by Ross Pennie
Dr. Wakefield nodded solemnly and handed Art a tissue. “Zol arranged for a medical student to come and help me out. He arrived the day before yesterday and took a couple of the night shifts. He says this reminds him of his nurse-practitioner days in northern Manitoba — some frozen outpost this side of North Overshoe.”
“That’s all very well, but how come they sent you a student instead of a real doctor?”
“Todd’s better than any resident. More experienced and far slicker at IVs. And you know the best thing? He never complains.”
Dr. Wakefield made a face and straightened the crease in his trousers. “Mr. Greenwood, I feel terrible about Betty. I just can’t understand why she’s not getting better. I’ve done everything I can think of — blood work, X-rays, nasogastric suction, intravenous fluids, antibiotics.”
“What if those things don’t work, Doctor?”
“I . . . I really don’t know.”
Dr. Wakefield jammed his nose into a chart. Whatever anyone might say about the bluntness of his manner, this man could focus on a task like no one else.
Art dabbed at his cheeks until he was sure they were dry. He gripped his handlebars and said, “Dr. Wakefield? I wonder if I can show you something?”
“What’s that?”
“When you’re done.”
“Sure. In a sec. Let me write one more order.”
Dr. Wakefield finished with the chart and placed it in a rack beside several others. He closed his ballpoint and placed it in his shirt pocket. Then he fixed his blue-eyed gaze on Art’s face as though no one else on the planet was worthy of his attention.
Art took a deep breath. “Earl got struck with a brilliant idea. So we’ve done a little sleuthing on our own. And remember, this is our home. We know this place inside out.”
“You certainly do.”
“What we’ve got is a little complicated. Better to show it to you than tell you about it. Has to do with our survey.”
“I already know about your survey. Zol and Natasha went through those food questionnaires and said nothing turned up.”
“But this is a different survey.”
“Really? What’s it about?”
“We have it laid out in my room. Can you come and take a look?”
“Give me fifteen minutes to finish up here.”
Art reached over his handlebars and squeezed Dr. Wakefield’s forearm. “Doctor, would you make it five?”
CHAPTER 16
Art’s door was wide open, so Hamish knocked and walked in. The cinderblock walls, closed dark drapes, plain pine table, and gooseneck reading lamp gave the place the feel of a military outpost he’d seen in a movie.
Someone had taken down a painting and leaned it against the wall. It depicted the Normandy D-Day landing descending into a line of war graves blanketed with maple leaves. The artist’s portrayal of malevolent power and raw emotion took Hamish by surprise, especially in the confined space of Art Greenwood’s modest room. A plain whiteboard hung in the picture’s place.
Earl hunched over the pine table. A laptop was open in front of him, and sheets of paper were stacked beside it. He touched the peak of his Blue Jays ball cap. “Morning, Doc. Hope you’re full of energy. We’ve been up half the night, but we’re still raring to go.”
“He’ll be up for this, all right,” said Art.
“Up for what?” said Hamish.
The two men looked at each other, their impish expressions betraying a conspiracy they were dying to share.
Art picked up a pen and tapped the stack of papers. “You started it,” he told Earl. “You tell him.”
Earl pulled off his cap and scratched his thatch of thick silver hair. He replaced the hat, adjusted its position with both hands, then fixed Hamish with his pale eyes. “We need your appraisal of our analysis.”
“What did you find?”
“Actually . . .” said Art. “We’re not completely sure.”
“Come on,” said Earl, “we didn’t pull an all-nighter for nothing.” He patted his laptop. “Our electronic buddy here has done some heavy collating, and we’ve drawn one pretty solid conclusion. Natasha would be proud of us.” He pointed to the empty chair to his right. “Have a seat and I’ll show you what we’ve got.”
As Hamish sat down, Art handed him a sheet from the stack on the table. It was a printed questionnaire, similar in layout to the one Natasha had used to survey the residents’ food preferences. This one listed diagnoses.
“At our age,” Earl began, “we’re preoccupied with two things: our bowels and our medications. You already know too much about our bowels. Now it’s time to take a look at our drugs.”
