Diagnosis Death pft-3

by Richard L Mabry

  Elena climbed in and waved her hand toward the dash. "Don't you get tired of riding around in the midst of all this equipment? I'd be afraid I'd touch something and bring a SWAT team running."

  Frank laughed, a throaty, full laugh that made Elena smile. "You get used to it. And it's nice to know that if I needed backup, I could get a SWAT team here in a flash." He reached out his hand. "All I'd have to do is-"

  "Never mind! I'll take your word. Now how about that lunch?"

  The place Frank chose was a tiny building, apparently a converted home, where, according to the menu, the "best Tex-Mex in Summers County" was served. Everyone there seemed to know Frank, and he seemed proud to introduce Elena as "my friend, the new doctor in town."

  They ordered and Elena sampled the chips and salsa. If the rest of the food was this good, she could see herself coming here regularly. But something bothered her. "Frank, why did you bring me here? Was it because I'm Hispanic? Do you think that's all I eat?"

  Frank spread his hands wide. "Hey, I didn't mean to offend you. If you ask any of the staff, they'll tell you that I eat here about three times a week. Sure, I noticed your looks don't exactly scream 'Caucasian,' but I don't pay any attention to that sort of thing."

  The food arrived, and Elena decided to let the matter drop. Maybe she was sensitized by her conversation with Cathy this morning. She took a bite of her tamale. It tasted wonderful. She definitely wouldn't have to drive back to Dallas for a Tex-Mex food fix.

  Frank dug into his meal as though he hadn't eaten in a week. How could he eat that much and maintain his physique? He had a classic swimmer's build: broad chest, narrow waist, hips that were- Stop it, Elena. You've only been a widow for a few months, and you're already checking out men. Besides, there's David. Wow! Despite her best intentions, she was already comparing the relative merits of two eligible men. She wondered if it might be a reaction to her late husband's letter. Careful. Right now you're the poster girl for rebound.

  Frank's voice made her look up from her plate. "I was wondering if you'd like to-"

  Elena's hand went to her purse to silence her cell phone. Then she recalled she was on emergency room call. "Sorry, I've got to take this." She punched the button to answer. "Dr. Gardner."

  "Dr. Gardner, this is Glenna Dunn. I'm the head nurse in the ER at Summers County General. I understand you're covering for Dr. Sewell. One of her patients just came in by ambulance with a possible MI. Do you want to see him, or shall I contact the internist on call?"

  "No, I'll be right there. Thank you for calling." Elena could imagine the reaction of an internist who was called out to see a "heart attack," only to find that the patient had acid reflux, or some similar uncomfortable but by no means life-threatening problem. Of course, if it was a myocardial infarction, there was a limited window of time for administration of proper treatment. In either case, she needed to be on her way. Elena dropped her fork on her plate, crumpled her napkin beside it, and rose. "Frank, I'm sorry to interrupt our lunch, but I've got to get to the ER. Let's put those lights and siren to use."

  11

  Elena knew the moment she walked into the treatment room that this was no case of simple acid reflux. According to his paperwork, the man on the gurney was in his mid-50s, but he looked ten years older than that. His complexion was ashen and dotted with beads of perspiration. The collar of his dress shirt was loose, his tie at half-mast.

  One glance at the monitors above the patient's head confirmed her suspicion. Definite T-wave inversion, ST elevation- myocardial ischemia for certain. No Q waves yet, so it was early. Blood pressure down a bit, although she had no idea what his normal level was. Pulse a little rapid.

  Elena ran her eyes down the chart. Oxygen by mask, an aspirin chewed and swallowed, IV started but no drugs given yet, lab work drawn and sent stat. "Nice job, Glenna. But will you raise the oxygen flow to eight liters per minute?"

  The ER nurse adjusted a dial. "Our standard protocol is six. Will eight be your usual?"

  "Yes, please." Nice. No argument. Elena addressed the patient for the first time. "Mr. Nix, I'm Doctor Gardner, Doctor Sewell's new associate. Tell me what happened."

  A middle-aged woman stood beside the patient. Her hands fluttered about like frightened birds. She responded before Nix had a chance to speak. "I'm his wife. He came home for lunch, and right after his first bite of chicken fried steak he clutched his chest and slumped over. That's when I called 911."

