The Diagnosis is Murder (A Dr. Valorian Mystery Book 1)

by Steven Gossington

  “Never in an ER,” Betty said. “Years ago on the medical floor, I’d give an enema if the doctor ordered it. I will admit, though, a good colon cleanout might improve the dispositions of some of our ER patients.”

  Laura turned to leave, and Derek followed her into the brightly lit emergency patient area.

  “It’s still early in the day,” Laura said. “We only have three patients now. We’ll get busier later.”

  They strolled down a wide hall, which had patient stretchers along both sides. The main beds were in rooms with doors. As they walked, their steps echoed around the glistening tile floors and walls. Circular buff marks were visible along the floor, and a faint smell of alcohol and disinfectant drifted from the patient rooms.

  Laura stopped and pointed to a door. “The man I examined earlier in this room has had abdominal pain for the last few hours. The pain woke him up. I’m worried about appendicitis. We’ll talk about his workup in a minute. The other two patients here are holdovers from the night shift. They’ll be admitted to the hospital soon, to beds upstairs.”

  Betty led a new patient into the hall and past Laura and Derek to a treatment room.

  “What I want you to do, Derek, is to evaluate any patient you want to and present your history and physical exam to me. Then we can decide on the workup and treatment. Now, this is very important. If you feel uncomfortable with a patient’s problem, or if a patient appears ill or unstable, let me know immediately. Understood?”

  Derek nodded. “Entiendo.”

  “Ah, you know Spanish. Good. That can be helpful sometimes in the ER.”

  “I can only speak a few words and phrases. I’m learning it on my own.”

  Laura indicated a patient room a short distance away. “Betty just triaged your first patient. Go ahead and do your evaluation, and then we’ll talk about the case.”

  “I’m ready.” Derek clapped his hands and hurried away.

  Ten minutes later, Derek rushed into the doctors’ office with a big grin on his face.

  “Okay, what’ve you got? You look excited,” Laura said.

  “I am. I think this patient has hyperthyroidism, just like in the textbooks.”

  “You mean, she hasn’t been diagnosed with it before? This is a new case?”

  “Yes, a new one. She’s been developing worsening symptoms now for several months or more. But she’s never been sick like this. For one thing, she has proptosis.”

  “Define proptosis for me, Doctor.” Laura caught his smile. She knew he’d enjoy being addressed as a doctor, even though he wasn’t a real one yet.

  “It’s a displacement of the eyeballs forward, too far forward, in their sockets.”

  “That’s a good answer. Let’s go see her together.”

  They walked into the patient’s room. The middle-aged woman sitting and rocking on the stretcher had an enlarged thyroid gland at her lower neck, and her eyes were bulging.

  “Hello, Ms. Miller. I’m Dr. Valorian. I understand you’ve been feeling bad recently?”

  “Yeah, I’m real jittery, and my heart’s been racing. I don’t feel good at all.”

  Laura turned to Derek. “You’re right. And now for a little test. Do you remember some of the eye signs of hyperthyroidism?”

  Derek gulped, looked to the ceiling and launched into a listing of different physical findings concerning the eyes in patients with overactive thyroid glands.

  “You’re doing great. Now just show me some of those physical signs that Ms. Miller has.” Laura addressed the patient. “I’ll be asking Derek some questions if you don’t mind. He’s a medical student, and I’m his supervisor. Is that okay?”

  “No problem.”

  “Thank you. Could you just lie back for us, Ms. Miller?”

  Derek stepped to the bedside. “Well, first and most obvious is the wide open stare of the eyes.”

  Laura stood at the bedside next to Derek, watching the patient—who looked like she’d just seen a ghost—and Derek’s performance. He continued his response to the impromptu oral quiz and placed his hands on the patient’s face to retract the upper and lower lids of the right eye with his fingers. “I want to get a good look at the motility of the eyeball to test the muscles of eye movement, since these muscles may not function properly in thyroid disease.”

  Derek began to pull the lids away from the eyeball.

