Diagnosis Death pft-3

by Richard L Mabry

  Cathy felt herself drawn into the story, first as the clinical picture unfolded, then as Elena told about her relationship with her mother-in-law. Her heart was touched by the enormous responsibility thrust on Elena when Mark's prognosis became obvious.

  "And how did Mark's mother react to all this?" Will asked.

  "She thought I should have noticed symptoms earlier and gotten Mark to the doctor."

  Cathy couldn't help herself. "But he had a berry aneurysm." She looked at Will. "A weak spot in the wall of an artery in the brain. Most often there aren't any symptoms. The first you know of it is when it ruptures, like this one did."

  Elena nodded. "Makes no difference. She was convinced I'd missed the diagnosis, that I should have somehow gotten him better treatment. But the thing that put the final barrier between us was that she kept holding on to the idea that, if Mark were kept on life support long enough, he'd eventually recover. I think she had visions of his being moved into her home where she could nurse him back to health-and get him away from me."

  Cathy spoke softly, but still her voice seemed too loud for the circumstances. "How did it finally play out?"

  "The neurologic damage Mark sustained was extensive. There might have been a chance-a very slim chance-that he could be weaned off the respirator, but he'd remain in a coma. He'd never function as a sentient human again."

  "So it was up to you to withdraw life support," Will said.

  "That's right. But Lillian kept arguing." Elena paused and chose her words carefully. "After two weeks, Mark came off life support and-" The words seemed to hang in her throat.

  "I understand how you must feel." Will's voice was calm. "I know a little about survivor guilt, not from firsthand experience, thank goodness, but from counseling with lots of widows and widowers when we prepare to probate wills."

  "Oh, there's that," Elena said. "I live with survivor guilt every day. But I know that I'll get over it eventually. What I can't get away from are the phone calls that come at midnight every Tuesday."

  Elena told them about the phone calls and the card, and explained why she thought Mark's mother was behind them. She told them about the financial morass in which she was trapped because of Mark's final expenses. More and more came rushing out. She appeared not so much to finish as to simply run out of steam.

  Cathy exchanged glances with Will. He gave a faint nod. Elena appeared to be telling the truth. Now for the big question.

  "Elena," Cathy said, "I realize how this must have weighed on you. I need to know how this affects your ability to function as a physician."

  "Of course, it's made it more difficult for me to see stroke patients. I guess I tend to identify more with their families, but that's probably not all bad. It makes me work harder to make sure the patients get the best possible care."

  "And you have no problem functioning in an ICU environment?"

  "I'll admit, there were some flashbacks early on, but it's never interfered with my clinical performance, never affected my judgment that I can tell. Actually, I have a patient in the ICU at St. Paul Hospital right now who's postsurgical after an intracranial bleed. I don't think he's going to make it, and I believe my experience has made me more empathetic, better able to counsel his wife."

  "Two more questions and we'll let this go," Cathy said. "First, can we help you stop those harassing phone calls? Will is an attorney. Maybe he can get some kind of injunction or something."

  Elena was shaking her head before Cathy finished. "I hope a move will be all it takes. I plan to have my Dallas number disconnected, no notification of the new number. I want it to be a dead end."

  "How about your cell number?"

  "To my knowledge, Lillian doesn't have it. I called her from my cell a couple of times when Mark was in the ICU, but I doubt she'd be savvy enough to check her call logs that far back."

  Will said, "If you change your mind, let us know. I think the other thing Cathy intended to ask was whether you'd like some counseling to help you get past this more quickly."

  "As usual, my husband has read my mind," Cathy said. "There's an excellent therapist in Fort Worth. Maybe a half-hour, forty-minute drive from here. Close enough to be relatively convenient, but far enough away that no one here in town will know about any visits you make."

  "I guess I'd have to think about that."

  "Well, I can highly recommend him. I saw him myself when I first moved here and was working through some issues."

  Elena forced a smile. "Thanks. I'll give it some serious consideration."

  Cathy had the sense that Elena wasn't about to consider seeing a therapist. But things could change. She'd be certain the option remained open.