  Mrs. Nix looked younger than her husband. Elena figured there might have been some nips and tucks along the way to help that image. A few dark roots showed that the woman's blonde hair owed more to Clairol than to Nordic genes. Mrs. Nix would call herself "pleasingly plump." Elena's assessment was "running to middle-age spread."

  Elena turned back to Nix. "Are you having any pain?"

  He pointed to the midpoint of his chest.

  "Anywhere else?"

  "My neck and jaw." He indicated his left side.

  "Are you on any medications?"

  Mrs. Nix dug into her purse and pulled out two bottles. "I thought you'd want to see these."

  "Let's have a look." Elena studied the labels. Generic versions of Digoxin and Toprol. "So Dr. Sewell has been treating you for heart failure and high blood pressure."

  Nix forced out the words through clenched teeth. "Dr. Sewell, and Doc Gladstone before that."

  "Excuse me, Doctor." The ward clerk hurried in and handed Elena a slip of paper with several values written on it. "The lab just phoned with the results of Mr. Nix's chemistries."

  "Thank you." Elena studied the figures for a moment. The enzyme levels were rising but were not too high yet. "Mr. Nix, right now you're in the early stages of a heart attack. So far there's been very little heart damage. We need to keep it that way."

  "How?" Nix grunted.

  "A heart attack occurs when the blood flow to the heart is interrupted. The blockage can be due to a blood clot or an obstruction by what we call plaque-hardening of the arteries. What we need to do is unblock the vessels and get circulation restored." Elena turned to Glenna. "Get some tPA ready, please."

  "May I speak with you, Doctor?" Without waiting for a reply, Glenna stepped into the hall.

  Elena excused herself and joined her. "What's the matter?"

  "You probably don't know this yet, but we have an interventional radiologist on staff. Dr. Rosenberg does all our cardiac angiography. I thought I'd better tell you before you ordered tPA."

  Elena felt like kicking herself. She needed to get out of the mindset that when she left Southwestern Medical Center to practice in a smaller community hospital she'd be without all the modern technology on which she'd depended. She silently blessed Glenna for discreetly pointing out the availability of cardiac angiography. If she'd given Nix the "clot buster," the risk of hemorrhage with any subsequent procedure would be multiplied. The angiogram should come first, if one was available.

  "Thank you, Glenna. That's my mistake for not asking. Would you please page Dr. Rosenberg for me? And I might as well ask: Do the internists here normally follow these patients, or do FP privileges extend to post-MI care?"

  Glenna grinned. "Dr. Sewell fought this battle when she came here. Those patients can be cared for by either family practitioners or internists."

  "Good. Since Mr. Nix is already Dr. Sewell's patient, we'll keep his care in the practice. In the meantime, let's get Dr. Rosenberg down here. We have ninety minutes from symptom onset to get an angioplasty done, and the clock's running."

  A gentle tapping noise diverted Cathy's attention from the lab reports spread out on her desk. "Yes?"

  Jane stood in the open doorway. "Doctor Sewell, there's a call on line one. It's Dr. Gardner."

  "Thanks. Would you close the door on your way out?" Cathy punched the flashing button on the phone. "Elena, what happened? Where are you? We tried to call, but you didn't answer your cell phone."

  "I'm at Summers County General. Apparently cell phone reception inside
the hospital isn't very good. I've had to step outside to get a signal."

  "Okay, that explains where you are. Now, why are you there?" Cathy heard the exasperation creeping into her voice. "I'm sorry. I didn't mean to come off sounding like your mother."

  "My mother's been dead for so many years, I have no recollection of how she sounded."

  Score one for Elena. "I apologize. Poor choice of words. What happened?"

  She listened to Elena's story of Milton Nix's myocardial infarction. "Dr. Rosenberg did a cardiac cath. There was a forty percent blockage of the anterior descending coronary artery. Rosenberg was able to open it with a balloon angioplasty. He didn't think a stent was necessary."

  "How did Mr. Nix come through it?"

  "So far, so good. He's in the cardiac care unit. They tell me that FPs can take care of their own post-MI patients here. I'd imagine you'd want that, but if you'd feel better passing Nix off to an internist, I'll contact one. Your call."