“But we’re talking about an epidemic here,” Hamish told him. “Fever, diarrhea, and dehydration. I’m sorry, but that adds up to infection, not medication side effects.”
“Maybe,” Art said, “but a detailed exploration of our diets turned up nothing.”
“I figure,” Earl said, “it’s like the Battle of Hastings. A thousand years of myth and erroneous assumptions buried the truth about King Harold’s logistical failures. Same applies here.” He frowned, shifted in his chair, then touched his belly as though gripped by some sort of spasmodic discomfort. After a moment his face relaxed. “We knew we had to start with a clean slate.”
Art pointed to the paper in Hamish’s hand. “Have a look at that,” he said. “As a prelude to a survey of our medications, we started with a menu of our ailments: arthritis, bronchitis, cancer, diabetes, heart condition, high blood pressure, kidney problems, tummy troubles, and skin rashes.”
“Did you include those who recently passed away?”
“Yes,” Art said. “As best we could.”
“Arthritis was tricky,” said Earl. “Practically everyone has it. It’s as natural to aging as wrinkles, so we weren’t going to include it. But Phyllis suggested we break it into two groups: mild, requiring ordinary pain killers, and severe, requiring prescription medications.”
“That turned out to be brilliant,” said Art. He peered at his weather-beaten wristwatch. He always wore it over his shirt cuff, where it looked unfashionably gauche but was easy to read. “Where is Phyllis, anyway? She should be back from Tim’s by now. I’m parched.”
Earl’s gnarled fingers clicked at his keyboard. No hunting and pecking for the professor who must have typed hundreds of academic papers and thousands of revisions.
A data table flashed on the screen.
“Natasha phoned me yesterday,” Earl said. “Boy, she’s keen. Told me to divide the residents into two groups: those who’ve had the epidemic gastro and those who’ve remained free of it.”
“Just a lot of numbers that don’t say much,” said Art, his eyes twinkling.
Earl clicked again at his keyboard. “Until you turn them into percentages.”
Art grinned. “That was my idea.”
Another table flashed onto the screen.
Hamish ran a finger back and forth between the two columns — Gastro and Gastro-free — looking for a pattern in the data. “You’ve done a case-control study here.”
Earl beamed and puffed out his chest. “That’s what Natasha called it. Of course, she hasn’t seen these figures.” His hands darted over the sheets on the table. After a lot of muttering, and a couple of false starts, he found the page he was looking for and handed it to Hamish. “Here’s our working copy.”
The sheet was identical to the table on the screen, except that a pencil had scored out the diagnoses showing similar frequencies between the residents with diarrhea and the controls without it.
Only one diagnosis was left unmarked by the pencil: severe arthritis. Ninety percent of the gastro group were afflicted by it, but it affected only twelve percent of the gastro-free group.
“Have you verified your data?” asked Hamish. He’d visited his late grandfather in his seniors’ home and watched the residents at mealtime. Communicating their choices from a simple dinner menu was a complicated process. Li
mited eyesight, poor hearing, and failing memory fuelled many a misunderstanding, ending with disappointment on the dinner plate. Did these Camelot questionnaires suffer from similar limitations?
“We’ve reviewed each questionnaire twice, and our data entry three times,” Earl replied.
“That ought to be good enough,” said Art.
Hamish raised his finger, saw the two faces beaming at him with the eagerness of first-year medical students, and dropped his hand to the table. He couldn’t disappoint them.
“So?” said Earl. “What do you think?”
“This is a strong correlation. And it raises a number of questions. What sort of arthritis and exactly how severe? And what medications are they taking for it?” He let that sit for a moment while he thought about it. And then he said, “There are some heavy-duty arthritis drugs that make people vulnerable to unusual infections by weakening the immune system. Maybe you’re on to something.”
“We’re not done yet,” Art cautioned, then looked eagerly at Earl.
The professor pointed to the data table on the monitor. “We’ve designed another case-control study.”
“Last night at supper, we got everyone’s consent to enter their medications into our database,” Art said.
