Critical Judgment (1996)

by Michael Palmer

  Around the room three nurses and the pediatrician waited expectantly for her orders. Abby knew that at that moment none of them appreciated the situation the way she did. Peggy Wheaton, though breathing and maintaining a blood pressure, was quite possibly brain-dead.

  Dreading what she was going to feel, she cut the gauze bandage away and, from both sides, carefully slid her fingers behind the woman's skull. The damage was massive--a broad, deeply depressed fracture beneath a large laceration. Abby withdrew her gloved hands slowly and glanced down at her bloodied fingertips. On several of them were strands of what she was certain was brain tissue. Breathing or not, blood pressure or not, it was already over. No medical miracle would save Peggy Wheaton.

  "Get MedFlight up here," she said. "Give her Decadron, ten IV. Get set to intubate her. She needs a neurosurgeon."

  Or, more likely, a priest.

  "Please, let me in. Excuse me." A graying, extremely handsome man in his forties rushed to the bedside. His tanned face was pale. "I'm Gary Wheaton," he said.

  "Abby Dolan."

  Abby stripped off her rubber gloves and pulled the sheet up to Peggy Wheaton's shoulders.

  "Dr. Dolan, I've heard many good things about you. I'm glad you're on duty today. How is she doing?"

  Abby glanced down at the woman, searching for the right words, the right tone, but knowing that what she had to say could never be done right.

  "She's not doing well, Mr. Wheaton." Abby looked around the room and realized that the staff, too, were hanging on her words. "She has a fractured skull, and my initial exam suggests that there may be extensive damage beneath the fracture."

  "Oh, my God. Is she ... I mean, she's going to make it, isn't she?"

  Abby shrugged.

  "I've sent for MedFlight. She needs a neurosurgical evaluation."

  Just then the nurse in charge of Willie Cardoza hurried in.

  "Dr. Dolan, his pressure's fifty."

  "Is that the man who did this to my wife?" Gary Wheaton demanded to know.

  "Dr. Torrance," Abby said, pointedly ignoring the husband's question, "please keep an eye on things here. I'll be back as soon as I can. Once they're set to intubate her, go ahead if her breathing deteriorates."

  "I, um, I think I'd best call you if that happens," the pediatrician said.

  "Fine. Mr. Wheaton, you can wait in the family room if you want."

  "I'm staying right here. Dr. Dolan, I don't want you leaving my wife."

  "I know," she said, moving to the door. Nobody does.

  Before reentering Cardoza's room, Abby glanced about the ER. The orthopedist was in, examining Rebecca Mason's fractured leg. But Abby knew he was less equipped to perform an emergency abdominal exploration than she was.

  Cardoza was slipping away.

  Desperately, Abby tried to remain calm, to sort through the possibilities. If he was bleeding that badly into his belly, there was probably nothing she could do. The answer was to start from the beginning--the ABCs. His airway was fine, as was his monitor pattern. But while examining his chest, she hit pay dirt. The tube she had inserted was kinked, and Cardoza's original problem had recurred. She straightened the tube without much difficulty and tacked it down. Once again Cardoza's pressure came up and his color improved.

  "Please get some blood up now," she ordered. "Uncross-matched if they have his blood type. O negative if they don't. I'll take responsibility."

  She was in the middle of inserting the gastric lavage tube when Mary Wilder called from the door.

  "Peggy's having difficulty breathing. She's stopped completely twice. Dr. Torrance is trying to get a tube in, but she's having trouble."

  "Tell her to stop trying to intubate and just use a bag and mask. I'll be there in a minute."

  "But--"

  "Please!"

  Abby completed the insertion of the abdominal tube and watched as the saline she put in, then drained out of the cavity, came back bloody.

  "Hang two units as soon as possible," she ordered.

  She was racing back into the trauma room when both George Oleander and Martin Bartholomew entered the ER. They followed her into the room. Abby was not the least surprised that both were on a first-name basis with Gary Wheaton.

  "Thank God you're here," Wheaton said to the two men. "This woman left my wife to go in there with the man who hit her. Now Peggy's not breathing."

