The Patient

by Michael Palmer

  “You scare me, Alex.”

  “Sometimes, even after all these years, I scare myself. Jessie, I know how difficult it was to decide to help me. Thank you for trusting me.”

  “I don’t,” she said.

  JESSIE WATCHED AS he made his way down the corridor, pausing just long enough to glimpse into room 2 as he passed. Five years. Almost as long as it had taken her to complete her neurosurgical residency. It was a hell of a long time to chase an obsession—especially with so little success. Now, with no firm proof that the patient in 2 was Malloche, and with the man so near death, it was possible Alex’s quest would end not with a bang, but with the whimper of lingering uncertainty.

  Jessie checked the time—nearly twenty minutes since her page to Emily had been sent. She wondered if Emily’s beeper could possibly be malfunctioning or might simply have been turned off. At that instant her own pager sounded. The display gave Alice Twitchell’s name and extension.

  “Oh, Dr. Copeland, I’m so glad you answered so quickly,” Carl’s meticulous assistant said. “I’m in Dr. Gilbride’s office with Mr. Tolliver. He’s having a severe headache—a migraine. He told me to page you and not to bother trying to find Dr. Gilbride. Could you possibly come down and have a look at him?”

  “I’ll be right over,” Jessie said. “Alice, do you by any chance know where Emily DelGreco might be?”

  “Gee, no, Dr. Copeland,” the woman said apologetically. “I have no idea.”

  CHAPTER 22

  WHEN JESSIE ARRIVED, EASTMAN TOLLIVER, WEARING gray slacks and a navy blue blazer, was supine on the Moroccan leather sofa in Carl’s waiting room, a pillow under his knees, his feet hanging several inches over the armrest. He held the crook of his elbow pressed tightly across his eyes, and was actually trembling with discomfort. There was a wastebasket strategically placed on the rug beside him. Alice Twitchell was trying to move his arm enough to get a damp washcloth onto his forehead.

  “Eastman, it’s me,” Jessie said, kneeling at his side. “Can you hear me all right?”

  Tolliver nodded.

  “It’s beginning to let up,” he said hoarsely. “I’ve had these before.”

  His speech sounded just a little bit thick.

  “How long has it been this time?”

  “Fifteen or twenty minutes,” Alice said. “Dr. Gilbride was supposed to meet Mr. Tolliver forty-five minutes ago, but he called to say he’d be late.”

  “We had some business to attend to in the unit,” Jessie said.

  She gently removed Eastman’s arm from across his face.

  “You look a little peaked, my friend,” she said, beginning her neurological evaluation with the observation that the skin fold on the right side of his mouth was marginally less pronounced than that on the left. “Could you open your eyes? … Good. Now, follow my finger if you can.”

  Pupils midposition, reactive … Slight weakness in lateral gaze, right eye … Possible slight droop, right lid…

  “Eastman, could you show me your teeth, as if you were smiling?” Possible facial weakness, right … “Please stick out your tongue. Good. Now, squeeze my hands.” No obvious upper extremity weakness.

  “It’s letting up,” Tolliver said.

  “Good. Eastman, when’s the last time you saw a doctor for these headaches?”

  “I don’t know. A couple of years, maybe. He said they were migraine headaches.”

  “Do you take medicine?”

  “Over-the-counter sometimes. That’s all.”

  Jessie walked over to where Alice Twitchell stood watching.

  “Alice, please call the ER and have them send a surgical resident, a gurney, and a nurse up here, stat, ” she said. “Then call radiology and tell them I’m going to need an MRI tonight.”

  “Yes, Doctor.”

  Alice scurried away.

  The color had begun to return to Tolliver’s face, and his eyes no longer seemed glazed over. The abnormal neurological findings were persisting, but while they were potentially a harbinger of serious pathology, like an aneurysm or a tumor, they were also consistent with certain variations of migraine. Fortunately, Jessie knew that with the technology at her disposal, it wasn’t necessary to guess—or to wait very long.

  “Eastman, how is it now?”

