by Robin Cook
Carol stuck the needle into the IV and depressed the plunger. Even before she’d injected the last few cc’s, the result was dramatic. Cassi stopped convulsing and seemed to regain consciousness. Her lips opened and sounded as if she were trying to say something.
But the improvement didn’t last. Cassi sank back again into unconsciousness, and, although she did not convulse again, the isolated muscles continued to contract.
When the code team arrived, Carol reported what she had done. The senior resident examined Cassi and began issuing orders.
“I want you to draw blood for electrolytes, including calcium, arterial blood gases, and a blood sugar,” he said to the junior resident. “And I want you to run an EKG,” he said to the medical student. “And Miss Aronson, how about another ampule of fifty-percent glucose?”
While the team fell to work, Lenore picked up the bedside table, replacing the phone. With her foot she pushed the shards of glass from the broken pitcher into the corner. The drawer had come out of the table and Lenore replaced it. It was then she found several used vials of insulin. Shocked, she handed them to Carol, who in turn handed them to the resident.
“My God,” he said. “Was she supposed to give herself insulin blindfolded?”
“Of course not,” said Carol. “She had insulin in her IV and was being supplemented according to the amount of sugar in her urine.”
“So why did she give herself insulin?” asked the resident.
“I don’t know,” admitted Carol. “Maybe she was confused with all her sedatives and gave herself the medicine by rote. Hell, I don’t know.”
“Could she do that blindfolded?”
“Sure she could. Remember, she’s been injecting herself twice a day for twenty years. She couldn’t get the dose right, but she could certainly inject herself. Besides, there’s another possibility.”
“What’s that.”
“Maybe she did it on purpose. The day nurse said she was depressed, and her husband said she’d been acting strangely, I guess you know who her husband is.”
The resident nodded. He didn’t like to think of the case being a suicide gesture because he hated psych cases, especially at three o’clock in the morning.
Carol, who had been filling another syringe with glucose while talking, handed it over. The resident injected it immediately. As before, Cassi improved for a few minutes, then again lost consciousness.
“Who’s her doctor?” asked the resident, taking a third syringe of glucose from Carol.
“Dr. Obermeyer, Ophthalmology.”
“Somebody give him a call,” said the resident. “This isn’t a case for a house officer to fool around on.”
The phone rang and rang before Thomas groggily reached out and picked up the receiver. He had taken two Percodan before stretching out in his office, and he found it very hard to concentrate.
“You’re a hard one to wake up,” said the cheerful hospital operator. “You had a call from Dr. Obermeyer. He wanted to be put through immediately, but I told him you’d left specific orders. Do you want the number?”
“Yes!” said Thomas, fumbling on the desk for a pencil.
The operator gave Thomas the number. He started to dial and then stopped. Noticing the time, he was concerned. Obviously it was about Cassi. Going into the bathroom he splashed water on his face, trying to gather his wits.
He waited until some of the drug-induced fog receded before dialing.
“Thomas, we had a complication tonight,” said Dr. Obermeyer.
“A complication?” asked Thomas anxiously.
“Yes,” said Dr. Obermeyer. “Something we didn’t expect. Cassi gave herself an overdose of insulin.”
“Is she all right?” asked Thomas.
“Yes, she seems to be fine.”
Thomas was stunned.
“I know this must be a shock for you,” Dr. Obermeyer was saying, “But she is okay. Dr. McInery, her internist, is here and thanks to the quick thinking of the charge nurse, he says Cassi will be fine. We’ve moved her to the ICU for the time being just as a precaution.”
“Thank God,” said Thomas, his mind whirling. “I’ll be right over.”
As soon as he reached the hospital, Thomas rushed to Cassi’s bedside. She seemed to be resting peacefully. He noticed that the patch on her right eye was gone.
“She’s sleeping but she’s arousable,” said a voice at his side.
