Critical Judgment (1996)

by Michael Palmer

  "Do you want to do my job, too? Is that it?"

  Abby refused to allow him to push any of her buttons, although lately he'd become something of a virtuoso at it. She wanted to ask him about the headaches he'd been having. But that might well have pushed one of his buttons, and she simply had no time or desire for a battle.

  "I'll be home by eight-thirty," she said instead. "How about I bring home some Chinese food and rent a movie?"

  "Sure. That'd be great."

  There was no enthusiasm in his voice. The problem had to be his job. For the first few months after he'd started as director of new product development at Colstar, the job had been the best thing that had ever happened to him. Then, suddenly, there were constant deadlines--new products that always seemed to be at a make-or-break stage. He had never been particularly vulnerable to pressure at work. Now he seemed overwhelmed, disorganized.

  Meanwhile Abby's decision to apply for the sudden opening in the ER at Patience Regional Hospital seemed only to have added to Josh's stress. Since her move up to Patience, there had been almost constant tension between them. Perhaps he had never expected her actually to give up the job she loved out of deference to their relationship. Maybe, over the months they'd been apart, he had simply discovered he liked being on his own. Or maybe, she sometimes allowed herself to think, he had met someone else.

  The doors to the ambulance bay glided open, and the rescue squad wheeled in a stretcher. The man on it had his face swathed with blood-soaked gauze. Protruding from beneath the gauze, over the cervical collar, was a full, gnarled gray-black beard, matted with drying blood. Old Man Ives.

  "Look, Josh, I gotta go," she said. "I'll tell you what. Count on me to provide dinner and X-rated entertainment. If you want to watch the movie afterward, we can do that, too."

  "I'll be here."

  Abby started to tell him that she loved him. Instead what came out was, "Great, see you later."

  She set the receiver down and headed out to evaluate her new patient, thinking that she shouldn't have called home. The last thing an ER physician needed at work was to be distracted. The job was hard enough, the traps were everywhere. From now until her shift ended she would have to be especially vigilant.

  The PRH emergency room had a row of five treatment bays separated by curtains, and five individually numbered rooms, reserved for minor surgery and orthopedics, special procedures, major medical, pediatrics, and codes. Abby felt some relief at seeing Bud Perlow direct the rescue squad to wheel Mr. Ives into room one, where most of the routine suturing was done. She just wasn't up for anything major.

  She paused to check on some of the lab results on the two enigmas. To no surprise, they were all normal.

  "Ouch! Hey, easy. You just took half my hair off on that tape!"

  Perlow met Abby beside the door to room one. From behind him she could hear their new patient jawing at the rescue squad.

  "Some hikers found him facedown on a trail. Apparently two men followed him out of town, started yelling at him to stay away from Patience, and then beat him unconscious with their fists."

  "I guess different isn't one of the best things to be around here."

  "Pardon?"

  "Oh, nothing. How does he look?"

  "He's awake and alert, in case you couldn't tell. Deep lacs on both cheeks, through one brow, and across his chin."

  "Alcohol?"

  "I couldn't smell any. But, then, Ives is a few months short of a shower."

  "I understand."

  Abby liked that she heard nothing judgmental in the nurse's voice. It was human for any physician or nurse to be offended by a person's smell, or obesity, or age, or even illness. Everyone had an upbringing and a history to deal with. Everyone had sensibilities. But it was not acceptable to her when medical personnel withheld a full measure of care because of their prejudices.

  She took the chart from Bud Perlow and was reading it as she entered the room. Old Man Ives was Samuel Ives. His address was given simply as North Hills, Patience. His age was fifty-one. She wondered if, in just sixteen years, the people of Patience would be calling her Old Lady Dolan.

  She put on a paper gown and rubber gloves and began her assessment before even reaching the bedside. The man's face had taken a pounding, but it was not as fearsome as she had imagined.

  "Mr. Ives, I'm Dr. Dolan. How're you doing?"

  "They stole my money."

  Abby glanced over at the paramedic, who shook his head.