  "No, tell him and his wife that I'll be by this evening after I finish in the office."

  "Do you want to do that? I can make sure he's okay before I leave, and you can see him on rounds in the morning."

  "Fine. Be sure to call me if you have any questions. And thanks for taking care of this."

  Cathy was about to hang up when she heard Elena's voice. "What was that?"

  "I said I'm going to need a ride to pick up my car when I leave the hospital."

  "Why is that?"

  Elena cleared her throat. "Well, I was at lunch with Frank Perrin when I got the call. He took me to the hospital, but my car's still back at the office."

  Cathy had her choice of sharp retorts, but she bit back all those words. She fought to keep her voice level. "Do you think you'll be finished in another hour?"

  "Should be."

  "Be at the ER door at that time. I'll ask Will to come by and pick you up."

  "Thanks."

  Cathy hung up the phone and leaned back. She'd hoped Elena's relationship with Frank Perrin would be limited to the time they'd already spent together. It was nice of J. C. Dunaway to have someone guide the new doctor until she got her bearings. But why did he pick Frank Perrin? Surely J. C. was aware of the rumors.

  Of course, Cathy knew they were more than rumors. She had some facts. But how much could she tell Elena?

  She picked up the phone again and punched in Will's number. Bless his heart, he was always there to help out-with a ride for a stranded colleague or with advice for his wife who found herself facing an ethical dilemma.

  Will pulled his pickup into one of the parking spots designated "Medical Staff." He'd decided long ago that when he was acting as Cathy's agent he was sort of a medical staff member by proxy. Thinking like a lawyer, again. He was out of the vehicle and halfway to the emergency room door when it opened and Elena hurried out.

  She climbed in and had buckled her seat belt by the time he resumed his spot behind the wheel. "Thanks for coming by," she said. "I guess I could have walked, but it's a bit too far. Besides that, there's a pretty good chance I'd get lost."

  Will stifled a smile. He couldn't imagine anyone getting lost in this town. Then again, he'd lived here pretty much all his life. "It's not that bad. We'll drive you around and help you get your bearings. Pretty soon you'll know our fair city like the back of your hand." Will pulled out of the parking lot, turned left, and pointed. "The office is building is up there, less than a mile away."

  Elena ignored Will's pointing finger. "Cathy seemed angry that I had lunch with Frank Perrin. Was it because I didn't accept her invitation to lunch? Did I violate some sort of unwritten rule?"

  "I don't recall putting anything into your employment contract about mandatory lunches with your associate. No, I think she was concerned that the person you ate with was Frank Perrin."

  Will sensed more than saw Elena grow tense beside him. "Wow. I've made one friend since I arrived in town, and Cathy doesn't like him. Why?"

  "Elena, none of us likes to spread rumors, and that's all I have."

  "I understand, and I can make up my own mind when I have more facts, but what's the basis for those rumors? Does he kick dogs, take candy away from little children, give tickets for three miles an hour over the speed limit? What?"

  Will wondered if this was a mistake, but Elena deserved to at least have more than a nonspecific warning. "All I can say is the consensus around town is that nice women don't go out with Frank Perrin."

  Elena kept silent through the remainder of the trip. When Will pulled into the professional building's parking lot, she had the door open almost before the vehicle had rocked to a halt. "Thanks for coming by for me."

  Will watched Elena beep her car unlocked, climb in, and drive away. Maybe he'd said too much. On the other hand, maybe he hadn't said enough.

  "Good morning." Elena felt her words drop like icicles from a roof, cold and sharp. So be it. That was how she felt.

  "Morning," Cathy replied, her voice about thirty degrees warmer than Elena's. "Why don't you get a cup of coffee and join me in my office? I'd like to clear the air about yesterday."

  In a few minutes, Elena was looking across the desk at Cathy. Were they going to butt heads over something as insignificant as the person with whom Elena had had lunch? If that was the case, better to find out now instead of later.

  Cathy leaned across the desk. "I'm afraid I came off a bit strong yesterday. First, let me repeat that I appreciate the way you handled Mr. Nix's case. This morning I spoke with Dr. Rosenberg, and he transferred care back to me. I plan to send Nix home tomorrow. Dr. Rosenberg agrees with me that you did a nice job."