  Laura nodded. “You’re doing just fine—” She gasped as Ms. Miller’s right eyeball popped out of its socket like a hard-boiled egg and came to rest on her upper cheek. The patient’s right hand flew up and pushed the eyeball back into the socket with the index and middle fingers. No one moved or even breathed.

  After a few seconds, the patient let out a loud sigh that became a groan. “Ahhhhhh. What happened?”

  Derek looked at Laura with a gaping mouth and eyes as wide open as Ms. Miller’s.

  Laura touched Ms. Miller’s arm. “Everything’s all right. You just rest here. And please, keep your eyes closed for a while if you can. We’ll be back in a few minutes.”

  Laura and Derek left the room and closed the door behind them.

  Derek’s breath rushed out. “What the hell was that?”

  They hurried back to the office, and Derek closed the door. He and Laura stood facing each other.

  Laura’s words came rapid-fire. “I’ve never seen that happen before, though I’ve heard about it. In some types of hyperthyroidism, the eyeballs are pushed forward, giving the patient a bug-eyed look. Rarely, so much tissue builds up behind the eye that the globe can actually pop out of the bony orbit, even though it’s still tethered by the optic nerve and the already stretched eye muscles and other tissue.”

  Derek put his hands to his temples. “Wow, it looked like something from a horror movie. Her eyeball really popped out. They won’t believe this back at school. They’ll think I made it up.”

  “Don’t worry. I’ll vouch for you, I think.”

  “You think? What do you mean, ‘you think’?”

  Laura smiled. “If you do well here—make a good grade—then I’ll back you up. Otherwise, I’ll say you hallucinated.”

  Derek laughed and shook Laura’s hand. “Okay, it’s a deal.”

  They plopped down in the chairs. “I’m glad she popped the eye back in herself,” Derek said. “I don’t think I could’ve done it for her.”

  “You’ll be surprised at what you can do in urgent situations. Just keep your head and do what’s necessary. By the way, you kept calm with her. You didn’t panic. That’s good.”

  “I may’ve looked calm, but I couldn’t breath for a few seconds. I guess you can’t be totally prepared for everything that might happen in here.”

  “Even after years of ER practice, I still see the unexpected. And you can count on this: when things are going along too smoothly for a while, something bad or weird is bound to happen. I get worried when I’m feeling snug as a bug in a rug about work, because more often than not, trouble is just around the corner.”

  “Oh, no. It’s my first day, and you’re worried already.”

  Laura chuckled. “It’s not you. Work has been smooth sailing recently with nothing out of the ordinary—until your eyeball lady.”

  “What do you think Ms. Miller felt?” Derek said.

  “Well, we’ll go ask her and explain things to her, but I’ll bet she experienced double vision or saw stars or flashes of light or something like that.”

  “How can she be treated?”

  “She’ll need specific therapy for hyperthyroidism from a specialist, although some of the eye symptoms may be difficult to treat. I’ll call a consultant for advice about any immediate therapy we can offer.”

  At the office door, Derek turned back to Laura. “I can’t wait to see what’s in store for the rest of the shift.”

  Out in the ER, Laura determined that the man in Room Three still had abdominal pain. After evaluating the laboratory data and reexamining his abdomen, Laura had a strong clinical impression t
hat he had appendicitis. He was tender in the right lower quadrant of his abdomen. Since the man didn’t have a doctor, Laura would have to find one for him. She returned to the ER doctors’ office and sat down near Derek.

  “Don’t you need a CT scan before you call the surgeon?” Derek asked.

  “Not always. I think the data we have so far points to appendicitis, or at least a surgical abdomen.”

  “That might save him some radiation exposure, right?”

  “Yes, I agree. We’ll see what the surgeon says. In the meantime, I’ll order an IV antibiotic.” Laura called out to the unit clerk. “Who’s the surgeon on ER call today?”

  After a few seconds, the answer came back. “Dr. Preswick. Want me to page him?”

  “Yes,” Laura said with a groan.

  “I’ve heard stories about him,” Derek said.

  “Dr. Roderick Preswick is actually a colon and rectal surgeon—”

  “I’ve heard med students—if they don’t like him—call him a proctologist.”

