Critical Condition

by Peter Clement

  He dialed the long-distance number he'd come to know by heart.

  "Fountainhead Pharmaceuticals," said a receptionist with a heavy Spanish accent. "Extension two-six-five, please."

  After a few rings a man answered. "Yeah?"

  "It's Edwards. That matter we discussed. I think it's time to bring the deal to a conclusion." Sunday, June 24, 10:35 a.m.

  "Dr. Sullivan's making wonderful progress, Dr. Hamlin," Rachael Jorgenson said during her Sunday morning phone report.

  He'd gone on tearing himself apart with worry well into the weekend, and had avoided the hospital altogether by letting the residents do the daily rounds on his patients.

  "She's more than ready for her trach."

  His stomach tightened at the news. "Really," he said, toweling off his forehead. He'd been working out on his treadmill downstairs when his wife had yelled for him to come up and take the call.

  "Yes. Dr. Ingram was in to see her as well today. He asked about when we were going to do it. It would be more comfortable for her, and she could try talking by covering the opening. Though she can't flex or extend her wrist or support her arm at all, she's actually able to hold a cup in her right hand, and her fingers are beginning to move in her left, so—"

  "We'll do it Monday," he said, his innards churning at the prospect of Sullivan repeating her charges against him for all the nurses in ICU to hear. It marked the first time he admitted to himself that Blaine and Lockman might be right, that his only way out would be if the woman died. Not that he'd ever think of deliberately harming her. After all, he was a physician. But even in experienced hands, a tracheotomy could be a tricky procedure. In the hands of a resident, anything could happen. "In fact, I'll let you do it. Go ahead and make the arrangements," he said on impulse. No sooner were the words out of his mouth, than he recoiled at the idea. What am I doing?

  "Why, yes, Dr. Hamlin . . ."

  "Is there anything else?"

  "Well, not about the patients. But I'd like to see you, privately."

  Hamlin flushed, and turned his back on his wife who sat nearby reading the Sunday paper. "I can't talk about that right now," he whispered. "It's not talk that I had in mind, Tony," she said, her voice all at once temptingly husky. "I thought maybe we could meet in your office again, to rate my performance under your tutelage."

  Despite his misery, or perhaps on account of it, he found the offer irresistibly appealing. "I'll call you back." He felt himself grow hard even as Rachael hung up, so he had to keep his back to his wife.

  "Trouble with the hospital, dear?" she asked.

  "Oh, the usual. You know. Residents complaining we're always looking over their shoulders during the week, then they can't get through the weekend without calling one of us in."

  "Ah, no, don't tell me you have to go on duty today? I planned for us to have tea at the Plaza this afternoon. You know how I love all those little sandwiches and cakes they serve with it."

  Yes, he was afraid he did, he thought, as he eyed her varicosed plump thighs protruding from the hem of a yellow floral housecoat and a belly that seemed to billow through its folds. He absently patted his own flat abdomen, something he was proud of at sixty-one. It validated him as a man as much as his stature in neurosurgery did as a doctor, and he worked equally hard at keeping both. His wife annoyed him, the way she seemed comfortable with growing old. Not him. He knew how to feel young. And he needed a dose of Rachael Jorgenson right now. But when he got to his office about an hour later, an unexpected message was waiting for him on his hospital e-mail.

  We have to discuss your patient in ICU, privately. Meet me at the film showing in Bryant Park Monday evening. I've booked a table in your name for eight-thirty on the upstairs terrace of the restaurant there. I'll slip in after the movie starts. It's essential no one sees us together.

  P.E.

  The date showed it had been sent Saturday afternoon, but not from Edwards's usual hospital service. He'd used an Internet cafe near the university in the East Village.

  He could only hope Edwards would be more helpful this time. Hamlin deleted the passage as Rachael let herself in his door without knocking. She was wearing OR greens and, he soon found out, nothing beneath. Monday, June 25, 9:15 a.m.

  "I tell you, Jo, I know drug-induced hallucinations can be so vivid people can't distinguish them from reality at the time, but after a while, they at least acknowledge what they saw could have all been in their minds. She's been so coldly persistent, her story never wavering, that I'm beginning to think the unthinkable."