  "I just can't ventilate her by mask with that collar on," Susan Torrance explained.

  Then take it off! Abby wanted to scream. Breathing first Everything else next!

  "Abby, what's going on here?" Oleander demanded.

  Abby didn't bother responding. She loosened Peggy Wheaton's collar and gave her several good, ventilating breaths through the bag and mask. The woman's heart rate, which had dropped dangerously, sped up. Still, Abby knew, it was an exercise in futility. She prepared to insert a breathing tube through Peggy's nose and into her lungs. But at that instant Dr. Mehta, the anesthesiologist, arrived.

  "Abby, let Dr. Mehta take over," Oleander ordered with far too much bluster. "Sandon, Mrs. Wheaton needs a nasotracheal tube. Would you insert it, please?"

  "Right away, George."

  Abby backed away. She was expert at putting in breathing tubes. But this was not the time for debate or ego. The anesthesiologist inserted the tube with ease.

  "MedFlight's been sent for, Dr. Oleander," Abby said with exaggerated evenness. "The problem's in her left occipital region. You should glove and check it out yourself, as I did. Dr. Bartholomew, I need you for the man in major medical. He's got a positive abdominal lavage. We're getting blood running, but I'm certain you're going to have to explore him soon."

  "Is he the one who did this?" Bartholomew asked.

  Abby tried ignoring the question.

  "He had a tension pneumothorax," she said, "but a chest tube seems to have stabilized that. We're having trouble keeping his pressure up, though."

  "I asked if he's the man."

  "Yes."

  "I'll be in there when I'm sure of the situation with Mrs. Wheaton. Not before."

  Abby didn't respond for fear of what she might say.

  "I'm truly sorry about your wife," she muttered to Gary Wheaton as she left the room.

  Willie Cardoza had responded well to the repositioning of the chest tube and to an infusion of blood. He was now fully awake, though dazed.

  "Willie," Abby said, "I'm Dr. Dolan. You're doing better, but you've got some problems in your belly. Maybe a tear in your spleen. Do you understand me?"

  Cardoza nodded. He tried to look at her, but flinched.

  "There's something in my right eye," he rasped.

  Abby noted tiny shards of glass remaining throughout the man's brows and in his hair. Carefully, she lifted his lid, but the discomfort made it impossible for him to keep the eye open. She inserted a drop of anesthetic, and seconds later his eyes opened. Abby slipped on a pair of magnifying glasses.

  "There's a tiny piece of glass stuck in your cornea, Mr. Cardoza. Just stare at a spot on the ceiling and I'll get it out. Whatever spot you choose, stay right on it. Don't move."

  Despite his distress, Cardoza was the perfect patient. Abby took a fine needle, slipped it under the edge of the embedded glass, and popped it free. The cornea, a clear dome over the front of the eye, looked okay. But to be certain it hadn't been damaged in a way she couldn't see, Abby put in a drop of fluorescent dye. Any cuts in the cornea would fill with the dye and would light up brightly under a black light.

  She ordered the overheads cut. The cornea looked fine, but a golden ring glowed around the base. She had never seen anything quite like it. Some sort of irritant, she thought--a roughened area that was picking up the dye. Then she noticed that under the black light, the other eye had a glowing ring of equal brightness in exactly the same place. And that eye had gotten no dye at all.

  She was trying to connect with something to explain the fascinating finding when, from the doorway, a throat was cleared. Ab
by looked up. Framed by the light behind him was George Oleander.

  "Peggy Wheaton's dead," he said. "Why in the hell did you leave her like that?"

  CHAPTER SEVENTEEN

  Ted Bogarsky, Abby's ER backup, arrived soon after Peggy Wheaton died. Together the two doctors worked their way through the huge backlog of patients that had developed during the hours following the nightmare at the country club. Still, it was after six in the evening before the waiting room was empty.

  Willie Cardoza had made it into and out of the operating room and was now stable in the ICU under round-the-clock police guard. Martin Bartholomew reluctantly performed the surgery on him and, as Abby had suspected, found a tear in Cardoza's spleen. Aside from that and the chest trauma, he had no other critical injuries. Barring an unforeseen complication, there was no reason he wouldn't make it, unless, of course, the unmitigated hatred seething through the hospital and the town led someone to proclaim himself Cardoza's executioner.

