Diagnosis Death pft-3

by Richard L Mabry

  Elena moved a bit so she was in Mrs. Lambert's line of sight. "Dr. Shelmire and I will handle this. Don't let it worry you."

  Mrs. Lambert knuckled her eyes, spreading tears across her cheeks. "I slipped out to get some breakfast. When I came back Min, that Mr. Godwin was at Charlie's bedside. He started in on me, and then Dr. Shelmire came in." She looked at the neurosurgeon. "Thank you for standing up to that awful man. How can he be making these decisions? He's not even a doctor."

  Shelmire and Elena exchanged looks. Elena said, "Actually, he is a-"

  "You're right. He's only an administrator," Shelmire said. "Medical decisions are up to us. And rest assured that Charlie is going to get the care he needs."

  Mrs. Lambert followed Dr. Shelmire into the hall to talk further while Elena moved to the head of the bed and did a quick exam on Charlie. He was definitely better, but he was a long way from "waking up."

  As Elena turned to leave, her hip bumped the partially open drawer of the bedside table. She started to close it but stopped when she saw what it contained, in addition to a washcloth and a Gideon Bible. Nestled in the corner of the drawer was a syringe-needle unit, still in its plastic case. Beside it was a small vial of injectable material. Elena picked it up and read the label: Anectine. Her heart raced and a cold sweat dotted her forehead. Who had put it here? And why would they want to kill Charlie Lambert?

  Elena studied the diplomas and certificates on Marcus Bell's office wall. Bachelor's degree from Princeton. Medical school at Columbia. Surgery residency at NYU. Certified by the medical boards of New York and Texas. Fellow in the American College of Surgeons. Master of Business Administration in Health Care Services from SMU.

  She could imagine the history behind the displays. His education and training were in the New York/New Jersey area, so he was probably from that region. Marcus had told her he was widowed, and she could identify with a desire for a change of scenery after that event. She wasn't sure why he'd picked this mid-sized Texas town for relocation. Maybe, as with her, it was the only life raft available in an ocean of trouble.

  He'd come here to practice surgery, but somewhere along the line there came an appointment as chief of staff. To be better prepared for that role, he'd done something Elena would never have tackled. He went back to school-probably part-time-to get that MBA. Then, for reasons that apparently had more to do with politics than capabilities, "Dr." Nathan Godwin had taken over most of the administrative duties at Summers County General. That couldn't have sat well with Marcus. Well, if that was the case, he would love what she had to tell him now.

  "Sorry to keep you waiting." Marcus sank into the chair behind his desk and handed her one of the two Diet Cokes he carried. "Don't drink it if you don't want it, but I sort of figured that if your day was like mine, you'd either want to rehydrate or use it as an icepack on your head." As if to illustrate, he held the frosty can first against one temple, then the other. He leaned back, put his feet on an open desk drawer. "What's up?"

  Elena popped the top on the can and took a long swallow. "I was in Mr. Lambert's room this morning."

  Marcus looked blank.

  Elena went on to explain. "He's a patient in ICU who had an intracranial bleed six days ago. Mr. Lambert sort of fell through the cracks of the system and has no insurance coverage. He's recovering from surgery. He's off the vent, but he still has a ways to go. Godwin was in there this morning trying to browbeat Dr. Shelmire into sending Lambert to a charity hospital-I guess he meant Parkland."

  "Unfortunately, that seems to be Nathan's motto. If it doesn't pay the bills, ship it out. I presume Shelmire stood firm."

  "He did, but here's where it gets interesting. The drawer of the bedside table was partly open. On my way out, I started to close it when I saw a syringe and a vial of Anectine inside." She drank deeply from the can, then brushed a stray lock of hair from her eyes. "Someone-and, in my mind, everything points to Godwin-planned to inject Lambert with it."

  "Wow!" Marcus chewed on his lower lip. "Clever. Anectine is easy to get in the hospital. Snatch a vial off any anesthesia cart. Inject it IV, just like they do when they put a patient to sleep. But this time, when it paralyzes the muscles, there's no ventilator to take over breathing. And in, what? A couple of minutes? Anyway, in short order, the patient is dead. And the beautiful part is that the drug is metabolized so fast that, by the time of an autopsy, there's no trace. That is, assuming they think to look for it at all."

