Flashback

by Michael Palmer

  I promised him I'd speak to you-both of you-about it… ask you to keep your eyes and ears open. I feel we owe it to him. You were too young to remember, Frank, but that man all but saved your life when your appendix burst."

  Frank's fists relaxed a bit, though Zack could tell that he was still smarting from the Judge's threat. Personality clashes, power plays, and political machinations were, he knew all too well, as omnipresent and as integral a part of hospital life as IVS and bedpans. But he sensed something more to all of this-something virulent. "Annie!"

  Cinnie Iverson's cry was followed instantly by the crash of dishes. With reflexes born of years of crisis, Zack was on his feet and headed toward the kitchen as Frank and the Judge were just beginning to react. Annie Doucette was on the floor. Her back and neck were arched, and her limbs were flailing uncontrollably in a grand mal seizure. As Zack knelt beside the woman, he felt the change sweep over him.

  Early on, he had heard about the phenomenon from other, older docs, but did not undergo it himself until midway through his second year of residency, when he witnessed the cardiac arrest of a patient. In that moment, his world suddenly began to move in slow motion. His voice lowered and his words became more measured, he sensed his pulse rate drop and all his senses heighten. It was unlike anything he had ever experienced in similar emergencies. Movements became automatic, observations and orders instinctive. Dozens of facts and variables were processed instantly and simultaneously. Later, with the patient successfully resuscitated and stabilized, he would learn from the nurses that he had acted quickly, decisively, and calmly. It was only after hearing their account of his performance that he realized fully what he had done. The change had been part of him ever since. "Mom, call an ambulance, please, " he said as he rolled Annie to one side to prevent her from aspirating her own stomach contents, should she vomit. His fingertips were already at the side of her neck, feeling for a carotid pulse. As the change intensified, all sense of the woman as a friend, a loved one, a patient, yielded to the objectivity of assessment. If it became necessary, in any way, to hurt in order to heal, then hurt he would. "Frank, my medical bag is in a large carton at the back of the van. Could you get it, please? " Please. Thank you. The use of these words during a crisis kept everybody calmer, including, he suspected, himself. Stroke, heart attack with arrhythmia, epilepsy, sudden internal hemorrhage causing shock, hypoglycemia, simple faint mimicking a grand mal seizure, the most likely diagnostic possibilities flowed through his mind, each accompanied by an algorithm of required observations and reactions. Annie's color was beginning to mottle. Her back remained arched and her arms and legs continued to spasm. Her jaw was clenched far too tightly to slip any buffer between her teeth. Again and again, Zack's fingertips probed up and down along the side of her windpipe, searching for a pulse. She had had chest pain at the table. Zack felt certain of that now. Heart attack with an irregular, ineffective beat or complete cardiac standstill moved ahead of all other possibilities in his mind. "Judge, are you okay to come down here and help? Good. I'm going to put her over on her back. If she starts to vomit, please flip her back on her side, regardless of what I'm doing. Lisette, check the time, please, and keep an eye on it."

  Zack eased the woman onto her back. Her seizure was continuing, though her movements were becoming less violent. Again he checked for pulses, first at her neck, then in each groin. There were none. He delivered a sharp, two-fisted blow to the center of her chest and began rhythmic cardiac compressions as Frank arrived with his medical bag. "Judge, please fold something up and put it beneath her neck, then lay that chair over and put her feet up on it if you can. That's it. Frank, there are some syringes with needles already attached in the bottom of the bag. I need two. Also, there's a little leather pouch with vials of medicines in it. I'll need Valium and adrenaline. That one may say 'epinephrine' on it. Mom, did you get the ambulance? Good. How long?"

  "Five minutes at the most."

  "Frank, can you do CPR?"

  "I took the course twice."

  "Good. Take over here, please, while I get some medicine into her to stop her seizing. Don't bother trying mouth-to-mouth until she stops.

  Just pump. You're doing fine. Every one's doing fine." Zack placed his fingertips over the femoral artery. "A little harder, Frank, please," he said. "Time, Lisette?"

  "Just over a minute."