  Abby did her best to focus one by one on each patient she saw, but it was hardly easy. The staff was extremely distant and uncooperative. Finally she gave up asking for assistance and got her own suture setups and discharge sheets. Shortly after she had left Peggy Wheaton in the care of Drs. Oleander, Bartholomew, and Mehta, the woman had lost her blood pressure and her heart rate had dropped into the teens. Massive doses of medication held her for a short time, but the MedFlight chopper had not even arrived when she suffered an irreversible cardiac standstill.

  Abby had little doubt that the coroner would document the lethal nature of Wheaton's head injury. But she also had little doubt that the finding would not matter to many people in Patience.

  She had just finished suturing a child's knee when Ted Bogarsky came over. He was a jovial family man and a steady ER doc. He lived some distance from the hospital and had always seemed removed from the politics and personalities of the place. If, like the others, he condemned Abby for deserting an all-American mother of three to care for the lowlife who destroyed her, Bogarsky hid it well.

  "Why don't you go on home?" he said now. "I'm on tonight, anyhow. Besides, we just found out our ten-year-old's going to need braces, so I can use the overtime."

  "Ted, you're already getting the overtime. I don't think I should leave early. I'm just not sure what it would say to people if I did."

  "I understand. It's been a hell of a day. For what it's worth, I think you handled everything brilliantly--as well as anyone possibly could have. If I'd been in your place, I know I'd have come completely unglued."

  "Nonsense, but thank you. I need to know that at least someone understands what went on here."

  "Everyone will with time. People are just a little raw right now."

  "I hope so. Ted, let me ask you something. Have you ever seen or heard of any condition that causes a ring around the base of the cornea, bilateral, that can't be seen normally, but glows under a strong UV light?"

  "Like the rings in copper poisoning? What are they called?"

  "Kayser-Fleischer rings. They don't fluoresce. But, yes, that's the idea. Same exact place in the eye."

  Bogarsky shook his head.

  "Why do you ask?"

  "Just something I read. I can't remember the details, though. Look, why don't I stick around for a while longer? If it stays slow, maybe I will leave a little early."

  "Fine."

  "I'll be in the on-call room for a few minutes. I just want to wash up."

  Abby wanted to explain that she had seen the curious rings in the eyes of Willie Cardoza. But there was nothing to be gained by doing that until she understood more. As far as she could remember, none of the articles she had read on cadmium toxicity spoke of eye findings. But there was something in one of them--something that seemed to be just eluding her. The articles were in her briefcase in the on-call room, although she hadn't had time to read any of them today before the ER had gone crazy.

  She set them on the desk, wondering if someone was sitting at a monitoring console someplace watching her. Skimming the articles quickly, she stopped at one entitled "Medical Findings in Nickel-Cadmium Battery Workers." Thirty-eight workers were studied. Thirty-four of them had headache; twenty-six had weakness, fatigue, and lassitude; sixteen had dizziness; one died from a syndrome like Lou Gehrig's disease; and CT scans on six of the workers revealed brain atrophy.

  She set the article aside. It was impressive for the number of central-nervous toxic effects of the metal. But it wasn't the information that was nagging at her. Ten minutes later she was about to give up and rejoin Bogarsky when she found it. It was an article in a chemistry journal.

  Cadmium in the liver and in the kidney, the abstract read, can be measured in the lab by the technique of X-ray fluorescence.

  The science was simply too technical for her to understand. But at least the hint was there. Under certain circumstances cadmium in tissues did glow. She would have to try to get the original article and then maybe ask a biochemist to explain it.

  She massaged her aching neck and shoulders. Tension, strain, and nearly ten hours of nonstop work had taken a toll on her body. It felt as if she had gone ten rounds with a heavyweight. Enough, she decided. She had had enough of this day. If it wasn't busy out there, she would leave. She opened the door and nearly collided with Joe Henderson, the president of the hospital. Henderson was a well-built, balding outdoorsman who had lacquered trophy fish on his office wall along with an NRA poster extolling the constitutional right to bear arms. No matter how grim or intense the subject he was discussing, Henderson always seemed to be grinning. Not today, though.