  "That's the way I see it. The question is, what do we do?"

  "I don't suppose you brought the vial and syringe with you?"

  Elena's mind began to race ahead. She could see where this was headed, and she didn't like it. "No. I was so shocked that I put the vial back in the drawer, slammed it shut, and left. Then I called your office and made this appointment."

  Marcus rocked forward, and his feet hit the floor with a resounding splat. "Let's get up to the ICU. I want to see this for myself."

  In a few minutes, they stood side-by-side in Lambert's room. Mrs. Lambert hadn't seemed unduly concerned to see two doctors, one of them unfamiliar, show up. By now, she probably wasn't surprised by anything. A week in an ICU would do that, Elena thought.

  "Mrs. Lambert, this is Dr. Bell. He's a colleague. I was telling him how well Mr. Lambert is doing." Elena tried to muster her biggest smile. "We're going to be here for a bit. Would you like to slip out and get something to drink, maybe get a sandwich in the cafeteria?"

  "That would be lovely. I'll only be a few minutes."

  Marcus closed the door behind Mrs. Lambert. He drew the blinds, cutting off the view of the room from the nurses' station. "We don't need anyone else peeking at us right now."

  Elena's hand hovered over the drawer pull. She started to use the tail of her white coat to open the drawer, then realized that there were dozens of fingerprints already there. No need to try to protect against adding more to the drawer pull. And what about the vial? Were there fingerprints there too? If so, maybe they could be checked. If the culprit had ever been fingerprinted, that would pin down his identity-or hers. Of course, Elena would have to give her prints for comparison, because they'd be on the vial as well.

  "Well, open it." Marcus's voice had an edge. Was he as nervous as she was?

  She yanked the drawer open and gasped. It contained the same Gideon Bible and washcloth she'd seen earlier. Nothing else. The syringe and the vial-with her fingerprints-were gone.

  Restless nights were nothing new to Elena, but this one had them all beat. For hours she watched the numbers on the clock change. The minutes ticked away, the hours rolled over, but still sleep eluded her. Instead, her mind called the roll of the demons pursuing her.

  When she finally fell into a troubled sleep, somewhere near dawn, wakefulness gave way to nightmares, always featuring the triumvirate of doctors she'd come to call "the tribunal."

  "You were going to kill that patient," the monk-like doctor said.

  "We have your fingerprints on the vial," came the pronouncement of the doctor with Coke-bottle glasses.

  "Your only hope is to beg us for mercy," said the movie star clone.

  "I didn't do it. I didn't do it." Elena tried to say the words, but nothing would come out. They lodged in her throat like a lead weight. She couldn't swallow. She couldn't breathe. She was choking, suffocating.

  "This is your punishment." The middle doctor looked over his glasses at her, and his countenance was like an Old Testament prophet proclaiming doom on a city. "Just as your patient was to die, so shall you be starved for life-giving oxygen. Your brain cells will begin to die like waves of soldiers advancing into a cannon's fusillade. Your heart will quiver in fibrillation, no longer able to pump blood. Soon, all your organs will cease to function."

  "When?" she choked out.

  "Your death will be announced by the ringing of this bell." The handsome doctor held up a small brass bell and began ringing it. "When it stops, you will cease to exist."

  Elena tried
to reach out her hand to grab the bell and ring it. No matter how far she reached, it always remained just a few feet away. She stretched out her arm, again and again.

  Her hand hit something, there was a crash, and Elena snapped awake. The tribunal was gone. She was in a strange bed, in a strange room. The lamp she'd knocked off the bedside table lay on the floor, its shade askew. Slowly it came to her. This was the Kennedy home. She was in their guest room. And the ringing was her cell phone, the ring tone she'd assigned to the hospital.

  Elena sat up, pulled the covers around her to combat the chill she felt, even though the room was warm. She picked up the phone from her nightstand.

  "Dr. Gardner."

  "Doctor, I'm sorry to bother you this early. This is Glenna Dunn. I'm working in the ICU, and your patient, Charles Lambert, has a temp of a hundred and two. What would you like us to do?"