  Without bothering with a tourniquet, Zack injected Valium and adrenaline into a vein in the crook of Annie Doucette's arm. In seconds, her seizure stopped. Frank continued pumping as Zack hunched over the woman and administered half a dozen mouth-to-mouth breaths. Moments later, Annie took one on her own. "Hold it, Frank, please, " Zack said as he searched, once again, for a cartoid artery pulse. This time he felt one-slow and faint, but definite. He checked in her groin. Both femoral artery pulses were paldable.

  I. N Again, the woman took a breath, then another. Come on, Annie, his mind urged. Do it again. Just one more. Just one more. He slipped a blood pressure cuff around her arm and then worked his stethoscope into place with one hand while he returned his other to the side of the woman's neck. "I hear a pressure, " he announced softly. "It ain't much, but for right now, it's enough."

  Annie's breathing was still shallow, but much more regular. Softly, but steadily, she began to moan. Her lips were dusky, but the terrible mottling of her skin had lessened. At that moment, they heard the whoop of the ambulance, and seconds later, strobelike golden lights appeared in the living room window. Zack looked up at his older brother, who knelt across the woman from him. For an instant, he flashed on two young boys kneeling opposite one another in a dusty, vacant lot, shooting marbles. For ten seconds, twenty, neither man moved or spoke. Then Frank reached over and took his hand. "Welcome to Sterling, " he said. THE AMBULANCE WAS one of several well equipped vans owned by Ultramed-Davis and operated by the Sterling Fire Department. Zack sat beside Annie in the back, watching the monitor screen as the vehicle jounced down the narrow mountainside road toward the hospital. A young but impressively efficient paramedic knelt next to him, calling out a blood pressure reading every fifteen or twenty seconds. Sterling, New Hampshire, was small in many ways, but Zack could see Ultramed's influence in the emergency team's response. This was big city medicine in the finest sense of the term. Annie was still unconscious, although her breathing seemed less labored and her blood pressure was inching upward. "Eighty over sixty, " the paramedic said. "It's getting a little easier to hear."

  Zack nodded and adjusted the IV which the young man had inserted flawlessly, and even more rapidly than he himself could have done. Frank had stayed behind to tend to the family and contact a cardiologist. They would meet later at the hospital. Zachary felt tense, but he was also charged and exhilarated. When it all came together, when it all worked right, there was no comparable feeling. Come, Watson, Come! The game is afoot. Zack loved the quote, and often wondered if Arthur Conan Doyle, a physician, had transferred the energy of his experience with medical emergencies to his detective hero. After a brief stretch on the highway, the ambulance slowed and turned into the long, circular driveway leading uphill to the hospital. A large, spotlighted sign at the base of the drive announced, ULTRAMEDDAVIS REGIONAL HOSPITAL–COMMUNITY AND CORPORATE AMERICA WORKING TOGETHER FOR THE BETTERMENT OF ALL. Zack smiled to himself and wondered if he was the only one amused by the hubris of the pronouncement. The Betterment of All. Ultramed Hospitals Corporation and Davis Regional Hospital could certainly never be accused of setting their sights too low. Still, although he had a few lingering concerns about working for a component of what some had labeled the medical-industrial complex, his conversations with Frank and the Judge, and his investigations of the hospital and its parent company, had provided no cause to doubt the proclamation, however audacious.

  Ultramed-Davis, now a modern, two-hundred-bed facility, had a proud history dating back to the turn of the century, when the Quebecbased Sisters of Charity placed ten beds in a large donated house and named it, in Frenc
h, Hopital St. Georges. Over the decades that followed, brick wings were added, until, ultimately, the old house was completely replaced. The hospital's capacity grew to fifty patients, and eventually, to eighty. In 1927, the St. Georges School of Nursing was established, and before its closing in the early seventies, produced more than 350 nurses. In mid-1971, the ownership and administrative control of St. Georges was transferred from the Sisters of Charity to a community based, nonprofit corporation headed by Clayton Iverson, already a Clarion County circuit judge, and was renamed after Reverend Louis Davis, the pastor who had donated the initial structure to the town. Over the years that followed, a succession of inadequate administrators, most of them using Davis Regional as a stepping-stone to bigger and better places, made a succession of unfortunate decisions, opting too often for projects and personnel additions that looked progressive but could not support themselves financially. Gradually, but inexorably, community support for the facility dwindled, and benefactors became scarce. Older physicians began retiring earlier than they had planned, and a lack of financial inducements kept young recruits from taking their places. Bankruptcy and closure became more than theoretical possibilities. It was then, with the wolves howling at the hospital door, that the Ultramed Corporation appeared on the scene. A subsidiary of widely diversified RIATA International, Ultramed assailed the hospital board with slide shows, brochures, stock reports, pasteboard graphs, and more financial information on the facility than even the most diligent trustee possessed. Suspicious of outsiders and wary of losing control of an enterprise that had, for most of a century, been at the very heart of their community, a majority of the board opposed the sale, favoring instead another bond issue and one more stab at doing things right. Clayton Iverson, citing what he called "the bloodred writing on the wall, " knew the community had no sensible alternative but to sell.