  "That he actually molested her?"

  "I feel nuts even saying the idea out loud, it's so preposterous. But it's as if she's sucking me into her paranoia. No matter, I just can't dismiss what she's saying."

  Richard had asked Jo O'Brien to have a coffee with him in his office, sworn her to secrecy, then unburdened himself of what Kathleen had been saying about Hamlin for nearly a week now. They were sitting across from each other at his desk. "I'm sorry to dump this on you, but if I don't talk it out with somebody, I'm going to go nuts."

  The woman leaned forward and patted his hand. "I'm glad you did Richard. It isn't the kind of thing you should keep to yourself."

  "But she's got to have imagined it," Richard insisted. "At least that's what I kept telling myself. Now I'm not so sure anymore."

  "I'd err on the side of Kathleen. Report him!"

  "But you know how it is with a sexual-assault allegation against a doctor. Even the rumor of it can be a career-ender."

  "Would you sit on this if another of your patients told you the same thing?"

  He was startled by the question. "No, I wouldn't sit on it. Neither would I leap on the guy. I'd check it out, the way I am now."

  "So what's keeping you from doing something about it?"

  He didn't reply. The truth was, Kathleen's initial claim about Hamlin and Lockman putting something in her brain had seemed so crazy, it primed him to dismiss anything else she signaled as out of whack. But if Hamlin did touch her, he wondered, could her first story have something to it as well? No, that part was really too weird, he told himself, deciding he wouldn't say anything about it to Jo.

  "You know as well as I do," she continued, "the guy's a notorious skirt chaser. I can't count how many nurses and female residents he's gone through."

  "But that's between consenting adults. Have you ever heard a whiff of gossip that he's ever accosted a patient? That any of those women you mentioned who went to bed with him weren't willing and ready."

  She pursed her lips and stared at the ceiling, presumably consulting her storehouse of hospital gossip. After a few seconds she said, "I have to admit, the answer's no."

  "Well, neither have I. And that includes stretching my power as head of ER to sneak a look at his personnel file. It's squeaky clean. There's never been a single complaint of that nature."

  "So what are you going to do?"

  "Christ, I wish I knew. I mean, the guy saved her life with a masterful piece of heroic surgery, and here we repay him by—"

  "Have you seen him lately? Is he behaving as if he has something to hide? Is he acting peculiar in any way around you?"

  "Things were a little tense last week, but that might have been me. I mean, half the time I wanted to grab the guy and demand what he'd done. The other half of the time I felt ashamed at ever having thought him capable of something so creepy."

  "When did you last talk with him?"

  "Early this morning. It was a brief phone call, to tell me he'd arranged the tracheotomy on Kathleen for this afternoon."

  "Have it out with him afterward. Clear the air, or bring the matter to a head. Better still, once the tube is out and Kathleen is finally able to talk, listen to her first. When you can actually hear what she has to say, you'll be better able to judge whether it rings true. Then confront Hamlin. If his side of the story smells fishy, nail him."

  Monday evening arrived, and Kathleen still hadn't had the procedure. It had been b
ooked for three P.M., but a series of emergency surgeries had bumped her time in the OR. Richard had ended up hanging around the whole afternoon and into the night, determined to be with her.

  At nine-thirty the call finally came to ICU that they were ready for her. But now Hamlin, who'd been around during the day, was nowhere to be found and wasn't answering his page. Normally someone from ENT, or the ear, nose, and throat division, would have overseen the procedure, but the neurosurgeon routinely waved them off, having a reputation of never letting anyone else touch his patients.

  "Goddamn it," Richard muttered. "Do I have to do it myself?"

  Jorgenson had been in and out all afternoon, obviously as impatient to get the job done as he was. All at once she reappeared at the curtains and announced that she'd had authorization from Hamlin to start the job so as not to lose the slot, and he'd be along. "Will the anesthetist be present in the meantime?" Richard asked. Residents did tracheotomies, but their skills varied greatly, and by law they were never to do them without supervision. He'd be damned if he'd let some novice bend the rules and possibly butcher Kathleen.