  "Give me a second." Elena looked at the clock. Four-twenty-two. She'd been asleep less than two hours. She padded to the bathroom and splashed water on her face. She cupped her hand and drank from the faucet. Better, but only slightly. She struggled to get her mind back in gear. "Glenna, I'm back. When did you notice this?"

  "We didn't wake him for vital signs through the night. That was Dr. Shelmire's order."

  "That's okay. So, what was his 9:00 p.m. temp?"

  "Ninety-nine two. He was a little behind on his fluids, so we speeded up his IV. He seemed okay during the night, but honestly, I didn't keep a really close eye on him. We had a couple of pretty sick patients, and we're working short-handed. That's why they called me in to work up here on my day off from the ER."

  "So why did you take his temperature now?"

  "When things finally settled down, I had a look at my other patients. He looked flushed, so I used the old manual thermometer-you know, hand to the head-and he felt warm. That's when I checked his temp."

  "Get a CBC. Urinalysis and culture from his catheter. I may want some other things, maybe a chest X-ray and blood cultures, but I want to see him first. I'll be there in about an hour. Call me if something else comes up before then."

  "Do you want me to give him an aspirin suppository?" Glenna asked.

  The mental index cards rippled in Elena's brain. Lambert wasn't taking anything by mouth-didn't even have a feeding tube in place. So oral meds were out. There were no IV drugs proven to effectively lower fever. An aspirin suppository would be the best choice, but aspirin had an effect on bleeding and clotting. It was a long shot, but if the fever was due to seepage of blood from the brain into the spinal fluid, aspirin might aggravate the bleeding. Besides, fever was a sign, not a disease. With a temp no higher than this, it was better to hold off and find the cause.

  It took only a couple of seconds for Elena to parse the possibilities and say, "No. Hold off on any meds until I get there. See you soon."

  She replaced the lamp on the table and started climbing into the clothes she'd laid out the night before, a habit born of long experience with calls in the middle of the night. As she dressed, she wondered what this latest development in the Lambert chronicle might represent. Was it something simple, like a urinary tract infection? More intracranial bleeding was possible, but quite unlikely. As she dressed, she tried unsuccessfully to ignore the possibility that kept popping into the forefront of her thoughts. Did this represent another attempt to kill Charles Lambert?

  All the way to the hospital, she couldn't get away from the idea that perhaps this was more than a simple fever in a post-op patient. But how could someone infect a comatose patient? Material from a contaminated syringe injected in his IV? Bacteria from a lab culture introduced into his lungs via the endotracheal tube? She discarded some of the possibilities as ridiculous, but then again, this whole scenario was ridiculous. Why would someone want to keep an unemployed truck driver from recovering? Had he been hauling illegal cargo, like drugs or stolen goods? Was this an attempt to keep him from talking?

  Or was this another move to discredit her? She was already under a cloud of suspicion for the deaths of two critically ill patients. Would Charlie Lambert's death be the third strike that ended her ability to practice medicine, here or anywhere?

  16

  The OB doctors' lounge at Summers County General was cool enough this morning, but David was sweating. When he'd been in residency, even though he might have gone to a new service or a new hospital, adjustment was relatively easy because things were done with a surprising amount of uniformity in the medical community in Dallas. And most of the town doctors there, except a few stubborn souls, took their lead from what was taught at the medical school.

  Here, he not only had to become familiar with a new hospital with a new cast of characters, but he'd already discovered a couple of things his new partner liked to do that were different from the practices he'd learned. How many more would there be?

  "Don't worry," Milton Gaines said. "I don't expect you to copy everything I do. We'll iron out the differences. I imagine you'll teach me a few things, and maybe I've learned some stuff along the way that will help you. The main thing is that our patients get good care, with as much uniformity as we can offer. That way they feel more comfortable no matter which of us they see."

  David drew a cup from the industrial-sized urn in the corner, tasted what apparently passed for coffee in the lounge, wrinkled his face, and tossed the Styrofoam cup into the trash.

