* * * *
“Of course it’s atypical,” Popovitch yelled into the phone. “Twenty percent of them are. But the ECG and enzymes confirm an inferior MI and he’s on streptokinase. You shouldn’t have withheld the ER visit in the first place! You guys are supposed to manage care, not withhold it!”
He slammed down the receiver and then turned to the openmouthed residents and quickly assigned each of them to a new case. When he’d finished, I motioned him to join me in the corridor and told him about the bed closures. This got me more than another arched eyebrow. “Jesus Christ! If it isn’t HMO gurus, it’s our own damned administrators. What are you going to do?”
“Declare war!” I proclaimed dramatically even though I didn’t have a single idea about my strategy or tactics.
Popovitch just shook his head, then ran off down the hall to deal with the rising chaos.
I checked with Susanne to see if I could help her with any immediate problems. She had one.
“It’s another DOA from the streets. That’s about the sixth derelict we’ve gotten since summer. I gave MAS hell, but they insist they’re spreading them around. They claim there are a lot of them lately.”
She handed me a sheaf of forms. “If you do the paperwork, I can at least find him a bed. The morgue always has room.”
She gave me a sly smile. “Your patient is waiting in Room C, Doctor,” she told me, and then got out of the way before I could hand back the forms she’d given me.
Sounds weird for a doctor, but being alone with a dead body gives me the creeps, and this was my second in less than twelve hours. It’s nothing to do with medicine. As long as there is even a spark of electricity left in some remaining cell, there’s still life somewhere, and we can try to treat. But a corpse is just too ... too final. I find myself holding my breath. It’s illogical because, unlike Kingsly’s corpse, I usually see one long before the decay sets up an odor.
The cadaver in front of me was middle-aged going on eighty. Sleeping on sewer vents, eating garbage, and guzzling cheap booze had mapped his face with broken red and blue lines. They spread over the gray and yellow parchment that had been his skin like an atlas of the winter alleys and dark streets that had got him here. Once he hadn’t been like this, but it was hard to imagine when he still might have had enough hope to avoid such a pathetic end.
Masked and gloved, I shivered and got on with it. I had to declare formally the absence of respirations and pulse. There were no gross traces of violence or trauma, and death was probably due to natural causes, if the living conditions that killed him could be called natural. It would take an autopsy to determine the cause of death for certain, but the autopsies mandated by law on Jane and John Does were often cursory ... to say the least. Even health care for the dead was over budget.
I quickly checked the DOA for local abscesses or thrombosed veins indicating repeated self-injection but saw none. Eager to get back outside, I was giving the rest of the body a hurried exam when I spotted a tiny speck on the man’s chest.
In normal circumstances, I never would have noticed so small a mark, let alone given it a second glance. Dark, innocuous, it might have been a mole, a bit of dirt even, or an insignificant scab. It was the location that set off the alarms. This man had a mark just left of the xiphoid-sternal junction, the lower tip of the breastbone—the usual site for an intracardiac injection.
I stared at it, wanting it to vanish, but there it remained. It was nothing near as big as the scab I’d found on Kingsly—this was merely a dot—but the location was exact.
I felt increasingly uneasy as I leaned down for a closer look. I still couldn’t tell what it was. I took a breath, lifted my mask, and blew on the mark in case the speck was a balled-up piece of fabric or some other foreign material that had ended up stuck there by chance. The spot didn’t move.
It might yet have proved to be a particle of dirt that would lift off with a wet Q-Tip and reveal intact skin underneath, but I didn’t want to disturb anything until I was sure this wasn’t something Watts should see first. Scanning the rest of the skin for similar marks, I found a few sebum-filled pockmarks on his face and neck that were blackheads, and benign moles on his extremities. I started to relax, but went back to the original mark. The surrounding skin seemed to be flat, not rolled or raised as was common with blackheads. I looked at the spot from the side and was able to see a slightly rounded elevation in the center. It could be a mole, but then again, maybe not. Feeling foolish, I gingerly pressed down on the man’s stiffened cold chest with the palm of my hand to verify that nothing poked or bubbled out from under the mark as had happened with Kingsly.
Nothing did.
Thank God! I thought, embarrassed at having been so easily spooked by something that was probably as simple as a mole. As I exhaled, I realized I’d been holding my breath again.
I was tempted to lay the matter to rest myself and confirm with a Q-Tip if it could either be washed away like sebum or dirt or was fixed like a mole and couldn’t be removed, but I still refrained from touching it. If it came off and was a scab, Watts and the police would have my head for interfering with the site before they checked if there was an underlying puncture mark and needle track—first by gross examination with magnification under a bright light, then microscopically after excising the area and mounting slices of the tissue on glass slides. Better leave it for Watts, I decided, feeling silly to bother him about a thing that was sure to be trivial. The idea of this guy being killed the same way as Kingsly was preposterous.
At the door I deposited my mask and gloves, picked up the death certificate, and returned to the nursing station, where I found a quiet corner to fill out the forms. On the second page was an outline of the human figure, front and back, to let me indicate any significant marks on the man’s body. I made a dot in the drawing at the left lower tip of the breastbone, drew a small circle around it, and marked it with an arrow from the margin. There I wrote, “Attention Dr. Watts: Pigmented lesion vs. small scab at left xiphoid-sternal junction. Check it out?” I was sure going to be red-faced if it turned out to be dirt.
