Diagnosis Death (21 page)

"That's the way I see it. The question is, what do we do?"

"I don't suppose you brought the vial and syringe with you?"

Elena's mind began to race ahead. She could see where this was headed, and she didn't like it. "No. I was so shocked that I put the vial back in the drawer, slammed it shut, and left. Then I called your office and made this appointment."

Marcus rocked forward, and his feet hit the floor with a resounding splat. "Let's get up to the ICU. I want to see this for myself."

In a few minutes, they stood side-by-side in Lambert's room. Mrs. Lambert hadn't seemed unduly concerned to see two doctors, one of them unfamiliar, show up. By now, she probably wasn't surprised by anything. A week in an ICU would do that, Elena thought.

"Mrs. Lambert, this is Dr. Bell. He's a colleague. I was telling him how well Mr. Lambert is doing." Elena tried to muster her biggest smile. "We're going to be here for a bit. Would you like to slip out and get something to drink, maybe get a sandwich in the cafeteria?"

"That would be lovely. I'll only be a few minutes."

Marcus closed the door behind Mrs. Lambert. He drew the blinds, cutting off the view of the room from the nurses' station. "We don't need anyone else peeking at us right now."

Elena's hand hovered over the drawer pull. She started to use the tail of her white coat to open the drawer, then realized that there were dozens of fingerprints already there. No need to try to protect against adding more to the drawer pull. And what about the vial? Were there fingerprints there too? If so, maybe they could be checked. If the culprit had ever been fingerprinted, that would pin down his identity—or hers. Of course, Elena would have to give her prints for comparison, because they'd be on the vial as well.

"Well, open it." Marcus's voice had an edge. Was he as nervous as she was?

She yanked the drawer open and gasped. It contained the same Gideon Bible and washcloth she'd seen earlier. Nothing else. The syringe and the vial—with her fingerprints—were gone.

Restless nights were nothing new to Elena, but this one had them all beat. For hours she watched the numbers on the clock change. The minutes ticked away, the hours rolled over, but still sleep eluded her. Instead, her mind called the roll of the demons pursuing her.

When she finally fell into a troubled sleep, somewhere near dawn, wakefulness gave way to nightmares, always featuring the triumvirate of doctors she'd come to call "the tribunal."

"You were going to kill that patient," the monk-like doctor said.

"We have your fingerprints on the vial," came the pronouncement of the doctor with Coke-bottle glasses.

"Your only hope is to beg us for mercy," said the movie star clone.

"I didn't do it. I didn't do it." Elena tried to say the words, but nothing would come out. They lodged in her throat like a lead weight. She couldn't swallow. She couldn't breathe. She was choking, suffocating.

"This is your punishment." The middle doctor looked over his glasses at her, and his countenance was like an Old Testament prophet proclaiming doom on a city. "Just as your patient was to die, so shall you be starved for life-giving oxygen. Your brain cells will begin to die like waves of soldiers advancing into a cannon's fusillade. Your heart will quiver in fibrillation, no longer able to pump blood. Soon, all your organs will cease to function."

"When?" she choked out.

"Your death will be announced by the ringing of this bell." The handsome doctor held up a small brass bell and began ringing it. "When it stops, you will cease to exist."

Elena tried to reach out her hand to grab the bell and ring it. No matter how far she reached, it always remained just a few feet away. She stretched out her arm, again and again.

Her hand hit something, there was a crash, and Elena snapped awake. The tribunal was gone. She was in a strange bed, in a strange room. The lamp she'd knocked off the bedside table lay on the floor, its shade askew. Slowly it came to her. This was the Kennedy home. She was in their guest room. And the ringing was her cell phone, the ring tone she'd assigned to the hospital.

Elena sat up, pulled the covers around her to combat the chill she felt, even though the room was warm. She picked up the phone from her nightstand.

"Dr. Gardner."

"Doctor, I'm sorry to bother you this early. This is Glenna Dunn. I'm working in the ICU, and your patient, Charles Lambert, has a temp of a hundred and two. What would you like us to do?"

"Give me a second." Elena looked at the clock. Four-twenty-two. She'd been asleep less than two hours. She padded to the bathroom and splashed water on her face. She cupped her hand and drank from the faucet. Better, but only slightly. She struggled to get her mind back in gear. "Glenna, I'm back. When did you notice this?"

"We didn't wake him for vital signs through the night. That was Dr. Shelmire's order."