  By his own spirited account, he worked his way through the trustees one by one, cajoling, arguing, calling in markers. In the end, Zack had been told proudly, the vote was unanimous. Unanimous, that was, save one Only Guy Beaulieu remained opposed, though out of respect for the Judge he declined to vote at all. Never one to relinquish power with a hook, the Judge extracted two concessions from the corporation in exchange for the sale of the hospital, a provisional four-year period after which the board of trustees could repurchase the facility, including all improvements, for the original six-million-dollar price, and the serious consideration of his son for the position of administrator. As near as Zack could tell from his father's account, following an exhaustive series of interviews, Ultramed had selected Frank over dozens of applicants-most with extensive hospital experience. That decision, for whatever reasons it was made, had proved brilliant. Orchestrated by Frank, and aided by time-tested business practices and public relations techniques, the turnabout in the hospital was immediate and impressive.

  New equipment and new physicians underscored the corporate theme of "A Change for the Better, " and the remaining opponents of the facility-mostly in the poor and uninsured sectors of the community-experienced increasing difficulty in finding a platform from which to voice their concerns. In just a few years, Ultramed-Davis Regional Hospital had been transported from the backwater of health care to the vanguard. "Hang on, Doc, " the ambulance driver called over his shoulder to Zack. "We're here."

  Zack braced himself against Annie's stretcher as the man swung a sharp turn and backed into the brightly lit ambulance bay. Alerted by the ambulance radio, a team of three nurses dressed in blue scrubs and an orderly wearing whites was poised on the concrete platform. Before Zack could even identify himself, two of the nurses, with tight-lipped efficiency, had pulled Annie's stretcher from the ambulance and sped past him into the emergency ward. Zack followed the stretcher to a well-equipped room marked simp1Y, TRAUMA, and watched from the door as the team transferred Annie to a hospital litter, switched her oxygen tubing and monitor cables to the hospital console, and began a rapid assessment of her vital signs. One nurse, apparently in charge, listened briefly to Annie's chest, then took up a position at the foot of the bed, supervising the evaluation. "Excuse me, " Zack said to the woman, who wore a white lab coat over her scrubs. "Could I speak to you for a moment?"

  The woman turned, and Zack felt an immediate spark of interest. She was in her early thirties, he guessed, if that, with short beach-sand hair, fine, very feminine features, and vibrant, almost iridescent, bluegreen eyes. Instinctively, and quite out of character for him given the situation, Zack glanced at her left hand. There was no ring. "I… I'm Dr. Iverson, Zachary Iverson, " he said. Had he actual stammered? "I'm a neurosurgeon due to start on the staff here tomorrow. That woman we just brought in is… I mean was… sort of like my governess when I was young. Mine and my brother Frank's."

  "Now there's a name I recognize, " the woman said, cocking her head to one side as if appraising a painting in a museum. "Yes, " Zack said.

  Several seconds passed before he realized that he had not yet finished explaining what he wanted. He cleared his throat. "Well. Frank said he would arrange for a cardiologist-a Dr. Cole, I think he said his name was-to come in and take over Annie's care. Has he arrived yet?"

  "No, " the woman said thoughtfully. "No, he hasn't, Doctor."