As I wrote, the familiar sounds of the department getting busy pattered in the background.
“Portable chest in three, please.”
“Right.”
‘Triage at the desk.”
“Has CMU called for the MI in bed three yet?”
“No, and the streptokinase is nearly through.”
“Still stable?”
“Sort of. His BP’s a little low, but I kept the drip going.”
Concentrating on the blanks that reduced the end of a life to a few hasty scrawls, I tried to ignore the chatter around me. But I knew it meant we had a heart attack patient in danger of going into shock from the drugs we were giving to dissolve the blood clot in his coronary arteries.
“CMU on line four; they’ve no more beds.”
“What!”
Now I also knew they had no room for that heart attack patient in the cardiac monitoring unit.
“Ambulance in the corridor.”
“Triage at the desk, stat!”
“V. tach. in bed five!”
“Shit!”
Ventricular tachycardia is a potentially lethal cardiac rhythm. Another patient was about to arrest.
“Ninety-nine, emergency! Ninety-nine, emergency!”
Christ, I wondered, could this day be real?
I threw aside the uncompleted forms and ran to help Popovitch.
* * * *
The cardiac arrest in bed five made it, but during the resuscitation the condition of the heart attack case in bed three had grown worse, much worse. He’d been unattended and gone hypotensive on his streptokinase drip while all the nurses in his area were helping us two beds over. By the time they got back to him, saw what was happening, and stopped the drip, he was in shock.
We gave intravenous volume to try to regain his pressure without overloading his already damaged heart, but he remained hypotensive.
> Pale, scared, and young, “the cardiac” became a name. Donald Cummings, denied a cardiac bed and proper monitoring in order to save money, now required an even more expensive level of care in the ICU, and would probably end up with nothing more than a monitored dying. The good news, for a cynic, was that the ICU did have a vacancy. The man I’d resuscitated the night before had died.
My rage at reducing Donald Cununings to economics was replaced by dread as I faced his wife. She was white with fear and trembled as she held her husband’s hand and gently stroked his head. Her courage was as limp and frail as his heart. I felt dirty when I finally walked away to go to my office.
My secretary was out for coffee, but she’d obviously been busy.
The first note I saw on my desk confirmed that most of the chiefs whom I’d asked to attend the meeting at noon would be there. Then there was the message to call Bufort. The detective apparently had phoned while I was trying to resuscitate Cummings, demanding to see me immediately. He could damn well wait his turn. So could the reporters. All three of them who’d called to get a quote from me about Kingsly’s death. Probably wanted a lot more than a quote. I tore up those messages.
The morning’s correspondence had been screened, prioritized, and stacked to one side. That signaled it would be mostly calls to meetings and minutes of previous meetings mixed with a few cranky letters of complaint— the stuff of a routine paper-shuffle and even less inviting than a meeting with Bufort.
I looked at the wall unit of files. When I had first chosen emergency twenty years ago, it was because of the allure of high-risk medicine, the chance to literally raise the dead and be part of the medical elite on the front line of care. It also meant freedom. The cowboys who worked in the pit seemed excused from the stuffy social conformity that dominated the rest of the profession. We could do a few shifts, then head off to a rock concert in a VW bus and not get shunned by the hospital elders as long as we performed well in the ER.
Now everything had changed. The profession in general was much freer, largely as a result of medical schools recruiting people from a wider range of backgrounds and encouraging women to join our ranks in equal numbers. The all-male bastion crumpled, and medical thinking reflected ideas from the arts as well as the sciences. And I was a respected chief, forty-eight years old, and weighed down by looking at the paperwork from seven years of talk. Had any of it done anything? So much pointless chatter recorded in dusty stacks of minutes, and yet we still slid into more cuts, more compromise. I’d skip these sessions altogether, but it was a constant fight to limit the harm being done, and that morning I’d failed. Donald Cummings had overcome his HMO trying to deny him a visit to the ER, only to pay the price of the bed closures. It was a far cry from how I had thought medical practice would be back in the shining time of beards and long hair.
I leaned out of my inertia toward the phone, intending to get my call to Bufort over with, but I’d barely picked up the receiver when the door opened after a perfunctory knock and the good detective himself strode into my office, two uniformed policemen trailing him. “Dr. Garnet,” he said without preamble, “I want your files of departmental meetings and personnel records. Now, please!”
The demand was like a club slammed on my desk.... Or maybe right into my midsection.
“What on earth—” I began, half rising out of my chair.
“You heard me,” he snapped. “The minutes of your departmental meetings and your personnel files!” He came up and stood directly opposite me, my desk still between us. I got the rest of the way to my feet, and the two uniformed policemen moved to either end of the desk, as though I might make a run for it.
“What are you doing?” I asked, looking from one cop to the other and then back to Bufort. He put both his hands on the desktop, leaned forward, and said, “Well?”