  “That’s an older term for the same kind of surgeon. Anyway, he takes call for general surgery, and he’s technically good, but wow, what a prima donna. He can be so annoying to deal with. He doesn’t like ER call and is only included on the on-call list because he has to be. It’s hospital policy. To have admitting and operating room privileges, most doctors have to rotate on ER call for their specialty.”

  “That makes sense. So, he’d prefer to limit his practice to his own patients?”

  “Yes. My patient is uninsured, and Dr. Preswick dislikes taking care of a patient who can’t pay or who has insurance that doesn’t pay well. Also, ER patients often interrupt his office or his OR schedule.”

  The office phone rang and Laura picked it up. “Hello, this is Laura Valorian. I have a patient I think has acute appendicitis. I’d like you to see him.” She heard a snort from the other end of the phone, and the skin of her face began to heat up.

  “Listen. I’ve taken out way too many normal appendices recently because you ER people are always jumping to conclusions. Why don’t you start antibiotics, send him home, and recheck him in 12 hours? I’ll bet he doesn’t have insurance.”

  Laura ignored the last part of his tirade. Her throat tightened. “Well, this patient is a man with right lower quadrant abdominal tenderness, all the signs and symptoms of appendicitis with a typical history for appendicitis, and an elevated white blood cell count. Not a terribly extensive differential diagnosis. He needs your surgical care.”

  Preswick often tried to make her feel inferior. He spoke to her as if she were an inexperienced schoolgirl. On one past occasion, during a heated argument, he’d told her that women should stick to nursing, or at least pediatrics, and leave surgery to the men.

  Laura waited. She knew that younger, greener ER doctors might continue a futile argument, or they might weaken under the Preswick pressure to get out of the urgent consultation. Not so with Laura—not today. She wouldn’t give him an easy out.

  Preswick snorted again, muttered an indistinct expletive, and then spoke louder. “Oh, all right. I’ll be down to see him. I may order a CT scan after I examine him.”

  That’s fine. Just do your damn job and take care of the patient.

  After she hung up the phone, Derek leaned toward her. “I guess he gave you a hard time?”

  “Yes, ER consults often put him in a bad mood. Many hospitals have at least a few on-call physicians like him.”

  “I’ve heard he can be hard on students and residents, too.”

  Laura straightened her back and turned to him. “When the consultant resists your advice, stand your ground. Do what’s right for the patient.”

  Derek nodded. “Got it.”

  “Now let’s get out there and get to work.”

  Later in the morning, Laura spotted Preswick in the ER. She’d already guessed that he was around, since the nurses were acting more uptight. She avoided him, mainly because she was much too busy with other patients.

  At one point, Laura was close enough to hear a man speaking with Preswick in the hall, a balding man she didn’t recognize. The stranger was gesticulating with an earnest look on his face. Laura caught a few words of their heated exchange before the stranger threw up his hands and stomped away: “investment . . . nothing to show . . . embezzle . . . dead wrong.”

  An hour after Preswick left the ER, the man with abdominal pain was in the operating room. Preswick had examined the patient, reviewed the lab data, and then had made what Laura thought was a proper medical decision: he skipped the CT scan and scheduled the patient for urgent surgery.

  “Dr. Valorian?” Laura turned to face the unit clerk in the hallway.

  “You have a phone call. He said his name is Eric, a friend of yours.”

  Laura rolled her eyes. Eric was a triathlete and enjoyed showing his muscles and throwing his macho around. Laura had dated him for several months. She thought at first she’d give him a chance to appreciate her. Instead, she soon discovered that she was only one of several unsuspecting female admirers that he was cavorting with.

  “I’ll walk back to the office and take the call,” Laura said.

  Closing the office door behind her, she plopped into a chair and picked up the receiver. “Eric,” she said, drumming her fingers on the table. “I thought I asked you not to call me at work.”

  “Sorry, baby. I had an overwhelming desire to hear your voice right now. I just couldn’t stop myself.”

  “Listen. You’ve stood me up one time too many. I—”

  “Hold on. I couldn’t help that. You know why—”

  “I have it on good authority that you were with another woman. Don’t try to deny it.”