  Her expression was at once coy and challenging, and Zack, often oblivious to women's attempts at nonverbal interplay, felt ill-equipped to respond with an expression of his own. "I see, " he said finally, wondering if he was looking as flustered and restless as he was feeling.

  His ego was goading him to be assertive-to remind the woman that, while he might have momentarily been taken aback by her, he was, at least until the arrival of Dr. Cole, in charge. He cleared his throat again and, unconsciously, stood more erect. "Well, then, " he went on, with a bit more officiousness than he had intended, "would you please have someone call him again. I'll be in there with Mrs. Doucette. Just send him in as soon as he gets here. Also, could you order an EKG and a portable chest X ray."

  "Certainly, Doctor, " the woman said as he strode past her and into the room. Bravo, his ego cheered. Well handled. He glanced back over his shoulder. The woman had not yet moved. "Could you call the lab, too, please, " he ordered, wishing her eyes would stop smiling at him that way. "Routine bloods."

  "Certainly, " she said. "Cardiac enzymes, too?"

  Damn her cool, Zack thought. "Yes, of course, " he responded. "Have them draw extra tubes as well. Dr. Cole can order whatever else he wants when he gets here."

  He walked to the bedside without waiting for an acknowledgment of his request, and forced himself not to look back. Annie's eyes, still closed, were beginning to flutter. "I'm Dr. Iverson, " he said to the two nurses who were attending her. "How's she doing?"

  "Her pressure's up to a hundred over sixty, " one of them, a husky, matronly woman in her fifties, said. "She's moved both arms and both legs, and it looks like she's about to wake up."

  "Good, " Zack said, aware that a portion of his thoughts, at least, were not focused on the matter at hand. He slipped his stethoscope into place and checked Annie's heart and lungs. "Annie, it's Zack," he said into her ear. "Can you hear me?"

  Annie Doucette moaned softly. Then, almost imperceptibly, she nodded.

  "You passed out, Annie. You're at the hospital now and you're going to be all right. Do you understand that? " Again, a nod. "Good. Just relax and rest. You're doing fine." He turned to the nurse. "Dr. Cole's due here any minute. Until he gets here, we'll just keep doing what we're doing."

  The nurse looked at him queerly, then glanced over at the door. Zack followed her line of sight and found himself, once again, confronting the enigmatic ocean-green eyes. This time, though, the disconcerting woman behind them stepped forward and extended her hand. "Dr. Iverson, I'm Dr. Suzanne Cole, " she said simply. Her expression was totally professional, but there was an unmistakable playfulness in her eyes.

  Zack felt the flush in his cheeks as he reached out and shook her hand.

  "I'm so
rry, " he mumbled. "It was sort of dumb for me to assume… what I mean is, you weren't exactly…"

  "I know, " she said. Her tone suggested an apology for having allowed him to dig such a hole for himself. "I'm sure it was this outfit that confused you"-she indicated the blue scrubsuit-"but I just finished putting in a pacemaker." She nodded toward Annie, who was now fully awake and beginning to look around. "You seem to have done quite a job bringing this woman back, Dr. Iverson. Congratulations."

  It was nearing midnight. Zack Iverson sat alone in the staff lounge at the back of the emergency ward, sipping tepid coffee, sorting through what had been, perhaps, the most remarkable June the thirtieth of them all, and trying to slow down his runaway fantasies concerning Suzanne Cole. It had taken several hours to ready a bed for Annie in the coronary care unit and to effect her transfer there. During that time, Zack had stayed in the background, watching Suzanne as she managed one dangerous cardiac arrhythmia after another in the woman, balancing complex treatments against their side effects, checking monitor readouts, reviewing lab results, then, suddenly, stopping to mop Annie's brow, or to smooth errant wisps of gray hair from her forehead, or simply to bend down and whisper encouragement in her ear. Unlike what Zack had imagined from her cool composure during their initial meeting, she was actually quite tense and frenetic during critical moments, moving from one side of the bed to the other then back, checking and rechecking to ensure that her orders were being carried out correctly.

  Still, while she seemed frequently on edge, she was never out of control and it was clear that the nurses were comfortable with her ways, and even more important, trusted in them Who are you? his mind asked over and over as he watched her work. What are you doing up here in the boondocks?