“Vik from Steeltown Apothecary has us all in his medication administration record,” Earl explained. “The nurses use it as a reference when there’s a question about our meds. Your medical student showed us where they keep it.”
“Can I see what you’ve got so far?” Hamish asked, amazed at the ingenuity of these two charmers.
“Afraid not,” said Earl.
“The puzzle sisters are still entering the data,” said Art. “They used to be keypunch operators.”
“They’re very methodical,” said Earl. “We figure it’ll be after lunch before we can have a look at the data.”
Hamish answered a rap at the door. Phyllis stormed in pushing a wheelchair, its seat loaded with four Tim Hortons coffees and three paper bags filled with the smell of fresh baking.
“That place has a licence to print money,” she huffed, “but Lord, they’re slow. They make our dining-room staff look like efficax exempoator.” She whipped off her scarf and peered at Hamish over the top of her spectacles. “And efficiency exemplified, they’re not — believe me.”
Phyllis blew the crumbs from a plate she retrieved from the windowsill, then opened the bags and laid out the snack: bagels, muffins, cream cheese, and jam. Hamish hoped he’d get to snaffle the bran muffin, protected inside its paper baking cup.
Phyllis pulled a hanky from her sleeve and dabbed the drops of wintry dribble from the tip of her nose. Her eyes narrowed and her hand jerked as she clutched her chest. “How’s Betty?”
“Just the same, I’m afraid,” Hamish said.
The others helped themselves to the bagels while Hamish washed his hands in Art’s sink. There was no bottle of hand sanitizer anywhere in sight. Hamish took the unclaimed muffin and broke off a mouthful, taking care to leave the paper wrapping intact.
“Maybe you don’t have the correct diagnosis, Doctor,” said Phyllis. “My sister’s pulmonary embolism was misdiagnosed by four different doctors before somebody got it right.”
“For heaven’s sake, Phyllis,” Art said. “Of course Dr. Wakefield has got Betty’s diagnosis right.”
Hamish chewed on the muffin and said nothing. Maybe Phyllis was correct. Perhaps he didn’t have Betty’s diagnosis entirely correct. She did have C diff — the horsey smell of para-cresol in her room had been unmistakable, and the lab test came back clearly positive. But why was the vancomycin not working? Was old age slowing her response to the appropriate treatment? Or perhaps she had an underlying bowel disease — ulcerative colitis, diverticulitis, cancer of the colon?
“Earl,” said Hamish, “let me see the names of the twenty-one residents in the gastro group.”
Betty was on the list, of course. In fact, she’d come down with fever and diarrhea three times since Christmas. Art and Earl were there too, both hit by two bouts of diarrhea that were never as severe as Betty’s. Phyllis, despite sharing their table at every meal, had stayed in the clear.
What had Earl said about the Battle of Hastings? Myths, assumptions, and logistical failures? Hamish wondered what false assumptions had been leading him astray.
Perhaps Betty hadn’t told him her full medical history. The unabridged list of her medicines might point to a pre-existing diagnosis she’d failed to mention. Patients did that frequently. They came to you with fever and backache, and didn’t bother to tell you they’d recently received six months of treatment for melanoma or bladder cancer. It didn’t occur to them that the fever, the backache, and the cancer treatment were intimately linked.
“Tell me,” Hamish said, “what’s the name of the pharmacist who looks after you here? Did I hear you call him Vik?”
Earl nodded. “Vik. From Steeltown.”
“He’s foreign,” said Phyllis. The word was a rebuke, not a description.
“Yugoslav,” said Art.
“Croatian, to be exact,” said Earl. “He has an interesting story. Came as a refugee from Sarajevo. Lost his family there.”
“I find him rude and offhand,” Phyllis said. “Delivers our medications, grunts a few words to Gloria and the nurses, then leaves.”
“He loves hockey,” said Earl. “Mention the Leafs and you’ll get a big smile out of him.”
Hamish’s pulse quickened in his throat. He touched his neck. That sore spot was still there. “Was he hospitalized recently?”
