Lethal Practice

by Peter Clement

  “He’s dead!” I whispered, trying to get him to shut up. “They found him last night in his office.” But it was too late.

  Hurst leaped to his feet. “How dare you speak ill of the dead!” he roared. He didn’t even wait for a collective gasp before adding, “For years I’ve put up with your snide remarks and outright insults about the poor man, but this morning, it’s too much!”

  Sean and I were frozen. The others kept darting their eyes to us and back to Hurst. For a moment I thought he’d snapped. His cheeks were violently red and his body shook. Then he stiffly drew himself straighter, just as I’d seen him do in Kingsly’s office earlier that morning. But now, unlike then, his eyes were hard and focused. This was an act, and I realized what he’d been up to all along.

  “It is my extremely sad duty,” he began, in a low tone now, with just the right tremble in his voice, “to announce the untimely passing of Mr. Kingsly. He was found dead in his office last night.”

  No lies there. The expected “Oh, no,” “That’s awful,” “How sad” broke out around the table, but no one asked a single question about cause of death. I guessed everyone simply assumed it was related to his drinking.

  “And I am doubly shaken,” Hurst continued, his voice again rising, filling with a carefully honed anger, “by the insulting words of Drs. Garnet and Carrington regarding our poor friend and leader.”

  He gazed slowly around at his audience so none would miss the look of hurt he wore because of Sean and me. “I tried to carry on business as usual in the way I know the man would have wanted us to, but now simple dignity demands that we adjourn this meeting.” He wearily sat back in his chair and covered his eyes.

  The better to hide his triumph, I thought.

  He’d rammed through the cuts, used Kingsly’s death to shut off debate, and made Sean and me, his two most troublesome chiefs, seem like malicious malcontents.

  Tic, tac, toe.

  One glance around the table told me they’d all bought it.

  More futility, but I had to try. Again for the record, in case there ever came a time when it might actually matter, I asked, “Are the closures a fait accompli, or are you asking the chiefs to vote?”

  The incredulous stares of everyone leaving the table confirmed I was the village idiot.

  The only person not looking at me was Fernandez. He was staring off into space with the relieved expression of a man who’d just gotten a negative cancer test.

  Chapter 4

  A thin, gruel-colored light seeped through the end window and down the still-deserted corridor. It made everything look gray. As I swung into a better lit stairwell leading to emergency, I glanced at the wall clock:

  7:45. It normally took until noon before I was this mad.

  It was a relief to hit the bright, familiar bustle of our department after the idiocy upstairs. I walked through the sounds and smells of morning signout rounds, a ritual at dawn carried out in every ER in the world where the night people hand over their patients to the day staff. The aroma of coffee mingled with the smell of toast, scrambled eggs, and the overnight odor of unwashed patients. An even worse stench came from the unemptied bedpan on a nearby stretcher.

  The nursing station, a large central room, had huge windows with views of the department and the area just outside, where ambulances rolled in and unloaded patients. Wide countertops ran under the windows and were crowded with telephones, monitors, computer screens, keyboards, and racks of requisition forms. A curl of messages dangled down to the floor from our sole fax machine, but nobody had taken the time to rip them off yet, let alone read them. Parked here and there beside the counters were chairs on rollers, but most were unoccupied. The nurses stood while they scribbled notes, used the phones, or read orders and then hustled back out the open doorways that led to the surrounding stretcher and resuscitation areas. A clutter of abandoned half-full paper cups gave testimony to how busy they were.

  In one corner, I spotted Dr. Michael Popovitch, listening intently to the quiet murmur of our residents and interns giving report. I silently gave thanks that this calm, bearded man was on duty today; I’d need both his expertise and humor. He raised a finger in greeting, cocked an eyebrow at the piles of charts around him, and returned to the liturgy being delivered by a sleepy-looking medical student.

  “Patient twenty-one is a fifty-year-old male who experienced chest pain that woke him at three this morning....”