"That's okay. So, what was his 9:00 p.m. temp?"

"Ninety-nine two. He was a little behind on his fluids, so we speeded up his IV. He seemed okay during the night, but honestly, I didn't keep a really close eye on him. We had a couple of pretty sick patients, and we're working short-handed. That's why they called me in to work up here on my day off from the ER."

"So why did you take his temperature now?"

"When things finally settled down, I had a look at my other patients. He looked flushed, so I used the old manual thermometer—you know, hand to the head—and he felt warm. That's when I checked his temp."

"Get a CBC. Urinalysis and culture from his catheter. I may want some other things, maybe a chest X-ray and blood cultures, but I want to see him first. I'll be there in about an hour. Call me if something else comes up before then."

"Do you want me to give him an aspirin suppository?" Glenna asked.

The mental index cards rippled in Elena's brain. Lambert wasn't taking anything by mouth—didn't even have a feeding tube in place. So oral meds were out. There were no IV drugs proven to effectively lower fever. An aspirin suppository would be the best choice, but aspirin had an effect on bleeding and clotting. It was a long shot, but if the fever was due to seepage of blood from the brain into the spinal fluid, aspirin might aggravate the bleeding. Besides, fever was a sign, not a disease. With a temp no higher than this, it was better to hold off and find the cause.

It took only a couple of seconds for Elena to parse the possibilities and say, "No. Hold off on any meds until I get there. See you soon."

She replaced the lamp on the table and started climbing into the clothes she'd laid out the night before, a habit born of long experience with calls in the middle of the night. As she dressed, she wondered what this latest development in the Lambert chronicle might represent. Was it something simple, like a urinary tract infection? More intracranial bleeding was possible, but quite unlikely. As she dressed, she tried unsuccessfully to ignore the possibility that kept popping into the forefront of her thoughts. Did this represent another attempt to kill Charles Lambert?

All the way to the hospital, she couldn't get away from the idea that perhaps this was more than a simple fever in a post-op patient. But how could someone infect a comatose patient? Material from a contaminated syringe injected in his IV? Bacteria from a lab culture introduced into his lungs via the endotracheal tube? She discarded some of the possibilities as ridiculous, but then again, this whole scenario was ridiculous. Why would someone want to keep an unemployed truck driver from recovering? Had he been hauling illegal cargo, like drugs or stolen goods? Was this an attempt to keep him from talking?

Or was this another move to discredit her? She was already under a cloud of suspicion for the deaths of two critically ill patients. Would Charlie Lambert's death be the third strike that ended her ability to practice medicine, here or anywhere?

T
he OB doctors' lounge at Summers County General was cool enough this morning, but David was sweating. When he'd been in residency, even though he might have gone to a new service or a new hospital, adjustment was relatively easy because things were done with a surprising amount of uniformity in the medical community in Dallas. And most of the town doctors there, except a few stubborn souls, took their lead from what was taught at the medical school.

Here, he not only had to become familiar with a new hospital with a new cast of characters, but he'd already discovered a couple of things his new partner liked to do that were different from the practices he'd learned. How many more would there be?

"Don't worry," Milton Gaines said. "I don't expect you to copy everything I do. We'll iron out the differences. I imagine you'll teach me a few things, and maybe I've learned some stuff along the way that will help you. The main thing is that our patients get good care, with as much uniformity as we can offer. That way they feel more comfortable no matter which of us they see."

David drew a cup from the industrial-sized urn in the corner, tasted what apparently passed for coffee in the lounge, wrinkled his face, and tossed the Styrofoam cup into the trash.

"I see you've learned a valuable lesson already," Gaines said. "Don't drink the coffee in the OB doctors' lounge unless you have a death wish. I'll buy you a cup in the cafeteria after we finish rounds. It's better than this, which isn't saying much. The best coffee comes from the nurses' break room. Be nice to them, and they'll share."

"Fair enough." David popped a stick of gum into his mouth, but it was no match for the lingering bite of the coffee. "Ready for rounds?"

Gaines eased himself to his feet. "Let's go."

Gaines had two postpartum patients still in the hospital, both doing well after delivering healthy babies, both anxious for discharge. He introduced David to each woman. "This is Dr. Merritt, my new associate. If I'm out or tied up, you'll see him. He's a good man, well-trained and caring. I know you'll like him."