It took me several seconds to gather my thoughts enough to answer. “The ER minutes are filed upstairs with all the other minutes of meetings held around here. You can get them there.” Why the hell hadn’t Kingsly’s staff just given them to him?
Bufort stared at me.
I was regaining my wits quickly now. “As for my personnel records, those are confidential. They contain among other things the record of any peer review or disciplinary action a physician has been subjected to. I’m bound by hospital bylaws to protect that information from unauthorized scrutiny. You would need a subpoena, and it would have to be for a given individual. You can’t just go fishing through a whole department’s confidential files.”
“You refuse?” he asked, still staring at me without blinking.
“You know I have to,” I answered, growing a little impatient at his obvious attempt to intimidate me.
At first he didn’t reply. His expression showed nothing—not anger, not disappointment, not even resentment. But the widened blacks of his eyes warned me he was pumped with adrenaline. I felt my stomach knot as I waited for his next move.
“There’s one file you could give me permission to see.”
“Oh, whose is that?”
“Yours.”
I didn’t believe I’d heard him correctly. He’d spoken very softly, but with an edge in his voice that startled me. “Pardon?”
“You could let me see your file,” he repeated, still in a quiet tone, but I noticed that his beefy cheeks were flushed.
A chill went through me. Before I could speak, he spun around and left the office, his two policemen in tow.
I was left standing behind my desk, trying to figure out what had just happened. Bufort must have been told he could have any minutes he wanted without having to ask me. And more than anyone he would know he couldn’t go through confidential files for the asking.
Then I got it. He hadn’t wanted minutes or files. He wanted me, my reactions. He’d been checking me out. He’d wanted to see how I’d react to him going after old minutes and private files, particularly my own. But why? I felt another twinge of alarm. However crude his bursting in on me had been, he must have had a reason. What had he found or heard about me that interested him? Remembering the parting look on his face was giving me the willies.
My fretting was cut short.
“Ninety-nine, emergency! Ninety-nine, emergency!”
I’d started to run out the door when I heard “Cancel ninety-nine, emergency! Cancel ninety-nine, emergency!”
This meant the arrest code was called off for some reason. I slackened my pace but was still pretty brisk in covering the remaining ground back to the ER.
Susanne met me with an outstretched palm to slow me down. Without my asking, she explained. “One of the cleaning men walked in on the DOA you left in C.”
“I left?”
“Yeah. Our cleaning guy just took a staff CPR course. Saw the body, called ninety-nine, and started mouth-to-mouth.”
“On a corpse?”
“You know civilians. They can’t tell how long somebody’s been dead. Hell, they’re taught not to quit until a medic or someone qualified says so.”
“Where’s he now?”
“In the can, barfing. The corpse is on the way to the morgue.” She shoved a sheaf of papers at me. “Now, for God’s sake, do the paperwork so they don’t send him back.”
It took less than a minute to finish signing off on the forms, but then I hesitated. Looking at my note about the mark on the derelict’s chest after Bufort’s astonishing behavior, I wondered if making a fuss about such an unlikely possibility might draw his attention even more in my direction. Would he see my note as a feeble attempt to send the hospital’s pathologist on a wild-goose chase? If I could have erased the entry and had Watts check out the mark first, I would have. I even wondered if I should document the inappropriate attempt to resuscitate a long-dead corpse. To a trained doctor or nurse, it would have been inconceivable to start CPR on an obvious DOA. I certainly had never imagined that an inexperienced civilian with recent CPR training could walk in on one of our bodies and start pumping.
But the
same thing had happened with Kingsly. We never would have noticed the blood coming out from around the broken needle if the two cleaning women hadn’t started CPR on a body that had obviously been dead for hours. If such a scenario was inconceivable to a doctor or nurse in the ER, could the person who murdered Kingsly have made the same assumption—that by the time Kingsly’s body was found it would have been so evidently beyond resuscitation that CPR would never even come to mind, let alone be tried? An experienced resuscitator, trying to get away with Kingsly’s murder, would never have guessed that a course for the non-medical staff in CPR would give him away.
Chapter 5
Watts scowled at me. “Look, why don’t you leave the detecting to the real detectives?” He’d had to delay Kingsly’s autopsy until the forensic experts who’d initially gone over the body for evidence could return from the medical examiner’s office. With his other work backed up, he was not thrilled by my surprise visit. I’d taken the half hour remaining before my meeting with the other chiefs to slip down the back staircase that connected to the morgue and the morass of tunnels leading to Watts’s office in the basement. In the old days at the beginning of the century, a corpse could be dug up at the cemetery, brought to this back door, and then end up on the dissection table, no questions asked and twenty-five dollars forfeited to the grave robber. A generation of friendly family doctors had learned anatomy on such grisly remains.
“Please answer my question,” I said. “What would you have put on the certificate as Kingsly’s cause of death if one of those women hadn’t started pumping him and exposed the needle? Even with his clothes missing would you have started looking for a needle hole in his chest?”
I waited; he was still reluctant to answer.
“Come on, Robert, what would your first thought have been? Kingsly naked, reeking with booze, found dead?”
He took another moment, but then went along with my invitation to play what-if.
“Finally” was all he said at first.
Lethal Practice Page 5
