Diagnosis Death (15 page)

They talked on and on. That was one of the things she missed about having David near. They never seemed to run out of things to talk about.

"And have you heard that Dean Dunston is retiring?" David asked.

"Oh, I have some insider news on that front," she said. "It seems—"

She heard a click on the line and saw there was another call ringing through. The Caller ID read Sum Gen Hosp. "David, the hospital's calling. I'm covering the ER for Cathy, so I need to take it. I'll call you tomorrow."

She pushed the button to answer the new call. "Dr. Gardner."

A familiar voice responded. "Doctor, this is Glenna in the ER. The EMTs just brought in an elderly man found unconscious by his wife. They don't have a family doctor. Could you come in?"

"I'll be there in five minutes. Meanwhile, please—"

"We'll get an IV going, start him on oxygen, draw blood for a stat CBC and chemistries, put radiology on standby for an MRI of the head. Anything else?"

"Glenna, you're a wonder. I'm on my way."

Thirty minutes later, Elena turned to Glenna and said, "I think he's had a stroke. And with his obesity and his uncontrolled hypertension, it's probably a hemorrhagic one. Let's get that stat MRI of the head, and I need to contact a neurosurgeon. Do we have one in town?"

"The closest one is Dr. Shelmire in Denton. Shall I try to get him on the phone?"

"Please ask the ward clerk to do that. Then I need some Labetalol. I'll give 20 milligrams slow IV push to see if we can drop his pressure some."

Glenna had the vial in her hand almost before Elena finished speaking.

Twenty minutes later, Elena cradled the phone against her shoulder as she reached for her cup of ultra-strong coffee from the ER break room. "I've got the MRI right here," she told Dr. Shelmire. She scanned the images. The story they told wasn't good. "It's definitely an intracerebral hemorrhage. I'm guessing a ruptured aneurysm or AVM."

"Okay, I'm leaving now," Shelmire said. "Talk with the family and tell them he's probably going to need an emergency craniotomy. And you might prepare them for the worst-case scenario."

Elena ended the call and headed for the waiting room where the patient's wife and two adult children waited. Although what Shelmire undoubtedly considered a worst-case scenario was death, she knew of an even worse outcome.

Elena swallowed hard to choke back the bitter taste of bad coffee and bile. She knew what she had to do. Talking with the family would be hard, but she'd done it before. Dealing with the consequences of the stroke and the surgery could be even harder, for them and for her.

Elena hovered behind Dr. Shelmire and admired the way he knelt to be on eye level with his patient's family. "Mr. Lambert is in the recovery room," he said. "A vessel in his brain burst, and the accumulation of blood pressed on some vital structures. Even though we got him to surgery within a couple of hours of the injury, some irreversible damage may have occurred."

The thin, elderly woman sat frozen as Shelmire delivered this news. A middle-aged man and woman flanked her, leaning in as though to keep her from falling. "How much damage?" she asked.

"We won't know until he begins to wake up . . . if he does. I don't look for him to regain consciousness for at least twenty-four hours. If he doesn't, we simply have to wait. Sometimes these patients surprise us."

And sometimes, they don't.
Elena turned away and stared into the semidarkness of the waiting room. A television set mounted high in the corner, its sound muted, pelted the area around it with flickering strobes of color. Life moved on in the outside world. But here, for this family, life had come to a dead stop. Now all they could do was wait. Elena wondered if they'd pray, as she had. And if there was no apparent answer to those prayers, would these people ask her or Dr. Shelmire to end their loved one's misery?

Shelmire was patient with the family's questions, the answer to most of them being a simple "We have to wait and see."

He gave Elena a meaningful look, and she returned an almost imperceptible nod. He rose and nodded toward her. "Dr. Gardner practices here, and she'll be looking in on your husband. I'm in Denton, but I'll make it a point to come by every day. We'll consult freely by phone, and if I'm needed I'll come right over."