In the hall, Gaines said, "I have one other patient. She's a Hispanic female, nearly at term, admitted recently with preeclampsia. It's a struggle to keep her blood pressure down, and I'd appreciate any help you can give me."

David took the chart Gaines offered and studied it. His senior partner had done all the right things: magnesium sulfate, hydralazine, beta-blockers, oxygen, careful control of fluids. The woman—Maria Gomez—had not yet had a seizure, which was in her favor, but her blood pressure remained high despite treatment.

"I see you estimate that she's at thirty-three to thirty-four weeks gestation," David said. "Are you thinking of inducing her?"

"Definitely. I figured one of us can manage the induction while the other takes care of the office. Want to handle it?"

David closed the chart. "Sure. Why don't we examine her?"
My first OB in private practice and it's a patient with early toxemia of pregnancy. Welcome to the real world.

David could see that the girl—and that's what she was, just a girl—was frightened. He could understand why. About to have a baby, lying in a bed in a strange hospital being cared for by people who didn't speak her language; no wonder she was scared.

Gaines warned David that the husband would be his interpreter, but one of the first things he'd learned in medical school was that in any encounter, especially the first one, the patient should be the focus. He stood at Maria's bedside and lightly touched the back of her hand, careful to avoid the IV there. "Maria?
Soy el Dr. Merritt. Cuidaré de usted."

She nodded and managed a weak smile. The husband offered his hand. "
Soy
Hector."

"Hector, I've used up most of the Spanish I know to introduce myself to your wife and tell her I'll take care of her. Can we speak English?"

"My English is not so good, but I will try."

David explained that he and Dr. Gaines needed to examine Maria. "We think that it may be best to help the baby get here as soon as possible."

"I understand. Do what is needed, and I will share what you tell me with Maria."

Thirty minutes later, the three men stood at Maria's bedside. In simple English, augmented by the few Spanish words he had picked up during his residency, David explained what was planned. Medication given in Maria's IV would stimulate labor. He would be at the bedside or nearby during the process. The baby was old enough to safely come into the world, and that was necessary to lower Maria's blood pressure and prevent such complications as convulsions. David stumbled on the last word, but Hector assured him it was the same in Spanish.

Maria was nodding even before David finished. "
Si, comprendo."
Obviously, she understood more English than he or Gaines realized.

"If you're okay to stay here and handle this, I'll get back to the office," Gaines said. "I'll check with you later today. If you need me to relieve you, we can switch."

David took the chart Gaines handed over, feeling like a runner who'd just been handed the baton for the final leg of the race. He prayed he wouldn't stumble.

Elena handed Jane the chart and yawned for what seemed like the fiftieth time that morning. Her jaw popped. "Excuse me."

"Tough night?" Jane asked.

"They called me about four. Mr. Lambert was running a fever."

"Anything serious?"

"Nope. Just a urinary tract infection."

"Glad it wasn't anything worse," Jane said.

Elena thought again about the dictum she'd heard repeatedly since her first physical diagnosis class in med school. When you hear hoofbeats, think horses, not zebras. But last night she'd focused on zebras as soon as the call came.

All the way to the hospital, she'd imagined all the worst possible causes for Charlie Lambert's fever. As it turned out, a third-year medical student could have made the diagnosis and started treatment. Elevated white blood count and pus cells in the urine added up to a urinary tract infection, the most common cause of fever in a patient with an indwelling urinary catheter, and one that was easily treated.

After ordering the appropriate antibiotic, with a mental note to adjust it after the urine culture results were available, Elena carried out a thorough neurological evaluation. Although his endotracheal tube was still in place, Lambert hadn't required ventilator assistance for thirty-six hours. He was moving all four extremities in random fashion, occasionally bucking against the breathing tube in his throat. He uttered a few groans, although the presence of the tube prevented him from talking.
Time to take out the endotracheal tube.
She left a note for Shelmire, letting him make the final decision.

Jane's voice brought Elena back to the present. "That's the last patient until this afternoon." The nurse strode off toward the front office to file the morning's charts.

Elena was barely through the door to her office when her cell phone vibrated. She pulled it from the pocket of her white coat. The Caller ID showed "anonymous caller." What now?

"This is Dr. Gardner."

"Elena, Sam Shelmire."

She closed the door, dropped into her chair, and leaned back. "Are you a mind reader? I was thinking about you."

"No psychic powers. Just responding to your note. I'm on my cell, headed back to Denton."