  Will drew a line through the last string of words on his legal pad. "I think we've covered everything. That's the gist of the contract. I'll print it out and send it to you, and I'd suggest you have your own attorney read it over before you sign."

  "Do you have any questions?" Cathy asked.

  Will let the exchange that followed wash over him, taking one final stab at sizing up Elena Perez Gardner. Her brown eyes still bore the evidence of deep inner turmoil. The furrowing of her brow might be explained by concentration, but he was willing to bet there were some deeply troubling thoughts running through Elena's brain.

  He tuned back in to the conversation in time to hear Cathy say, "Call me next week. Meanwhile, I guess that's it."

  "One second," Will said. "Elena, we might be able to save you a trip back to Dainger. It occurs to me you'll need someplace to live. Do you want to drive around and look for a place to rent?"

  It was obvious Elena hadn't thought this far ahead. Will opened his mouth to make some suggestions, but Cathy beat him to it.

  "Why don't I make a phone call? I know a wonderful couple who have a spare room they'd probably be glad to make available until you've been here long enough to know what you want."

  Without waiting for an answer, Cathy picked up the phone and punched in a set of numbers she obviously knew well. The conversation lasted only a couple of minutes, and when she hung up she was beaming. "Let's go meet these people. This is a very special couple, and I think you'll really enjoy living with them."

  "Well…" Elena stammered. "I don't… I mean, I suppose.. ."

  "Don't worry. I stayed with them myself a few years back before Will and I were married. You'll love them, and they'll love you."

  Will frowned. At this point, he was pretty sure Cathy still had designs on getting Elena to open up. That's why she was setting her up to stay with his parents, Matthew and Dora Kennedy, in the parsonage of the First Community Church.

  "Matthew, Dora," Cathy said, "This is Dr. Elena Gardner."

  Elena studied the couple who stood in the doorway. Matthew Kennedy was whip-thin and sinewy. When she took the hand he extended, she found it slightly callused but the grip gentle. His white hair was thinning a bit. Blue eyes sparkled behind rimless glasses. Elena had the feeling she was looking at a preview of Will Kennedy thirty years hence.

  Dora Kennedy wiped her hands on a plain blue apron and stepped past Elena's outstretched hand to enfold her in a hug. Dora was a bit plump, a head shorter than her husband, but her twinkling eyes and white hair matched his. "Oh, Dr. Gardner. We're so thrilled that you're going to help Cathy. And when she called to ask if we'd put you up in the spare room, why that was the frosting on the cake." She stepped back and gestured the group inside. "And speaking of cake, I just took a peach pound cake out of the oven, and I have some fresh peaches to go on top of it. Let's go into the kitchen."

  "I don't really-" Cathy's faint headshake made Elena stop in mid-sentence.

  "Thanks, Dora. We'd love to," Cathy said. "I suspect a few days of your cooking will do wonders for Elena. I don't think she's felt much like eating the past few weeks."

  As the group trailed Dora and Will through the living room into a cozy kitchen, redolent with the enticing smell of fresh cake, Will whispered in Elena's ear, "My mother is the best cook i
n seventeen counties. I know we've just eaten, but I've learned it's better to take whatever she offers than argue with her. Besides," he added, "I'll bet you finish a piece and ask for seconds."

  Elena noticed that even Cathy, who'd said not an hour ago that she was trying to watch her weight, took the proffered cake.

  "Coffee?" Dora asked.

  Elena and Will accepted; Cathy said water would be fine.

  "Oh, yes," Dora said. "What am I thinking, offering you caffeine? I'm going to have to get used to your being pregnant. I need to get my grandmother hat on."

  Matthew gave a "What are you going to do?" glance, and Cathy combined a nod with a brief, wry smile.

  Elena picked up her fork but stopped when Matthew Kennedy said, "Will, this is the first time you and Cathy have broken bread with us in a while. And we're so glad to have Elena in our home. I'd like to express our gratitude for all that. Why don't I pray over the food before we eat?"

  Elena eased her fork back onto the table and bowed her head, wondering what she'd gotten herself into.

