Diagnosis Death pft-3 Read online

  She looked down at the frail figure on the bed and located the pulsations of his carotid artery. Enough pressure on one spot-a spot she could easily find-and his heart would slow and stop.

  Elena knew how to spare Chester from a living death. If she did that, Erma Pulliam would be spared too-spared the guilt that comes from making the decision that ends the life of a loved one. Sure, she'd grieve for a while, but eventually she'd move on. She wouldn't be tied for who knows how long to a husband whose brain no longer functioned, whose body shriveled with contractures and wept with bedsores.

  Mrs. Pulliam was waffling. Elena recognized all the signs. And delaying the decision would just bring about a host of problems. Chester would have recurring kidney infections because of his catheter. Despite frequent suctioning through his tracheotomy, pneumonia would finally come. The staff would turn him frequently, but eventually he'd develop decubitus ulcers-ugly sores that smelled foul and ran pus, poisoning his system. He'd shrink to a husk of the man Erma Pulliam had known. And thanks to the miracles of modern medicine, his life-if you could call it life-would go on.

  Elena could prevent all that. And that knowledge was what made her heart sink, as she stood alone at the bedside, pondering what to do.

  Twenty minutes later, Elena tapped the keys of a computer in the hospital library to call up the last of the articles and research papers she needed. She snatched the papers from the printer as quickly as it spit them out, turned, and moved toward the elevator. Had she done the right thing? Well, what was done was done. From here on, it was out of her hands.

  Her pager went off as she stepped off the elevator. Elena pushed through the doors of the ICU and stopped. Something was going on in Chester Pulliam's room. A resident, one whose name she couldn't recall, bent over the bed. He listened for a few moments, then straightened and looped his stethoscope around his neck. The nurse, Ann, stood next to him. He murmured something to her. She nodded assent and pulled the sheet over Pulliam's face.

  As the doctor edged through the door, he saw Elena. "I didn't expect you to be around for this."

  She plucked at his sleeve, but he kept walking. She hurried after him, matching his long strides. "What do you mean? I got a page and came in here to use the phone."

  He ducked into the head nurse's office and closed the door behind them. "We told Mrs. Pulliam it was time to take him off life support, but she couldn't bring herself to do it. The nurses saw you talking with her this morning. They figured you told her about Mark."

  "I did, but the decision still had to be hers."

  He grunted. "Pulliam's nurse had to help when one of the other patients in the unit went sour. Half an hour later, when Ann went in to check him, Pulliam's respirator was turned off. His wife was at his bedside, holding his hand."

  Elena couldn't believe what she was hearing. "Maybe Mrs. Pulliam decided to do it herself. Say good-bye, flip the switch, sit there with him while he died."

  "No, she said it was off when she returned to the room. The nurse figured you did it to save Mrs. Pulliam from having to make the decision. That's the way I see it too." He frowned as his pager beeped. "I'm going to sign it out as death due to his stroke." He thumbed the pager button, looked at the display, grimaced. "For the record, I think it was probably all for the best. I saw the DNR order you wrote on his chart today. I hope Dr. Clark is okay with it."

  The resident rose from his chair. "Gotta answer this page. See you around."

  "Wait!" she called. But the young doctor was already out the door, on his way to handle the next emergency.

  Elena slumped into a chair and buried her head in her hands. What next?

  Elena stumbled through her clinic duties that afternoon. Time after time she had to ask patients to repeat themselves, their answers drowned out by the words that still rang in her ears: "I saw the DNR order you wrote on his chart today."

  "Mrs. Murchison," Elena said, "Your blood pressure is creeping up a bit, but so is your weight. Are you following that diet I prescribed?"

  "Well, doctor…"

  Elena knew what the answer was before the woman was halfway through her detailed justification for ignoring her diet. High blood pressure was truly the silent killer. Until the symptoms were severe enough-headaches, dizziness, shortness of breath-people tended to ignore the warnings of their doctors. Mrs. Murchison was no exception.

