Diagnosis Death

by Richard L Mabry

  "Of course," Cathy said. "We haven't made any appointments for you yet. I want to let you get your feet on the ground. However—"

  Elena didn't like the sound of that "however." But this was her boss, and she'd better get used to it. So much for being out on her own and independent. "Yes?"

  "I'm on emergency room call for the hospital this week. I thought it might be a good idea for you to take those patients. That should help you build a patient base."

  That didn't sound so bad. Elena had been to the hospital only two days ago, not to mention the brief tour with Cathy on her first visit. And she'd seen it from a distance just this morning. She was fairly certain she could find it again without getting lost—or calling Frank Perrin for help. At the thought of the deputy, she found herself wishing she could see him again.

  Elena tried to put her finger on why she felt attracted to Frank. Maybe it was his resemblance to Mark. After the not-so-subtle distaste her landlady showed, maybe Elena's feelings were the same ones that drive people to test a wet paint sign or to see if an iron's still hot. Anyway, it was nice to have a friend here, one who wasn't also a colleague. Maybe she'd call Frank and offer to buy lunch. Sort of return the favor from the other day.

  The morning passed uneventfully, and Elena picked up Cathy's routine quickly. The office was well organized. The diseases and problems presented by the patients were diverse but not particularly challenging. Cathy took the time to introduce each patient to Elena, following the same pattern each time. "This is Dr. Gardner. She'll be joining my practice. She's very well-trained, and I think you'll like her."

  While the two women waited in Cathy's office for Jane to prepare a female patient for an examination, Elena said, "Why did that last patient frown when you introduced me?"

  Cathy gnawed for a moment on her lower lip. "You won't see a lot of this, but there's a bit in every community. I introduce you as Dr. Gardner. They expect to see someone who looks like them. Instead, they see a woman with darker skin, long black hair, high cheekbones—a classic Latin appearance. Most patients are fine with this. But a few are thinking, This woman is a Mexican. Did she train in Guadalajara? Does she even speak English?"

  Elena's stomach knotted like the fists her hands were forming. "Did you expect this when you took me into the practice?"

  "Of course I did. And maybe I should have mentioned it to you ahead of time. But, frankly, the color of your skin doesn't matter to me. As I've said, you won't find a lot of this here, and once these folks get to know you, it won't make any difference to them, either. You speak clear, unaccented English. You trained at Southwestern, which in my opinion is second to none. You're an excellent doctor, whether your name is Gardner or Perez or whatever."

  Elena saw Cathy's dilemma. She couldn't very well introduce her new colleague by saying, "This is Dr. Elena Perez Gardner. She's a U.S. citizen. She was raised as an Anglo. She trained at UT Southwestern Medical Center. Don't let the color of her skin bother you."

  "Okay, I see where you're coming from," Elena said. "I guess it's up to me to overcome any prejudices these folks might have." She frowned. "What do you think is the best way to do that?"

  Cathy smiled and patted Elena's shoulder. "Be yourself. Let the real Elena come through. After that, things will take care of themselves."

  "That's the last patient," Jane said, and disappeared down the hall.

  Elena had been surprised at how busy the morning was. No wonder Cathy wanted help—pregnancy or no pregnancy. But it was a good experience for Elena. Now she had a decent working knowledge of the way the office ran. All but a couple of the patients warmed to her. And, as the morning wore on, she began to relax.

  Cathy stopped Elena in the hall. "How about letting me buy your lunch? We can go to RJ's. As I recall, our last meal there started out okay but ended up sort of intense. Maybe this one will be better."

  "I guess that—"

  Jane's voice carried clearly from the front desk. "Dr. Gardner, there's a call for you on line one. Do you want to take it? It's Deputy Perrin."

  Elena could hardly miss the way Cathy's lips pinched at the mention of the name. She'd have to pursue that later. Right now, though, it seemed as though Frank had read her mind. Lunch with him was certainly appealing. She'd been with Cathy all morning, and the furthest thing from Elena's mind was a lunch where the sole topic of conversation was the practice of medicine in Dainger. She needed a break, and Frank Perrin promised to provide a lovely one.

  "Yes, I'll take it." Elena held her hands out palms up in a "what are you going to do?" gesture. "He probably wants to ask me more about the accident report I filed yesterday. Why don't you go ahead? I'll pick up a sandwich somewhere around here."

  "We start again at one," Cathy said, lowering the temperature in the office at least ten degrees with her attitude shift. She shucked out of her white coat, grabbed her purse from a desk drawer, and disappeared out the back door.

  Elena closed the door to the office before she picked up the phone and punched the blinking button. "Frank, this is a surprise."

  "Just keeping my promise to show you the town. Why don't I pick you up in about five minutes? We can grab a quick bite and still have time to drive around before you have to be back."

  "That sounds great. But I have two requests."

  "Name them."

  "Pick me up outside the back door of the office."

  "Secretive, but I'm game. What's the other?"

  "Let's go somewhere other than RJ's."

  Elena dawdled in Cathy's office for five minutes, then stuck her head out the door like a teenager trying to sneak off to a concert. No movement. No sound. She tiptoed down the hall and saw that the front desk was empty. Apparently Jane was at lunch. Good.

  She grabbed her purse and hurried out the back door. As he'd promised, Frank sat in his sheriff' s department SUV outside the rear entrance.

  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 ha
ve 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?"