  Susanne turned from one of the countertop phones she’d been using. “What’s this crap? Admitting tells me there are no beds and not to expect any. They’ve got discharges planned, but orders came from Hurst not to assign the expected vacancies on the floors to us. No patient’s gone upstairs since late yesterday afternoon, and we already have twenty admitted and another fifteen—” Then, registering the expression on my face, she stopped. “Uh-oh!”

  To underline her point, on the security monitor for the ambulance bay I could see two ambulances wheeling through the garage doors. Within moments our latest guests were rolled in, end to end, with all the panache of a pizza delivery. Both patients were bundled, old, and scared.

  Susanne turned from me and pressed the intercom. “Triage!” Through the station windows, I saw Lisa Gray emerge from behind a curtain, put down a bedpan, and approach our new arrivals with a smile that visibly calmed them both. Behind me, the dirge from signout droned on, unfazed. “... pain was burning, and when he called his doctor, a nursing assistant advised a bit of Maalox but wouldn’t approve an ER visit...”

  I returned to Susanne and led her outside the nursing station to a quiet spot in the corridor near where Lisa had received the new patients from the ambulances.

  “It’s that bad, eh?” she asked.

  “Yeah, it’s that bad. The mighty minds upstairs have decided to close a hundred beds to balance their books.”

  “What?”

  I might as well have hit her.

  “Are they nuts,” she screeched. It wasn’t a question.

  Two attendants rolled in another ambulance patient. Lisa, still smiling, met them. Incredulous, Susanne sagged against the wall. I changed topics.

  “You know about Kingsly?”

  “Yeah, not many will weep for that lech. Was it his heart?”

  Her cold indifference to the man’s death made me flinch. I shrugged since I didn’t want to lie and walked quickly back into the nursing station before she could ask any more questions.

  Hospital telegraph had gotten out the news Kingsly was dead, but for the moment only a few of us, the murderer included, knew he’d been killed. I for one intended to keep it that way. The ER had enough problems without my letting the secret out and getting in hot water with the police.

  Yet it was Susanne’s callous remark that burned at the back of my brain. I didn’t blame her. Tragically, I knew, it was how most hospital personnel would react. What stung me was the way it echoed the times I’d also bad-mouthed Kingsly, and I felt ashamed. While Susanne stayed in the hallway to help Lisa with triage, I pretended to study the admissions list as my mind flashed to eight years ago—an era when Kingsly’s opinion still carried weight—and I again recalled his welcome endorsement ... that first smile and handshake. I had to force myself to focus on our immediate dilemma.

  “When my secretary gets in,” I said to the clerk, “have her call all our docs for an emergency meeting at five.” The anger in my voice surprised both of us. “Sorry,” I quickly added, embarrassed at the lapse. She just smiled and shrugged it off, probably putting it down to stress over the buildup of patients. ‘Then have her get me all the chiefs,” I continued in a calmer tone. “I want to see them at noon.”

  But none of this impressed any of the nurses within earshot. What we needed were beds, not meetings and phone calls. Through the open door to the triage area I saw Susanne roll her eyes at the ceiling as another patient was brought in on a stretcher. Lisa had stopped smiling.

  I thought of one phone call that might help. “And get me t
he director down at MAS,” I added rather loudly. “I’ll try and get him to back off sending us ambulances for a few hours.”

  * * * *

  With an extreme situation, I could usually bypass the brain-dead twits who “managed” day-to-day operations at MAS, the acronym for Metropolitan Ambulance Services, and go directly to Zak Evans, their medical director. So far I’d been five minutes on hold.

  Ambulance services in Buffalo, in all of Erie County for that matter, were coordinated by a central dispatch system run out of city hall, but the staff was managed by a large national corporation that specialized in urban and rural prehospital care. Zak Evans was essential to their operation.