  “Well, no one serious. Who told you that, anyway?”

  Laura paused and ran her fingers through her hair. She almost capitulated. But he’d lied to her several times before. “Listen to me. It’s over. Don’t call me any more. I mean it.” Her hand trembled as she slammed the phone down.

  She became aware of someone at the door of the office. Derek stood there, looking as if he was unable to decide whether to enter the office or turn around and walk away.

  Laura glared at him and stomped out, muttering, “Men.”

  As morning stretched into afternoon, Laura and Derek evaluated, treated, and discharged or admitted patient after patient. The problems represented were common ones, including kids with fever, youngsters and oldsters with various kinds of injuries and broken bones, a couple of people with migraine headaches, a few with chest pain or back pain, a man suffering a heart attack, two with vomiting and diarrhea. Laura reviewed all of Derek’s patients with him. Derek worked at his own pace and managed to see more than one-quarter of all the patients.

  Late afternoon, during a temporary lull in the ER hustle and bustle, Derek and Laura walked out from the doctors’ office. “Wow, you do see a large variety of patient problems in here,” Derek said.

  Laura nodded. “Some days, the ER even seems surreal to me, the patient rooms like a series of strange images of people in varying postures and unusual facial expressions.” She stopped and scanned the hallway. “It reminds me of when I walked down Fifth Avenue in New York City one evening. In many of the doorways, I saw silhouettes of people in weird poses or just standing like mannequins. Spooky.”

  “I’ll make a mental note to talk with you before I visit Fifth Avenue.”

  Laura turned to him. “Patients seem to like you. That’s good. Some students, and some practicing physicians for that matter, could use remedial training to improve their bedside manner.”

  “Thank you. I usually relate well to people.”

  “Speaking of bedside manner, I see a few new patients have been triaged. Let’s get to it.” She pointed to a room. “Go see that patient, and I’ll take the next one.”

  Laura and Derek were soon cruising—one patient after another—through the remaining hours of the shift, which were routine and uneventful—until the very end. The
night ER doctor was due to start at 7:00 p.m., and Laura usually had some medical records to complete after her patient responsibilities were finished.

  At 6:50 p.m., an ambulance call came in over the ER radio. “En route to your facility with a 45-year-old male patient, cardiac arrest. CPR in progress. Patient intubated. ETA two minutes.”

  Laura readied herself in the critical care room to receive the patient. The night ER doctor hadn’t arrived yet. Large and brightly lit, the critical care room was the closest patient room to the ER ambulance entrance. Cabinets and drawers ringed the walls, and the cabinets had glass doors so that the doctor or nurse could easily spot the shelved items. Each drawer was labeled with its contents. Every conceivable order could be satisfied for the critical patient.

  Laura leaned toward Derek. “When the patient gets here, check the carotid pulse and breath sounds. Then tell me if CPR is being done adequately.”

  A wailing siren approached the ER entrance. Laura heard the automatic doors open, and ambulance personnel wheeled a stretcher into the critical care room. An endotracheal tube had been inserted through the patient’s mouth and into his trachea, and an intravenous catheter was in place in the right forearm. A monitor showed his heart activity, or rather the lack of it. One paramedic compressed the patient’s chest in a smooth and rapid cadence, and a second paramedic rhythmically squeezed a pliable plastic bag, providing oxygen and lung ventilations through the endotracheal tube with a soft, swooshing sound.

  Derek walked to the side of the stretcher and examined the patient. He nodded to Laura, indicating that he felt a pulse with compressions and heard through his stethoscope satisfactory breath sounds in both lungs, confirming that the endotracheal tube was positioned properly.

  “CPR is adequate,” Derek said.

  “Thank you, sir,” one of the paramedics said as they relinquished CPR duties to the ER nurses and respiratory therapists and lifted the patient over to the ER stretcher.

  Laura knew the paramedics well. She noticed beads of sweat on the forehead of the younger one, who was the chest compressor. She turned to the senior paramedic, who launched into the patient report.