Thomas turned to face Dr. Obermeyer. “Do you want to talk with her?” he asked, reaching to shake Cassi’s shoulder.
Thomas caught his arm. “No thanks. Let her sleep.”
“I knew she was upset tonight,” said Dr. Obermeyer contritely. “I ordered extra sedatives. I never expected anything like this.”
“She was panicky when I saw her,” said Thomas. “A friend of hers died last night, and she’s been very upset. I hadn’t planned to tell her, but I learned one of the psych residents had the poor judgment to do so.”
“Do you think this was a suicide attempt?” asked Dr. Obermeyer.
“I don’t know,” said Thomas. “She could have just been confused. She is accustomed to giving herself insulin twice a day.”
“What do you think about a psychiatry consult?” asked Dr. Obermeyer.
“You’re the doctor. I can’t be very objective. But if I were you, I’d wait. Obviously she’s safe in here.”
“I took the patch off her right eye,” said Dr. Obermeyer. “I’m afraid the bandages may have been a large factor in her anxiety reaction. I’m happy to say her left eye is still clear. Considering the fact she just had a grand mal seizure, which is probably the severest test imaginable for my coagulation of that vessel, I don’t think we have to worry much about further bleeding.”
“What’s her blood sugar?” asked Thomas.
“Pretty normal right now, but they’re going to follow it closely. They think she gave herself a whopping dose of insulin.”
“Well, she’s been careless at times in the past,” said Thomas. “She’s always tried to minimize her illness. But this seems like more than carelessness. Still, it’s possible she just didn’t realize what she was doing.” Thomas thanked Obermeyer for his good work and walked slowly out of the ICU.
The nurses at the desk looked up as he went by. They had never seen Dr. Kingsley so depressed and anxious.
Twelve
Cassi became conscious of her surroundings around five o’clock in the morning. She could see the large wall clock over the nurses’ station and thought she was in the recovery room. She had an awful headache, which she attributed to the eye surgery. Indeed, when she tried to look from side to side she got a sharp pain in her left eye. Gingerly she felt the bandage over the operative site.
“Well, Dr. Cassidy!” said a voice on her left. She slowly turned her head and looked into the smiling face of one of the nurses. “Welcome back to the land of the living. You gave us quite a scare.”
Bewildered, Cassi returned the smile. She stared at the nurse’s name tag. Miss Stevens, Medical ICU. That confused Cassi further.
“How do you feel?” asked Miss Stevens.
“Hungry,” said Cassi.
“Could be your blood sugar is a bit low again. It’s been bouncing up and down like a rubber ball.”
Cassi moved slightly and felt an uncomfortable burning sensation between her legs. She realized she’d been catheterized.
“Was there a problem with my diabetes during surgery?”
“Not during surgery,” said Miss Stevens with a smile.
“The night after. As I understand it, you gave yourself a little extra insulin.”
“I did?” said Cassi. “What day is it?”
“Five A.M., Friday morning.”
Cassi felt very confused. Somehow she’d lost an entire day.
“Where am I?” she asked. “Isn’t this the recovery room?”
“No, this is the ICU. You’re here because of your insulin reaction. Don’t you remember yesterday at all?”
“I don’t think so,” said Cassi vaguely. Somewhere in the back of her mind she began to remember a sensation of terror.
“You had your operation yesterday morning and were sent back to your room. Apparently you’d been doing fine. You don’t remember any of that?”
“No,” said Cassi without conviction. Images were beginning to emerge from the haze. She could recall the horrid sensation of being enclosed within her own world, feeling acutely vulnerable. Vulnerable and terrified. But terrified of what?
“Listen,” said Miss Stevens. “I’ll get you some milk. Then you try to go back to sleep.”
The next time Cassi looked at the clock it was after seven. Thomas was standing by the side of her bed, his blue eyes puffy and red.
“She woke up about two hours ago,” said Miss Stevens, standing on the other side. “Her blood sugar is slightly low but seems stable.”
