The woman on the stretcher was desperately casting her eyes about for help. Her bronchial tubes had shut down, and her breath was cut off. Her chest heaved. She was unable even to speak. She clawed at her clothes and gave panicky whimpers. Her nicotine-stained fingertips with downwardly curving nails—a sign we called clubbing— told the reason: end-stage emphysema. A lifetime of smoking had come down to a few desperate seconds.
“What do you want to do?” I commanded more than asked, to get the resident thinking again.
“Ventolin?”
“Good answer—except it’s too late for Ventolin now.” She’s so shut down she needs an airway.”
“Won’t she buck the tube if we try before she arrests?”
“Good question, but I want to prevent the arrest and relieve her distress. We’re going to crash her before she crashes on us. Get your intubation equipment ready.”
He looked relieved to have a familiar job. I knew he’d just come to us from an anesthesia rotation.
Susanne, anticipating where we were heading, had filled the pancuronium, succinylcholine, and ketamine syringes. Our lady was reduced to useless, flailing movements like a stranded fish. She already had an IV.
As I worked, I talked out what I was doing for the sake of the resident. “First a defascicutadon dose of short-acting curare to prevent muscle twitching when we paralyze her outright.”
I shot in the pancuronium.
“Never paralyze someone and not sedate them. Though unable to breathe or move anything, she’s still conscious—the living dead, so to speak, and terrified. For this scenario we use ketamine.”
In it went.
We started to bag her before intubation. I continued to talk. “That sedates, gives analgesia, and dilates her bronchial tubes.” I let it take effect.
“Now we paralyze,” I said, and injected the succinylcholine.
A few twitches, modified by the preceding curare, and she was flaccid, unable to move a muscle, including her diaphragm. We were committed; either we succeeded in getting an airway or she was dead.
“All yours. Doctor,” I said as I stood back to let him intubate. Given his recent training, it was unlikely he’d have any trouble. But in the OR, the resident was used to a calm, well-planned routine for intubation. Here we had to snatch the same technical precision from a lot messier setup.
He moved in and positioned her head. I gave three quick puffs with the bag and mask and then removed it. He scissored open her mouth with his right hand; with his left he slid in a laryngoscope. The curved blade with a light in its tip pushed aside the tongue and illuminated the vocal cords. Through them he’d slide a tube into her trachea. The nurses went quiet. The resident steadied the light in position.
“Do you see the cords well?” I asked him to confirm this crucial step.
“Yep.” He picked up the endotracheal tube with his right hand and slid its tip carefully over the tongue held aside by the blade of his scope. He paused with the tip of the tube aligned at the small opening in the windpipe, then slipped it through. “Got it!” he announced, and the nurses began to chatter again.
He hooked up the bag to the tube, squeezed in a few test puffs of air while listening at the bases of the lung for confirmation. “We’ve got air entry!” He sounded surprised at his own success.
“Of course. Doctor, good job.” I knew he’d build on this case. Respiratory emergencies would no longer frighten him.
We added some Ventolin down the tube, started steroids through the IV to dampen down the underlying inflammation of the lung, then arranged the transfer to ICU. I let the resident continue bagging her and supervise the trip upstairs. He’d enjoy presenting his win. The lady looked pink.
Before this week I never would have thought I’d be using shifts in the ER as a way to relax.
* * * *
The whole department was present, a first, but then, they’d never been summoned because of an injunction before. Even Sylvia Green, who was on duty, came up to the meeting room, but she stayed near the phone, ready to be called to the ER in an instant. And I’d had Carole make two special calls: to Kradic, who had finally put his phone back on the hook, and to Jones. She’d given them my order to be here, and they were—sullen, withdrawn, and sitting at opposite ends of the table, but they were present. Jones avoided my eyes; Kradic seemed oblivious of me. Finally he realized I was staring at him and looked annoyed, but then, he always looked annoyed to me.
There were a few wisecracks sent my way about the accident. The usual type of stuff—”Anything for a day off.” “What’d the other car look like?”
