But in every other way our rooms were completely opposite. For one thing, mine was decorated almost exclusively with dirty clothes. Stephen used to say that whenever he looked at it, he knew exactly what Saks would look like if it were ever leveled by a tornado. In contrast, Claudia’s room, like her life, was arranged with the precision of a naval cadet. Of course, I liked to think that the rigors of her schedule gave her an unfair advantage. Years of wearing nothing but surgical scrubs had not only winnowed her wardrobe down to two manageable categories—socks and underwear—but left the hospital responsible for her laundry, while I had no choice but to dress like a grownup.
I knocked softly on her door and waited. When it comes to personal relationships, I believe in taking people at their word. Unlike my mother, when someone says they don’t want to talk about something, I change the subject. Not only that, but when told to go away, I leave. I’m not sure why so many people find this bewildering.
Claudia’s voice, hoarse from crying, bid me to come in. Inside, the room was dark, the only illumination coming from the desk lamp in the far corner of the room. But even through the darkness I could see that she hadn’t changed out of the day’s blood-splattered scrubs. She had also been crying for a long time.
“Is everything okay?” I asked quietly, setting myself gingerly onto the corner of her bed.
She shook her head in reply, still struggling to muster the composure to speak.
“Has something happened? Are your parents okay?” I pressed.
Hugging her knees to her chest, Claudia forced herself to take a couple of deep breaths. “My parents are fine,” she answered finally, managing something that was meant to be a smile. “I’m afraid it’s me that’s the mess.”
“Why? What’s wrong?”
“I lost a patient today.”
“Another patient?” I demanded reflexively. On some level every lawyer is a prosecutor, even against their better judgment. “Another respiratory arrest?”
“Not another patient,” replied Claudia, the words bitter in her mouth. “My patient. My very first patient.“
“What do you mean?” I demanded. Even though they were often more highly skilled than their counterparts in private practice, the surgeons in Claudia’s training program were not technically responsible for their patients’ care. As physicians in training, they were required to work under the direct supervision of one of the senior physicians on the medical staff. In practice, of course, the opposite was more often the case. At Prescott Memorial it was the fellows, working trauma full-time, who were considered at the top of their game. It was the rare attending physician who challenged their instincts or interjected themselves in the management of patient care.
“It doesn’t make one fucking bit of difference who the surgeon of record was,” Claudia declared miserably. “I was the surgeon who did the case. I’m the one who is ultimately responsible. McDermott never even set foot in the operating room.”
“It was McDermott’s patient?” I asked, the first inkling of bad things beginning to stir at the base of my brain.
“I told you it doesn’t matter whose name was on the bottom of the chart. I was the one who operated on her, and I was the one who killed her.”
“What was her name?” I demanded, instinctively taking the interrogator’s tack of starting with simple questions and easy answers.
“Camille Estrada,” said Claudia, as if even uttering the name was painful. “She arrived in the ER day before yesterday complaining of abdominal pain. They sent her up to OB-GYN, where Farah Davies had a look at her and admitted her with a tentative diagnosis of endometrial adhesions. While she was on the OB-GYN service they worked her up. When her abdominal ultrasound revealed cholelithiasis, Farah referred her to Gavin, who scheduled her for surgery.”
“Would you mind telling me what happened again, but this time in English?”
“Instead of female trouble, she had gallstones,” replied my roommate. “That’s what was causing the pain in her belly. I’m surprised Farah Davis didn’t suspect gallstones right off the bat. Farah is usually an excellent diagnostician, and Mrs. Estrada fit the perfect four-F profile.“
“Meaning she was exempt from the draft?”
“No. Meaning she was fair in terms of her coloring, fat, forty, and fecund, i.e., she’s had children. For some reason most gallstone patients fit that profile. So anyway, she was on the schedule for a laparoscopic cholecystectomy this morning—that’s a relatively new procedure for removing the gallbladder. You make a small incision and go in with a scope, kind of like playing a video game, but the small incision means that patients have less pain and heal faster.”
“So why didn’t McDermott do the procedure?”
“In the middle of the night last night Mrs. Estrada started complaining of pain in her abdomen and began running a fever. The resident ordered a lab workup, and the results came back with an elevated white-blood-cell count, so, not knowing his ass from a hole in the ground, he called me. I just assumed that she was experiencing a flare-up of her cholecystitis and told him to bump her off the OR schedule until the inflammation calmed down.“
“Is that normal?”
“Absolutely. I figured we’d watch her for a day or two and see if she got any better. If she didn’t, we’d have to send her home and wait for the acute attack to pass before rescheduling her surgery.”
“So did things get better for her?”
“No, they just got worse. Instead of subsiding, the pain started to localize, which means that it not only became sharper but it seemed to move. But what really caught my attention was that it didn’t move to the right upper quadrant, which is where the gallbladder is, but to the right lower quadrant of the abdomen.”
“Meaning?”
