Diagnosis Death

by Richard L Mabry

  So she'd have lunch on her own. Where? She could go back to one of the cafeterias on campus. Bad idea. She'd see people who'd want to know how she was doing. They'd offer sympathetic words as sweet as cotton candy, but with no more substance. Poor Elena. Her husband died—she may have killed him, you know—and now she's been asked to leave the campus before her residency is up. Wonder what's behind that?

  Elena climbed into her car and said a silent "See ya" of her own to the campus. She navigated down Harry Hines Boulevard and turned onto Maple Avenue, sad that this might be her last trip along this street that boasted so many excellent Tex-Mex restaurants. She hoped Dainger offered a few of its own.

  David wadded his surgical mask and paper head-cover into a ball. Without breaking stride, he dropped them in the trash can outside the operating room.

  "You handled that case very well. Removing a tubal pregnancy via laparoscope requires good hand-eye coordination and a smooth touch, and you have them both." Dr. Steve Cobb accompanied his words with a manly slap on the back.

  David appreciated the praise of the staff surgeon, although he could have done without the slap. Although Cobb was now a part of the medical school faculty, only a decade ago he'd been an All-American linebacker at SMU, and while many college football players tended to get soft after their playing days were over, Cobb not only stayed in shape, he bragged that he could bench-press more now than in his football heyday. Based on what he'd just felt, David had to agree. He shrugged his shoulder and rubbed his left arm.

  "You want to write the orders and op note?" Cobb asked.

  "Sure. Seems fair, since you let me do the whole case."

  "Got to get you ready for private practice. Tell me again where you're going."

  David fished his wallet from the hip pocket of his scrubs and extracted a card. "I'm going into practice with Milton Gaines."

  Cobb glanced at the card and nodded. "Good man. He trained here, you know. Finished a year ahead of me. Tell him 'Hi,' will you?"

  David hung back at the swinging doors to the recovery room, mainly because there wasn't room for anyone to walk through them side-by-side with Dr. Cobb. He cleared the doorway in time to hear, "This woman's going into shock."

  The anesthesiologist, Ron Ward, was at the patient's bedside. "I extubated her in the OR. Her vital signs were stable when we started the transfer to the recovery room. But as soon as we got in here, her pressure had dropped twenty points systolic. Pulse rapid and thready."

  Cobb was the first to respond. "Run that Ringer's full speed. Start another IV in the other arm." He turned and called to the ward clerk. "She's got three units of blood holding in the blood bank—send for them and start one as soon as it gets here."

  The nurse adjusted the IV while Dr. Ward hurried around the bed to insert a second intravenous line. David didn't wait to be told. He started toward the door. "I'll scrub up."

  Minutes later, the patient was back on the operating table, her abdomen reduced to a rectangle of skin colored a muted orange by the antibacterial prep solution, outlined by green drape sheets, and illuminated by strong overhead lights.

  "She's under, but very lightly. Let me know if she moves." Ward's voice was steady. "Fluids running full. First unit of blood going up in a minute."

  Cobb motioned David to stand on the patient's right, the spot reserved for the surgeon. "Your case, doctor, start to finish. I'm here to help."

  David breathed a silent prayer and held out his hand for a scalpel. His brain riffled through hundreds of mental index cards, each the product of countless hours of study. Anatomy, physiology, surgery, everything had to be collated and applied.

  Here goes. David cut through the skin of the patient's abdomen in a ruler-straight vertical incision. He dropped the scalpel onto the instrument tray and held out his open hand. "Deep knife. Get the Bovie up to co-ag the bleeders."

  Cobb was the perfect assistant. He was a big man, but his hands were those of a concert pianist—fast and accurate. The dissection went smoothly: skin, fat, muscle. Suddenly, dark blood mixed with clots welled out of the incision.

  David's words were crisp and confident. "Suction."

  Cobb held out his hand for the suction tube and inserted it into the wound.

  "Lap pads."

  David took moistened gauze packs from the scrub nurse and shoved them into the depths to absorb blood.

  "Self-retaining retractor."

