Critical Judgment (1996)

by Michael Palmer

  "Chance of making it in your opinion."

  "Dammit, Joe! All right, all right. If it would make you any happier, I'll say it. In my opinion. Now, let's just drop it."

  "Did anyone else see these findings in Cardoza's eyes?"

  "Not yet. But anyone who wants to can do it anytime."

  "It won't be quite as easy as that. Cardoza was transferred to a prison hospital early this morning."

  "Which one?"

  "I'm afraid I'm not permitted to give that information to anyone."

  Abby sighed.

  "What a carnival."

  Henderson clearly found her remark offensive.

  "We don't think so, Doctor," he snapped. "This hospital and the Colstar corporation take the health of the people in this area very seriously. Two and a half years ago, when the community first raised health concerns about the company, investigators from the Environmental Protection Agency and the Occupational Safety and Health Administration were welcomed up on the hill and given free rein. The two teams were each here for almost a week. They found a few minor violations, which were dealt with immediately, but nothing that could have caused any health danger in the valley or to the plant workers. You were up there. You saw how they operate that plant."

  Another nonsecret.

  "How do you know I was up there?" she asked.

  "Abby, what difference does it make? The problem is that you have gone out of your way to create conflict where none existed. It seems to us that your temperament, your way of doing things, is much more suited to ... to a place that's not as ... tightly woven as our valley. The letters of recommendation from your directors at St. John's were glowing. Superb. Perhaps you should consider returning to some sort of academic environment, where controversy is more a way of life."

  "Joe, I don't think patients like Bill Tracy and Hazel Cookman and a number of others I've cared for would say that I foster controversy and conflict. I know I'm having trouble adjusting to some aspects of living in this community, but once I step through the doors of the emergency room, I feel totally at ease. Before I came here, I was dreading having to work with no backup in the hospital. Now I've discovered that I actually enjoy the challenge. I don't want to leave. At least not right now."

  Henderson shook his head.

  "I heard there are some nurses and doctors who aren't even speaking to you anymore."

  "They're upset about Peggy Wheaton. That's understandable. Just about everyone is. But they'll come around. And those who don't, still have to take care of the patients."

  "Abby, I'm sorry. It just isn't working."

  She took a deep, calming breath.

  "Joe, after you called this morning, I read over my contract. It spells out very clearly what I can be fired for. I don't believe that anything you've said this morning about me and my job performance qualifies."

  "I don't want to fire you, Abby. I want you to consider resigning."

  "And if I say no?"

  Henderson drummed his fingers on the desktop, then removed a folder from his desk.

  "I believe that one of those reasons spelled out in your contract has to do with demonstrating flawed judgment in critical situations. I have here the autopsy report on Peggy Wheaton."

  He opened the report to a specific page, studied it for a very dramatic ten or fifteen seconds, and then slid it and another page across to her.

  Abby looked at him quizzically.

  "I was present for the autopsy," she said. "The whole thing. Start to finish. I don't understand what--"

  "Just read those pages, Abby."

  The first page in the technically written document was the description of the removal of the top of Peggy Wheaton's head, and the examination of the trauma to her skull and brain. The single-spaced, computer-printed paragraph covered most of the sheet. Abby read it in shocked disbelief. The injury described was far less serious than the massive fractures and brain damage that Abby had diagnosed in the ER and confirmed through her observation of the autopsy. In fact, as described, the trauma was minor enough to have easily not caused Peggy's death.

  "This is a lie," she said. "Every word of it."

  "I think you should read the next page as well."

  The second sheet described the findings in Peggy's chest--a contusion to the heart with a traumatic hemopericardium--a constricting accumulation of blood between the heart muscle and covering membrane. If the finding was true, and Abby knew from having seen Peggy's perfectly normal heart that it wasn't, she would have been guilty of missing the very treatable cause of the woman's death.

  "You're crazy if you think you can get away with this. I'll just insist that the tissues be reexamined."

  "Feel free. I believe what tissue remains will conform completely with this report. The report is official, signed by the medical examiner, Dr. Barrett."

  Abby groaned. Barrett was the chief of pathology at Patience Regional. He also ran the laboratory that had never found cadmium in anyone.

  "I can't believe you all would sink to this."

  "Abby, I assure you that no one wants this report to become public knowledge. It would reflect badly on the hospital, and terribly on you. In fact, I wouldn't be a bit surprised if Gary Wheaton and his attorney choose to pursue the matter in court. That would tie you up indefinitely."

  "Am I that great a threat to Colstar, that you all would do this? What in the hell is going on here?"

  "We would like you to give us two weeks' notice."

  "If I refuse?"

  "Then I'm afraid we'll just have to decide what's in the best interests of this hospital and this community."

  At that moment Abby's pager went off, and at almost the same instant the loudspeaker outside Henderson's office sounded.

  "Code ninety-nine, X ray. Code ninety-nine, X ray."

  Abby glanced down at her page.

  "It's the ER, and it's urgent," she said, pushing back from the desk. "They need help at the code."

  "We can complete our conversation later," Henderson replied icily. "Perhaps we'd better see what's going on in radiology."