  "Dr. Gardner, we know what you did. We know what you did, and you have to pay."

  Elena squirmed in the hard chair. She was so far back from the tribunal that she had to squint to see the three doctors. One man had a gray tonsure ringing an otherwise barren dome, giving him the appearance of a very unhappy and unforgiving monk. The second peered out through Coke-bottle glasses that made him look bug-eyed. The third was surprisingly young for a doctor charged with such a solemn responsibility. His dark good looks reminded Elena of some TV star. The name tickled at the edge of her consciousness, but stayed hidden.

  She raised her hand like a third-grader. "But I'm a good doctor. Doctor Sewell said so yesterday. She's going to take me into her practice."

  "But not as a partner," said the monk clone, his voice thundering as though coming from the cloisters his appearance suggested. "She didn't offer you a partnership. You're on probation."

  "That's right," said the TV star. "And when we tell her what you did, you'll have to pay."

  "You'll have to pay," joined in the doctor with the thick glasses, his eyes growing more prominent with every word. "We're calling her now to tell her."

  The near-bald doctor picked up the phone sitting at his elbow and punched in ten digits.

  "Please don't call her. I'll do anything. Anything."

  "Too late. It's ringing."

  Elena heard the synthetic tone that sufficed for a ring in most phones. But why could she hear it? Maybe if she could answer before Cathy did, she could talk her way out of this mess. Her fingers scrabbled around on the table beside her until they felt the hard, cold plastic of a phone receiver. She fumbled it to her face and fairly screamed, "I can explain. I can explain."

  "Explain what?" a familiar voice asked. It wasn't that of the doctor/judge. It was someone she trusted-someone who could help her.

  "David!"

  "Hey, did I wake you? I'm so sorry. It's almost 9:00 a.m. I figured you'd be awake by now."

  Elena swung her feet out of bed and squinted at the clock. "No, no, I should be up. You woke me from a nightmare. I should be thanking you."

  "Are you okay to talk?"

  "Give me time to splash some water on my face and get coffee going. I'll call you back in five minutes."

  She took ten. Elena could smell the coffee brewing as she dialed David's number. "I'm so sorry. I must have sounded like an absolute nut."

  "Not a problem. I've had nightmares that were so real it took me most of the day to shake them. Want to talk about it?"

  "Not really." She didn't want to think about what it meant. She already knew.

  "I don't suppose you'd like to go to church with me this morning?" David asked, hope mixing with resignation in both his tone and words.

  Church? Oh, it was Sunday. But all Elena wanted to do was start planning for her move. "David, I appreciate the offer, but I'll have to pass."

  "Well, would you like to meet afterwards for lunch? You can tell me about your interview."

  She had to give him full marks for persistence. And he was a friend-perhaps the only one she had. "Sure. Call me when you're ready."

  The coffee was brewed by the time Elena hung up. With cup in hand, she sank into a kitchen chair, leaned her elbows on the table, and wondered if her nightmare had been an attempt by her subconscious to cleanse her soul of the guilt it felt. Or was it a portent of trials yet to come?

  6

  The ICU was a terrible place to start the week, but Elena was drawn to it this morning like iron to a magnet. She had to talk to Erma Pulliam again. If the woman was to do the right thing for her husband and herself, she had to do it soon.

  Elena pushed through the double doors into the unit. Off to her right, a nurse glanced at her and ducked into a patient room. Did the nurses resent her visits now? Chester Pulliam was no longer her patient. There was never any change to report, but conveying that information to her took precious minutes out of their already overcrowded day. Should she stop bothering everybody? But just as it was impossible not to explore a sensitive tooth with your tongue, Elena couldn't stay away.

  As she paused outside Pulliam's door, Elena heard the rhythmic chuff, chuff, chuff of the respirator. Apparently the patient still had no spontaneous drive to breathe. The machine was keeping him alive.

  Elena tapped lightly on the door and entered the room.

  "Dr. Gardner." Erma Pulliam tried to smile, but Elena saw there wasn't much behind it. "Nice of you to come by."