  "Thank you."

  "I know you're miffed because I showed my disapproval of your having lunch with Frank Perrin. Let me make it clear. You're free to see anyone you want, so long as it doesn't keep you from your responsibilities to the patients in this practice."

  Elena gripped her coffee mug tighter. "Then what was it? Because even though you didn't say it in so many words, you disapprove of Frank Perrin. Why?"

  "What you've heard so far is only based on rumors, and that's unfair to you and to Frank." Cathy tented her fingers beneath her chin. "I guess it's time to give you more information."

  "I finally got Will to admit that the consensus around town was that 'nice women don't go out with Frank Perrin.' Would you care to elaborate?"

  Cathy drew in a deep breath and exhaled through pursed lips. "Okay. Part of this is covered by doctor-patient confidentiality, but since you're now my associate I suppose you're entitled to the information as well, since it concerns this practice."

  Elena struggled to keep her tone neutral. "Thank you."

  "Since I've been here, I've had two pregnant women come to me wanting abortions. I managed to convince one of them to carry the baby to term, but the other was adamant. I later learned that she drove to Dallas for the procedure."

  "What does that have to do with Frank?" Elena said.

  "I'm coming to that. Both women were divorced, had been for a couple of years. Neither would name the person responsible for the pregnancy. One followed my recommendation to have the baby. Milton Gaines did the prenatal care and delivery. I later learned from him that Frank Perrin paid that bill."

  Elena pondered this. "So Frank was a nice person helping out a woman who made a mistake. I'd think that would be a mark in his favor."

  "The clinic in Dallas that terminated the pregnancy of the other woman called our office for information. It seems the receptionist accidentally transposed some numbers and their bill to the responsible party was returned." Cathy's lips tightened. "They wondered if we had the correct address for Frank Perrin."

  Elena turned this over in her mind. "That's not exactly firm evidence that he was the father."

  "Perhaps, but there are other rumors, ones I can't substantiate, so I won't repeat them. I guess I'd just encourage you to be careful."

  "I think I've learned how to assess men," Elena said. Of course, I thought I
'd done a good job when I chose Mark, but look how that turned out. No, she had to put that aside and move on. "But I appreciate your concern. So far, Frank has been the perfect gentleman. If I see any evidence that's about to change, I'll back away. Fair enough?"

  "Fine," Cathy said. She picked up her mug, took a swallow, and grimaced. "I'm not especially fond of herbal tea, and I hate it when it's cold. I need to nuke this."

  Elena rose and followed Cathy out of the office. So this attractive man, one who seemed to be interested in her, might be trouble? Well, she was used to trouble-dealt with it on a regular basis in the ER. She was sure she could handle it. And if it got too bad, she'd take the advice of a former president: "Just say no."

  "Dr. Gardner, thank you for coming in." Nathan Godwin gestured Elena to a chair on the other side of his desk.

  It struck Elena that what she'd observed before held true here: the smaller the man, the larger the desk. Maybe Godwin was compensating for his stature with a desk that appeared to be large enough to require its own ZIP code. Then again, perhaps he had a lot to do and needed room to work. She put that idea aside when she observed that the vast expanse of mahogany was unencumbered by papers. It held a phone with a handful of pushbuttons, a handsome pen and pencil desk set, and a single photo, the frame angled so she couldn't see it.

  Godwin fiddled with the cufflinks on a spotless white dress shirt. "We have in hand your application for privileges at Summers County General Hospital, and they will be acted upon in the usual fashion. But right now we need to address an irregularity."

  There was a discreet tap at the door. "Nathan, sorry I'm a bit late. I know how you hate to be kept waiting."

  The speaker, a middle-aged man, was tall and muscular, a marked contrast to Godwin. Beneath his white lab coat, he wore an Izod golf shirt and khaki slacks. His wavy brown hair receded ever so slightly in a widow's peak. Rimless glasses did little to hide brown eyes that smiled, despite his neutral expression.

  Godwin remained seated while he gestured the newcomer to the chair beside Elena. "Come in, Marcus. Dr. Elena Gardner, this is Dr. Marcus Bell. He's a general surgeon who also functions as our hospital chief of staff."