  "I see you've learned a valuable lesson already," Gaines said. "Don't drink the coffee in the OB doctors' lounge unless you have a death wish. I'll buy you a cup in the cafeteria after we finish rounds. It's better than this, which isn't saying much. The best coffee comes from the nurses' break room. Be nice to them, and they'll share."

  "Fair enough." David popped a stick of gum into his mouth, but it was no match for the lingering bite of the coffee. "Ready for rounds?"

  Gaines eased himself to his feet. "Let's go."

  Gaines had two postpartum patients still in the hospital, both doing well after delivering healthy babies, both anxious for discharge. He introduced David to each woman. "This is Dr. Merritt, my new associate. If I'm out or tied up, you'll see him. He's a good man, well-trained and caring. I know you'll like him."

  In the hall, Gaines said, "I have one other patient. She's a Hispanic female, nearly at term, admitted recently with preeclampsia. It's a struggle to keep her blood pressure down, and I'd appreciate any help you can give me."

  David took the chart Gaines offered and studied it. His senior partner had done all the right things: magnesium sulfate, hydralazine, beta-blockers, oxygen, careful control of fluids. The woman-Maria Gomez-had not yet had a seizure, which was in her favor, but her blood pressure remained high despite treatment.

  "I see you estimate that she's at thirty-three to thirty-four weeks gestation," David said. "Are you thinking of inducing her?"

  "Definitely. I figured one of us can manage the induction while the other takes care of the office. Want to handle it?"

  David closed the chart. "Sure. Why don't we examine her?" My first OB in private practice and it's a patient with early toxemia of pregnancy. Welcome to the real world.

  David could see that the girl-and that's what she was, just a girl-was frightened. He could understand why. About to have a baby, lying in a bed in a strange hospital being cared for by people who didn't speak her language; no wonder she was scared.

  Gaines warned David that the husband would be his interpreter, but one of the first things he'd learned in medical school was that in any encounter, especially the first one, the patient should be the focus. He stood at Maria's bedside and lightly touched the back of her hand, careful to avoid the IV there. "Maria? Soy el Dr. Merritt. Cuidare de usted."

  She nodded and managed a weak smile. The husband offered his hand. " Soy Hector."

  "Hector, I've used up most of the Spanish I know to introduce myself to your wife and tell her I'll take care of her. Can we speak English?"

  "My English is not so good, but I will try."
<
br />   David explained that he and Dr. Gaines needed to examine Maria. "We think that it may be best to help the baby get here as soon as possible."

  "I understand. Do what is needed, and I will share what you tell me with Maria."

  Thirty minutes later, the three men stood at Maria's bedside. In simple English, augmented by the few Spanish words he had picked up during his residency, David explained what was planned. Medication given in Maria's IV would stimulate labor. He would be at the bedside or nearby during the process. The baby was old enough to safely come into the world, and that was necessary to lower Maria's blood pressure and prevent such complications as convulsions. David stumbled on the last word, but Hector assured him it was the same in Spanish.

  Maria was nodding even before David finished. " Si, comprendo." Obviously, she understood more English than he or Gaines realized.

  "If you're okay to stay here and handle this, I'll get back to the office," Gaines said. "I'll check with you later today. If you need me to relieve you, we can switch."

  David took the chart Gaines handed over, feeling like a runner who'd just been handed the baton for the final leg of the race. He prayed he wouldn't stumble.

  Elena handed Jane the chart and yawned for what seemed like the fiftieth time that morning. Her jaw popped. "Excuse me."

  "Tough night?" Jane asked.

  "They called me about four. Mr. Lambert was running a fever."

  "Anything serious?"

  "Nope. Just a urinary tract infection."

  "Glad it wasn't anything worse," Jane said.

  Elena thought again about the dictum she'd heard repeatedly since her first physical diagnosis class in med school. When you hear hoofbeats, think horses, not zebras. But last night she'd focused on zebras as soon as the call came.

  All the way to the hospital, she'd imagined all the worst possible causes for Charlie Lambert's fever. As it turned out, a third-year medical student could have made the diagnosis and started treatment. Elevated white blood count and pus cells in the urine added up to a urinary tract infection, the most common cause of fever in a patient with an indwelling urinary catheter, and one that was easily treated.