  The first thing Elena noticed was a plastic tube taped to Chester Pulliam's right nostril, the end plugged to keep a milky fluid from dripping out. There were a couple of vials of pills at the bedside, along with an old-fashioned pharmacist's mortar and pestle. The nurses would use those to grind medicines before inserting them into the feeding tube. No more need for IVs.

  The feeding tube represented an intermediate stage. Surgical procedures came next: a gastrostomy to provide a permanent means of feeding and a tracheotomy to allow unrestricted airway access. These operations were an accepted part of the road to what physicians called a vegetative existence. Nice words, but they failed to describe what would happen to the patient-and to his family.

  Mrs. Pulliam didn't know what lay ahead of her, but Elena did. Once more, she led the woman into the hall for their conversation.

  "Has your family been here yet?" Elena asked.

  Mrs. Pulliam shook her head. "We have two sons, both married and living on the other side of the country. They couldn't get away to come here, but they both said it didn't matter." She nodded toward the room they'd just left. "'That's not my dad in there,' they said. They want to remember him the way he was."

  "And what did they say about taking him off life support?"

  Mrs. Pulliam wiped her eyes with a tissue, then began shredding it. "They think I should do it. But I… I can't. It seems so wrong."

  "Do you have religious scruples about it? I can ask the hospital chaplain to talk with you."

  "No, I recognize the difference between taking someone's life and not prolonging the existence of a body with no brain function. It's just that I don't know if I have the courage to do it."

  Elena patted the woman's shoulder. "I know how you feel. I've been where you are."

  Surprise showed on the woman's face. "And what did you do?"

  Elena swallowed hard. When could she stop reliving that awful experience?

  "That's all right. I can see it's hard for you to talk about. I shouldn't have asked."

  Elena shook her head. "No, you need to know that you're not the first person to agonize over this decision. I finally came to the conclusion that it was best for Mark-and for me-to take him off life support and let him die with dignity."

  "I just don't know if I can do that."

  "It's hard," Elena said. "But not doing it can lead to things that are much harder."

  Mrs. Pulliam put her hand on Elena's arm. "Would you mind staying here with
Chester for a few minutes? I want to walk down to the coffee shop. I need to get away for a bit. And somehow, I can't leave him alone."

  "Of course. I'll be here when you get back."

  The woman kissed her husband's forehead. She'd taken two steps toward the door when she turned back and kissed his cheek once more. "I love you, Chester."

  Alone in the room with Chester Pulliam, Elena pulled a chair to his bedside. She drew back the sheet a bit to expose his hand. Gently, she covered it with her own.

  A tap on the door jarred her away from her thoughts. Elena turned to see a nurse peek into the room, wheeling a medication cart in front of her. "Oh, Dr. Gardner."

  "I can step out if you like."

  "No, I was just checking on him. Do you think there's any change?" This wasn't the nurse who'd avoided her earlier. This one seemed to care.

  Elena glanced at the woman's nametag. "Not for the better, Ann. And I don't think there'll be any. Do you?"

  "No, I don't." The nurse nodded toward the figure on the bed. "It's pitiful, isn't it? You're so good to stand by Mrs. Pulliam through this. I know it can't be easy. I hope you help her do the right thing."

  A beeping noise issued from Ann's pocket. She consulted her pager. "Oh, they need me stat. I guess the cart will be safe here with you." She looked up and it seemed that her gaze went to the center of Elena's soul. "I'll pray for you." With that, Ann hurried away.

  Elena tried to recall all the people who'd told her they'd be praying for her. Most of her recent thoughts had been questions, not supplications, but surely God would count them as prayers. Other than that, she hadn't prayed since Mark's death.

  She closed the door and began to look around the room. Everything she saw reminded her of a way to end Pulliam's marginal existence.

  The most obvious action would be to disconnect the respirator from his endotracheal tube. Two or three minutes, and it would be over.

  She scanned the medication cart. Pills? It would be difficult to get them down the feeding tube. Something injected? The IV had been removed, but there were needles and syringes on Ann's cart along with vials of various medications. One intramuscular injection would release Chester Pulliam from his prison.