  "I'm going to ask the nutritionist to talk with you again. Meanwhile, let's add this to the blood pressure medication you're already on." Elena filled in the prescription as she talked. "Let's see you back in two weeks. I want you to be two pounds lighter by then. Will you try?"

  Mrs. Murchison left, trailing promises and good intentions behind her. Elena wrote a note and tossed the chart into the basket beside her desk. She wondered if she'd be here in the clinic in two weeks when Mrs. Murchison returned.

  The clinic nurse stuck her head through the door. "That's your last patient."

  "Thanks, Mary." Elena sat for a moment, torn between going home to lick her wounds and picking up the phone to make a call that would either resolve her problem or make it much worse. The strident bleat of her pager put an end to her indecision.

  The number included the medical school prefix. She felt that she should recognize it, but the identity danced in her head just out of reach. She dialed it, and the voice that answered reminded her why it seemed familiar. It was one she'd heard on a daily basis while Mark was in the ICU.

  "Dr. Matney."

  "This is Elena Gardner. You paged me?"

  The chairman of neurosurgery cleared his throat. "Elena, I believe we need to talk. How soon can you come to my office?"

  "I'm at St. Paul, but I can be there in fifteen minutes. Is that okay?"

  "Come as soon as you can. We'll be waiting."

  Dr. Matney's call set alarm bells ringing in Elena's head. His use of the word "we" increased the cacophony a dozen-fold. What "we"? Who else would be waiting for her? She thought she knew, and the prospect was far from pleasing.

  No condemned man ever walked his last mile any more slowly and unwillingly than Elena trudged down the hallway to enter Dr. Bruce Matney's outer office. His secretary gave two sharp raps on the closed door of the chairman's inner sanctum, opened it, and motioned Elena in. The closing of the door behind her made Elena want to bolt, but there would be no escape from this meeting.

  It was his office, his meeting, and Matney held center stage. He sat behind his desk, flanked by Dr. Amy Gross on his right and Dr. James Clark on his left. Matney motioned Elena to the straight chair across from him.

  "Elena, thank you for coming."

  She wanted to say, "I had no choice," but decided that silence had served her well before so it was worth a try here as well. She simply nodded.

  Matney picked up a thick manila folder. "This is Chester Pulliam's chart."

  Elena felt her heart creep into her throat. Droplets of sweat trailed down her backbone. She hunched her shoulders, but the muscles remained tense as bowstrings.

  Clark took the chart from Matney's hand and flipped it open. This time the page was marked with a paper clip, but otherwise the feeling of deja vu was complete. "I believe I intimated that Chester Pulliam had virtually no hope of recovery. I know you communicated this to his wife, and frankly, I appreciate that. It's difficult to break this kind of news. But there are some questions about the way he met his end, and we think you can answer those questions." He tapped the page with a manicured fingernail. "Here is a DNR order you wrote-an order about which I knew nothing. And Pulliam was found dead, disconnected from his respirator, immediately after you were alone in his room. The inference is obvious."

  Elena licked her lips but remained silent.

  Matney frowned. "If it were not for the similarities between this case and that of your late husband, this might have gone unnoticed, or at least been ignored. As it was, because of your involvement in the case, Dr. Clark brought this to my attention. We thought it best to deal with the matter i
n this setting, rather than mounting any kind of official inquiry."

  Amy leaned forward. "Elena, you're about to finish your residency. I don't want you to go out under a cloud of suspicion. It's possible that what you say in this room can stay in this room, but the three of us need assurance this sort of action won't be repeated."

  Elena cleared her throat. "Could… could I have some water, please?"

  Matney swiveled in his chair and plucked a bottle of water from a mini-fridge behind him. Elena took it and drank deeply. "Thank you."

  Matney came right back on point. "Can you give us the assurances your chairman has asked for?"

  "I can give you assurances, but not the ones you want," Elena said. "I can assure you that I neither wrote that DNR order nor disconnected Chester Pulliam's respirator."

  7

  Elena's words hung in the silent room like the last notes of a grand symphony dying away in a concert hall.

