Diagnosis Death

by Richard L Mabry

  The nurse moved closer, and Elena sneaked a look at her nametag. Karri Lawson. Of course. How could she forget Karri? The pretty brunette had been the nurse responsible for Mark's care almost the entire time he was in the ICU. In fact Karri had been Mark's nurse the day—. Elena shook her head. Don't go there. Don't go back.

  If Karri noticed Elena's discomfort, she made no mention of it. Instead, she gave Elena a brief hug. "I haven't seen you since . . . since that day. I'm sorry for your loss." She made a gesture toward the closed doors leading to the ICU. "We all are."

  Elena had heard "sorry for your loss" so many times, it was almost meaningless. Her response was automatic. "Thank you."

  "Would you like to come in and see the other staff?" Karri looked at her watch. "The day shift isn't here yet, but there may be some nurses you remember from when . . . from your time here."

  "I don't think so." Elena reached out and touched Karri on the shoulder. "I have a meeting. But tell everyone hello for me. Tell them I said 'thanks.' "

  "The coffee here is surprisingly good," Elena said. "Everyone always says that hospital food, especially hospital coffee, is terrible."

  "I agree," Helen Bennett said. "I wish my receptionist could make coffee like this. She's a jewel, but in fifteen years with me she's never learned to make coffee that doesn't taste like it's brewed from homogenized tire treads."

  "Don't be too hard on her, Helen. I'm looking forward to working with her. And with you, of course."

  Helen placed her mug on the table as carefully as an astronaut docking the space shuttle. "Well, that's what we need to talk about." She looked around to make sure there was no one within earshot. Around them, the cafeteria was filled with bleary-eyed residents, medical students, and nurses, but no one seemed interested in the conversation at their table. "I'm afraid you're not going to be working with my receptionist, or my nurse, or me."

  "What—"

  Helen stemmed Elena's words with an upraised hand. "Let me give you the whole story. Then I can answer questions if you have any—assuming you're still speaking to me by then."

  The hollow feeling in Elena's stomach intensified.

  "I've been in private practice for fifteen years, going it alone. There aren't many of us left in solo situations, but I've held out. I've managed to get other doctors in various groups to share call with me, but lately that's been somewhere between difficult and impossible."

  "I know. That's why you wanted to bring me into the practice," Elena said.

  "True, but that's changed. The Lincoln Clinic has approached me to join their family practice section. Actually, they want me to head it. They've made me a great offer. Not just the money, although that's good. The whole package seems tailor-made for me. I'll be supervising six other doctors, and I'll be exempt from night call. A great retirement plan and benefits." Helen looked down at the tabletop. "I couldn't turn it down."

  Elena's mind scrambled for a solution. The ship was sinking, and she grabbed for something to keep her afloat. "So why don't I take over your practice? I can buy you out. I mean, I won't have the money right way, but I can pay you over several years. It'll be sort of like an annuity for you."

  Helen was already shaking her head. "No, one part of the deal was that I bring my patients with me. The clinic will hire both my receptionist and nurse, and give them a good package as well. They'll even buy my equipment from me. I've already terminated the office lease. I'm moving out in ninety days."

  Elena forced back the tears she felt forming. "Helen, do you realize what this does to me?"

  "I know. I just—"

  "No." Elena worked to keep her voice level. "You don't know. You don't know how I've struggled to get through my residency after Mark's death. You have no idea what it meant to me to have a practice waiting for me. No need to lease space, to remodel and buy equipment. No waiting to build up a practice. There'd be a guaranteed income and a chance to pay off a mountain of debt."

  "Elena—"

  Elena shook her head. "I finish my residency in less than a month. Thirty days! Now you've pulled the rug out from under me. I have four weeks to find a way to do the only thing I know how to do—practice medicine." She turned her back to Helen, thinking that Helen had done the same thing to her. "No, I realize this is good for you, but I don't think you really know the effect it has on me."

  "Elena, I had to do this. Once you get over the shock, you'll think about it and agree. But listen, I'm not going to leave you hanging."