Obviously no one except the murderous driver knew that the hit-and-run had been deliberate. All the banter ended when I mentioned the injunction.
“We’ll get to that in a minute. First I need to talk about Kingsly’s murder. For those not up-to-date on the situation, when we found him early Monday morning, he had been stabbed with a cardiac needle. No one knows why, let alone by whom.” I paused a second, then said, “Because of the way Kingsly died, anyone with the skill or means to perform intracardiac insertions is under scrutiny. Each one of you will be questioned, starting tomorrow.”
Now there was more dismay than offense.
“They gotta be kidding.”
“That’s nuts.”
“Christ!”
I waved the noise down. “I know. I share your feelings. But until they get some clue as to what’s going on, be careful. Anything unusual, take note, and get back to me.”
The initial shared outbursts were being replaced by averted eyes.
“Look, I don’t mean I want you to spy on your colleagues or anything. I mean, we all have to remember that after this ends we’re still going to be working together and, I hope, continuing to trust one another.”
My attempt at perspective sounded feeble even to me. I tried the practical example. “Here’s what I mean. This past Monday there was a DOA derelict found in the street and brought here without any resuscitation attempt tried on him. The post found marks from an intracardiac needle. Anyone here know of any practice procedures on the body?”
I had asked this looking directly at Kradic. He swallowed and then quickly glanced down at his lap. The rest of them answered my question by saying no or shaking their heads. All except Jones. She just stared at the center of the table.
“Dr. Jones?” I asked to get her attention.
“No, I don’t,” she said resentfully without even looking at me.
I turned back to Kradic. “And you. Albert?”
His head snapped up, and he seemed surprised, but that could have been because I called him by his first name, which was rare. “Of course I don’t.” He scowled, then added even more resentfully, “Why are you asking us about this anyway?”
“Because, as I said, the DOA had a needle track into the heart we can’t account for. And, since we can’t explain it, I have to think the derelict was also murdered, the same way as Kingsly.”
Kradic looked startled. Others at the table expressed their shock.
“Another one?”
“Good Lord!”
“Like Kingsly?”
“What the hell is going on?”
But I just kept staring at Kradic. He looked even angrier now, and leaned forward as he spoke over the noise of the others. “Are you saying the cops will blame that on us too?” he demanded, his voice rising.
Everybody in the room went quiet.
“As I warned you, the police will start questioning you tomorrow about Kingsly’s death. I don’t know what they’re doing about the derelict.”
He was red in the face now. “Jesus Christ! What kind of setup is this?” He began pounding the table with his right forefinger as he spoke. “I don’t know about the rest of you, but I’m getting a lawyer!” He rose partly out of his seat and used that same finger to point across the table at me. “And you,” he yelled, “are letting the staff of this department be hung out to dry!”
Then he sh
oved back his chair and stomped out.
His accusation hung in the silent room. Some looked at me, obviously nervous; others looked anywhere but at me.
My mouth was too dry when I first tried to speak. I had to take a sip of water and try again. “I don’t need to tell you this is a very serious matter. Perhaps each of you should consider legal counsel before talking with the police.”
The silence remained, but now nobody was looking at me except Popovitch. He gave me a sad little smile and then came to my defense.
“I’m sorry,” he started to say, and got everyone’s attention, “but Dr. Garnet can’t change what has happened in the last few days. The police are looking for a killer, and until they succeed, this department, along with a few other areas in the hospital, will be under scrutiny. It may not be fair, and it’s certainly not desirable, but it can’t be helped.” He looked around at his colleagues, then spoke rather sternly. “It is absolutely unacceptable to blame the messenger, and I insist, on behalf of all of us, that we dissociate ourselves from Dr. Kradic’s inexcusable behavior.”
Most quickly came to my defense, but a few still looked pretty worried. Jones was scowling at Popovitch now, probably still smarting from his rather public rebuke of her this morning in front of the residents. I turned back to Popovitch.
