by Mortal Fear
“The fact that you don’t is what makes you a good doctor,” said Judith, attending to the paperwork associated with a death.
Jason accepted the compliment, but he knew his attitude toward death went far beyond the profession. Just two years ago death had destroyed all that Jason held dear. He could still remember the sound of the phone at quarter past midnight on a dark November night. He’d fallen asleep in the den trying to catch up on his journals. He thought it would be his wife, Danielle, calling from Children’s Hospital, saying she’d be delayed. She was a pediatrician and had been called back to the hospital that evening to attend to a preemie in respiratory distress. But it had been the turnpike police. They called to say that a semi coming from Albany with a load of aluminum siding had jumped the central divider and rammed into his wife’s car head-on. She had never had a chance.
Jason could still remember the trooper’s voice, as if it had been yesterday. First there’d been shock and disbelief, followed by anger. Then his own terrible guilt. If only he’d gone with Danielle as he sometimes had, and read at Countway Medical Library. Or if only he’d insisted she sleep at the hospital.
A few months later he’d sold the house that was haunted by Danielle’s presence and his private practice and the office he’d shared with her. That was when he had joined the Good Health Plan. He’d done everything Patrick Quillan, a psychiatrist friend, had suggested he do. But the pain was still there, and the anger, too.
“Excuse me, Dr. Howard?”
Jason looked up into the broad face of Kay Ramn, the unit secretary.
“Mrs. Harring is in the waiting room,” Kay said. “I told her you’d be out to talk with her.”
“Oh, God,” Jason said, rubbing his eyes. Speaking to the relatives after a patient died was difficult for any doctor, but since Danielle’s death, Jason felt the families’ pain as if it were his own.
Across from the coronary care unit was a small sitting room with outdated magazines, vinyl chairs and plastic plants. Mrs. Harring was staring out the window that faced north toward Fenway Park and the Charles River. She was a slight woman with hair that had been allowed to go naturally gray. When Jason entered, she turned and looked at him with red-rimmed, terrified eyes.
“I’m Dr. Howard,” Jason said, motioning for her to sit. She did, but on the very edge of the chair.
“So it is bad …” she began. Her voice trailed off.
“I’m afraid it is very bad,” Jason said. “Mr. Harring has passed away. We did all we could. At least he didn’t suffer.” Jason hated himself for voicing those expected lies. He knew Cedric had suffered. He’d seen the mortal fear in his face. Death was always a struggle, rarely the peaceful ebbing of life portrayed in film.
The color drained from Mrs. Harring’s face, and for a moment Jason thought she would faint. Finally, she said, “I can’t believe it.”
Jason nodded. “I know.” And know he did.
“It’s not right,” she said. She looked at Jason defiantly, her face reddening. “I mean, you just gave him a clean bill of health. You gave him all those tests and they were normal! Why didn’t you find something? You might have prevented this.”
Jason recognized the anger, the familiar precursor to grief. He felt great compassion for her. “I didn’t exactly give him a clean bill of health,” he said gently. “His lab studies were satisfactory, but I warned him as I always did about his smoking and diet. And I reminded him that his father had died of a heart attack. All these factors put him in a high-risk category despite his lab values.”
“But his father was seventy-four when he died. Cedric is only fifty-six! What’s the point of a physical if my husband dies just three weeks later?”
“I’m sorry,” Jason said softly. “Our predictive abilities are limited. We know that. We can only do the best we can.”
Mrs. Harring sighed, letting her breath out. Her narrow shoulders sagged forward. Jason could see the anger fading. In its place came the crushing sadness. When she spoke, her voice was shaking. “I know you do the best you can. I’m sorry.”
Jason leaned forward and put his hand on her shoulder. She felt delicate under her thin silk dress. “I know how hard this is for you.”
“Can I see him?” she asked through her tears.
“Of course.” Jason got to his feet and offered her a hand.
“Did you know Cedric had made an appointment to see you?” Mrs. Harring said as they walked into the corridor. She wiped her eyes with a tissue she’d taken from her purse.