  “Quite a bit better.”

  “Good. I’ve noticed some things in the rather incomplete exam I just did that concern me. I think you should have a few blood tests and an MRI.”

  “Are you sure I need all that?”

  “I’m very sure. Your symptoms and my findings are quite possibly all due to migraine headaches, but I can’t be positive. It may be fine for you to travel back to California, but not before we see your MRI. Have you had one before?”

  “No, I haven’t,” Tolliver said, still lying motionless enough so that Jessie knew his pain was persisting.

  “Okay,” she said, “just take it easy. The stretcher will be here before long. Don’t try to sit up.”

  “You’re the boss.”

  Carl Gilbride cleared his throat to announce his presence in the doorway.

  “What’s going on here?”

  “Oh, hi, Carl. Mr. Tolliver’s having a headache. Twenty or twenty-five minutes now, pretty severe. He has a history of migraines.”

  Gilbride approached the sofa.

  “Eastman, how are you feeling?”

  “Not perfect, but improved, thank you.”

  “Well, that’s excellent news. Excellent. I’ve made dinner reservations for us at the Four Seasons. But you can feel free to rest a bit more for now. We have plenty of time. The chef there is the best in the city.”

  “Um, Carl, could I speak with you for a moment?” Jessie asked.

  “Certainly, what is it?”

  “In your office.”

  “Oh, nonsense,” Tolliver cut in. “Carl, Dr. Copeland has had a chance to examine me. She is concerned enough to want me to have an MRI and some blood tests.”

  “For a migraine?”

  “Carl,” Jessie said, “Eastman had a slight right facial droop, a little bit of thickness of his speech, and maybe some eye signs as well.”

  Without excusing himself, Gilbride inserted himself between her and Tolliver, and peered down at the man’s face.

  “Follow my finger, Eastman,” he ordered, repeating some of the maneuvers Jessie had already done. “I don’t see anything,” he pronounced.

  Not, I don’t see anything now, Jessie noted. The implication in his words and tone was that there was nothing the matter—that the observations that had so concerned her were inconsequential. Jessie steeled herself for a confrontation. Whether or not the signs were still present was immaterial. They had been there, and many serious neurological conditions had waxing and waning findings at some stage. Her patience with her department chief had just about run out. Tolliver saved her from a potentially destructive blowup.

  “Look, Carl,” he said. “I like a good meal as much as the next fellow, but I also want to be certain this headache is a plain old migraine. It hurt like the devil.”

  “Very well, then,” Gilbride replied in a voice that already had some pout in it, “I’ll call down and see if we can get a CT scan.”

  “Carl,” Jessie said, “I’ve got a team from the ER on their way up here right now to bring Eastman down for some bloodwork and an MRI.”

  Unseen by their patient, Gilbride glowered at her.

  “That’s fine,” he said icily. “More than I would have done for what seems like a garden-variety migraine, but if Eastman doesn’t mind missing dinner, we’ll do it. I’ll take over from here and walk him down.”

  “Actually, Carl,” Tolliver said, “I’d prefer it if Dr. Copeland continued as my doctor.”

  “But—”

  “I know it upsets you, but I am the patient. And at the moment, if it is all right with Dr. Copeland, she is my choice.”

  Was Tolliver’s unequivocal insistence on her some sort of comment on the bungled surg
ery? Jessie suspected so. Whatever the reason, she felt nothing but delight.

  “I’ll be more than happy to honor your request, Eastman,” she said, carefully avoiding eye contact with her chief.

  At that moment, both Jessie’s and Gilbride’s beepers went off almost simultaneously. Then the phone across the hall in Gilbride’s office began ringing.

  “It’s the unit,” Jessie said.

  “Mine, too.”

  Alice Twitchell came racing over breathlessly.

  “Dr. Gilbride,” she said, “Count Hermann has had a cardiac arrest. They’re working on him now, but they want you over there. Dr. Copeland, the people from the ER are on the way up.”

  “Thank you,” Jessie replied.