“Thank you, Michael, now let’s deal with this courtorder nonsense.” I told them my plan, but I doubted many of them had much confidence in my ability to pull it off.
And I still had no idea who had tried to kill me.
* * * *
Coming home that evening was more like entering a boys’ camp than being at the site of a recent attempted murder. Right away I knew Doug’s men were out in force when I saw the number of pickup trucks wedged into my driveway. The warm scent of pizza greeted me as I stepped into the kitchen. “Hi, Doc!” and a chorus of other welcomes came from those filling the room. Someone opened the fridge, which was now full of beer, and handed me a can. Seemed like Doug had made my mental well-being the primary responsibility of his crew.
I recognized some of the guys from the renovation work on the cabin, and the others cheerily introduced themselves. Doug’s best. Many had families they were abandoning for the evening to baby-sit me, and I was warmed and flattered.
“Thanks, guys.”
“Hey, no problem. Our pleasure. Glad you’re okay.”
Doug led us into the living room where, clearly, he’d made replacing the large-screen television a priority and had hooked up our still-functioning VCR. He punched Play. Casablanca, in all its original black and white, was starting to unfold its tale of love and glory. It was my favorite movie of all time. “How’d you know?”
They answered with pleased, knowing grins. Doug must have called Janet.
“C’mon, Doc, sit down. We’ve got it cued up so he’s about to do the ‘Of all the gin joints in all the towns in all the world, she had to walk into mine’ bit.”
And I did sit down. I watched that famous craggy face and took courage from it. I felt blessed.
It was after midnight when Janet called me from the case room. “How’d you like it?” she asked.
“Would have been better with you.”
“Flatterer.”
“You okay?”
“Yeah. you?”
“I’ll be better when we get our life back.”
“How’s Muff?”
“I dropped by the vet’s on the way from work. Sedated, fever, but pressure and urine output are up. I left one of our pillows. She didn’t know I was there, but if she ever does wake up, she’ll recognize our smell.”
“I’ll go see her in the morning. ‘Night, love.”
“ ‘Night, Janet. I love you.”
Chapter 11
Hurst started his meeting promptly at seven A.M., and almost everyone was present. Not surprising. I was relieved to see that Gil Fernandez had turned up. He was bathed, his beard trimmed, but still he seemed subdued. Even his pocket handkerchief was less puffed up than usual.
Sitting beside him was a uniformed policewoman with a stenographer’s pad in front of her. On the opposite side of the long table, but farther down, a second uniformed police officer, a pad also in front of him, sat between Bufort and Riley. A dozen legal-size file folders were stacked near Bufort, and two open briefcases were on the floor near his chair.
I happened to sit by Watts. He leaned over and quipped, “If those are Kingsly’s financial records, it’ll be ruled justifiable homicide.”
Hurst stood, cleared his throat, and we were off.
“Though this special meeting of the chiefs of staff was requested by Detective Bufort, I want to remind you we are under police orders not to discuss the details of Mr. Kingsly’s murder. A sordid tragedy such as this is disruptive enough without the appalling sort of headlines we saw in yesterday’s paper.” As he slowly turned his head, his glare spared not one of his medical colleagues at the table. I suspected he was more concerned about bad publicity than any negative impact a leak might have on Bufort’s police work. “For those of you interested,” he added, “a memorial service for Mr. Kingsly will be held next Monday at one o’clock in the hospital Chapel.” Some of the chiefs made a gesture to note the announcement. I was saddened to think of how few of them would actually bother to go. Hurst sat down with a curt nod at Bufort.
Bufort sat motionless for a few seconds, as if waiting to make sure he had our undivided attention. The two uniformed police picked up their pens and got ready to write. Even Riley had taken out a notebook. “There’s a rule of thumb in homicide,” he began, “that the most important evidence is found within the first few hours after a crime. Then the trail grows cold quickly.” He seemed tense, and I was surprised to see dark shadows under his eyes. Without me as a suspect, I wondered, did he feel the case was slipping out of his grasp?