  Clark pinched his lip and furrowed his brow. Matney leaned forward and opened his mouth, but Amy Gross spoke first. "Elena, I recognize how difficult it must have been for you to be involved with a patient whose situation so closely mirrored Mark's. Are you sure you're not simply denying-even repressing-an action you regret?"

  Elena scanned the tribunal before her. She realized that's exactly what they represented: a tribunal. As surely as Caesar and his buddies decided the fate of a gladiator, these people held her professional life in their hands. Thumbs up or thumbs down. Well, she wouldn't go without a fight.

  "I've admitted that I wrote the 'do not resuscitate' order on Mark's chart. After I made up my mind, I decided to write the order before I backed out." She fixed her gaze on Dr. Matney. "I didn't think it would matter whether I told you or the resident about it or wrote it myself. Obviously, that was a bad decision, a breach of protocol, but I wasn't exactly at my best after practically living in the ICU for two weeks waiting for Mark to show some sign of recovery."

  Matney raised a hand like a sixth-grader trying to get the teacher's attention, but Elena plunged ahead. "I don't think I was the one who disconnected Mark's respirator. I have no memory of doing so, but it's possible that I did and repressed it. I've told you-at least, two of you-all that before." She picked up the water bottle and finished it in two greedy gulps.

  "But-" Amy said.

  "But in this circumstance, I'm absolutely clear about my actions."

  "You don't deny you were alone in Pulliam's room," Matney said.

  "Why deny it? It's true. There was even a witness. A nurse-Ann was her name-came in after Mrs. Pulliam left. We talked briefly before she left the room to help with another patient."

  Matney bored in for the kill. "Turning off the ventilator would only take a few seconds. How long were you alone in the room?"

  "I don't know. Maybe five minutes." She read the doubt in their eyes. "Yes, long enough to do any number of things to end Pulliam's life. And I thought about every one of them. But I didn't."

  Amy pushed Pulliam's chart across the desk and pointed to a line on the order sheet. "This is the order not to resuscitate Pulliam. There's your signature. Do you deny writing it?"

  Elena didn't even look at the chart. Instead, she pulled a blank sheet from the notepad on Matney's desk and scribbled on it. " This is my signature. Does it match?"

  Amy took the sheet of paper and the chart. Her gaze ran back and forth a couple of times before she passed them to Matney. He scrutinized them and handed them to Clark, who spent almost no time comparing the signatures before he dropped the chart on the desk, saying, "They're not the same."

  Elena scanned the group. "Get a handwriting expert to compare them if you want to."

  "That won't be necessary," Amy said. "It's pretty obvious that someone else wrote this."

  Matney tapped his fingers absently on the chart cover. "If you didn't write that order, who did?"

  "I think there's a more important question," Elena said.

  Amy was the first to voice it. "Who took Chester Pulliam off his respirator? And why did they want the blame to fall on you?"

  David waved to Elena and motioned her to the corner of the hospital cafeteria where he sat with the remains of his breakfast. She shuffled over and slumped into the chair opposite him.

  "Bad night?" he asked.

  "Bad week. Bad month. Bad year." She drank deeply from the coffee cup she held. "Bad life, I guess."

  "Do you want something to eat? I'll get it for you?"

  Elena shook her head and emptied her cup. "Just coffee for me this morning. If I ate anything, I'm afraid it would come right back up."

  David rose and took her empty cup, returning in a moment with two full ones. "Here. If you're going to be caffeinated, you might as well go all the way."

  That brought the faintest trace of a smile to her lips. She nodded her thanks.

  "What's the problem? Want to tell me about it?"

  She launched into a retelling of the circumstances of Chester Pulliam's death and her meeting with the neurosurgeons and Dr. Gross. Elena's voice was flat, her face showed no emotion, but it was obvious to David that her composure hung by the merest thread.

  He waited until he was sure she was finished. "So how did they leave things?"