  "Tell your secretary to call and say I'm on my way. And in case I forget to say it later, Joe, you're a son of a bitch."

  The overhead page was continuing to broadcast the location of the code ninety-nine as Abby sprinted down the hall to the stairway. The radiology department was on the ground floor, not far from the ER. She tried to recall what doctor from her ER group was on the schedule for today. Whoever it was would certainly be there running the code. Just as she raced through the open doors to radiology, she remembered that the ER doc on duty was Jill Anderson. And that, she knew, could mean trouble. Jill was skittish and insecure, and prone to bursts of temper. Talk about impaired critical judgment! Abby had wondered more than once what Jill was doing in a specialty that required nothing if not a cool head. She was a disaster waiting to happen every time she put on her clinic coat.

  A technician stationed by the doors pointed down the brightly lit corridor.

  "The MRI suite, Dr. Dolan!" she called out. "Please hurry!"

  The magnetic resonance imaging suite consisted of a small waiting/reception area, a dressing room, and the room housing the massive MRI unit itself. The code ninety-nine was being conducted in there. Several people, including two nurses, were standing outside, craning to see through the thick glass walls.

  "Just bump someone out and go right in," one of them said.

  Over her years as a med student, resident, and then emergency specialist, Abby had been involved in hundreds of code ninety-nines. But the bizarre scene in the crowded MRI room was one she would never forget. Jill Anderson, tears streaming down her face, muttering to herself, was fumbling with the equipment to do a subclavian IV insertion in a woman who was kicking and flailing her arms about desperately. Every bit of the patient's skin that Abby could see was flaming red. Standing across from Jill, Dr. Del Marshall, a radiologist in his sixties, was trying to ventilate the patient with a black Ambu breathing ba
g. Even from the doorway Abby could tell he was doing an ineffective job of getting air into her lungs.

  "What's up?" Abby asked as a nurse stepped back to give her room by the stretcher.

  "Anaphylactic shock," Jill said. "She went into it while she was inside the MRI cylinder. Her jaws are clenched too tightly to get a tube in. She's hardly breathing."

  Why in the hell didn't you wheel her out of this closet and back to the ER? Abby wanted to scream. The forty-five seconds or so that such a move would have taken would have been repaid a thousandfold with the space and equipment at their disposal in the ER. Now Abby couldn't tell if time was too precious for that.

  She moved behind Del Marshall to get a better look at the patient, and at what the radiologist was doing. Above the black rubber face mask, she saw the patient's bright-red hair. Marshall backed away and let Abby handle the breathing bag. She lifted it from the woman's face. Lying there, her eyes wide with panic, fighting desperately and futilely to get air past the swollen tissues in her throat, was Claire Buchanan.

  CHAPTER TWENTY-FIVE

  Claire Buchanan's face, puffed and crimson, was barely recognizable. She was thrashing about as if someone were smothering her with a pillow.

  Jill Anderson looked only marginally better. Her mascara was beginning to smear beneath both eyes, and her normally pale complexion was bloodless.

  "I've got to get this line in so we can paralyze her with some Anectine," she said. "Once her jaws are relaxed, maybe I can get a tube in."

  Paralyze. Tube. From what Abby could tell, Claire Buchanan was still conscious. The use of such words in this situation was totally inappropriate. To make matters worse, the time that was being lost as Jill struggled to get an IV in could prove fatal. The lactic acid that was rapidly building up in Claire's bloodstream from her low oxygen levels could cause a cardiac arrest at any moment.

  By the accepted rules of practice Jill was in charge of the code ninety-nine. But there was no way Abby could allow things to continue as they were. Besides, what did she have to lose? Henderson had more or less just fired her.

  "Jill," she said with undisguised firmness, "let me help."

  At that moment Jill looked like a frantic, treed animal who had just realized there was no place else to run.

  "Take over," she said.

  Thank God.

  Abby was already experiencing the familiar slowing of movement and muffling of sound as her mind and body homed in on the critical elements of the situation at hand. In just a few seconds she understood the crisis and what she and the others had to do to reverse it.

  "Jill, please get a tourniquet on that arm," she said. "Someone else keep a couple of fingers on her femoral pulse until we can get our portable monitor hooked up."

  She next turned to the nurse, Mary Wilder. Before Peggy Wheaton's death they had been on a first-name basis--allies in the ER war. Since the triage episode the nurse hadn't spoken a kind word to her.

  "Mrs. Wilder, please give Dr. Anderson point eight of epinephrine on a twenty-seven needle."

  Wilder looked at her dispassionately.

  "Yes, Doctor."

  Despite the situation, and in spite of herself, Abby flashed on the nurse's horrible death in her nightmare. If you only knew ...

  "Jill, don't worry about a line," Abby said. "Just find some little vein and get the epi in. You can do it. I know you can. Put it in her femoral or external jugular if you have to. Just make sure it's IV."

  She checked Claire's jaws, which were, in fact, rigidly closed. Trying to get a breathing tube through her mouth was out of the question. But there was another way--in fact, there were two. One of the techniques, nasotracheal intubation, she could possibly do right there. The other, an emergency tracheotomy, would require the surgical lighting, wall suction, and equipment of the ER. And that meant a risky dash.