“The first days of this investigation seemed to go well,” he continued. “We discovered a probable motive for Kingsly’s killing, and were looking at a few suspects.” He looked at me briefly, then continued. “But recent events, some of which were brought to our attention only two days ago”—he frowned in the general direction of Watts—”have made it necessary to widen our investigation. While it’s unusual for us to conduct a session like this, we’ve been forced to do it to try to make up for lost time. We hope that after hearing about some of the evidence gathered so far, one or more of you may realize you have information or insights that will help us find Mr. Kingsly’s murderer.”
Damn, if he was this desperate, he was really back at square one. Then I noticed something strange. While Bufort talked, neither Riley nor the two uniformed police were looking at him. Each had his eyes fixed on a different section of the group at the table.
Bufort stood as he resumed speaking. “One of the avenues we have explored to find out why Kingsly was killed and by whom is his hospital records. The other avenues, his personal life, his associations beyond hospital life, haven’t yielded anything so far. Besides, as you probably know, the manner in which he was killed suggests it was done by someone in this hospital, someone with a special skill.”
Hurst was starting to squirm. I wondered if Bufort had questioned him on his ability to needle a heart. The policewoman opposite Hurst watched him for a couple of seconds, then wrote something on her pad.
“In these records,” Bufort continued, “we find what I take it all of you are aware of: The hospital’s finances are in a mess. Every department, it seems, has a debt. It isn’t easy for the auditors we’ve called in to determine who controls what expenditure. People just forward requests for equipment, tests, and supplies, and other people fill those requests from preauthorized labs and medical supply houses. No one at any level seems to know why existing supply and service contractors were chosen. The authority to question alternatives, let alone actually implement any attempt at more cost-effective measures, doesn’t seem to be exercised in any consistent or logical way.”
He paused. Around him a ri
ng of puzzled faces echoed my own confusion. It sounded more like a management seminar than a murder investigation. Riley and his two colleagues watched their sections of the table but wrote nothing down. And Hurst was really squirming now.
“The budget of this place is one hundred and twenty million annually. That’s a great deal of money by anyone’s standards. And Kingsly and the director of finance, Thomas Laverty, alone controlled its allocation.”
Everyone at the table looked around. Laverty wasn’t present. The police officers watched our faces, and I slowly caught on. Bufort and his people were checking for reactions again.
“The opportunity for diddling the till here is immense,” he continued, starting a professorial strut behind the chairs occupied by the policeman and Riley. “Increasingly Mr. Kingsly was ... well, incapacitated. The clerks up in finance kept sending checks to pay the bills as they came in. Overdrawn, why not? A lot of hospitals are these days. The bank relishes racking up interest charges, and loans to the health care system are a cash cow to the moneylenders, so they don’t complain. End of the year, there’s a deficit. The board screams, then approves borrowing the money to pay the interest and further service the debt. The bank now has interest on interest but assumes that even if the hospital is in danger of defaulting, another institution is likely to buy it out and make good on the loan. So for the time being, who even thinks of paying back the principal? After a few years the entire mess becomes such a routine, it gets no more than token scrutiny. The familiarity gives a false sense that it’s all proper, and the diddling continues.”
He had us all now. Hurst looked as if his second heart attack had plugged his pump. His first one, ten years ago, was the reason he’d given up surgery. His hands rolled into fists; his mouth made sucking movements. I leaned forward and took his arm. He wrenched it free. I saw the policewoman write something else on her pad.
“We don’t have many details yet,” continued Bufort, “and we haven’t finished looking at all your departmental salary pools, but we have a pretty good example of wrongdoing. The first oddity was a receipt for etchings and prints from a place called Renaissance Art Gallery. More than two hundred thousand dollars’ worth, labeled as institutional art, that no one knows about. We have no idea where they ended up. There wasn’t a trace of the stuff in Kingsly’s home.”
Lethal Practice Page 19