Elena spoke for the first time. "I haven't had time to have cards printed, but I'm entering the practice of Dr. Cathy Sewell. I'll write down my name and number for you. Feel free to call me anytime." She looked at her watch. A little past 1:00 a.m. "I'd suggest you go home, get a little sleep. This isn't a sprint. It's a marathon. We'll call you if something changes."

An hour later, Elena rubbed her eyes and yawned. Mr. Lambert's condition was stable. What seemed to be an excellent ICU nursing staff was monitoring his status. Maybe she could drive home for a quick nap—at least a shower and a change of clothes—before morning.

"If you need me in the next few hours, here's my cell phone number." Elena handed a card with the information to the charge nurse.

"Thanks, Dr. Gardner. We'll call you if there's any change. But we both know that's pretty unlikely."

Elena wove her way through the dark corridors of the hospital toward the parking lot where she'd left her car. As she stepped through the door, her cell phone chirped. Someone must have called while she was in the hospital and out of cell phone range. She leaned against the doorpost, luxuriating in the feel of the night air against her skin, and pressed the button to retrieve a voice mail message.

"You have one new call," the electronic voice proclaimed. "Wednesday, 12:01 a.m."

Elena wondered who could have called this late when she heard a whiskey alto voice that made her shiver despite the late June heat. "Don't think you can escape. I know what you've done, and you'll pay."

S
ince you don't have any scheduled patients, you should have slept in a bit," Cathy said. "No need to get to the office this early after a late night."

Elena gripped her coffee cup like it was the last life preserver on the
Titanic.
"No, I've pulled all-nighters before. If I skip out every time I get a late-night call, I won't be much good to you, will I?"

Cathy tried to reassure her new associate. "Listen, you're not on trial here every minute of every day. Relax. Loosen up. You're doing fine."

"Apparently not in my choice of friends," Elena murmured into her cup.

"We've discussed that, and as far as I'm concerned, the matter's closed. Just be careful."

Elena touched the bottom of her cup to the bit of coffee she'd spilled on the break room table and began to form interlocking rings. "There . . . there may be some other problems too."

"Before I forget about it, this came for you. It must have arrived at the medical school after you cleared the campus, so they forwarded it here."

The return address on the legal-size envelope grabbed Elena's attention: Texas State Board of Medical Examiners. "This reminds me, I need to give them a change of address."

"Tell Jane. She'll take care of it for you," Cathy said.

Elena pulled out the single page, scanned it, and felt a hollowness in the pit of her stomach she hadn't experienced since her first roller coaster ride. "This must be some kind of terrible administrative foul-up."

"What?" Cathy asked.

Elena worked to stop the trembling of her hands so she could read. "We have received your request to voluntarily surrender your license to practice medicine. Please reply to this letter, advising in detail your reasons for this request. We must warn you that we are obligated to report any possible criminal activity associated with your actions."

"I take it you didn't make that request."

Elena swept her arms wide in a gesture of innocence, sending her coffee cup to the floor, where it shattered. "This is just one more bit of harassment. I thought that when I moved here it might stop."

Cathy decided that, as usual, her husband had been right. "Want to talk about it?"

"Not really. But I think I need to. You know about the phone calls I got after Mark's death?"

"I remember. From your mother-in-law."

Elena nodded. "That's what I thought. But before I left Dallas I got a letter from a lawyer. Lillian's dead. And she's been dead since shortly after Mark's death. Unless her obituary was some kind of sick hoax, there's no way the calls could have come from her."

Cathy took a moment to think that over. "So we don't know who was making the calls. Still, they should stop now that you've moved away from Dallas and changed your phone number. You did change it, didn't you?"

"I had my home phone disconnected. I gave this office as my forwarding address, and limited even that. As for my cell phone, I didn't think it was necessary to change it. Probably . . ." She ticked off numbers on her fingers. "Probably half a dozen people have the number, and I trust them all."