  "Abby," he said, "they told me I'd find you here. Got a minute to speak with me and a couple of others?"

  "Well, I don't know how things are going out there."

  "They're fine. I just checked with Ted Bogarsky."

  "Then I guess I've got a minute."

  "Terrible thing that happened to Peggy Wheaton. Just terrible," he said as he led her to the small conference room just off the ER.

  Len McCabe, the elder statesman of her ER group, was there along with George Oleander and a third man, who introduced himself as Terry Cox. Cox looked like a person whose passions included good food, fine wine, and money.

  "I work for the hospital," he said. "I'm an attorney. But I'm also an old friend of Gary and Peggy Wheaton."

  An attorney. What a surprise.

  "Should I be getting a lawyer of my own?" Abby asked, far too weary to be civil.

  "Abby," McCabe said, "there's no need to get angry. We'd just like to know what went on out there today."

  "With a lawyer present?"

  "A concerned friend," Cox corrected. "And a hospital representative. Needless to say, Gary and his family are distraught. I thought I could help explain things to them."

  Abby calmed herself with a deep breath.

  "Okay," she said. "What happened out there was that for almost twenty minutes our disaster-alert system failed to bring in another physician except for one pediatrician. I examined Mrs. Wheaton and determined that she would not benefit from my time and effort as much as Mr. Cardoza would. I felt that his life was on the line, while hers was already lost."

  Cox grimaced.

  "You mean," he said, "that after less than a minute with Peggy Wheaton--a young woman with a pulse and blood pressure, breathing on her own--you could tell that she wasn't worth trying to save, while the man who murdered her was?"

  "Mr. Cox, this isn't a courtroom," Abby said, "and I don't like the sense that you're cross-examining me." She paused while the lawyer mumbled an apology. "I'm horribly saddened by Mrs. Wheaton's death," she went on. "But I'm trained to evaluate patients quickly and to make decisions. That's what ER doctors do every moment they're on duty. Most of those decisions are quite minor and routine, some are life-and-death. The decision to concentrate on Mr. Cardoza was an extremely painful and difficult one for me to make, but it was the right one. I felt so at the time. I feel it even more strongly now."

&n
bsp; At that moment, inexplicably, she flashed on Willie Cardoza on his back on the Colstar Park grass, holding Angela Cristoforo tightly, yet tenderly, as he kept her from hurting herself anymore.

  She would have done the same for me, he had said to Abby. We company grunts have to stick together.

  "Would you have done things differently if you had had more time?" Cox was asking.

  Abby didn't answer him. Instead, she turned to Oleander.

  "George, did you examine Mrs. Wheaton's skull? Did you see the extent of the damage?"

  The medical chief flushed.

  "I ... no. No, I didn't," he admitted. "There was too much happening too fast. Abby, please understand, we're not accusing you of doing anything wrong. I've been trying to explain to you some of the differences between a city like San Francisco and a place like Patience. By now everyone in town has heard some version of what went on here today. We just want to make sure that when we tell the hospital's side of it, we're all on the same page."

  "And are we?"

  "What?"

  "On the same page."

  Abby had no intention of making excuses for anything she had done. For years she had feared being faced with a day like this. Now it had happened. And whether this impromptu men's club wanted to accept it or not, she had performed damn well. Whether they were pleased about it or not, a man's life had been saved. And whether they truly believed it or not, Peggy Wheaton was doomed before she had ever entered the ER.

  "I ... yes, I suppose we are," Oleander said. "Joe, Terry, Len?"

  The men exchanged glances. None of them looked pleased, although none of them looked as if he had anything further to say. Abby thought she could read their eyes, though, and the set of their jaws. Our community has its way of dealing with people who turn their backs on us, Dr. Dolan. You've had a number of chances to demonstrate you really want to fit in here. Don't count on being around much longer.