I waited for more.
“Yeah, me and everyone else in the hospital would say he finally did it. Drank and then screwed himself to death, or, at least, died trying to screw. He never actually raped anyone, at least not according to what I heard.”
“Would you expect his clothes to be where he fell, or even be surprised if you’d found him nude?”
“If we didn’t know he’d been murdered?” He thought a minute, then answered slowly, “No, probably not. I’ve heard the guards have found him with half his clothes missing a few other times. The women he’d hit on sure as hell never came up with them.”
Watts thought a bit more. “I might wonder about most of his clothes being gone, but I can’t say I’d make much of it. No, I wouldn’t be surprised. I’d have thought he finally started an MI with his sexual exertions someplace earlier, made it back to his office, and collapsed.”
“What about the thermostat being turned up? Would that make you suspicious?”
“Not necessarily, if I wasn’t suspicious in the first place. I’d likely figure he’d felt cold, being nude, and had jacked up the heat before he arrested.”
“So, with all of us thinking that way, could the actual needle and its mark have gone unnoticed if no one had pumped him?”
“You could count on it. Same thinking as this morning. We all saw how Hurst would have grabbed any chance to cover up and prevent a stink at the hospital. He would have explained it the same way, but in this case we probably would have agreed with him.”
“The point is, Robert, not to think of the setup from Hurst’s mentality but from the mentality of the killer. To count on all these presumptions is to know about the hospital. I mean really know. The way you and I do. Only someone intimate with our secrets and foibles would set up this play, dump Kingsly’s nude body in his office with a needle fragment buried in his heart, and still consider it a good plan to cover up a murder.”
“What are you getting at?”
“To think like that, it’s not just someone who knows the hospital. It’s someone so experienced in CPR he never even thought anyone in a hospital would attempt to resuscitate an already stiffening corpse.”
Watts gave me a skeptical look.
“Come on,” I said. “There was every chance of it being called, even by yourself, a freaky but natural death.”
“Okay, Sherlock, so the killer knows the hospital and CPR. Is maybe even one of us. That’s at least five hundred doctors, well over a thousand nurses, and God knows how many other trained staff members.”
I’d already figured how to narrow that group down considerably, but I needed the postmortem on Kingsly to be sure. The problem was, if we found what I expected, I was going to have a hell of a lot more trouble with Bufort.
“Maybe,” I mumbled, getting up to leave. “By the way, we got another DOA that gave me something of a surprise. When I was checking him, I found a mark at his left xiphoid-sternal junction.”
“What!”
“Relax, it’s probably a mole. But given what I found on Kingsly, I’m afraid I overreacted and noted it on the form, asking you to verify it.”
I thought he’d make some parting crack about making moles into mountains.
“Earl, you don’t need a goddamn pathologist to diagnose a goddamn mole, no matter where the goddamn thing is located!” he exploded, shocking the hell out of me.
“Robert, I’m sorry. Don’t bite my head off. I was just being careful, obviously too careful. Let’s forget about it.”
Watts took a breath. “Sorry, Earl, this killing’s got to me too. I shouldn’t have jumped all over you like that. It’s just that it’s doubled my work, and I’m behind as it is. The last thing we need around here is someone of your experience and background seeing needle marks every time you spot a mole.” He smiled, then added, “We all need to relax, and just do what we normally do. Think horses, not zebras, remember?” It was an old saying from medical school. It was meant to keep the overactive imagination of untrained students from galloping off after uncommon diagnoses.
I grinned at him, feeling pretty sheepish. “Thanks, Robert,” I said, then let myself into the warren of tunnels and catacombs outside his dissection room.
Dripping noises mingled with silence; cobwebs mixed with a lot of dust; a jumble of pipes and wires ran overhead. Some of these drooped down in tangles and resembled malignant varices, enlarged tortuous vessels dissected open and left hanging. Several layers of fuzzy mold riddled with scurrying eight-legged life, grown fat on droppings from Watts’s table, covered the pipes and wires.
This was where his next two patients waited to receive their final medical act, shrouded, silent, and parked on stretchers. Then I realized one of them might have been our DOA. Watts would declare him yet another victim of the street, and my embarrassing note would disappear onto some dusty shelf. At least I didn’t have to worry about Bufort’s reaction to it now.
The tunnel stretching in either direction was occasionally pocked with a dim pool of light that added more gloom than illumination. I gratefully fled back up the stairs to the comfort of the noise, confusion, and bright lights of my own department.
Entering my office, I managed to jostle my secretary, who was on her way out with an armload of paper.