  Elena turned back to face the woman who'd been her mentor, the friend who was now betraying her. "What do you mean?"

  "The clinic gave me a very short deadline to accept or reject their offer. I only made my final decision this weekend. But the second call I made, after the one to the clinic administrator, was to your chair, Dr. Amy Gross. She and I are both putting out feelers for a place you can practice." Helen reached across the table and patted Elena's shoulder. "We know how hard this past three months have been on you. We worry about you. And believe me, we won't abandon you now. God has something out there for you. Trust Him."

  Elena drained the last of the coffee from her cup. When she set it down, she knocked her fork off the table. The dull clank of silverware on vinyl floor was barely audible over the low hum of voices that filled the cafeteria. "Trust God? I don't think so. I trusted Him when Mark lay there fighting for his life, but it didn't seem to do any good."

  "I know. But He's still in control."

  Elena shook her head, while one more hobgoblin joined those already dancing in her brain.

  2

  Elena hesitated in the doorway. She felt her adrenaline titer rise in response to the most ancient of reflexes: fight or flight. Unfortunately, neither was an option right now. "You wanted to see me?"

  Dr. Amy Gross, chair of the Department of Family Practice at Southwestern Medical Center, sat behind a desk devoid of papers except for a thick file barely contained by a slightly ragged manila cover. To her right, Dr. Bruce Matney, chair of the Department of Neurosurgery, adjusted his white lab coat to better cover his gray-green surgical scrubs.

  Dr. Gross waited until Elena settled into the single chair centered in front of the desk. "I appreciate your coming here today."

  As though I had a choice. When the chairwoman's secretary calls residents and asks them to be in her office in an hour, it's pretty much a command performance.

  "We know that the wound from Mark's death is still tender," Gross continued.

  Elena glanced at Dr. Matney and saw the frown that crossed his face. He'd liked Mark, and his inability to save her husband after his intracranial bleeding episode probably still ate at the neurosurgeon.

  Gross tapped the file. "But there's something here we need to discuss with you." She flipped to a spot marked by a yellow Post-It note. "Dr. Matney was in Medical Records yesterday to dictate summaries and sign charts. They'd sent Mark's chart back to him for a signature on something he'd missed, and he noticed this. It's an order he didn't write."

  No problem there. Lots of doctors wrote orders—residents, staff taking call for a colleague. Stay quiet, Elena.

  Gross turned the chart to face Elena. "Tell us what you see here."

  Elena leaned forward and read the words she already knew were at the heart of this matter. "DNR."

  "And the signature?"

  "It's mine."

  Gross frowned. "Elena, we all know how difficult it was for you as a physician to let someone else direct your husband's care. And we recognize that the decision not to resuscitate your husband was yours to make. You told Dr. Matney repeatedly that you couldn't bring yourself to withdraw life support. Then, on the same day that a 'do not resuscitate' order appeared on the chart—not written by the attending physician—your husband's respirator was disconnected without the knowledge or participation of any of the staff." She paused like Perry Mason addressing a particularly reluctant witness. "Can you explain that?"

  Two pairs of eyes focused like lasers on
her. What could she say? Best to keep it simple. "I'd held off as long as I could, but I finally accepted that we couldn't keep Mark on life support any longer. Dr. Matney, you were in surgery, and I was afraid that if I didn't follow through right then I'd change my mind. Writing the order was sort of symbolic for me."

  Matney's voice was like polished steel. "And did you turn off Mark's respirator?"

  The silence seemed to stretch on endlessly. Elena's shoulders sagged. She looked down at the floor. "I don't know." She swallowed hard. "I honestly can't recall."

  No one seemed to know how to respond to that. Finally, Gross said, "I can understand. It was a very traumatic experience, and we often tend to block out those memories." She looked at Matney, then back at Elena. "I believe we can overlook your writing that order, although you recognize it was a serious breach of both protocol and ethics. And, if you did take matters into your own hands to end Mark's suffering, we can understand that as well. But we have to be certain that nothing like this will ever happen again. You can't let this carry over to affect other patients under your care."