  David spread the incision widely, and almost immediately saw a tiny scarlet fountain spurt with every beat of the patient's heart.

  "Aberrant branch of the ovarian artery." There was no condemnation in Cobb's voice. Just a simple statement of fact.

  "I don't recall coming close to it," David said, as much to himself as to his mentor.

  "Well, it didn't cut itself, but we can talk about that later. Tie it off, then put a stick tie on for good measure."

  After both he and his staff man were satisfied the problem was corrected, David closed the wound. But while his fingers were busy with catgut and nylon, his mind churned over other matters. Again and again, he went through the sequence of the laparoscopic operation. Had he seen that artery? Was there a possibility he'd nicked it? An injury to an artery could cause the tiny ring of muscles in the wall of the blood vessel to go into spasm. Sometimes this was sufficient to staunch any bleeding. Later, as the vessel wall relaxed, hemorrhage could occur. That must have been the sequence here.

  "I know what you're thinking." Cobb's off hand comment made David look up from tying a suture.

  "What?"

  "You're going over and over the laparoscopy. You want to know what you might have done to cause this. More important, you want to be sure it doesn't happen again."

  David focused on finishing the knot. "How do you know that?"

  Cobb snipped the suture to the proper length. "Because that's what I'd do. It's what any surgeon worth his salt would do."

  "So, what's the answer?" David dropped the needle holder on the instrument tray. "Staples, please."

  Cobb blotted the incision line, although there was only a bit of blood there. "There's no magic formula. Personally, before every operation I review a mental checklist of the things that could go wrong. Then I try not to let them happen."

  "And if they do?"

  Cobb used a pair of fine-toothed forceps to pinch the skin of the incision closed while David applied staples. "Good surgeons know they're human, and they operate in a less-than-perfect world. Mistakes happen. When they do, good surgeons admit it and address them."

  "And bad surgeons?"

  "A bad surgeon is the one who says he never makes mistakes. That's a doctor I don't want holding the knife if I'm on this table."

  "Drat!" Elena dropped the cardboard box and picked her way among its mates, through the maze from her bedroom to the living room, toward the ringing phone.

  She stretched out her arm and snatched the receiver off the cradle. "Hello."

  She heard only silence. Oh, don't hang up just when I get here.

  "Hello," she repeated.

  "Elena?"

  "David?"

  "I meant to call earlier, but I had a complication in the OR this afternoon, and after that everything ran late. How about dinner?"

  She looked at her watch. Six o'clock. "I don't know. I still have quite a bit of packing to do. And I'd have to clean up, change clothes."

  "Why don't I pick up some Chinese and bring it over? I won't stay long. I might even be able to help you pack."

  "Sure, why not?"

  Elena figured she had maybe an hour before David arrived. That should give her time to clean out Mark's clothes. After his death, she couldn't bring herself to give them away. It seemed too final. Now, the move made the decision for her. Any clothes David couldn't wear were headed to the Goodwill drop-off box in the morning.

  She decided to start with things she was sure David wouldn't want. Underwear and socks went into the box first. Then pajamas. Handkerchiefs.

  H
ow about shirts? Mark had some nice ones. She'd put them aside and let David decide.

  The shirts were folded because, in the days when he traveled, Mark found it easier to pack them. The habit carried forward, and now she stared at a large drawer filled with folded dress shirts. She carefully transferred the three stacks to the bed.

  She opened the closet. Suits, pants, sports coats—each of them bore the scent of Mark's cologne. Elena's eyes filled and overflowed. She couldn't do this. Not even this long after Mark's death. She'd ask David to go through them. He could choose what he wanted and put the rest in boxes for her.

  Her stomach knotted as she considered the finality of her actions. Mark wasn't coming home. Ever. That had been true before she started to clean out his things. It would still be true when she was in the car with her suitcases and boxes, on the way to a new life. But right now it was too much to contemplate.

  Enough! She had to put an end to the pity party and get back to packing. While she was staying with Will's parents— and she still wondered about that—she'd determined to get by with a few boxes and a couple of suitcases of clothes. A mover was coming to pack and move the rest.

