Critical Judgment (1996)

by Michael Palmer

  The cardiologist would insert a guiding needle into the vein located beneath Hazel's collarbone and then thread a wire through it until the tip made contact with the inner lining of her right ventricle chamber. The other end of the wire would be connected to a temporary pacemaker box, which would kick in any time the inborn pacemaker rate dropped below seventy per minute. Once she was stable, a permanent pacemaker could be implanted beneath her skin. But until the temporary wire was in, she was in the gravest danger.

  Hazel blinked twice, still clearly unaware of the commotion beginning to swirl around her.

  "Well, Doctor," she said, "are you or are you not going to fix my arm?"

  "Not just yet," Abby said. "Mrs. Cookman, you and I need to talk."

  Bud Perlow finished inserting an IV. Then he wheeled over the external pacemaker. Strictly an emergency apparatus, the pacer had paddles that were placed beneath the spine and beside the breastbone. The electrical pulse would shoot through the patient's chest, contracting all the muscles in her body, including her heart. Not at all pleasant, but lifesaving. Abby noted that, unlike almost all the equipment in the hospital, the rarely, if ever, used machine was quite an outdated model.

  Her gaze never leaving the overhead cardiac monitor, she did her best to explain the situation to Hazel.

  The octogenarian listened with surprising interest and patience. She even asked about what the permanent pacemaker would feel like beneath her skin.

  Abby had just started her explanation when the large, regular waves indicating heartbeats vanished. Heart block again. Hazel's eyelids drifted down.

  "Give the atropine!" Abby ordered, again kicking the footstool into place. "Lew, do you know how to use that external pacer?"

  "Not really."

  "I do," Bud said as he injected the cardiac stimulant. "We had an in-service on it a year or so ago."

  "Start it up. Clear, everyone!" Abby called out. "The external pacemaker is being turned on."

  Abby positioned the heel of her hand just above Hazel's sternum, ready to set it down and pump, just in case the pacemaker failed to produce an effective heartbeat.

  "I can't get this machine working, Dr. Dolan," Bud said. "I think it's shorted."

  Her mind racing, Abby set her hands down to begin pumping. Then, as it had before, Hazel's heartbeat reverted to normal. And as before, in seconds, the woman was wide-awake and completely unaware she had passed out.

  "Have we reached the cardiologist?"

  "It's Dr. Price," the head nurse said. "He's not in-house. We've paged him, but no answer yet."

  "Doctor, I'm still waiting for you to fix my arm," Hazel said.

  "Soon," Abby replied. "You had another one of those spells."

  "I didn't feel anything."

  "I know."

  Abby told the nurse to keep a steady eye on the monitor and have more atropine and another drug, Isuprel, ready. Then she motioned Lew to one corner of the room.

  "I don't think we should be relying solely on the atropine or Isuprel."

  "Agreed."

  "How many pacemakers have you inserted?"

  "One, a few years ago. You?"

  "Same. I've always had cardiologists around. Well, that's two between us, and I don't feel like standing around waiting for disaster to strike."

  Lew glanced up at the monitor.

  "I like your style, Doctor," he said. "Let's do it. But let's not let anyone know we're both scared stiff."

  With Hazel Cookman grousing at them almost continuously, Abby and Lew completed the temporary-pacemaker insertion without a hitch. Abby numbed up the area beneath Hazel's collarbone and disinfected it. Then, guided by landmarks she could only feel, she smoothly inserted the large-bore needle through the skin beside the bone, and into the subclavian vein. Lew handled the electrocardiograph machine, calling out directions and encouragement as Abby slid the fine wire through the needle, along the subclavian vein and the superior vena cava into the heart, then across the right atrium and tricuspid valve, and finally into place, wedged in the right ventricle.

  "Hold it," he said. "You're there. You're there."

  He hooked the wire to the small pacer box. The capture of Hazel's heartbeat was instant.

  Abby angled her body to shield her hands until they stopped shaking. If Lew hadn't been there, she doubted she would even have attempted the insertion, much less completed it.