  “Oh, that’s just awful news about Count Hermann,” said Tolliver. “Simply awful.”

  Gilbride looked almost apoplectic. Jessie imagined that there was no place on earth he would less like to be than supervising the resuscitation on his recent surgical calamity.

  “Jessie, I’d appreciate it if you would honor Eastman’s request and function as his primary physician,” he said, through nearly clenched teeth. “Meanwhile, I’d best hurry on over to the NICU.”

  “I’ll be up to help as soon as I can. Carl, have you seen Emily around?”

  “DelGreco?”

  “Yes.”

  “Not today I haven’t.”

  “Thanks,” she said, but he had already hurried off.

  Moments later the elevator arrived, and the team from the ER emerged.

  Jessie introduced Tolliver to the resident and nurse.

  “Eastman, you’re in good hands for now,” she said. “While they’re getting your tests done, I’m going to run over to the unit and see if I can help Dr. Gilbride. I’ll see you downstairs in just a little while.”

  “I have the utmost confidence in you,” Tolliver said. “Let’s hope this is nothing serious.”

  “Let’s hope that, indeed,” Jessie replied.

  But as she aided Eastman onto the stretcher and helped wheel him over to the elevator, every bit of instinct and intuition she possessed was telling her otherwise.

  CHAPTER 23

  PHILANTHROPIC DIRECTOR COMES TO EVALUATE neurosurgical program and ends up needing an emergency MRI.… Patient he watched be operated on has catastrophic result, then has cardiac arrest.

  What else could possibly go wrong? Jessie wondered as she hurried down the corridor of the office wing and through the doorway to the Surgical Tower. As a medical student, and even as a resident, she had always been excited by the frenetic action and drama of a full code 99. Now, while she accepted them as an essential part of the hospital, codes no longer held any allure. Their outcomes were, more often than not, preordained. Patients could frequently be hauled through the initial crisis, but unless the underlying problem was dealt with, and quickly, it was just a matter of time before their next code 99.

  Catherine Purcell, the evening nursing supervisor and a long-term veteran of the hospital wars, was standing just outside the doorway to room 2.

  “Hey, Catherine,” Jessie said, “how goes it in there?”

  “I think the Grim Reaper is well ahead. The patient was sort of stable, then suddenly he lost his pressure and went into V. fib. Now even that rhythm is degenerating. Thank God Joe Milano from cardiology is running the code.”

  “Is Dr. Gilbride in there?”

  “Oh yes, he certainly is. What’s with him, Jess?”

  “What do you mean?”

  “He stopped by the unit an hour or so ago to check on Count Hermann. Two of my nurses were talking and one of them laughed. Gilbride thought they were laughing at him, even though both of them claim he wasn’t even the topic of conversation. He called me and is threatening to have the nurse who laughed disciplined or even kicked out of the ICU.”

  “Which nurse?”

  “Laura Pearson.”

  “Jeez. These nurses can be harsh at times, but of all of them, she’d be the least likely to say anything unpleasant about anyone. Carl’s just a wreck over this calamity, I think—hypersensitive for a while. He’ll get over it.”

  “He’d better. I have a black belt in defending my nurses. Does the Count have any chance brainwise?”

  “Not much. I’d better get in there and see if I can lend a hand.”

  “If you have a chance, speak to Gilbride about Laura.”

  “Will do. Catherine, have you by any chance seen Emily?”

  “DelGreco? No. But I’ve only been wandering around the wards for a couple of hours. If I do see her, I’ll tell her to give you a page.”

  “Thanks.”

  There was the usual code 99 crush of bodies in room 2 of the neurosurgical ICU—nurses, med techs, a respiratory tech, an anesthesiologist, and several house officers, with a couple of medical students thrown in just to increase the critical mass. And of course, there was Carl, still in his spotless, starched lab coat, standing just close enough to the action to act as if he were in charge, while deferring—at least Jessie hoped he was—to the medical resident and to cardiology fellow Joe Milano, each of whom was far better equipped to handle a code than any staff person.