  "I need a six-oh nasotracheal tube," she said.

  The nasotracheal breathing tube was made to be passed through the nose, down the back of the throat, and between the vocal cords. Because the NT tube was held tightly in place by the long nasal passage, it caused less tissue injury over long periods of assisted ventilation than the more wobbly endotracheal tube, inserted through the patient's mouth. But the nasal technique was slower to perform, technically more difficult, and damaging to the nose if not done correctly. Usually, when inserting the nasal tube, a lighted laryngoscope blade would be slipped into the patient's mouth to push the tongue aside and allow the physician to use a long-handled clamp to guide the NT tube downward through the vocal cords. This time, though, because of Claire's tightly clenched jaws, using the laryngoscope was out of the question. Abby would have to do the insertion blind, by feel--and hearing--alone. It was a technique she had practiced many times but had seldom used in an emergency situation, especially with a patient who was still awake and thrashing about.

  She turned away from Claire Buchanan for a moment and added softly, "And somebody please get over to the ER and get us ready for a tracheotomy if I can't get this in."

  She turned back to the stretcher and set about trying to calm Claire down. She also used the mask and bag to deliver high-flow oxygen along with what little air the woman was managing to get in on her own.

  Their worst enemies right now were time and the cramped quarters in which Jill had opted to work. Abby identified the people who were not essential to the moment and asked them to wait outside. Del Marshall she motioned back to a corner, out of the way. The radiologist, who was hardly used to this kind of crisis, readily complied. He was tight-lipped and plaster pale. For a moment Abby worried he was going to pass out. As she watched him move aside and brace himself against the wall, her line of vision connected with Joe Henderson, who was watching and listening from just outside the doorway. For the briefest moment their eyes met and held. Then, with no other acknowledgment, she turned away.

  Claire's face was horribly swollen now and a mottled crimson. Her lips were like sausages. Her eyelids and the surrounding tissues were so puffed that it was impossible to tell whether her eyes could even open. And to make matters worse, her struggles were weakening.

  Come on, Jill, Abby urged silently. Get that epi in.... Dammit, come on!

  The nurse working the crash cart handed over the nasotracheal tube.

  "Did you check the balloon?" Abby asked.

  Too often she had seen a breathing tube inserted flawlessly, only to discover that the circumferential balloon used to seal the space between the tube and the inner wall of the trachea was defective. The insertion would have to be repeated with another tube, but this time through vocal cords that were often traumatized and swollen from the initial attempt.

  "No, Doctor," the nurse muttered. "Sorry."

  "Do it, please," Abby demanded. "And it's got to be lubricated better."

  Keep upsetting people like Jill and this nurse, and it will be a miracle if you're not lynched, she was thinking.

  "I've got it, Abby!" Jill exclaimed suddenly. "Epi's in!"

  "Way to go. I knew you could do it. Now, please get to work on that subclavian, and take your time. As soon as it's in, give her some IV steroids--make it forty of Solu-Medrol--and also give her fifty of Benadryl."

  Claire had stopped breathing altogether. In a few more seconds they would have to begin doing CPR. But without a way to get oxygen in, the pulmonary part of the CPR would not be possible. Abby couldn't remember the last time she had seen an anaphylactic-shock patient die in the emergency ward. The treatment was usually effective, and at St. John's there was just too much talent around, including skilled trauma surgeons who could perform a perfect tracheotomy in just a minute or two. But this time the severity of Claire's allergic reaction, plus Jill's indecisiveness and poor judgment, had put them in a deep hole.

  Abby tried one last blast of oxygen from the breathing bag. Claire's neck was as rigid as her jaws. The resistance to proper air flow was intense. On the other side of the litter Jill was moving with agonizing slowness. There was
no way Abby could wait for the IV to be established.

  She tried to rid her mind of all extraneous thoughts. But some images of Claire Buchanan--snippets of their two encounters--refused to be dispatched.

  "... Are you the nervous type?"

  "I don't think so, except that I'm very claustrophobic...."

  Abby glanced down the long, gleaming MRI cylinder. How in the hell could anyone with true claustrophobia make it in there for the forty-five minutes usually required to complete a study?

  Hang in there, Claire.... Please, just a little bit longer....

  Abby felt the icy fingers of panic beginning to take hold.

  "... I was a damn good dancer, at least for Sioux City...."

  Don't leave us, Claire.... Don't leave us now....

  "Okay, everyone, let's get this tube down. Mrs. Wilder, put your hands on both sides of her rib cage. When I ask you to, give her some rhythmic compressions. That way at least I'll have a little bit of a target. I'm making one pass. If I don't get it, we're going to the ER for a trach. Are we sure there's no surgeon in the house?"

  "The one on call has been paged, but he's coming in from his office."

  It had been six or seven years since Abby had performed her last emergency tracheotomy. But if she failed to get the ventilation tube in, there was no other option. If she had to, she would race Claire Buchanan over to the ER, suck up her courage, and do it.

  "Jill, hold off until I get this tube in, please. Everyone else, I need perfect silence so I can hear air moving through her cords. Ready, Mrs. Wilder?"