“I’m so glad you’re better,” said Thomas, noticing Cassi had awakened. “I’d visited you in the middle of the night, but you were not completely lucid. How do you feel?”
“Pretty good,” said Cassi. Thomas’s cologne was having a peculiar effect on her. It was as if the smell of Yves St. Laurent had been part of her devastating nightmare. Cassi knew that whenever she’d been unlucky enough to have an insulin reaction, she’d always had wild dreams. But this time she had the sensation that the nightmare wasn’t over.
Cassi’s heart beat faster, accentuating her pounding headache. She could not tell the difference between dream or reality. She was relieved a few minutes later when Thomas left, saying, “I’ve got surgery. I’ll be back as soon as I’m done.”
By noon, Cassi had been visited by Dr. Obermeyer and her internist, and released from the unit. She was taken back to her private room at the end of the corridor, but she raised such a fuss about being alone that they finally moved her to a multibed unit across from the nurse’s station. She had three roommates. Two had had multiple broken bones and were in traction; the other, a mountain of a woman, had had gallbladder surgery and was not doing too well.
Cassi had had one other insistent request. She wanted her IV out. Dr. McInery tried to reason with her, arguing that she’d just had a severe insulin reaction. He told her that had she not had the IV originally and gotten the sugar when she had, she might have slipped into irreversible coma. Cassi had listened politely but remained adamant. The IV was removed.
In the middle of the afternoon Cassi felt significantly better. Her headache had settled down to a tolerable level. She was listening to her roommates describe their ordeals when Joan Widiker walked in. “I just heard what happened,” she said with concern. “How are you?”
“I’m fine,” said Cassi, happy to see Joan.
“Thank God! Cassi, I heard that you’d given yourself an insulin overdose.”
“If I did, I can’t remember it,” said Cassi.
“You’re sure?” asked Joan. “I know you were very upset about Robert…” Her voice trailed off.
“What about Robert?” asked Cassi anxiously. Before Joan could respond, something clicked in Cassi’s mind. It was as if some missing block fell into place. Cassi remembered that Robert had died the night after his surgery.
“You don’t remember?” asked Joan.
Cassi let her body go limp, sliding down into her bed. “I remember now. Robert died.” Cassi looked up into Joan’s face, pleading that it wasn’t true, that it was part of the insulin-induced nightmare.
“Robert died,” agreed Joan solemnly. “Cassi, have you been dealing with your sorrow by trying to deny the fact?”
“I don’t think so,” said Cassi, “but I don’t know.” It seemed doubly cruel to have to learn such news twice. Could she have suppressed it or did the insulin reaction just remove it from her disturbed memory?
“Tell me,” said Joan, pulling over a chair so she could talk privately. The other three women pretended not to be listening. “If you didn’t give yourself the extra insulin, how did it get in your bloodstream?”
Cassi shook her head. “I’m not suicidal, if that’s what you’re implying.”
“It’s important you tell me the truth,” said Joan.
“I am,” snapped Cassi. “I don’t think I gave myself the extra insulin even in my sleep. I think it was given to me.”
“By accident? An accidental overdose?”
“No. I think it was deliberate.”
Joan regarded her friend with clinical detachment. Thinking that someone in the hospital was trying to do you harm was a delusion that Joan had heard before. But she had not expected it from Cassi. “Are you sure?” Joan asked finally.
Cassi shook her head. “After what I’ve been through it’s hard to be sure about anything.”
“Who do you think could have done it?” asked Joan.
Cupping her hand over her mouth, Cassi whispered. “I think it might have been Thomas.”
Joan was shocked. She was not a fan of Thomas’s, but this statement smacked of pure paranoia. She wasn’t sure how to react. It was becoming obvious that Cassi needed professional help, not just advice from a friend. “What makes you think it was Thomas?” Joan finally asked.
“I awoke in the middle of the night and smelled his cologne.”
