful with the keys, and they all understood how important this whole issue was. Their licenses and employment might depend on it.