“Meaning that the whole thing was turning into a mess. The abdomen doesn’t always give you pain directly above the diseased organ. Not only that, but by that time I’d been awake and on my feet for thirty-six hours straight. I wasn’t sure I could find a gallbladder if someone dropped one in my lap with a label on it. Besides, Mrs. Estrada was not my problem. She was assigned to the surgical service, not trauma. The only reason I got called to see her in the first place was because the resident was scared shitless of McDermott and wanted someone to back him up in case he needed to cover his sorry ass.”
“So what did you do?”
“Not much. I wrote orders for something for her pain and went and hid in the on-call room to see if I could catch some sleep before morning rounds.”
“And?”
“And the minute my head hit the pillow the fucking resident was shaking me again. Mrs. Estrada was being a pain in the ass. Not only was she refusing to take her medication, but she was screaming blue murder that this wasn’t her gallbladder, this pain was different. The resident begged, the nurses begged, please, go and see this woman and make her shut up.
“So I dragged my ass out of bed and went to see Mrs. Estrada, and damn if my examination doesn’t show exquisite tenderness in the lower right quadrant.”
“Meaning?”
“Appendicitis.”
“You’re kidding.”
“Nope. Just because you’re paranoid doesn’t mean you don’t have enemies.”
“So what did you do?”
“I started her on antibiotics, gave her some pain medication, which she took like a lamb, and left a message with McDermott’s service that his six A.M. cholecystectomy was now an appendectomy. Then I went back to bed.
“The next thing I know, the resident is waking me up again. Apparently Mrs. Estrada’s appendix was heating up, and he wanted to know what he should do. I got out of bed, letting him know in no uncertain terms what I thought about his prospects for making it as a surgeon if he didn’t hurry up and start growing a spine. Then I told him to alert the OR coordinator, page anesthesiology, and go scrub. In the meantime I paged McDermott and went to see Mrs. Estrada to see how she was doing for myself and get her signature on the surgical co
nsent forms.”
“How did she seem?”
“In a fair bit of pain and a little freaked out. She kept on repeating that she couldn’t believe this was happening to her.”
“Why would she say that?”
“Probably because she was in the hospital for one operation and was about to have another, that and the fact that the pain meds were making her goofy. I patted her on the hand, told her that she couldn’t have picked a better place for her appendix to go bad on her, and ordered the nurses to get her up to the OR stat.”
“So what happened to McDermott? Did her appendix rupture before he made it to the hospital?”
“Nope. He was scrubbed and ready to go when she got there. The only problem was that the OR coordinator called at the same time to say that Farah Davis was in OR four and needed a pair of hands stat. Apparently she had a patient with a uterine rupture and she couldn’t control the bleeding. She was asking for an assist from McDermott.”
“What did he do?”
“He had them page me to surgery and when I got there told me to get scrubbed and remove Mrs. Estrada’s appendix.”
“So what did you do?”
“I took out Mrs. Estrada’s appendix.”
“How did it go?”
“Piece of cake. Believe me, it’s a lot harder to give a good haircut than it is to take out an appendix. After I finished the appendectomy, I took a minute to irrigate her abdomen and check out her gallbladder since I was in the neighborhood.”
“How did you do that?” I asked, not sure that I wanted to know.
“All I did was slide a couple of fingers into the incision and move them toward the liver and gallbladder, gently pressing the liver with one hand to bring the gallbladder into reach.”
“And what did you find?”
“Nothing. That was the weird part. I didn’t feel anything at all. No stones.”
“So then what?”
“I closed her up and sent her to recovery.”
“Any complications?”
“None. I’ve just spent the last three hours going over and over every step of the procedure in my mind. Other than the fact that I didn’t find gallstones, there was nothing remarkable about it. The whole procedure couldn’t have taken more than twenty minutes from scalpel to suture.“
“Did you tell McDermott about not finding the gallstones?”
“Yeah. He told me it was no big deal. I guess sometimes the stones are so small that you can’t feel them. Not only that, but the tiny ones can actually cause more trouble than the big ones. He also made some crack about my knowing more about gunshots than gallbladders.”
“I thought you said the stones showed up on ultrasound,” I pointed out.
“You’re right, but that wouldn’t necessarily mean that you’d be able to feel them with your finger. Still, I must confess it bothered me, so I looked at the films when I pulled her chart. I’ve got to tell you this woman had stones—I mean, we’re talking cherry pits.”
“So when did you bring it up again with McDermott? „
“The next time McDermott and I had words, Mrs. Estrada was already dead. She coded around four o’clock this afternoon. She’d already been moved out of recovery into a regular room. The floor nurse went in to check her vitals and found her in full arrest.”
“Were you there?”
“No, I was busy checking your Mr. Delius out of CCU. But as soon as I got the page, I was out of there like a bat on speed. Not that it made any difference. By the time I got to her room, there was nothing left for me to do except pronounce her and break the news to the family.”
“How did they take it?”
“About as well as can be expected, which is to say pretty terrible. The husband kept on asking me how something like this could have happened, and I didn’t have any answers for him.”
“Was her death like the others?”
“You mean the other postsurgical deaths? Only in that I have no more idea of what caused it than anyone has about any of the others.”