  Elena looked up at the two doctors with what she hoped was the right expression of contrition. "You have my assurance."

  Matney scraped his chair backward and rose. He favored the two women with a single nod and left the room as though marching off to save the world. Gross leaned across the desk and extended her hand. The cold, formal voice she'd used moments before gave way to the kindly tone of an older sister. "Elena, my door is always open. Come and talk with me anytime."

  Even as Elena expressed her appreciation, she knew that no help would come from talking with Amy Gross or anyone else. Nothing would help.

  "I'm sorry, but I'm paying as much as I can each month. There's nothing more I can do right now." The insistent tones of her pager cut through the conversational buzz and clatter of the hospital staff cafeteria. Elena checked the display. Emergency Room. Stat.

  "I have to go." She flipped her cell phone closed and hurried toward the door, shoving her tray onto the conveyer belt without breaking stride.

  Elena slammed through the swinging doors of the ER, looked around, and saw a pair of EMTs wheeling a stretcher into treatment room two. She and the head ER nurse arrived at the door right behind them, trailed by a nurse's aide.

  "Sixty-eight-year-old male found unresponsive by his wife." The EMT grunted out the words as he and his partner shifted the patient from their stretcher onto a hospital gurney. "Comatose. BP 168 over 90, pulse 56, respirations 12 and irregular. He's on Cardizem, Lipitor . . ."

  Elena listened with one ear, her mind already focused on the problem at hand. She ran her hands over the man's scalp, moving aside the silvery gray hair, looking for bruises and lacerations, finding none.

  As she bent to check his eyes, she sniffed the man's breath for the smell of alcohol or the fruity odor that signaled diabetic coma. So far, so good.

  Elena flexed the man's head forward. No neck stiffness. She looked for blood in the ear canals. Good, no sign of a basilar skull fracture.

  When she thumbed back his eyelids, her pulse quickened. The right pupil was significantly larger than the left. Elena pulled a penlight from the breast pocket of her white coat and shined it into the man's eyes. The right pupil remained unchanged, the left contracted sluggishly.

  "Hand me the ophthalmoscope," she said.

  Elena used the instrument to look through the pupils to the back of the man's eyeballs. Sure enough, the nerve head of the right optic nerve was already bulging.

  "Blown pupil on the right." she said. "Get the neurosurgeon on call down here stat. This patient's had an intracranial hemorrhage." The aide turned and hurried out. "Hang a gram of Mannitol IV. Run the oxygen at high flow. Did you get blood for labs?"

  "Did it while you were checking him." The nurse patted her uniform pocket, and Elena heard the muted clink of glass.

  "As soon as you get the Mannitol going, send those to the lab for a stat CBC and metabolic profile. When you get a chance, put in a Foley catheter. And he's going to need an MRI, so put radiology on standby."

  The aide hurried back in. The nurse paused long enough to hand her the blood samples and whisper instructions. "I'm on it," the aide said, and scurried away.

  Elena registered the faint bluish tint to the patient's lips. She checked his fingertips and saw the same coloration creeping into the nail beds. The man's respirations were now weak and shallow. He needed more oxygen.

  "Give me the laryngoscope and a tube."

  The nurse placed an L-shaped instrument in Elena's left hand, slapped a curved plastic endotracheal tube into her right. Elena pried the man's jaws open with the tip of the laryngoscope and slid the flat end down his tongue. A light at the tip of the instrument showed the opening between the vocal cords, barely visible in a sea of pooled saliva. Elena gritted her teeth and slid the plastic tube downward along the laryngoscope. When the tube disappeared through the cords into the airway, she breathed again. Made it through another intubation. Quickly, Elena inflated the soft rubber cuff that provided an airtight seal around the tube. The nurse hooked the patient to the respirator and looked at Elena with raised eyebrows.

  "Set it at sixteen," Elena said. Soon the rhythmic sound of the respirator was accompanied by a regular rise and fall in the patient's chest. She watched for half a dozen cycles before nodding. "There, he's starting to pink up."

