Prescription for Trouble - 03 - Diagnosis Death Page 8

  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?"

  "Sometimes. 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.

  She slumped in a chair in her living room and tried to sort out the tangled mess that was her life. Mark was gone. She'd almost come to grips with that, although there were still times when she couldn't quite believe she'd never see him again. The thought brought a few tears to her eyes, but she counted that an improvement over the floods that came without warning right after his death.

  The harassment from her mother-in-law apparently wasn't going to stop, but maybe she could outrun it when she moved. In the meantime, she still had those Tuesday night calls and threatening letters to contend with.

  Her finances were in ruins. Mark's insurance—he'd been so stubborn about having his own coverage through work instead of being included with hers—had only paid a part of the expenses of his illness. There were still unpaid obligations for ambulance services, lab and X-rays, even the cost of his funeral. She'd been able to stave off her creditors, but eventually she had to pay those debts. And that meant hanging on to the position Cathy Sewell offered.

  Which brought her to her next quandary. The tribunal—she'd come to think of Matney, Gross, and Clark in that fashion—had promised they'd conduct their investigation discreetly, but would Amy Gross think it best to warn Cathy of this latest hiccup in Elena's professional career? Had they talked already? Would the practice offer, the lifeline to which she clung so desperately, be yanked out of her reach?

  No, it was better to face it head-on. She'd call Cathy and tell her the truth. At least, as much of the truth as Elena was prepared to offer. Maybe that would be enough.

  The first time Elena dialed Cathy's home number, the line was busy. Was Amy talking with Cathy even now? Elena cradled the phone, looked at her watch, and decided to give it fifteen minutes before she called again. She made a cup of tea. It sat untouched on the table beside her chair when she roused herself from thoughts that went round and round like horses on a carousel, ending where they started with no progress.

  She dialed again. One ring. Two. Three. Oh, please answer.

  "Dr. Sewell."

  "Cathy, this is Elena. Do you have a minute to talk?"

  "Sure. What's up?"

  How do I say this? "Listen, there's a problem here. I hope it won't affect your decision to offer me the contract, but you need to know about it."

  Elena told the story as unemotionally as possible. She started with Pulliam's presentation in the emergency room. She freely admitted that, because of the similarity to Mark's situation, she'd been drawn to Erma Pulliam and felt a need to counsel her. Elena told how she stood alone
in Chester Pulliam's room and wrestled with the concept of putting an end to an existence that was hardly a life. "But I didn't do it."

  "Elena, that's all understandable," Cathy said. "I'm glad you felt free to unburden yourself to me, but this isn't going to affect our relationship. Matter of fact, this was probably a breakthrough for you. Maybe it will help you get past Mark's death."

  "Unfortunately, the story doesn't stop there. Yesterday afternoon, I met at their request with Pulliam's neurosurgeon, the chair of the neurosurgery department, and Amy Gross."

  As she spilled out the rest of the story, Elena envisioned Cathy's face darkening, her thoughts already centered on how she could break the employment contract they'd signed. "So that's where I stand," Elena concluded. "They say I'm okay so long as I stay out of trouble, but it seems to me that trouble is actively seeking me out. If you don't want an associate who's tainted with a reputation for mercy killing, I'd understand. But I swear to you that I didn't discontinue Chester Pulliam's respirator."

  The silence on the other end of the line spoke volumes to Elena. Cathy was about to cut her loose. And then what would she do?

  "Elena, I accept what you tell me as truth. But let's look at it this way. Was there any hope for Chester Pulliam to live?"

  "Maybe one chance in a thousand he could come off the vent, but even then he'd never be a sentient human being again."

  "And his wife was leaning toward pulling the— Sorry. I've got to stop using that expression. She was about ready to discontinue life support?"

  "Yes."

  "So this isn't a case of murder, or manslaughter, or any other crime. What it represents is someone who wanted to get you in trouble professionally, for going outside protocol, for ignoring policy. Right?"

  Elena found herself nodding. "Yes, I guess so."

  "So the question we have to answer—"

  "Right, it's the same one Amy asked. Why did someone want to blame me?" Elena reached for the cold cup of tea and drained it, but her throat was still dry. "Does this mean you still want me there?"

  "More than ever. I think the sooner you leave Dallas and the medical school complex behind, the safer you'll be."

  Hours later, as Elena lay in her bed, Cathy's words made her shiver. Was this more than harassment? Was she actually in danger? And wasn't it ironic that her escape from danger hinged on a move to Dainger?

  She determined to keep a low profile for the next couple of weeks. If a patient with an intracranial hemorrhage presented to the emergency room, she'd get them into the hands of a neurosurgeon as quickly as possible, but there was no way she'd participate in their care. And afterward, she'd avoid their room like the plague. Matter of fact, she wouldn't even visit the ICU unless she was called there to help with a procedure. For the next two weeks and two days, she'd walk the straight and narrow.

  She'd start packing tomorrow night. In a couple of weeks, she'd jam cardboard boxes with the remnants of her life into every available space in her little Ford and set out for a new life, a new chance.

  Elena's positive thoughts crashed about her when the phone rang. She looked at the bedside clock. Midnight.

  She brought the phone to her ear and held her breath. She expected to hear sobbing, but this time there was none. Only silence.

  Finally, when she could stand it no longer, she said, "Hello?" Her voice shook, and she hated herself for it.

  No answer.

  "Hello?"

  The reply came in the same rough whiskey alto as the other calls, but the words were different this time. "I know what you did, and you have to pay. This makes twice."

  8

  The night brought no rest. Elena tumbled and tossed, wracked by dreams of faceless women who chased her through dark winding corridors. Before she left her bedroom, she stripped the sweat-soaked linens from the bed and deposited them along with her still-damp pajamas in the laundry hamper.