  Rolf Hermann had been detached from the respirator. A respiratory tech was squeezing a breathing bag to ventilate him through his endotracheal tube. The bedsheets had been thrown aside. Hermann’s naked body looked vulnerable, although the man was over six feet tall and quite sturdily built. In addition to the breathing tube, he had a monitoring/blood-drawing line in the radial artery at one wrist, an infusion line in a vein higher up in his arm, a tube through his nose and down into his stomach, connected to suction, and a catheter draining his bladder into a plastic bag that hung below the bed. There were cables connecting the EKG leads on his chest to the monitor, and others snaking up from an oximeter on one of his fingers and a port on the arterial line. Viewed this way, he looked like anything but the deadly, merciless killer of hundreds who had been the object of Alex Bishop’s obsession for five years. But illness and injury were great equalizers, and count or killer, there he was.

  Jessie worked her way through the crowd to Carl’s side.

  “How’s it going?” she asked.

  Gilbride kept his eyes fixed on the action. He looked frazzled and irritated.

  “What in the hell did you say to Tolliver that turned him against me?” he said out of the side of his mouth. “Joe, have you given him any IV bicarb?” he called over to the cardiology fellow.

  “We don’t use it anymore,” the fellow called back.

  “I knew that. I just thought this might be an exception. I think we should shock him again, yes?”

  “After we give him some more epi, Dr. Gilbride.”

  “Right. Give him the epi, then shock.”

  “Carl,” Jessie said, “I didn’t say anything at all to him except what you know—that he needs an MRI.”

  “Four million dollars,” Gilbride said, pausing theatrically between each word. “That’s what that man holds in his hand. Get ready to shock, everyone. Go ahead, Joe.”

  “We’re shocking. Everyone clear! Now!”

  There was a muffled pop from the paddles that the cardiologist held pressed against Hermann’s left chest, and four hundred joules of electricity were sent streaking through the Count’s body. His arms flapped off the bed, then fell back down heavily. His legs flared out, then relaxed. Five seconds passed with no response. Then the cardiograph pattern on the monitor showed one beat … then nothing … then suddenly another … and another.

  “I’ll be damned,” Jessie said, marveling at the quickness and skill of her younger colleagues, and trying to remember that once, not that long ago, she was as good at all this as they were now.

  Helped by a heavy dose of cardiac medications, Rolf Hermann’s heartbeat rapidly stabilized, and his blood pressure rose from zero to sixty to ninety. His blood oxygen content rose as well. The patient was a save … at least for the moment.

  “Do you think
he arrested because of increased intracranial pressure?” Jessie asked.

  “Maybe,” Gilbride replied, still looking straight ahead. “I’ll give him some more diuretic and up his steroids. If Porter hadn’t mistuned that damn robot of his, none of this would be happening.”

  Jessie was about to leap to Skip’s defense, but decided against it. Gilbride was on a knife’s edge as it was. This was not the moment.

  Hermann’s pressure and pulse were holding steady. One by one, the room began emptying out. This round, at least, had gone to the caregivers. But Jessie knew that the Reaper was, if nothing else, patient. Barring a miracle inside the Count’s skull, another round wasn’t far off.

  “Do you think we could talk for a couple of minutes?” she asked.

  “I’ve got to go speak to the Dragon Lady about her husband’s latest crisis. You know, if you hadn’t admitted these people to my service without waiting for my approval, none of this would be happening.”

  Jessie refused to be provoked.

  “What I have to say won’t take but a few minutes,” she said. “It has to do with the Count and his wife.”

  “I’ve got to go speak with Hermann’s family. Then I’m going to go down and check on Tolliver. After we confirm that his MRI is negative, there’s still time for me to get him to the Four Seasons and maybe smooth things over. I can’t believe he was in the OR for this fiasco.”

  Neither can I, Jessie thought.

  “Carl,” she said firmly, “I want a few minutes with you. Right now. It’s very important.”

  Startled by her tone, Gilbride looked directly at her for the first time. Still, he appeared distracted and unfocused.