"So you're through with the calls."

Elena pushed her cup away and put her fingertips to her temples. "Apparently not. I got another one at midnight last night—the same voice. It said, 'Don't think you can escape. I know what you've done, and you'll pay.' "

"But you've done nothing wrong."

"Evidently my caller doesn't hold that opinion."

"Let me talk with Will," Cathy said. "Maybe the investigator he uses can find out who's harassing you."

Elena moved her hands to the back of her neck and began to knead the muscles there. "There's more to it than that. I don't think I've done anything wrong. But there's a very real chance that I might in the future. I guess it's time for me to get some help."

Will made sure everyone was settled comfortably in his office. Elena and he had diet soft drinks, Cathy sipped from a bottle of cold water. He took a seat behind his desk, centered a fresh legal pad on the blotter, and uncapped a fountain pen. "Cathy has filled me in on what you all shared this morning, Elena. Suppose you tell us what it is that makes you afraid you'll do something wrong."

"I've told you about Mark's death. But I glossed over exactly how he came off life support. I stepped away from his ICU room for a bit. When I came back, they were removing his IV, EKG leads, everything. He was dead. I presumed he'd died in the short time I was gone. But later Mark's doctor, who was the chairman of Neurosurgery, called me on the carpet. I'd waffled about withdrawing life support, and when I finally made up my mind to allow it I wrote the DNR order myself."

"DNR?" Will asked.

"Do not resuscitate," Cathy explained. "And Elena's writing that order instead of conveying her wishes to the attending physician was a significant breach of protocol."

Elena nodded her assent. "The doctor—his name's Matney—the doctor also told me that he hadn't turned off Mark's respirator or authorized withdrawal of life support. He asked me if I'd done it."

Will opened his mouth, but Elena anticipated his question.

"Yes, if I'd done that myself, it would be another no-no. The thing is . . . I don't know if I did or not. I have no memory of the hour before Mark died."

Will looked up from his notes. "Can't you explain that on the basis of . . . what do you call it? Did you block out an unpleasant memory? Sort of a selective amnesia?"

"I'd like to accept that, but the story doesn't end there," Elena said.

Will glanced at the notes he'd made.
What more could there be to this story?
He soon found out, as Elena laid out the story of Chester Pulliam's death. "I'll admit it. When I couldn't convince his wife to authorize removing life support, I wanted to take matters into my own hands. I was alone in that room. I even went through the ways I could end his life so no one would ever know. But I didn't. Or at least I don't remember doing it."

"What about the DNR order in someone else's handwriting?" Cathy asked.

"I've thought about that a lot. I knew the signature on the chart wasn't my usual handwriting. That's why I gave Dr. Matney a sample of my signature and used that to bolster my argument that I had nothing to do with Pulliam's death."

"So what's wrong with that argument?" Will asked.

"What if I was functioning in a dream state? Our knowledge on the subject is still evolving. My handwriting might not be the same under those circumstances."

Will frowned. "What do you mean by 'functioning in a dream state?' "

Elena leaned forward as though to explain, but Cathy waved her back. "No, let me tell him. Because I see where you're going, and why you might be worried about caring for patients in a situation similar to Mark's." She took a long pull from her water bottle. "Elena is afraid she was in a fugue state."

Will said, "Fugue?"

Cathy smiled, obviously enjoying the opportunity to teach her husband something. "I know you think a fugue is some kind of a musical composition that you don't like, but this is different. It's a neuropsychiatric condition. A person in a fugue state can carry out actions with no conscious volition or subsequent memory of their actions."

"Wouldn't that be self-limited? And couldn't it still be due to the stress of Mark's death?"

"Not necessarily," Cathy said. "We used to think fugue states were part of the psychiatric spectrum, but there's a lot of new evidence that they may be related to seizure disorders. And if you've had one, you could have more."