  "Matney is going to talk with the ICU nurses. Maybe one of them knows who had the opportunity to write that note and discontinue Pulliam's life support. Personally, I don't hold out much hope there. And I sure don't see someone coming forward to say, 'Oh, I did it.' In the meantime, I'm to finish my residency and keep my nose clean."

  "So you're not in trouble over this."

  "I don't know why I should be! I did nothing wrong." She lifted her cup, but put it down without drinking. "I want to leave here with a clear record instead of going out with a cloud hanging over me, labeled as a doctor who practiced euthanasia."

  David had never felt so helpless. "If there's anything I can do-"

  She shook her head. "Thanks. I'll let you know if you can help. Right now, I don't know what anyone can do to make this better." She brushed away a tear.

  "Hey, you'll get through this. You've handled worse."

  "That's not it. With everything else that's happened, I forgot-this is Tuesday. Tonight is my night to get another call."

  "Do you think this business with Pulliam is connected to your mystery caller?"

  "I don't see how it could be," Elena said. "I still think the calls are coming from Mark's mother. And there's no way she could get anything done inside the hospital."

  "I guess that's good."

  "No, it's terrible. It means that there are at least two people out to get me. And I have no idea how to fight back."

  Elena brushed a strand of hair from her eyes. "Mary, please tell me I'm about finished."

  The clinic nurse held up a chart. "One more patient. After that, I promise you can go home and forget about this place."

  If only I could. "Thanks. Put him in room two. I'll be right there."

  Elena walked to the workroom and took a Diet Coke from the refrigerator. She held the cool can to her forehead until she heard, "Ready, Dr. Gardner." She popped the top and took several long swallows before heading for the exam room.

  "Mr…" She looked down at the chart. "Mr. Emerson, how can I help you?"

  "My wife's been after me to get a physical. I keep telling her it's old age, but she insisted."

  How many times had she heard that excuse? She hoped the man was right, but her intuition told her different.

  "Let me get a bit of history. Then I'll have a look at you." She eased onto the rolling stool and propped the chart on her knee. "What's the main thing that's bothering you?"

  "It's really nothing. I just get out of breath real easy."

  "How far can you walk without getting tired?" Elena asked.

  "Maybe from here to the front of the waiting room out there."

  The distance he indicated was less than a hundred feet. "Do you ever wake up short of breath?"

  "So
metimes. But it helps if I prop up on two or three pillows."

  Thirty minutes later, Elena sat in the exam room with the patient and his wife. "Mr. Emerson, you have what we call congestive heart failure." She saw the look of shock that the words "heart failure" always produced, so she hurried on. "There's no need to panic. This is fairly common, and we can treat it. I need to start you on a medicine to improve the efficiency of your heart. It's called digitalis, and doctors have been using it in one form or another for over two hundred years, so you know it must work."

  "I've heard of digitalis," Mrs. Emerson said. "Is that all that's needed?"

  "No. In this condition, the body accumulates fluid." Elena looked at Mr. Emerson. "This is why your feet and ankles are swollen. We treat that with medicines called diuretics. You've probably heard them called 'water pills.' "

  "Anything else?" To Mrs. Emerson's credit, she hadn't berated her husband for putting off this visit so long. But Elena got the distinct impression that Emerson's wife would definitely make sure he followed orders from now on.

  "There's salt restriction," Elena said. "That means you cook without added salt. And hide the salt shaker so your husband doesn't use it."

  While Mary phoned to set up an appointment with a cardiologist, Elena answered a few more questions. She rose and handed Emerson the appointment slip. "If you have problems before then, call us. We're here to help."

  On his way out the door, Emerson offered Elena his hand. "Thanks, doctor. I'm glad she bullied me into coming." The loving look he gave his wife took any sting out of the words.

  Elena decided that Emerson was lucky on two counts. He'd sought medical help before his disease became irreversible. And he had a partner, someone who'd help him through the days ahead. She wished she could say the same for herself.

  Elena must have eaten something that evening, but she couldn't remember what it was. Anyway, she wasn't hungry. She'd flipped on the TV when she got home, just as she did every night, but there was no comfort in the noise, and the flickering images made no sense.