“No, I didn’t,” Jason admitted.
“Next week. It was the first available appointment. He wasn’t feeling well.”
Jason felt the uncomfortable stirring of defensive concern. Although he was certain no malpractice had been committed, that was no guarantee against a suit.
“Did he complain of chest pain when he called?” Jason asked. He stopped Mrs. Harring in front of the CCU door.
“No, no. Just a lot of unrelated symptoms. Mostly exhaustion.”
Jason breathed a sigh of relief.
“His joints ached,” Mrs. Harring continued. “And his eyes were bothering him. He was having trouble driving at night.”
Trouble driving at night? Although such a symptom did not relate to a heart attack, it rang some kind of a bell in Jason’s mind.
“And his skin got very dry. And he had lost a great deal of hair—”
“Hair naturally replaces itself,” Jason said mechanically. It was obvious that this litany of nonspecific complaints had nothing to do with the man’s massive heart attack. He pushed open the heavy door to the unit and motioned Mrs. Harring to follow him. He guided her into the appropriate cubicle.
Cedric had been covered with a clean white sheet. Mrs. Harring put her thin, bony hand on her husband’s head.
“Would you like to see his face?” Jason asked.
Mrs. Harring nodded, tears reappearing and streaming down her face. Jason folded back the sheet and stepped back.
“Oh, God!” she cried. “He looks like his father did before he died!” She turned away and murmured, “I didn’t realize how death aged a person.”
It doesn’t usually, Jason thought. Now that he wasn’t concentrating on Cedric’s heart, he noticed the changes in his face. His hair had thinned. And his eyes appeared to have receded deep into their orbits, giving the dead man’s face a hollow, gaunt look, a far cry from the appearance Jason remembered when he’d done Cedric’s physical three weeks earlier. Jason replaced the sheet and led Mrs. Harring back to the small sitting room. He sat her back down and took a seat across from her.
“I know it’s not a good time to bring this up,” he said, “but we would like permission to examine your husband’s body. Maybe we can learn something that will help someone in the future.”
“I suppose if it could help others …” Mrs. Harring bit her lip. It was hard for her to think, much less make a decision.
“It will. And we really appreciate your generosity. If you’d just wait here, I’ll have someone bring out the forms.”
“All right,” Mrs. Harring said, with resignation.
“I’m sorry,” Jason told her again. “Please call me if there is anything I can do.”
Jason found Judith and told her that Mrs. Harring had agreed to an autopsy.
“We called the medical examiner’s office and spoke to a Dr. Danforth. She said they want the case,” Judith told him.
“Well, make sure they send us all the results.”
Jason hesitated. “Did you notice anything odd about Mr. Harring? I mean, did he appear unusually old for a man of fifty-six?”
“I didn’t notice,” Judith said, hurrying away. In a unit with eleven patients, she was already involved in another crisis.
Jason knew that Cedric’s emergency was putting him behind schedule, but Cedric’s unexpected death continued to disturb him. Making up his mind, he called Dr. Danforth, who had a deep resonant voice, and convinced her to let the postmortem be
done in house, saying death was due to a long family history of heart disease and that he wanted to compare the heart pathology with the stress EKGs that had been done. The medical examiner graciously released the case.
Before leaving the unit, Jason used the opportunity to check another of his patients who was not doing well.
Sixty-one-year-old Brian Lennox was another heart attack victim. He had been admitted three days previously, and although he’d done well initially, his course had taken a sudden turn for the worse. That morning when Jason had made rounds he had planned to move Lennox from CCU, but the man was in the early throes of congestive heart failure. It was an acute disappointment for Jason, since Brian Lennox had to be added to the list of Jason’s inpatients who had recently gone sour. Instead of transferring the patient, Jason had instituted aggressive treatment for the heart failure.
Any hope of a rapid return by Mr. Lennox to his previous state was dashed when Jason saw him. He was sitting up, breathing rapidly and shallowly in an oxygen mask. His face had an evil grayness that Jason had learned to fear. A nurse attending him straightened up from adjusting the IV.