  "Fine job," he said as she sutured the wire to Hazel's skin to keep it from dislodging. "The capture threshold is excellent. You can put one of these in me anytime."

  "Dr. Price just called," the head nurse announced. "He was seeing a consultation at the state hospital in Caledonia. He'll be here in half an hour."

  "Okay, Mrs. Cookman," Abby said, "I'm ready to fix your arm now. After that Dr. Price, the heart doctor, will admit you to the hospital. Even though the pacemaker Dr. Alvarez and I just put in is working fine, I'm sure he'll want you in the coronary-care unit until he can put in one of those permanent pacers I told you about. Do you understand all that?"

  "Oh, yes. I certainly do, dear. You've done a wonderful job explaining everything to me. And I really would be happy to come into your coronary unit."

  "Great."

  "But, unfortunately, I can't."

  "But--"

  "At least not until I turn off that chicken I left simmering. It would be a terrible waste of chicken and an even worse waste of my house when it burns down."

  Abby glanced at Lew but managed not to react to his amusement.

  "Aren't there relatives who could do it?" she asked.

  "None."

  "How about a neighbor or the police?"

  "I don't think Holly and Alex would like that very much at all."

  "Well, couldn't one of them do it?"

  The woman patted Abby's hand.

  "My dear, Holly is a one-hundred-pound German shepherd. I don't know exactly what Alex is, but he's bigger and meaner than Holly. Since my husband died, I've always had big dogs. These two are wonderful friends, and I certainly don't have to worry about locking up at night. But unless I'm there, no one could get inside the house without being attacked or having to harm my babies. I would never allow either thing to happen."

  "I see.... Mrs. Cookman, I'll be right back."

  "Just don't be long, young lady. I really do have to get home."

  Once again Abby motioned Lew to the far corner of the room.

  "This is crazy," she said. "Can she do this?"

  "Sign out against medical advice to turn off her chicken? I believe so."

  "But--"

  "Listen, her pacemaker's working fine, and her heart's totally protected," he said. "She lives just a mile or so from here. I think you should have her sign out AMA, then just load up on a few cardiac meds, call the ambulance, and go home with her."

  "Actually, since I'm on and you're done, I was thinking--"

  "No, no. Please. I'll do my part by staying here. She's your patient. I'll call my vet, Hank Tarver. He tends to my animals. He'll meet you at Hazel's house and take the dogs to his kennel."

  "I can't believe I'm going home with an eighty-four-year-old in complete heart block to turn off the gas under a chicken."

  "Welcome to Boondocks General, Professor. Wait until you start getting paid in chickens."

  Abby returned via ambulance from Hazel Cookman's bungalow prepared to tell someone--anyone--that her mission to turn off Hazel's chicken had gone like cluckwork. Actually, she couldn't remember ever feeling more energized about being a doctor.

  Hazel, her stove turned off and her dogs on their way to the kennel, took Abby's hand as they were hooking her back up to the monitor.

  "Thank you," she said. "Thank you for being so kind."

  "Nonsense," Abby replied. "You've fought the good fight for eighty-four years. You deserve the best any of us can give you."

  Abby wrote admission orders that would hold until the cardiologist took over in the critical-care unit. Then she sought out Lew. He wa
s in the office, finishing up a dinner that dietary had sent up. Even after a tough fourteen hours in the ER, he looked fresh.

  "You're all caught up," he said. "And I am ready to pour a glass of Chianti, turn my stereo on, put my feet up, and fall asleep to Villa-Lobos. I've decided paying my bills can wait for another day. I don't know if you've looked at the schedule or not, but tomorrow morning I'm your relief."

  "I hadn't looked," she said. "Come on. I'll walk you out."

  As they passed by the waiting room, a woman was just registering at the intake desk. Abby recognized her as one of the diagnostic problems she had seen--the redhead who, someone had told Abby, had once danced with the Rockettes. The woman caught Abby's eye, waved sheepishly, embarrassed at being back, and immediately began scratching her arm.

  Abby motioned that she would see her shortly, then walked with Lew across the ambulance bay and into the parking lot. The night was the sort never seen in the city--a glimmering full moon low in the northeast, a velvet star-laden sky to the west. The Milky Way was easily visible.