  "Mr. Ives," he said, with the overemphatic voice that most health-care workers seemed to use toward most patients, "I've got your wallet right here." He slipped a plastic bag under Ives's hand. "There's twenty-one dollars in it. Your book and what's left of your carvings are in the bag beneath your stretcher. They must have taken your groceries. We didn't see them anyplace." He turned to Abby. "The police came up to the trail with us. They think they know who did this, but Ives doesn't want to get involved. Whoever it was stomped on his carvings. There's not much left of them."

  "Are you hurting anyplace except your face, sir?" Abby asked.

  Ives shook his head.

  Abby briefly checked his ribs, heart, and abdomen. There was no tenderness.

  "Any problem with your vision?"

  "Nope."

  "Are you seeing double? Two of anything?"

  "I know what double means. No."

  "Mr. Ives, I think we should get some X rays of your face and neck."

  "No. They're fine. I've had broken bones. I know what they feel like. I don't have any broken bones and I don't want any radiation."

  Radiation. Not the word she would have expected from this man. She peered down at him, trying to look beyond the oil-stained clothes and the gashes and the beard, trying to see through her own prejudices. Samuel Ives's light-blue eyes were bright and piercing. So what's your story? she wondered.

  She checked his eyes and cheekbones to be sure there were no gross signs of a fracture. Then she loosened his cervical collar and felt along his spine. No tenderness there, either.

  "Okay," she said, "no X rays. I'll be back to examine you more thoroughly, then we'll get your face fixed."

  Ives looked directly at her for the first time, as if surprised at the ease with which she had given in.

  "Thanks, Doc," he said.

  "Dr. Dolan," Bud Perlow called out from the doorway. "Could I see you please?"

  "Hang in there, Mr. Ives," she said.

  "Dr. Dolan, a woman just brought in her six-year-old girl with a nosebleed. It's a gusher. I put them in three rather than the pedi room because the table and the light are better."

  "Perfect."

  "What do you want to do about him?"

  Abby glanced at the three other patients she had yet to finish. Samuel Ives's face was going to require several dozen carefully placed sutures. A good hour's work.

  "Call Dr. Bartholomew and ask him to see Mr. Ives," she said. "Is the ENT tray in with the child?"

  "On the counter."

  The girl's nosebleed, like most such episodes, wasn't as bad as it looked. The few that were as bad as they looked were absolute nightmares, as often as not ending up in intensive care, or the operating room, or both. But though the bleeding point in this child was higher than Abby would have liked, it was reachable. She was in the process of cauterizing it with a touch of silver nitrate when a shouting match began in room one.

  "You know, you shouldn't be marching into town looking like you do," Martin Bartholomew was saying. "You scare the kids half to death."

  "You probably scare quite a few of them, yourself," Ives countered.

  "People like you feel society owes them," the surgeon ranted on. "Feed me, clothe me, educate my children, take care of me when I'm sick."

  "I don't have any children to educate."

  "And you don't have any insurance, either. Do you think I'm going to get paid for sewing up these cuts of yours? Twenty years of school and training, my family's home waiting dinner, and I'm here sut
uring this ... this person who hasn't taken a bath in months."

  "Years," Ives said. "Listen, why don't you just stop and go home? That's what I'm going to do."

  "Hey, lie still! Dammit, lie still before I stick myself!"

  "I'm getting out of here."

  Abby apologized to the girl and her mother, set the silver nitrate stick aside, and hurried to the door.

  "Bud, would you please get them to stop this right away? Call security if you have to."

  She turned back to the child.

  "These stitches need to come out in a week," Bartholomew bellowed. "Come to the ER to have it done. I'm finished with you."

  Abby heard him storm out of the room. He had been with Ives for only twenty minutes, yet he was done. She turned as he reached the doorway of room three. His puffed face was crimson, his eyes froglike.

  "I'll be home or on my beeper," he said icily. "Thank you for the referral."

  He stalked off without waiting for a reply. Abby was reasonably sure, however, that he wouldn't be called on the carpet in George Oleander's office for his brusqueness to a colleague.