  He had worked emergency before the organization had hired him to solve some serious problems they’d encountered with the competence of their personnel. When the company first took over, it had either bought out local ambulance fleets or made contracts with private ambulance companies to acquire the vehicles, technicians, and paramedics needed to serve the city. But with so many different groups involved, enforcing standards of care had been difficult, and while most of the workers were reasonably qualified, some were clearly not. At a few of the smaller outfits, driving an ambulance had been little more than a better paid plum for union truckers to haul patients instead of cabbages. They’d received enough hours of rudimentary training so that legally they could call themselves technicians, but they remained far from adequate. Before the takeover, previous attempts to introduce a test of professional competence and accountability had been seen as a threat and had resulted in ambulances being firebombed.

  Zak was asked to pull all these disparate groups into a cohesive unit and upgrade the county’s prehospital care. It had seemed an impossible task, but he’d successfully integrated the better attendants and paramedics as team leaders throughout the ranks of the service, then empowered them to ensure their members were properly trained. For the most part, it had worked. A few of the rogue outfits were still on the road, but we all knew who they were, and we double-checked everything whenever we got a patient from one of them. As for Zak, we made him the saint of Erie County ERs.

  He finally answered his phone.

  “Zak, it’s Earl. How are you doing?”

  “Me? I’m fine, but I hear one of your great leaders bought it.”

  “I’m impressed, Zak. Too bad you can’t get me an ambulance as quickly as you get the inside dope.”

  “Hey, don’t get dirty. Earl. No mystery though. It came over the police band at dispatch.”

  Yeah, I thought, and now it’s probably all over every ER in the city.

  “What happened?” he asked, his attempt at disinterest failing. Zak prided himself on knowing secrets. “And why are the police involved?” he added a little too eagerly. I realized he still didn’t know Kingsly had been murdered. Maybe I had something to trade.

  I hunched down over the phone so people around the station couldn’t hear. “Zak, it’s terrible. This has to be kept strictly between you and me.”

  I also hoped my lower-voice routine would raise the exchange value of my secret. “The mighty minds here closed a hundred beds this morning after we found Kingsly dead. I think, well...”

  I paused to give the impression of a conspiracy. After a couple of seconds he nibbled.

  “What? Tell me. You know it stays with me.”

  Sure, until the next trade, I thought. I had to be careful exactly how I phrased this so I could still follow Bufort’s directive, sort of, and yet get what I wanted for the ER. “Zak, look, I need a ban on ambulances for twenty-four hours. I think Kingsly’s death was, well, suspicious.”

  Hell, if Zak would buy a linkage between closing beds and the mysterious death of an administrator, it could even be useful. Might cause an outbreak of competence elsewhere. Set a trend.

  “What?”

  “Yeah, and it’s going to take at least twenty-four hours to sort it out and get the beds open.”

  “Murder?”

  “I didn’t say that!” I blurted out. But here came the offer. I was whispering now. “Of course, with your cooperation so closely tied in to the developing situation here, we’d update you immediately on any breaks in the case.”

  I winced at how much I was sounding like a Scotland Yard movie. Zak, I knew, loved British mysteries.

  “He was murdered?”

  “I didn’t say that, Zak.”

  “But if I grant the ban, you keep me informed?”

  “Of course.”

  There was a pause. Then, “Okay, you’ve got it.”

  “Thanks. I owe you.”

  My giddiness at having won a little reprieve was short-lived. I suddenly realized only the residents were signing out. “Susanne, where’s Kradic?”

  She looked up from the chart she’d been writing in at the counter. “I know you don’t need this kind of grief today,” she answered, “but Kradic left early.”

  “What?”

  “You heard me. Kradic left as soon as Dr. Popovitch got here. Didn’t even do signout rounds. Claimed he had an important appointment. He said the residents knew the cases and could transfer them to Dr. Popovitch.”

  I couldn’t believe he’d had the gall to leave early right after I called him on the carpet for arriving late. That he left on a morning overloaded with patients was doubly unforgivable. The residents didn’t know yet how to decide who was safe to send home, who wasn’t, and either way, what the best treatment plan was. Popovitch would have had to double-check everything.