  "Just beautiful," Lew said.

  A car stopped at the patient drop-off space, and a man pulled himself up on crutches and hobbled in through the front ER entrance. Abby waited until the car had driven off and it was quiet once again.

  "Lew, I really appreciate your helping things go so smoothly tonight," she said.

  "No problem. I really enjoyed our pacemaker adventure. Besides, I actually feel as if I owe you more than just a little help in the ER. I owe you an apology. When you first got here, I found you a bit intimidating and standoffish. You're neither, and I'm sorry for thinking so."

  "You know, that's really funny, because I found you standoffish and intimidating, too."

  "I heard from the nurses that you've been going up to Sam Ives's hut to tend to his leg. That's a very kind thing to do."

  "He's got a deep fungal infection, maybe osteomyelitis. The cultures grew out aspergillus. I've been going up there because there's not much chance he'd come back here."

  "Not after the way he was treated the other night by Martin Bartholomew, there isn't."

  "Bartholomew's got big problems. But in general I've been really impressed with most of the staff. The town is growing on me, too. When I first moved here, I had serious doubts. I only left my job at St. John's and came to Patience to be with my ..."

  Her voice trailed off. My what? "Fiance" seemed a more remote possibility than ever.

  "Yes, I know. The man in charge of new-product design at Colstar."

  "My, this is a small town."

  She found herself a bit peeved that personal information about her would be making the rounds. But the truth was, even in the big city everyone was curious about everyone else--especially new docs.

  "So how about you?" she asked. "Do you like it here?"

  "I do. Most things, anyhow."

  "Most things? What do you have problems with?"

  She could tell immediately that he was having difficulty answering the question. He turned and looked away toward the east. When he spoke, it was in a harsh whisper.

  "I have problems with them," he said with unexpected force.

  Abby followed his line of sight. There, silhouetted against the full moon, was the Colstar cliff. Perched atop it, illuminated by dozens of floodlights, looking somewhat like a penitentiary, was the company. The letters of its name, filling much of the west-facing wall, were done in red neon.

  "But why?" she asked.

  At that moment another car drove up to the entrance. An older woman hauled out a wheelchair from the trunk and spread it open. Lew and Abby helped her move her husband from the passenger seat.

  "It's his chest pain," the woman explained. "It's all right now, but Dr. Robbins is on the way in to check him over."

  She hurried through the sliding doors and into the ER.

  "I'd better get in there just to keep an eye on things," Abby said to Lew. "If it's not too late when I finally get caught up, could I call you to finish our conversation?"

  "No calls about this," he said, too quickly. He realized she was taken aback and added, "Tell you what. I'll come in an hour early if you'd like, and we can talk."

  "If you don't mind getting up that early,"

  "I work a farm, Abby. I'm always up that early. Meet me right out here at seven. If you're busy, I'll wait. And, please, don't say a word to anyone about all this until we've talked."

  "O-okay," she said, bewildered by the precautions and by his tone.

  "Abby, I'm sorry if I seem paranoid," he said in his near whisper. "But I have every right to be."

  The woman's name was Claire Buchanan. She had been born and raised in the Midwest and had gone to New York City at eighteen to make it in show business. Her hair was colored flame-red.

  "I was a damn good dancer," she said, talking almost nonstop as Abby carefully examined her skin, eyes, and ears. "At least for Sioux City I was. But New York is a different story. Thankfully, though, I got lucky. I met Dennis Buchanan, and he took me the hell out of there. A few years later we were living outside of LA and Dennis was selling carpeting. He has a gift. Like they say, he could sell refrigerators to Eskimos. Anyhow, one day we were just driving around up here and we found this town on a map. Dennis liked the name. We decided to spend the night, and we weren't here fifteen minutes when he saw the For Sale sign on the John Deere tractor place. 'Claire,' he told me, 'this is it. This is as far as we need to go.' That was almost ten years ago. Now I'm beginning to wonder if maybe I've developed an allergy to the damn place or something. Or maybe I'm allergic to Dennis. I'll tell you this, I can't stand this itching anymore."