“Why, it’s Carole Lament,” I exclaimed playfully, bowing as I held open the door to let her pass.
“I’m glad to see you too.” She laughed. It was a shared joke. We sometimes went the better part of a day without seeing each other, only a string of notes and phone messages connecting us. Then we’d have a chance encounter and quickly update each other in a shorthand possible only after years of working together. “I’ll be back in a minute,” she called over her shoulder. “I need to talk to you.”
Carole Lamont was singly the person who had sustained me most through my time as chief. She kept the department afloat from day to day. More than a dozen doctors, all our residents, and a team of nurses and clerks deferred to her to coordinate staffing and keep the schedule covered. By slowly taking over most of these logistics, she had freed me to concentrate on teaching, medical matters, and standards of care.
Managing an ER is primarily a matter of managing people: knowing who to stroke, who to push, who to nail to the wall. Yet it was Carole who was the keeper of everyone’s secrets. She got them in bits and pieces as she made up the schedule. She knew who was in love, whose marriage was ending, who’d just been dumped, who had a sick child. All of it, even joy, could distract a physician and sabotage patient care. So we watched who wanted more time off, who wanted less, and why. From these requests and the reasons for them—revealed to Carole, not to me—we knew who I could ask to do what and when. Brusque at times, efficient always, Carole had a soft shoulder that was obvious nonetheless and encouraged people to confide in her.
“You heard?” I asked when she came back in the door, unencumbered by paper.
“About the bed closures, yes. About Kingsly, a bit. Is it true what they’re saying?”
“What’s that?”
She lowered her voice. “That he was murdered?”
The gossip network had finally gotten through.
“I’m afraid so.”
“How?”
After my recent encounter with Bufort, I felt no compunction about defying the pompous jerk’s previous order not to discuss the case—it was pointless now anyway—so I told her what I knew. But I left out Bufort’s little visit I didn’t want her worrying about me.
We got down to business. Although most of the chiefs had agreed to attend the meeting, Carole told me that some of them had complained about the short notice. I thought this over for a minute. “Before you leave for lunch, please tell them to meet me in the center classroom. I want them to walk through the mess out front.”
She smiled. We both knew it would save me a few hundred words. I also hoped it would soften their reflexes to resist.
I was wrong on both counts. After I’d told the chiefs my plan,
three-quarters of them thought I was as nuts as the scene out front they’d just been made to witness.
“Dr. Garnet, you can’t close emergency!” declared Arnold Pinter, a new and very insecure chief of medicine. Usually he slouched; now he was sitting bolt upright, looking nervously around the table. There were murmurs and nods of agreement from most of the others, but a few weren’t so quick to react. Arnold seemed puzzled by the lack of unanimity. “Can he close emergency?” he asked.
“I don’t know,” Sean Carrington said, “but maybe he should.” Sean was chief of surgery and had come straight from the OR, still in greens. He was peering at Arnold over the operating bifocals he used while performing delicate procedures.
“He can’t stop emergencies!” Hector Saswald insisted. As always, he was looking for approval. When it didn’t come, he moved to protect himself from being politically incorrect. “And I want it in the minutes that I said you can’t close,” he declared piously, jabbing his forefinger at me.
“There are no minutes, Sas,” I said.
This seemed to upset him even more than closing the ER.
“What exactly do you hope to achieve?” asked the chief of geriatrics. He was a rather humorless man, though brilliant at assessing mental competence. The doubtful frown on his face made me feel he was checking my capacity to develop even the vestige of a plan.
“Look,” I answered, “we all know how closing beds is crap, dangerous crap. I just had another cardiac go sour because we were playing ICU down here, and I’m not willing to go along anymore. Besides, it’s the goddamn idiots upstairs who need shutting down. They don’t seem to know their budget for carfare let alone for running the hospital. What I’m after is a complete review of the finances of this loony bin and an end to these clowns shutting down care every time they screw up.”
“You can’t do that!” It was Arnold Pinter again. This time his voice cracked. The thought of bucking administration seemed to terrify him.
“One of the real problems, Arnold,” I said, trying to control my impatience with this annoying little man, “is that you allow your guys to fill up the beds with soft admissions who are on fee-for-service plans, and then your department dawdles with those patients as long as the premiums allow because it’s easy money and little work. The nurses let you get away with it because it keeps the hard cases waiting in emergency and out of their hair.” It wasn’t blatant fraud, and it was never picked up on the chart audits that were meant to prevent outright billing abuses. It was simply what could be gotten away with if the chief of medicine was a wimp.