  “You want my suggestion?” Susanne asked, eyeing a walk-in patient who was bent over with pain. “Fire him!”

  “I just gave him hell last night about being late!” I called after her a bit defensively.

  I was mad enough to turf him out, but I tolerated Kradic in the department because he was a brilliant clinician. His resuscitations bordered on miracles, the residents loved his teaching, and he took every shift I could give him, including half of our permanent nights. Yet with his peers, he could be abrasive, sarcastic, and belittling. As chief of the department, keeping the place staffed was part of my job, and I’d give myself an even bigger problem with coverage if I made him leave. Still, arriving late and leaving early was serious, and I would have to deal firmly with him or discipline would go to hell. Another walk-in patient holding a bloody towel to his head was being led to a stretcher. Thirty percent of our admissions crawled, walked, or taxied to our door without ambulances, and we couldn’t redirect them. Right now I was going to have to fix the mess in front of me, and fast.

  * * * *

  I held the telephone receiver about six inches from my ear. Dr. Valerie Jones, who shared the night coverage with Kradic, was raging at me.

  “Why are you calling me on my time off? How dare you—”

  “Valerie, I need extra help today. The agreement is, you provide us with backup on the weeks you don’t do nights.”

  Eight years ago I’d hired Valerie to work nights. Since then several other physicians had taken the job with her... for a year or two. They were usually recent graduates just starting out who liked the free time during the days to study or to set up a practice. For them the job was temporary. But Jones stayed.

  “Hey,” she snarled, “I cover half the nights and any other shifts you need me for. I sure don’t deserve to be criticized for not pulling my share of the load.”

  “I’m not criticizing you, Valerie, only asking for your help.” She was as prickly as Kradic, but where he got loud, Jones got sullen and spiteful.

  “Ask Kradic!” she said with mock sweetness, as though she had guessed my thoughts.

  “You know very well he’s on nights this week,” I replied wearily. She had been resentful as hell ever since I hired him the previous year. Until then she had been the solo star of the night shift. Now his prowess with resuscitations matched her own, and she had to share the adulation of the residents.

  “Can you please come in?” I asked again, trying not to sound like I wa
s begging. In a pinch I’d humble myself to soothe her defensiveness, because when inflamed she bordered on paranoid. Even my tracking her down at home probably made her suspicious. “Look,” I started, lowering my voice to make it sound like I was revealing confidential information to her. “ER’s a mess. The idiots upstairs closed a hundred beds today. The overcrowding is already unmanageable, and we need you.”

  “Sorry, but I have a research meeting at MAS.”

  Christ, she was really going to make me struggle. “I thought this was what you wanted, Valerie, more shifts. You’re always complaining you don’t have enough work since Dr. Kradic joined our department.”

  I listened to her breathing while I hoped that her jealousy of Kradic would override her need to punish me.

  “I can come in starting tomorrow,” she said coldly.

  “Why, thank you, Valerie, that will be a big help today.” I hung up before she could answer back or hang up on me.

  I sat there fuming. It’s hard to fault research, especially new cardiac arrest work. But she threw it in my face whenever she could. The irony was that I was the one who’d encouraged her to become involved with the study in the first place.

  Four years ago, Zak had enrolled MAS and Buffalo area hospitals in a large American/Canadian trial of new drug protocols for the treatment of cardiac arrests. They had needed emergency physicians to ride the ambulances and supervise the prehospital portion of the study. Jones had already worked with them on other research projects requiring fieldwork by doctors out on the road, so I had suggested she participate in this, their largest effort to date. Whatever I thought of her personally, she’d accumulated more experience in emergency care studies than anyone else in the department and was our best candidate. I’d even offered to adjust her schedule to accommodate the additional workload, since our own teaching program benefited when a staff member was actively involved in research. I’d actually been pleased when she’d accepted, and doubly so when she did well.

  But I’d had enough of my departmental prima donnas for one day. I pushed away from my desk and headed out of my office back toward the ER.