  "Mrs. Buchanan--"

  "It's okay to call me Claire. Everyone does."

  "Claire, tell me. Did your itching get at all better with the cortisone pills I gave you?"

  "Maybe for a little while. The Benadryl might have helped a little, too. Then it just got bad again. Especially at night. I went to see Dr. Oleander, but he said he couldn't find much. He was very complimentary about you, though. He said that you had done a very thorough workup on me."

  "Except I can't figure out what's wrong."

  "He thinks it's nerves."

  "Are you the nervous type?"

  "I don't think so, except that I'm very claustrophobic. My mother and sister are, too. Dr. Oleander did one of those MRI tests on me for some stomach trouble I was having. If he hadn't given me a tranquilizer and a blindfold, I would have never made it into that tube."

  "What stomach trouble? When?"

  "I don't know. Six, eight months ago. The tests were all negative and my indigestion went away. But, Dr. Dolan, I can't sit around waiting for this itching to go away. You've got to do something to help me before I just throw myself into one of Dennis's combines."

  "I don't know what's going on with you, Claire, but I don't think it's in your head. I can sort of feel a fullness in places beneath your skin, a thickening, but I just can't see anything. And I can't tell if the thickness is from your scratching so much. I think the next step is a dermatology consult and maybe a biopsy."

  "Whatever you say."

  "Actually, it's whatever Dr. Oleander says. He's your primary-care physician, and we try to defer making any referrals to him. But I'm sure he'll be happy to send you to the dermatologist."

  "I don't think so," Claire said. "The last time you saw me here, you suggested I see a dermatologist. But Dr. O said this itching was either nerves or hives, and that all I would be doing was traveling thirty miles each way to have a so-called specialist tell me the same thing."

  "Well, now that you're no better after a course of oral cortisone, I think Dr. Oleander might be ready to change his mind," Abby said, certain that would be the case.

  For an area its size Patience had excellent specialty coverage. Cardiology, pulmonology, neurology, even rheumatology, as well as most of the surgical specialties like urology, ENT, and orthopedics. But no dermatologist. Actually, Abby did not disagree with
Oleander. Treating many of the common skin problems was a matter of applying common sense. The old and useful maxim regarding the specialty was: If it's dry, wet it, if it's wet, dry it, and when in doubt, use steroids. But from what Abby could tell, Claire Buchanan's skin problem went beyond the bounds of common.

  "I'll tell you what," she said. "It's only a quarter of ten, and Dr. Oleander is my medical backup for tonight anyway. Would you feel better if I gave him a call?"

  "Oh, I would. Thank you, Doctor. Thank you very much."

  Abby never liked encountering patients who were overawed by their physicians, although she did acknowledge that some patients seemed to be genetically bred to be so. It seemed to her to be the doctor's responsibility to break down such barriers to communication. From all she could tell, George Oleander was a damn fine primary-care doctor. As chief of medicine, he unquestionably ran a tight ship. But he did have an air of confidence that might inhibit some patients from questioning his decisions or from asking for a second opinion.

  She sent off another series of routine blood studies on Claire, just in case, and went back to the doctors' office. Oleander answered before the second ring.

  "George, hi, it's Abby Dolan. Sorry to call you at this hour, especially since this isn't about an emergency."

  "No problem, Abby. I was just reading and wondering why the hospital seemed so quiet."

  "Actually, it hasn't been. But our one admission was a unit case, and Brian Price is in with her."

  At Oleander's request she reviewed her odyssey with Hazel Cookman.

  When she finished, the medical chief laughed roundly.

  "I know those dogs of hers," he said. "And they are tough. But I think I'd prefer a run-in with them to one with Hazel. It sounds like you did a great job, Abby. And you can bet that within a day or two everyone in Patience will have heard about it--or at least some version of it. It's exactly what this community needs."

  "Thank you."

  Community. Abby tried to remember how many times Lyle Quinn had invoked the word.

  "I'm glad to hear this story, too," Oleander continued, "because I'd been meaning to speak with you."