  She put the finishing touches on a Vaseline pack in the six-year-old's nose, went over the nosebleed instruction sheet with the mother, and discharged them to the waiting room for a precautionary half hour. Then she went into room one. Samuel Ives was off the litter, his back to her. He was gathering his things.

  "Mr. Ives?" she said softly.

  He turned, and instantly Abby felt her temper reach boiling point.

  The sutures, probably 3-0 thickness rather than the much finer 6-0 or even 7-0 used for faces, were carelessly placed and tied in such a way that Ives's skin was bunched. Why hadn't the nurses let her know what was going on?

  She took a deep, calming breath. Not only had Martin Bartholomew done a sophomoric job of suturing, but it appeared that no one had bothered undressing Ives to examine him for signs of less apparent injury.

  Until we know someone, the way they say things is as important as what they have to say.... Practice being a little gentler on the staff....

  The world according to George Oleander. Abby forced herself to focus on the many kind, compassionate, intelligent, and professional things she had seen the nursing staff do over the weeks she had worked with them. It was really Bartholomew's fault. He had set the tone in room one. He had invited the staff to bring in their distaste for people like Samuel Ives. She closed the door behind her.

  "Mr. Ives, could you please lie back down?" she said. "I want to examine you a little bit more, and then I want to suture your face over again."

  For the second time Ives allowed his gaze to meet hers.

  "No X rays," he said.

  She peeked out at the treatment bays. Another patient was being brought in. She closed the door again, got Lew Alvarez's number from her clinic book, and called him. If he was free, could he possibly come in an hour early? She was already behind and was facing a complex suturing job. By their eight o'clock changeover, the place could be bedlam.

  "Fifteen minutes," Alvarez said, no questions asked.

  Abby next called Bud Perlow at the nurses' station. She would be in room one and did not need any help except for him to hold down the fort until Dr. Alvarez arrived. Oh, and one more thing. She would appreciate it if he told absolutely no one what she was doing.

  Samuel Ives closed his eyes as she widened the narrow, shaved track Bartholomew had made in his beard. Then she cut away the sutures, numbed the edges of the lacerations once again, set a pair of magnifying glasses low on the bridge of her nose, and began a meticulous closure.

  The repair took forty-five minutes. During that time not a word was exchanged between them. When the last knot had been tied and cut, Abby stepped back from the table, working the stiffness from her neck. She called it being "zoned." For forty-five minutes her brain had been free of all extraneous thoughts. She had probably not moved any muscle except in her hands and forearms through the entire procedure. Zoned. It was a joy to have been there.

  She unbuttoned Ives's work shirt, which was heavy with drying blood. A more careful exam showed his chest and belly were free of discernible injury.

  "Did they give you a tetanus shot?" she asked.

  "They did."

  "These stitches can come out in five days. Just come in and find me. No need to check in at the desk. I'm going to have the nurse give you a shot of antibiotic and five days' worth of pills. I'm also going to see if we can find you a shirt to wear home."

  "I've been having a little trouble with my leg," Ives said. "Pick out some pills that will help that, too."

  Abby gloved once again, and with Ives's help, lowered his fetid, bloodied jeans. The infection, covering five or six inches of his right shin, was long-standing and deep--undoubtedly deep enough to include the bone. Almost certainly chronic osteomyelitis, one of the most difficult, recalcitrant of all infections. She grimaced, not so much from the sight of the thick, raw inflammatory tissue, as from her knowledge of how difficult it was going to be to treat. Then she realized that he was watching her.

  "How'd you do this?" she managed.

  "A fall. I hit a rock."

  "When?"

  "Two, three years ago."

  "And you can get around okay?"

  "It hurts some."

  She sighed.

  "Mr. Ives--"

  "Just Ives. That's what people I like call me. Ives."

  "Ives, this is a pretty deep and serious infection. I don't know for sure if it's gotten into the bone, and I have no idea what germ is causing it. But if we don't treat it properly, sooner or later you're going to get very sick from it. You could even lose your leg."