“What did McDermott have to say?”
“Oh, McDermott said plenty,” replied Claudia, barely suppressing a shudder. “They had to page him at his office at Northwestern, and he was still ballistic by the time he got to Prescott Memorial. I was in the hall talking to one of the nurses on the floor where it happened, and he just shot out of the elevator and tore into me. We actually drew a crowd. Patients even came out of their rooms to see what was going on. I have never felt so humiliated in my entire life.”
Having been on the receiving end of more than one unfair tirade, I knew just how devastating they could be. “Did he say anything of substance?”
“You mean besides the fact that he thought I was incompetent and incapable of performing even the most basic procedure without him holding my hand?” she reported, the lash of the chief of surgery’s words still fresh. “I guess you could say that he did. He told me that if he had anything to say about it, I could consider my career over.”
“You know he didn’t mean that.”
“Oh, please, I haven’t even told you the worst part.“
“Which is?”
“Mrs. Estrada’s husband overheard the whole thing. He was still in her room collecting her things. He heard every single word.”
“Did you talk to him?”
“I tried, but he said that under the circumstances he thought it best if all our communications went through our lawyers.”
“But won’t the autopsy show what killed her?” I asked, wanting desperately to reassure her.
“Normally when a patient dies in the hospital after surgery, they don’t do a post. They just assume that the death was caused by whatever underlying disease prompted the surgery.”
“But I thought you said you couldn’t feel any gallstones.”
“I couldn’t, but there’s no question her appendix was inflamed, and I performed an appendectomy. Under those circumstances you’d expect McDermott to sign the death certificate, no questions asked.”
“Will he?”
“Not now. Mrs. Estrada’s family has requested an autopsy.”
“Well then, it’s out of your hands. Now it’s up to the medical examiner to find the answers.”
“The medical examiner isn’t going to be doing the autopsy. I’m sure they’ve hired an independent forensic pathologist.”
“I didn’t know there was such a thing.”
“Are you kidding? There’s even a mobile service. They call themselves 1-800-Autopsy. They show up in a black van and do the post on your loved one, parked in your driveway.”
“Remind me to add that to my list of signs that the apocalypse is near.”
“For me, I’m afraid it’s nearer than you’d think. I have to appear before the morbidity and mortality board on Monday.”
“What’s that?”
“The M&M conference? It’s a confidential, closed-door review board that’s supposed to catch and correct physician error. Every hospital has one, but the proceedings are secret. You aren’t even allowed to take notes. They can be pretty brutal.”
“Have you ever been asked to appear before one before?”
“No, but I sat in on them as a resident.”
“What about McDermott? Doesn’t he share responsibility for all of this?”
“Oh, sure. He’ll hang his head and say he’s sorry for letting me do the procedure solo, and they’ll give him a rap across the knuckles and tell him not to do it again. Then they’ll hang me out to dry.”
“Won’t McDermott stand up for you?”
“Why on earth would he do that when it’s in his best interest to crucify me? Don’t you see? Up until now, every single respiratory-arrest death has been his patient.“
“So was this one,” I pointed out.
“But he never even set foot in the operating room. Not only that, but I looked at her chart. He never so much as ordered medication. I mean, unless the pathologist determines at autopsy that Mrs. Estrada died
from having her abdomen palpated, then he’s off the hook.”
“And he gives up his title of Dr. Death,” I mused.
“Absolutely. Up until this afternoon, everybody’s been whispering about him. Has he lost his touch? His luck? His nerve? Could he be drinking? Dipping into the old pharmacy cupboard? But on Mrs. Estrada he’s clean, which means he has everything to gain from nailing it on me.”
“Who else knew that you were the one who operated on Mrs. Estrada?” I asked, suddenly seized by a truly terrible thought.
“The resident who assisted, the scrub nurse, and the anesthesiologist. Maybe the OR coordinator if she ever lifted her nose out of her romance novel.”
“Anybody else?”
“No. Not unless McDermott happened to mention it to somebody.”
“Would he?”
“Probably not. Technically what he did by letting me do the case wasn’t kosher. He wouldn’t want to advertise it. But I still have no idea what you’re getting at.”
“Don’t you see? Ever since you’ve been at Prescott Memorial, the hospital has been losing patients, all from respiratory arrest following routine surgery, all Gavin McDermott’s patients. No one can figure out why. Now, all of a sudden, Mrs. Estrada dies the same way after you operate on her.”
“Pm still not getting it.”
“To everybody but Gavin McDermott and the handful of people who were actually in the operating room with you, Mrs. Estrada wasn’t your patient, she was Gavin McDermott’s. What if those deaths weren’t caused by something that happened in the operating room? What if it was something that happened after?”
“You mean like an infection or a bad drug interaction? Believe me, Kate, the first thing they did was rule those things out,” protested my roommate.
“What I’m suggesting is much worse,” I said slowly. “I think somebody is going around Prescott Memorial Hospital killing off Gavin McDermott’s patients.”
CHAPTER 10
Dead Certain Page 10