If Joan had had the slightest concern that Cassi was schizophrenic, she would not have challenged her. But she knew Cassi was an essentially normal person who’d been placed under extreme stress. Joan felt it was advisable not to let Cassi build on her delusional thought patterns. “I think, Cassi, that smelling Thomas’s cologne in the middle of the night is awfully weak evidence.”
Cassi tried to interrupt, but Joan told her to let her finish.
“I think that under the circumstances, you are confusing a dream state with reality.”
“Joan, I’ve already considered that.”
“Furthermore,” said Joan, ignoring Cassi, “insulin reactions include nighmares. I’m sure you know that better than I. I think you experienced an acute delusional psychosis. After all, you’ve been under enormous stress, what with your own surgery and Robert’s unfortunate death. I think in that state it’s entirely possible you gave yourself the injection and then afterward suffered all sorts of nightmares you now think may be real.”
Cassi listened hopefully. She’d had trouble sorting out the real from insulin-induced dreams in the past.
“But it is still very difficult for me to believe that I could have given myself an overdose of insulin,” she said.
“It might not have been an overdose. You could have just given yourself your usual dose. You may have thought it was time for your evening shot.”
It was an attractive explanation. Certainly an easier one to accept than that Thomas wanted her to die.
“My real concern,” Joan went on, “is whether you are depressed now.”
“I guess a little, mostly about Robert. I suppose I should be happy about the results of the surgery, but under the circumstances, it’s difficult. But I can assure you, I don’t feel self-destructive. Anyway, they’ve taken away all my insulin.”
“It’s just as well,” said Joan, standing up. She was convinced Cassi was not suicidal. “Unfortunately I’ve got two legitimate consultations to do. I’ve got to get a move on. You take care and call if you need me, promise?”
“I promise,” said Cassi. She smiled at Joan. She was a good friend and a good doctor. She trusted her opinion.
“Was that lady a psychiatrist?” asked one of Cassi’s roommates after Joan left.
“Yes,” said Cassi. “She’s a resident like I am, but further along in her training. She’ll be finishing this spring.”
“Does she think you’re crazy?” the woman asked.
Cassi thought about the question. It wasn’t as stupid as it sounded. In a way Joan did think she was temporarily crazy. “She thought I was very upset,” said Cassi. Euphemisms seemed easier. “She thought that I might have tried to hurt myself in my sleep. If I start doing anyth
ing weird, you’ll call the nurses, won’t you?”
“Don’t worry. I’ll scream my bloody head off.”
Cassi’s other roommates, who had been listening, enthusiastically concurred.
Cassi hoped she hadn’t scared the three women, but in a way it made her feel more comfortable that they would be watching her. If it were true that she had given herself an overdose without knowing it, she could use a little nervous concern.
She closed her eyes and wondered when Robert’s funeral was. She hoped she’d be released in time to go. Then she thought of the SSD project and wondered what would happen to it. Remembering the printouts she’d taken from his room, she decided to see if someone could locate them for her.
She rang for the nurse, who promised to check Cassi’s former room. A half-hour later, the nurse returned and said that the two LPNs who had helped move Cassi had not seen the computer printout. The nurse added that she’d checked all the drawers herself without success.
Maybe the SSD data had been a hallucination, too, thought Cassi. She seemed to recall going into Robert’s room, picking up the material, and then bumping into Thomas. But perhaps it was all a dream. Cassi wondered how she could check. The easiest way would be to ask Thomas, but she wasn’t sure she wanted to do that.
Glancing around the room, Cassi was glad to see her three roommates getting ready for dinner. Just having them there made her feel safe.
Thomas stopped short of the bridge over the marsh inlet. He switched off the engine and checked for any traffic before opening the door. Getting out of the car, he walked out onto the arched wooden bridge, his shoes making a hollow noise on the old planks. The tide was on its way out and the current rushed beneath the small bridge, swirling in frenetic eddies about the support pilings.