“How are things going?” Jason asked, forcing a smile. But he didn’t have to ask. Lennox lifted a limp hand. He couldn’t talk. All his attention was directed toward his breathing efforts.
The nurse pulled Jason from the cubicle into the center of the room. Her name tag said Miss Levay, RN. “Nothing seems to be working,” she said, concernedly. “The pulmonary wedge pressure has gone up despite everything. He’s had the diuretic, the hydralazine and the nitroprusside. I don’t know what to do.”
Jason glanced over Miss Levay’s shoulder into the room. Mr. Lennox was breathing like a miniature locomotive. Jason didn’t have any ideas save for a transplant, and of course, that was out of the question. The man was a heavy smoker and undoubtedly had emphysema as well as heart trouble. But Mr. Lennox should have responded to the medication. The only thing Jason could imagine was the area of the heart involved with the heart attack was extending.
“Let’s get a cardiology consult stat,” Jason said. “Maybe they’ll be able to see if the coronary vessels are more involved. It’s the only thing I can think of. Maybe he’s a candidate for bypass.”
“Well at least it’s something,” said Miss Levay. Without hesitation, she went to the central desk to call.
Jason returned to the cubicle to dispense some compassion to Brian Lennox. He wished he had more to give but the diuretic was supposed to reduce fluid while the hydralazine and nitroprusside were supposed to reduce pre-load and after-load on the heart. All of this was geared to lower the effort the heart had to expend to pump the blood. This would allow the heart to heal after the insult of the heart attack. But it wasn’t working. Lennox was slipping downhill despite all the efforts and all the technology. His eyes now had a sunken, glazed appearance.
Jason put his hand on Brian’s forehead and pushed the hair back from his perspiring brow. To Jason’s surprise, some of the hair came out in his hand. Momentarily confused, Jason stared at it, then he carefully pulled on a few other strands. They came out as well with almost no resistance. Checking the pillow behind Brian’s head, Jason noticed more hair. Not an enormous amount but more than he would suspect. It made him wonder if any of the medications he’d ordered had hair loss as a potential side effect. He made a mental note to look that up in the evening. Obviously hair loss was not a major concern at the time. But it reminded him of Mrs. Harring’s comment. Curious!
After leaving word that he should be called after the cardiology consult on Brian Lennox and after one more masochistic glance at the sheet-wrapped corpse of Cedric Harring, Jason left the coronary care unit and took the elevator down to the second floor, which connected the hospital with the outpatient building. The GHP Medical Center was the impressive central facility of the large prepaid health plan. It incorporated a four-hundred-bed hospital with an ambulatory surgery center, separate outpatient department, a small research wing, and a floor of administrative offices. The main building, originally designed as a Sears office building, had an art deco flair. It had been gutted and totally renovated to incorporate the hospital and the administrative offices. The outpatient and research building was new, but it had been built to match the old structure, with the same careful details. It was built on pillars over a parking lot. Jason’s office was on the third floor, along with the rest of the department of internal medicine.
There were sixteen internists at the GHP Center. Most were specialists, though a few like Jason maintained a generalized practice. Jason had always felt that the whole panoply of human illness interested him, not just specific organs or systems.
The doctors’ offices were spread around the perimeter, with a central desk surrounded by a waiting area with comfortable seating. Examining rooms were clustered between the offices. At one end were small treatment rooms. There was a pool of support personnel who were supposed to rotate positions, but in actual fact the nurses and secretaries tended to work for one or another of the doctors. Such a situation promoted efficiency since there could be some adaptation to each doctor’s eccentricities. A nurse by the name of Sally Baunan and a secretary by the name of Claudia Mockelberg had aligned themselves with Jason. He got along well with both women, but particularly Claudia, who took an almost motherly interest in Jason’s well-being. She had lost her only son in Vietnam and contended that Jason looked just like him despite the age difference.