  She pulled a large suitcase out of the closet and opened it on the bed. When she shoved the shirts aside, one stack toppled, uncovering an envelope. Elena pulled it out and studied it. No address. The flap had come unsealed. Was this some sort of message from the grave? Or just a letter Mark had picked up that was trapped between clean shirts when he put them away?

  She pulled a single sheet of paper from the envelope. As she did, she noticed that her hands trembled a bit. Who could blame her? This might be a love letter Mark had meant for her.

  Elena opened the sheet. It was computer-generated, covering about half a page. She scanned it, then dropped to the edge of the bed and read it again. A third reading didn't change the words that by now were burned into her retina and her heart.

  I've struggled with this for days and weeks. In the end, maybe I'll deliver this news in person. But in case I'm weak and take the coward's way out, I'll say it here.

  It's over between us. I can't continue living a lie. There once was passion in our relationship, maybe even love. But there's someone else whom I love even more. And if I'm to be true to her, our relationship has to end.

  That was it. No salutation. No signature. Just simple words that spelled the end of a love she thought would last a lifetime.

  Elena wondered how long Mark had put off delivering this news to her. If he'd lived, how would their marriage have changed? Would he have destroyed the letter and devoted himself to her once more? Or could he have summoned up the courage to deliver this deathblow to her in person?

  The doorbell rang. That would be David. Could she share this latest development with him? Could she admit that her husband had gone outside their marriage because he found her so lacking? No. Not to David. Not to anyone.

  That's when it hit her. She was alone—totally alone. Even the memory of her dead husband was no longer there to sustain her.

  Elena locked the door of her apartment. The click was like an audible punctuation mark that ended this part of her life. The last two days had gone by in a blur, but she had no wish to recapture them. All she wanted to do was move on.

  When David walked through the door on Thursday night, Elena's determination not to share her news about Mark's infidelity disappeared like a wisp of smoke before the north wind. After her first few blubbering sentences, David dropped the bags of food in the living room and extended his arms to her. She wasn't sure how long he held her, but she recognized that there was more there than just a good friend offering support in a time of crisis. And, God help her, she found herself wishing she could stay in those arms.

  Eventually she'd disengaged from his arms, dried her eyes, and tried to gather herself. They'd talked for over an hour after that, carefully avoiding any mention of their embrace. When David left, they'd divided the Chinese food, joking that doctors could eat anything, including reheated Lo Mein, for breakfast.

  Elena had managed to fill yesterday with enough to keep her mind occupied. There'd been packing, phone calls, two trips to the dumpster, one to the local Goodwill center to dispose of all of Mark's clothing after David declined it. Elena didn't blame him.

  She shoved the apartment key into the pocket of her jeans and climbed into her car. The little Ford fairly bulged with luggage and boxes. Despite Elena's intentions to take only essentials on this trip—she'd be coming back soon to meet the movers—now she wanted as much familiar stuff with her as possible. She needed security.

  She punched a button on the dash, and the sweet strains of piano music filled the car. The song was "It Is Well With My Soul," and Elena thought nothing could be further from the truth right now. The CD had been a gift from a friend after Mark's death. Elena hadn't listened to it since, but now she hoped the music could help her purge the bitterness that clutched her heart.

  As she passed the Dallas city limit sign, she felt she should say something to mark the occasion. Something like, "Good-bye, Dallas; hello, Dainger." No, she didn't much like the ring of that. Finally, she settled on a brief wave into the rearview mirror.

  Elena drove for about an hour, navigating pretty much on automatic pilot, when she noticed the car in front of her weaving from side to side. She eased off the accelerator and dropped back a bit. If the driver was on the verge of an accident, she didn't plan to be involved in it. The car was a dark blue Buick, at least ten years old but polished and shiny as a new dime. One head showed through the rear window, silver hair that bobbed forward, then backward, like a cork on a windswept lake. Was the driver drunk? Or asleep?