Will made a few more notes. "I guess you'd know more than I do about confirming that diagnosis." He capped his pen. "So now we have the whole story."

"Not quite," Elena said. She turned to Cathy. "Did Dr. Matney contact you and say anything about my being on probation here?"

Cathy's bewildered look answered the question before she confirmed it. "No, not at all. Why should you be?"

"So that was a bluff," Elena said.

"What's Dr. Matney's stake in all this, anyway?"

"He's in the running for Dean Dunston's job, and he's anxious to avoid negative publicity for his department. That's why he wanted to rush me off the campus."

"You mean he just wanted the whole thing to go away," Cathy said.

"Right," Elena said. "I was worried about Matney and my reputation, but something bigger is at stake now. It's possible I might have taken two patients off life support and not even realized it. Now I'm participating in the care of another patient who might be in the same situation. What if I do it again?"

This time Will didn't reach for his pen. Instead, his mind churned with the legal ramifications of the case. Was ending the life of a patient kept alive only by artificial means subject to prosecution for murder? Or manslaughter? Could a fugue state be the basis for a defense based on diminished capacity? Or was someone manipulating these circumstances to cast suspicion on Elena, bent on wrecking her professional career?

While Elena and Cathy were tossing around phrases like "neurotransmitters" and "subconscious wish fulfillment" and "dissociative reaction," Will tilted his chair back, closed his eyes, and uttered a silent prayer. He certainly hoped God would help out here, because he didn't have the foggiest notion how to proceed.

Elena paused outside the examining room door and scanned the information on the page in her hand. Maria Gomez was not only her first patient of the morning; she was her first patient in private practice. Well, her first office patient, at least.

Mr. Lambert was still in the ICU, still dependent on the respirator, still in a coma with no signs of regaining consciousness. Elena was grateful that Cathy had taken over daily rounds on him. She didn't want to be worried about what she might do if another episode came upon her. If there truly were episodes. The jury was still out on that.

Enough. Time to go to work. Elena tapped on the door and opened it. According to the chart, the woman perched on the edge of the examining table was seventeen years old, but she looked twice that age. Her thin arms and legs were in marked contrast to her distended belly. The record sheet listed a chief complaint of "pregnant." Elena figured she could have made that diagnosis at a distance of fifty feet. The challenge now was what to do about it.

"Good morning, I'm Dr. Gardner." Elena moved a step closer. "How can I help you?"

"She does not speak English." Elena's eyes moved to the young man perched on a chair in the corner. His clothes were clean but very worn: faded jeans, a T-shirt, tennis shoes. "
¿Habla usted español?"

"
Solo un poco.
Just a little."

The man's look of disappointment confirmed to Elena that, once more, her lineage had betrayed her. She could imagine his joy at seeing a doctor so obviously Hispanic fade when he discovered her Spanish was limited.

"Your English is fine," Elena said. "If you don't know a word, give it to me in Spanish. I speak some, just not a lot."

"Okay." He swallowed. "Maria is . . .
embarazada."

"Yes, I can see she's pregnant. What brings you here?" His puzzled expression told her to stop relying on idioms. Try again. "What can I do to help?"

"Her time is coming near. She has the . . ." Again, a hesitation as he searched. "She has
dolor de cabeza severo.
And sometimes the things she sees, they are . . . how you say, not clear."

Elena nodded. Red flags went up immediately. A pregnant woman with severe headaches and fuzzy vision. "Has she been eating?"

Embarrassment colored his face. "Sometimes there is no food. I get work where I can, but . . ." He spread his hands.

So add poor nutrition to the mix. Elena recognized that getting the entire history would be a slow process. She already had a good idea of the problem, and she was itching to get the pieces of the puzzle that would tell her how severe it was. "I need to do an examination. The nurse will prepare her, and I'll be right back. Do you want to wait outside?"

"Please, no. I am her
esposo
. . . her husband." He beamed at finding the word. "And I must tell her in Spanish what is needed."