  Elena ran down a mental checklist. What had she missed? ABC. Airway, Breathing, Circulation: the mantra for handling emergencies, one of the first lessons learned by any doctor. The first two were taken care of. The man's heartbeat was strong, but she'd better check for cardiac damage. "Let's hook him up to the EKG."

  A few moments later she scanned the tracing. No abnormalities. Good.

  Anything else? As a resident physician at Southwestern Medical Center, Elena was part of a top-notch medical team. Chances were that if she forgot something, someone else would remedy the omission. But when she was out on her own in private practice, it would be totally up to her. That time would be here soon. Better get ready.

  Elena looked at the clock on the wall. Sometimes in an emergency, time seemed to slow down. At other times it seemed to be rocket-powered. This was one of those times when the minutes fled by. Where was the neurosurgeon?

  At Southwestern there were three separate hospitals on the campus—four if you counted Children's Medical Center. Chances were that the doctor this patient needed had to travel from Zale Hospital, on the far south end of the campus, to where Elena waited with the patient at St. Paul Hospital, at the far north end of the campus. Whether the neurosurgeon came by car or on the campus shuttle, surely he should have been here by now.

  Another glance at the clock. Another five minutes gone. Left unchecked, blood from the intracranial hemorrhage would force the brain down against the bony ring at the base of the skull, compromising the vital centers, shutting down the impulses that kept the heart beating, the lungs inflating. Without surgery to relieve that pressure, the man would die. Where was the neurosurgeon?

  "Who's on neuro call?" she asked the nurse.

  "Dr. Clark."

  "And you paged him stat?"

  The aide was back now, hovering behind Elena, awaiting instructions. "I asked the ward clerk to do that." She hesitated. "Do you want me to check?"

  "Yes, please." Elena hesitated a beat. "First, get me the tray for an emergency trephine. If he doesn't show soon, I may have to—"

  "Okay, I'm here. What's so important?" Dr. James Clark strode into the room and stopped at the foot of the gurney. He stared at Elena, and the look on his face said, "This had better be good."

  "Elderly male, hypertensive and probably atherosclerotic, found unresponsive by his wife. Right pupil dilated and fixed, left sluggish to react, definite papilledema. Vitals compatible with Cushing's triad. I've alerted radiology for a stat MRI."

  Clark grunted and picked up the ophthalmoscope from the table where Elena had laid it. He checked t
he patient's eyes, then traded that instrument for a reflex hammer and did a bit of tapping. He ran his thumbnail along the soles of the man's bare feet, frowning when the toes fanned and extended upward.

  "Okay, you're probably right." He turned to the ER nurse. "Send him for the MRI. Call the OR and tell them to set up for an emergency craniotomy. I want Dr. Miller for anesthesia. If he's doing another case, have him get someone else to take over. And page the chief neuro resident to help me. Make sure the patient's taken directly from radiology to surgery, along with his films. I'll be up there changing."

  He disappeared in a wave of self-importance, without so much as a "good pick-up" or even "please."

  "I'll go to radiology with the patient," Elena said. "I'll stay there and take him to the OR myself."

  "Dr. Gardner," the nurse said. "You don't have to do that."

  Elena didn't answer, just released the brakes on the gurney and started pushing it out the door. Clark might think his MD degree conferred immunity from any of the menial tasks involved in patient care, but Elena had a different point of view. She intended to see to it that this patient got the best possible care. There'd be no delays in his treatment. She knew all too well that delays could be deadly.

  After Elena turned the patient over to the anesthesiologist, she lingered in the hallway, praying the surgery would save the life of this man whose name she didn't even know. That he wouldn't be kept alive to simply survive in a coma. Not like Mark.

  The patient's name was Chester Pulliam. Elena sat in a corner of the waiting room with his wife, Erma, and explained the situation. "A blood vessel in your husband's brain burst. Usually it's because of a weak place, sort of like a bulging spot on a balloon. This is more likely to happen when there's high blood pressure and hardening of the arteries, and your husband has both these conditions."