Both women saw Jason coming and followed him to his office. Sally had an armload of charts of waiting patients. She was the compulsive one, and Jason’s absence had disturbed her carefully planned routine. She was eager to “get the show on the road,” but Claudia restrained her and sent her out of the room.
“Was it as bad as you look?” Claudia asked.
“Is it that obvious?” Jason said as he washed his hands at the sink in the comer of the room.
She nodded. “You look like you’ve been run over by an emotional train.”
“Cedric Harring died,” he said. “Do you remember him?”
“Vaguely,” Claudia admitted. “After you got called to the emergency room, I pulled his chart. It’s on your desk.”
Jason glanced down and saw it. Claudia’s efficiency was sometimes unnerving.
“Why don’t you sit down for a few moments,” Claudia suggested. More than anyone else at GHP, Claudia knew Jason’s reaction to death. She was one of only two people at the Center in whom Jason had confided about his wife’s fatal accident.
“We must be really behind schedule,” Jason said. “Sally will get her nose bent out of shape.”
“Oh, screw Sally.” Claudia came around Jason’s desk and pushed him gently into the seat. “Sally can hold her water for a few minutes.”
Jason smiled in spite of himself. Leaning forward, he fingered Cedric Harring’s chart. “Do you remember last month the two others who died just after their physicals?”
“Briggs and Connoly,” Claudia said without hesitation.
“How about pulling their charts? I don’t like this trend.”
“Only if you promise me you’re not going to let yourself”—Claudia paused, struggling for a word—“get into a dither over this. People die. Unfortunately it happens. It’s the nature of the business. You understand? Why don’t you just have a cup of coffee.”
“The charts,” Jason repeated.
“Okay, okay,” Claudia said, going out.
Jason opened Cedric Harring’s chart, glancing through the history and physical. Except for his unhealthy living habits, there was nothing remarkable. Turning to the EKG and the stress EKG, Jason scanned the tracing, looking for some sign of the impending disaster. Even armed as he was with hindsight, he could find nothing.
Claudia came back and opened the door without knocking. Jason could hear Sally whine, “Claudia …” but Claudia shut the door on her and came over to Jason’s desk. She plopped down Briggs’s and Connoly’s charts in front of him.
“The natives are getting restless,” she said, then left.
Jason opened the two charts. Briggs had died of a massive heart attack probably similar to Harring’s. Autopsy had shown extensive occlusion of all of the coronary vessels despite the EKG done during his physical four weeks prior to his death being as normal-looking as Harring’s. Also like Harring’s, his stress EKG had been normal. Jason shook his head in dismay. Even more than the normal EKG, the stress EKG was supposed to pick up such potentially fatal conditions. It certainly suggested that the executive physical was an exercise in futility. Not only was the examination failing to pick up these serious problems, but it was giving the patients a false sense of security. With the results being normal, there wasn’t motivation for the patients to change their unhealthy lifestyles. Briggs, like Harring, had been in his late fifties, was a heavy smoker, and never exercised.
The second patient, Rupert Connoly, had died of a massive stroke. Again, it had been a short time after an executive-style physical, which in his case had also revealed no alarming abnormalities. In addition to a generally unhealthy lifestyle, Connoly had been a heavy drinker, though not an alcoholic. Jason was about to close the chart when he noticed something he had missed before. In the autopsy report the pathologist had recorded significant cataract development. Thinking that he’d not remembered the man’s age correctly, Jason flipped to the information page. Connoly was only fifty-eight. Now cataracts were not entirely unknown at fifty-eight, but it was nonetheless rare. Turning to the physical, Jason checked to see if he’d noted cataracts. Embarrassingly he’d failed to include them, noting he described the “eyes, ears, nose, and throat” as being within normal limits. Jason wondered if he were getting sloppy in his “old” age. But then he noticed he described the retinas as appearing normal as well. In order to have visualized the retinas, Jason would have had to have sighted through a cataract. Not being an ophthalmologist, he knew his limitations in this regard. He wondered if certain kinds of cataracts impede the passage of light more than others. He added that question to his mental list of things to investigate.