“You bet he was,” Earl said. “Intensive care at your place, and then off work for a few weeks. A Lebanese fellow delivered our pills for a while.”
Hamish felt the blood drain from his face. He touched his neck again, then shuddered. He’d never forget the bear-like power of Viktor Horvat’s paws digging into his trachea in the intensive care unit on New Year’s Day.
The rage he’d seen in Horvat’s face that day had seemed strange for a man askew on a hospital bed, one false step from death. Acute meningitis and septic shock robbed most people of their energy and emotions, left them pale and limp, past caring whether they lived or died. But Horvat’s eyes had radiated a palpable fury.
“What?” Horvat shouted, a furious answer to Hamish’s professional scrutiny. “You wanting I kiss your feet?”
Hamish held the bedside chart like a shield in front of him and tried to compose a response — a few controlled and empathetic words that would preserve the dignity of both doctor and patient.
Horvat bolted from his bed, oblivious to the dozen wires and tubes connecting him to the high-tech frenzy of intensive care. He flung his hand toward the door. “Goddamn soldier-doctor, get out.”
No one had ever mistaken Hamish for a soldier before. It was true the precision of his blond flat-top, touched up by his stylist every ten days, might be mistaken for a military cut. But at five-foot-five, with a baby face and precious little fat or muscle on his frame, no one could mistake him for GI Joe.
Horvat scowled deeper furrows into the granite of his forehead then tapped his breastbone. “I am knowing.” He turned his finger and jabbed it at Hamish. “You are soldier.”
A second later, Horvat lunged. In an instant he had Hamish by the neck, his thumbs clamping Hamish’s voice box in a vise-like grip, squeezing tighter and tighter. Bracing for the crunch of his crumpling windpipe, Hamish stared into Horvat’s face. He read its hatred, knew the man was never going to let go. He pounded his assailant’s forearms with an upward thrust. He’d been taught the maneuvre as a teenager by a Red Cross swimming instructor. It was supposed to break the stranglehold of the victim you were rescuing from drowning.
Horvat’s arms didn’t budge.
Hamish focused more intently on his own upper limbs: fists balled, elbows bent, arms stiff. Stars swirled in the consuming darkness. He heaved for his life.
Horvat’s thumbs gave way. Wires flew, the monitor wailed, an
d Hamish stumbled from the bedside. He collapsed on a chair near the door and gasped. Lungful after lungful.
Three nurses stormed the room and flew into action, forcing Horvat back into bed and reconnecting his tubes and wires.
“Canada Army kill . . . kill . . .” Horvat bellowed. He pointed at Hamish’s chest, his eyes as wide as gun barrels. “Goddamn maple-leaf soldiers.” He bared his teeth, apparently incensed by the Canadian flag embroidered on Hamish’s lab coat. “Always stinking drunk.”
In the following days, Hamish had kept his distance and let the antibiotics do their thing for his delirious patient. Horvat recovered and was discharged home, though it had seemed strange for a previously healthy man to come down with listeria meningitis, a disease of the elderly and medically fragile. Hamish had chalked it up to one of medicine’s inexplicables.
He stared at the empty muffin cup scrunched in his fist, then tugged his tie away from his throat and massaged his neck. A second case of invasive listeria was coming to mind — Gloria’s mother, Raimunda, infected a month after Horvat. She, too, had responded well to treatment. But a few weeks later she came down with gastro and died very quickly. Was it really gastro? Or had her listeria relapsed, caused an illness that mimicked gastroenteritis, and finished her off before any tests could be run? Zol had asked the coroner to send off a post-mortem blood culture, but it would be weeks before the provincial laboratory would report the result, and it would go only to the coroner.
The textbooks didn’t consider listeria a proper intestinal pathogen. Laboratories looked for listeria in critical samples like blood and spinal fluid, but they never looked for it in stool specimens. Conventional wisdom dictated that detecting listeria in diarrhea stools was of no diagnostic value because the germ was present so often in the feces of healthy people.
Was that piece of conventional wisdom a myth, a medical old wives’ tale that could lead to errors in diagnosis?
There was only one way to find out.
CHAPTER 17