  "He's waiting for us now," Jorgenson replied.

  Richard took on the job of ventilating Kathleen with an Ambu bag as they made the trip through the hallways.

  Once they rolled into the OR and centered her under the harsh glare of the operating lamp— anesthetic equipment on one side, equipment trays on the other— Richard explained to Kathleen what would follow, stressing that she'd receive an injection to put her asleep while they worked. He didn't mention it would be midazolam again, the same agent that had made her paranoid.

  She blinked, yes, which he took to mean she understood, and when he held her hand she gave his a weak squeeze.

  "Wow!" he said, beaming down at her, delighted at the lift he got each time he felt her fingers move. Even though her hand was still a misshapen claw, her grip was a little stronger each day, and he used every incremental improvement to try and convince himself recovery was possible. Once the anesthetist had administered the sedation and taken over bagging Kathleen, Richard discretely withdrew to the doctor's lounge. He didn't want to hang around and make everyone nervous. To pass the time, he looked through a stack of magazines. They were so old they had articles about the Bush-Gore recount and market watchers predicting a quick turnaround of the Nasdaq toward ever new highs.

  Jorgenson had been thinking about the tracheotomy all day. In real life the procedure wasn't at all like in the movies or on TV, where George Clooney would say, "Hand me that ballpoint pen and find me a straw."

  "Trachs" were special. Infrequently performed, not every trainee got a chance to do them, and those who did bragged about the number over lunch in the cafeteria. As personal stats went, it was a claim to prestige against which there was no argument, like an earned run average or a tennis ranking. Those who hadn't "done one" yet would grow silent or laugh nervously as they listened, doubt flickering in their eyes and betraying the worry that they wouldn't make the grade when their turn came. She knew there wasn't a man or woman in the entire surgical program who hadn't coveted getting the nod, and when Hamlin announced he'd assigned her the case during rounds that morning, she could feel the heat of envious stares. Rather than miss the opportunity now, she'd lied about Hamlin's imminent arrival. She actually had no idea where he was or why he wasn't answering his page. But what could it matter, she reasoned, if an anesthetist were to watch over her instead? After all, both were qualified teachers. Nor did she see a problem in having said Hamlin was on his way. The operation usually took less than ten minutes, and if he wasn't coming at all, she'd be finished before anyone would realize. Tony, of course, would back her story up afterward. Of that she could be certain.

  Holding her hands up in the air, she gave them a final rinse under the taps, turned from the sink in the scrub room adjacent to the OR, and walked authoritatively into the operating theater. Already masked, she quickly slipped into a green surgeon's gown that one of the nurses held up for her and pulled on a pair of sterile gloves with a decisive snap. She moved precisely and quickly, wanting everyone to know that tonight, though just a resident, she was in charge. Nobody was going to interfere with her proving herself by undercutting her authority. Neither did she want them to suspect it was her first with a live subject.

  She'd only ever practiced a tracheotomy on cadavers in the pathology lab. Both times she got the tube in the wrong place, missing the trachea and wedging it in the subcutaneous tissue between the skin and the structures of the neck, much to the derision of her fellow house staff. She hadn't told that to Hamlin. Why should she, and risk his giving the nod to somebody else?" She's ready for you, Doctor," said the anesthetist, adjusting both the volume and rate of Kathleen's ventilations after hooking her up to a respirator. "Everything's set. I'll be in the next room doing another induction."

  "You're leaving?" Jorgenson felt a twinge of alarm as she stepped up to the table and stood over Kathleen's exposed neck.

  "Of course." He gave her a wink over the top of his mask. "We always work two rooms at night. The anesthesia technician here can handle switching the machine from the old tube to the trach. Besides, you said Hamlin's on his way, right?"

  "Yes, but—"

  "You're all set then." He turned and walked into the scrub room of the adjacent OR.

  Her mouth went dry, and she rested her hands on one of the sterile drapes to keep anyone from seeing the slight tremble that had developed in her fingers. She shouldn't be doing this without supervision, a voice cautioned somewhere at the back of her mind, but the stares of the nurses waiting for her to begin and her previous humiliation at having failed with the cadavers only increased her determination to proceed. She picked up the scalpel.