  Elena made coffee and decided to skip breakfast in favor of a donut on the way to the hospital. She was halfway to the front door when the envelope caught her eye. It peeked from the pile of bills and ads she'd chosen to ignore yesterday when she came in. Elena started to pick it up between her thumb and forefinger before she caught herself. Don't be silly. No one is going to fingerprint this. Just open it.

  It was like the other envelope—plain, self-sealing, available at a hundred stores—addressed in block capitals. This one bore only a single stamp. She squinted to read the smudged postmark—mailed from the central post office on Monday evening.

  Elena ripped the flap and pulled out a single sheet of plain paper. The same block capitals, written in blue ballpoint, spelled out a new message:

  THAT'S TWO STRIKES. WILL THERE BE THREE?

  Elena made it through the morning on autopilot. Clinic was mercifully light. At noon she took her bowl of soup to a quiet corner of the cafeteria. The bowl was empty when she returned her tray to the moving belt, but she had no recollection of what she'd eaten. All she could think about was "two strikes."

  This changed everything. The person who made the phone calls was connected with the circumstances of Chester Pulliam's death. Maybe they were the same person, maybe not, but they were certainly connected. Did Lillian's reach extend to the hospital? Could she know the effect of the cloud cast over Elena's professional reputation by recent events in the ICU? And if Lillian was behind this, how had she managed it?

  Elena consulted the large clock that hung over the door of the cafeteria. She had half an hour before she was due in the neurosurgery department's monthly M&M conference. She'd been in medicine so long she no longer thought of candy when she heard those initials. No, this was the Morbidity and Mortality Conference, the meeting where the menu centered on complications and death, neither a sweet subject.

  One of the "mortality" cases was that of Chester Pulliam. Matney promised that her possible role in the termination of his life support wouldn't come up, but although her attendance was pro forma, it was necessary. Now she had twenty-five minutes to make it across campus for the conference. Ten minutes to the shuttle bus stop, ten or more for the ride to the building that housed neurosurgery, another five to make it to the conference room. No, there was no time for what she wanted to do.

  Elena started for the door. First the conference, then the phone call. She promised herself she wouldn't forget it. She dreaded making it, but she had to know. This had to come to an end.

  Twenty-seven minutes later Elena opened the door of the neurosurgery conference room a cautious six inches and peered inside. A huge conference table occupied at least two-thirds of the room. A mixture of faculty and residents filled the chairs around it, with Matney at the head. Dr. Clark sat immediately to his right with the department vice chairman, Dr. Bruce Mickey, on Matney's left. The chairman whispered something, and the three men laughed. Elena took the opportunity to ease into the room and slide into a vacant chair along the back of the room.

  Two junior faculty members were seated to Elena's right. She wasn't particularly trying to eavesdrop, but their whispers came through as though channeled through a megaphone.

  "Did you hear about Dr. Matney?"

  "Yeah. Dunston's leaving, and Matney's the prime candidate to succeed him as dean. The Search Committee's giving him the once-over right now."

  The first doctor looked around. Elena casually directed her gaze to the bound journals lining the walls. Satisfied, he continued. "Matney's already given the word to the faculty. He wants this department squeaky clean. Anything that might look bad, sweep it under the rug or deep-six it some way. If it could bring attention, don't do it."

  "I know. He caught me in the surgeon's lounge and told me to stop giving a particular IV med to patients with cerebral edema because that was off-label usage."

  "Man, I'll be glad—"

  "Let's get started." Matney's eyes swept the room. All conversation stopped as though someone had hit a "mute" button. The chairman leaned back in his chair, apparently relaxed and comfortable.r />
  "Gershon?" This was a first-year resident, who presented the case of a patient who'd developed an infection at the operative site after an otherwise uneventful craniotomy. Elena knew that the most serious neurosurgical complications were vascular— either hemorrhage or obstruction to circulation. This one was unexpected but not what she'd consider major. Indeed, the patient responded well to antibiotics and had no further problems. Nevertheless, Matney spent fifteen minutes questioning the resident and his staff surgeon about how they might have prevented this postoperative infection.

  Elena felt her stomach doing flip-flops. If Matney handled the morbidity portion of the conference this way, what would he do when the mortality discussions started? She tried to dry her palms on her white coat, but it didn't seem to help. Her throat was parched, her heart was in her throat. She hardly heard Matney's next words.

  "Dr. Neely, tell us about Mr. Pulliam."

  This was the resident whose name Elena hadn't been able to recall, the one who had pronounced Chester Pulliam dead. He presented the facts in a monotone more appropriate for delivering an annual report to stockholders than a description of the death of a human being. Elena wondered if this was a coping mechanism adopted early in their training by neurosurgeons because they dealt every day with matters of life and death. She hoped she'd never become that callous about the loss of a human life. Then the irony of that thought brought her up short.

  Neely ground to a halt with, "The patient was maintained on life support, but showed no effective respiratory efforts and required IV dopamine to maintain his blood pressure. He had a diffuse dysrhythmia on EEG, showed a positive Babinski reflex, and we observed early decorticate rigidity developing. We discussed withdrawal of life support with his wife. Subsequently that was done and he expired quietly."

  That was it. No mention of an unidentified person disconnecting the respirator, or of the questionable DNR order. No finger-pointing by Clark or Matney. Instead, Clark encouraged the residents to maintain a high index of suspicion for arteriovenous malformations, the snake-like tangle of blood vessels around the brain that had ruptured and sent Chester Pulliam to his death. For the first time he looked at Elena and said, "Dr. Gardner, who's joined us today, did all the right things in getting immediate treatment for Mr. Pulliam. Unfortunately, his intracranial bleed wasn't a survivable one. That's why it's imperative to find these before they rupture."