  "It really doesn't bother me that much. How about just giving me some medicine now and--"

  "It's not that simple!" she snapped. She took another calming breath. Fatigue from the long, difficult day was catching up with her. She knew, especially after the debade with Bartholomew, there wasn't a chance in the world that Ives would ever willingly be an inpatient. "Ives, listen. Let me at least take a small biopsy to send off for culture and some slides. Then I'll give you some intravenous antibiotics. Tomorrow I'll talk to the infectious-disease person and one of the bone specialists. Okay?"

  "I don't--"

  "Ives, please."

  "Okay, okay."

  "Thank you."

  She opened the door and, for the first time in an hour, reconnected with the rest of the ER. Lew Alvarez was writing prescriptions for the last of the patients. She stood some distance away and watched him converse with the woman in fluent, animated Spanish. His English, she had noticed, was accent free. She wondered which was his native language. He was forty or so, and handsomer than any man needed to be. His eyes were dark and lively, and his thick brows and mustache were offset by rich copper skin. Of all the physicians in the ER, he was the one she found the most interesting.

  George Oleander's description of him as excessively opinionated and not a team player did not easily fit the man she was watching--the man who had responded to her call for assistance without a single quibble.

  He noticed her just as he was sending his patient away.

  "Ta da!" he sang, motioning to the now-empty ER.

  He moved toward her with a natural, easy grace. Regardless of what he had said about her to George Oleander, she could not imagine this man being intimidated by anyone.

  "Thanks for coming in," she said.

  "No problem. I understand you've had a day of it. Diagnosing Cushing's syndrome in the middle of a code. Hail to the chief."

  "It hasn't been confirmed."

  "It will be. And now, in comes Sam Ives."

  "It's just Ives, he says. He doesn't like being called anything else."

  "He was a college professor at one time. Or at least so I've been told."

  Abby was instantly intrigued.

  "Where? What'd he teach?"

  Alvarez shrugged.

  "No idea. A year or so ago he was looking
for odd jobs, so I gave him some work on my farm. We never talked much. I don't think he gets many offers. People around here are scared of him."

  "Has he ever hurt anyone?"

  "Hardly. Just being out of the ordinary is all it takes around here, and he is certainly that."

  "One of the nurses said he lives in a cave."

  Alvarez laughed.

  "His shack isn't much. No electricity, no plumbing. But it's not a cave."

  "He's got chronic osteomyelitis on his anterior leg. He needs a surgical debridement and intensive antibiotic therapy. Maybe even a graft. Right now all he'll allow me to do is a biopsy and some IV antibiotics. Want to help?"

  "Sure, if there's a chance something will rub off on me and I can diagnose Cushing's during a code."

  Abby started to react to his sarcasm. But there was only warmth in his expression. He was teasing her, true, but not maliciously; he really was impressed. They got the biopsy kit and culture tubes ready, and set up an IV of powerful antibiotics. Then they brought them into room one.

  Ives was gone. They checked the nearest bathrooms, but Abby knew he had skipped. She had come on too strong and frightened him away. Muttering curses at herself, she returned to the room.

  Beneath the litter was the plastic possessions bag. Abby dumped the contents out on the mattress. All it contained were sanded wood fragments--heads, torsos, and limbs of what might have been beautiful, delicately carved figures--and a well-worn copy of Conrad's Lord Jim.

  CHAPTER FOUR

  On the way home from Peking Pagoda, Abby ate an egg roll and half a carton of ribs. There was a time when she had smoked in response to stress--up to a pack a day of unfiltered Pall Malls. Soon after she'd given up cigarettes, she had found that, more and more, she was dealing with the people and events that upset her by drinking--only wine, and always top-shelf stuff. Eventually, she had felt obligated to limit her drinking to days when she wasn't worried about something or angry with someone, a move that effectively kept her on the wagon most of the time. With little time or inclination for regular exercise or meditation, food became and remained her pacifier. And the ten pounds between her clothes fitting well and feeling tight became a battlefield.