  She honked her horn, but there was no reaction from the driver. Then the head slumped forward onto the steering wheel and stayed there. Elena scanned her surroundings. She'd gone from the urban sprawl of Dallas to the farmland right outside Dainger. She couldn't recall seeing more than three cars in the past ten minutes. An occasional gravel road led off to the side of the highway, but there wasn't a house in sight. Wire strung between stout posts created fences that framed green fields and pastures where horses and cows grazed.

  Elena retrieved her cell phone and punched in "911." Her finger was poised over the "send" button when the Buick started a steady drift to the right. Elena leaned on her horn, without any evident effect on the driver. The car slowed as it moved inexorably off the road, onto the shoulder, across a wide patch of grass, rolling to a stop against a fencepost.

  Elena closed the distance to the car, pulled onto the shoulder, and hit the button to activate her emergency flashers. When she reached the Buick, the motor was idling but the car was held fast by the stout post in front of it. The driver, an older man, was neatly dressed and clean-shaven. There was no odor of alcohol in the car, although Elena did note a scent that reminded her of Juicy Fruit gum. The man's head rested against the steering wheel that his hands still clutched at the ten and two positions. She felt in his neck for his pulse—strong and steady. He was breathing rapidly but seemed to have no problem with air exchange.

  She did a quick once-over of the car's contents. An overnight bag rested on the passenger-side seat. A larger suitcase and a suit hanger bag lay across the back seat. She sniffed at the travel cup that rested in the console on the driver's side—coffee.

  Elena reached across the unconscious man, jammed the transmission into park, and turned off the ignition key. She backed away from the car and punched the "send" button on her phone.

  "Summers County 911. What is your emergency?" Elena had a brief moment of panic. She seemed to recall that cell phone calls to 911 were routed to the nearest city, but was that foolproof? Was this Summers County? She had no idea.

  "I just came up on a man who lost consciousness and ran his car off the road. I need EMTs and the police or sheriff or whoever is responsible for this area."

  "Is the victim breathing? Does he appear to be injured? Is he bleeding?"

  "He's breathing a
nd has a strong pulse. There's no evidence of an injury. But we need medical attention here."

  "What's your location?"

  "I'm not sure. I'm new here. I . . . I know I'm about an hour or so out of Dallas, going north toward Dainger." Elena looked around her. What was the number of this highway? "I'm pretty sure I'm on highway 287."

  "Are there any billboards there? Mile markers?"

  Elena turned a full circle. "None that I see."

  There was a brief pause. "That's all right. The units are rolling now, going south on 287. Turn on your flashers. They'll find you."

  "Please, can you get some help here as quickly as possible?"

  Elena heard radio chatter in the background. "They're on their way. Stay with the victim. Cover him to keep him warm. Don't move him."

  "I know what to do. I'm a doctor. Get those EMTs here ASAP."

  "Don't—"

  Elena ended the call and turned back to the man, who didn't appear to have moved since she discovered him. The fruity scent was stronger now, and his breathing was faster than before. Diagnoses ran through her head at lightning speed until one clicked: diabetic ketoacidosis. Blood sugar through the roof, no insulin to help burn it, so he was metabolizing his own body fat and the by-products were poisoning him.

  She grabbed the man's overnight bag and opened it on the car's left front fender. Clothes, a shaving kit, but no medications. If this man was a diabetic, where was his insulin?

  As Elena replaced the overnight bag, she saw something she'd missed earlier: a cord ran from the console's cigarette lighter into the back seat to a travel mini-fridge on the floor behind the driver. Of course. A diabetic would travel with insulin, but insulin required refrigeration.

  She opened the refrigerator. Bingo! Insulin syringes and needles, packets of cotton wipes, and two bottles labeled "Insulin, NPH." Good for him, bad for her. The man was on a regimen that only required insulin once or twice a day, so he carried a long-acting preparation. What he needed right now was insulin that would be effective in minutes, not hours. And every minute of delay meant the death of more brain cells. She could give him some of the long-acting preparation, but that, plus the proper treatment later, would probably send him into hypoglycemic shock, also carrying the potential for brain damage.