They spoke for a few minutes, ironing out details of treatment. Shelmire agreed with her suggestion to remove Lambert's breathing tube. Elena said she'd take care of that on rounds this evening.

"How long do you think it will be before he can go to a regular room?"

Shelmire paused, apparently measuring his words. "Don't quote me on this, but the moment Lambert leaves the ICU, your martinet of a hospital administrator is going to be all over me to get him to another hospital. He's still upset that there's no insurance coverage in this case. Frankly, I don't think a long ambulance ride up the road to Parkland is in Lambert's best interest quite yet. Do you?"

"You're the surgeon," Elena said. "But I think you're right. So, what you're saying is that we need to be very slow in moving Lambert out of the ICU."

"We won't make up anything, but I'll bet you can find a reason he needs skilled nursing care, even after he regains consciousness."

"If he regains consciousness," Elena said. "Just because he moves and groans doesn't mean he's going to wake up again."

After she ended the call, Elena sat for a moment and stared at the ceiling. She would love nothing more than to head home and fall into bed, but she had a full schedule of patients this afternoon. Or rather, Cathy had a full afternoon, and now these patients were Elena's.

She was about to slip out and grab a sandwich when Jane tapped on the door and opened it halfway, her expression apologizing for the interruption. "Frank Perrin's on the phone for you. Do you want to take the call?"

Elena noted that when Jane spoke Frank's name, she looked like she'd bitten into a persimmon. "I'll take the call," Elena said. As Jane was withdrawing, something made Elena add, "And I'll be careful."

Elena lifted the receiver and hesitated with her finger over the blinking button. How should she handle this? Chummy? Distant? Formal? She settled for neutral. "Dr. Gardner."

"Hey, Elena. This is Frank Perrin." Chipper, perky, just a friend calling another friend.

Elena adjusted her tone accordingly. "Good to hear from you, Frank. What's up?"

"I was wondering if you could break free for lunch. I know you're snowed under, what with Cathy out of the office for a while."

How did he know that? Was she the only person in town not on that grapevine? She shrugged. "I . . . I guess so. But I'll have to be back here by one. Will that work for you?"

"Grab your purse and walk out the back door. I'm sitting out here waiting for you."

Elena wasn't sure how to react to that news. How long had he been sitting out there? And how many times before that had he sat outside her office or home?
Get a grip. Now you're being paranoid.
Still, despite the bright summer day, she felt a shiver move up her spine as she climbed into Frank's patrol unit.

The vehicle must have been here in the sun for quite a while. The vinyl seat was searing, so Elena hunched forward.

Frank started the SUV and flicked the air conditioner to high before he lifted the microphone off its hook. "This is Frank. I'm out of service for lunch, but I have my radio on." He replaced the microphone and put the SUV in gear.

"I thought you'd say something like 'Base, this is Unit 3. I'm ten-ten.' What happened to those codes?" Elena asked.

Frank shrugged. "You've watched too many police shows. We did away with those a few years ago. This is more direct. If we want to say something without it going out over the air, we have cell phones."

"You're taking all the mystery out of police work," Elena said. "I've always pictured what you guys do as exciting."

Frank half-turned his head and shrugged. "Do you like burgers?"

The abrupt change of subject caught Elena off guard. It took her a moment to process the question. "Sure."

"Got anything against eating them in a hole-in-the-wall?"

"I've done that before and survived. I'll bet I can do it again."

He flicked his turn signal. "Then prepare for a taste treat."

This time Elena paid close attention to the route Frank took. She was never going to be lost in this town again. The unit rolled to a stop in a gravel parking lot before what could charitably be called a house, although Elena's description leaned toward "shack." The paint had at one time been blue, probably at least three shades of blue, but now the building was a uniform gray. Two windows, one of them covered with plywood, flanked a front porch that leaned at a precarious angle.

Frank followed her up the rickety steps and opened a warped front door with a loud scraping sound. Inside, Elena stepped into a room filled with picnic-style tables and benches. It seemed to her there was hardly room to maneuver around the tables and through the people who stood waiting for a place to sit. Frank's entry parted the standees like the Red Sea before the rod of Moses, and in a moment he and Elena were standing at the counter that ran across the back of the room. A black woman, her gray hair barely contained by a net, stood sweating behind the counter. Behind her, a man of similar age and coloration was flipping patties and assembling hamburgers at a record pace.