  The nurse standing opposite swabbed the front of Kathleen's neck, turning it brown with proviodine, washing it clean again with alcohol, then placing a sterile towel with a hole in the center over the area where the trach would be performed.

  Jorgenson quickly felt out the landmarks of Kathleen's voice box— beginning with her thyroid cartilage, or Adam's apple, moving below it to the semicircular shape of the cricoid, another cartilage piece, and beneath that to the top ring of the trachea. Counting down to the one below it, she brought the scalpel point to the surface of the skin, pressed the blade in and made a horizontal cut an inch wide. As with most novices, though, she hadn't pressed deep enough, slicing too superficially and missing the windpipe. But now, unlike in the cadavers, the tissue bled profusely, obscuring her view for a second try.

  "Sponges!" she said, far too excitedly.

  The nurses gave each other uneasy glances.

  Jorgenson pressed four-by-four pads into the incision, but the blood continued to flow.

  "Here, someone hold the pads while I complete my opening."

  Willing hands reached into the field, and after a minute of swabbing and pressing, she could see her first cut, and the still intact tissue of the trachea underneath. Using her left hand to steady the structure, she felt the endotracheal tube still inside. Should I remove it first, she wondered, only then realizing that her practice and instruction on a corpse hadn't involved there being a tube already in place. Having no idea how she should proceed, she resorted to an old resident ploy. "How do the anesthetists do this here? Cut into the trachea with the tube in place, or remove it first?" Phrasing a question to imply that her ignorance embraced only the local practices of New York City Hospital had saved her ass before.

  "Leave the old tube in place, cut down to it, then pull it back until it clears your incision," said the anesthesia technician, "then you can put the new trach tube through the opening." He was a big man with ebony skin and kind eyes who spoke in a calm matter-of-fact way, but the completeness of his answer told her she hadn't fooled him about the extent of her inexperience.

  "Thanks," she said, and sliced the gray band of connective tissue that stretched between the glistening-white rings. The cut parted, revealing the bright orange s
urface of the tube beneath. "Pull back," she ordered, her voice still way too loud.

  He did much more, first shutting off the respirator so that it wouldn't be blowing air out through the opening she'd just cut, then deflating the cuff that wedged the tube solidly in place, a preliminary step preceding removal.

  She should have ordered the nurses to do that, she realized as the orange airway slid up out of view. Settle down, she told herself, or you'll really screw up.

  "Quickly now, Doctor," said the technician. "Remember she's no longer breathing."

  Her face flushed. He was now telling her what even a medical student would know. More flustered than ever, she picked up the curved tube she was to slide into the trachea and tried to insert its tip through the opening.

  It wouldn't fit.

  Prickles of sweat emerged between her shoulder blades and across her forehead. "The opening's still too small!" she said, her voice skipping even higher.

  "Then cut it wider!" snapped the technician, his gentle calm vanished.

  The nurses started to call out readings.

  "02 sat is dropping!"

  "Pulse and pressure falling."

  "I'll get the anesthetist!" added a third, racing from the room. Jorgenson got the scalpel into position, and gingerly extended the cut.

  Again the tube wouldn't fit.

  "Patient's turning blue!"

  "Pressure's sixty over thirty; pulse forty."

  "Shit!" said the technician, struggling to re-advance the original endotracheal airway.

  All her poking around had got it hung up.

  The door flew open from next door as the nurse who'd gone for help returned at a run and raced for the wall phone. "The other case is a bullet wound to the heart who's crashing, and nobody can leave him. See if Steele's still here. I'll page anybody else who's around." She grabbed the receiver and punched 0.

  Someone hit the intercom. "Dr. Steele! We need you in OR C stat!"

  Her hands shaking more than ever, Jorgensen took another slice at the trachea. This time she used too much pressure, and the blade slashed through another half inch of skin. Blood flooded out of the opening. Once more unable to see anything, she tried to insert the trach tube by feel alone. At first it didn't go, and she increased the pressure. It gave a sudden lurch, and went into the neck. "Got it!"