Of course, Arnold started to deny it, but Sean leaned in from the other end of the table and cut him off. “What’s more, Arnold, you’ve got the nerve to let other medical cases pile up in my surgical beds, and I end up canceling admissions for the OR.”
A brief look of fear crossed Arnold’s face as he found himself caught between us—and caught dead to rights. He slumped in his chair, a field mouse within the hawk’s shadow, and began his patented squirming.
“I’ve told you, Sean, many times, that I don’t have the staff,” Arnold said. ‘Ten of my specialists have resigned in the last year, and with the resident cutbacks we have too big a load. I can’t move cases any faster. We’re spread too thin, and it’s going to get worse.”
Good old Arnold, the prince of whine. Maybe he was hoping we wouldn’t expect much of him—certainly nothing hard, if he seemed pathetic enough.
He was wrong. Sean came at him with the keenness of a scalpel edge slicing through bloated flesh. “Look at the stats!” he snapped. “You admit a lot more pneumonias and keep them longer when you’re paid fee-for-service than when it’s by managed care.”
Arnold got a bit white at this shot. He didn’t say it, but his questioning expression asked, Don’t we all have to diddle a few extra bucks when we can? He shrugged, then looked around at the other chiefs and turned his palms up to the heavens. “What do you want, Sean?”
“What I want, my dear Arnold,” Sean said, “is for you to stop running a patient’s stay here as a private pet farm to make money.”
A look of fury flashed across Arnold’s face. He flew out of his seat and stood eye to eye with the muscular surgeon. Fortunately the PA interrupted.
“Dr. Carrington, OR, stat! Dr. Carrington, OR, stat!”
Sean gave Arnold a wicked grin and left without another word.
Arnold slowly recovered his composure and settled back into his chair. I looked at the hostile expressions on the faces of the remaining chiefs, sighed, and said, “You don’t have to do anything. It would be better if we had your support, but I’m putting it to our docs tonight, and they’ll decide. We’ll be the ones who close and who take the heat. Hurst can stop us only if he opens the beds and orders an audit.” I felt even more weary as I realized how alone we were going to be during the long fight ahead. I’d nothing left for diplomacy.
“It’s this simple,” I continued, my voice getting harder. “We’re doing it. You can consider this meeting formal notification. I’m not here to negotiate with you.”
There wasn’t much left to say. Arnold looked deflated, and the rest of them seemed either resigned to my decision or relieved that I’d taken responsibility for it myself. No one had even mentioned Kingsly. Obviously, the hospital gossip about his murder hadn’t reached these upper echelons yet. As they rose to leave, I was left wondering if one of them could be the murderer. Each knew the hospital, but so did a few hundred others. Yet I had my hunch, and if Watts found what I was afraid he would find at the postmortem, then by tonight Bufort’s hunt for the killer could be narrowed to about thirty people.
The funny look on Fernandez’s face earlier came to mind. It still puzzled me. I thought about him now only because he had declined to come to the meeting, telling Carole that the bed cuts didn’t affect him much, so he didn’t need to attend.
* * * *
“Will your surgeons support us, Sean?”
Carrington and I were having coffee together in the surgeons’ lounge. It was two P.M., and I’d arranged to meet him there when he was between cases again. He looked relaxed and at home stretched out on a couch, still in his greens with a surgical mask hanging loosely on his chest. He’d been operating since he left my meeting.
“I think so,” he replied. “A few will be worried about the damage to their incomes, but I haven’t heard any other bright ideas to save us from Hurst and his cuts, and in the long run, that will cost them a lot more.”
Half of the major surgery done in the hospital came from emergency. Obviously, our closure would affect the incomes of his departmental members. Even in this room, a few of the other surgeons who’d been reading newspapers had put them down and were leaning forward to try to hear our conversation.
“In any case,” Sean added, “I’ll support you, and I’ll talk to the others.” He stretched, sat up, and leaned closer to my chair. In a near whisper, he asked, “What’s this I hear about Kingsly being murdered?”
“How’d you find out?”
“It’s all over the hospital—rumors, cops beginning to poke around. How come you didn’t tell me?”
“Those same cops told me to keep my mouth shut.”
“Well, now that it’s no longer a secret, you can open your mouth.”
We had another cup of coffee while I told him what I knew. Again, I omitted that Bufort had singled me out for special attention. Not knowing why he’d done so was making me increasingly uneasy, and I wasn’t going to fuel any rumors about myself. I had just finished the story when a nurse stuck her head into the room and called over to a gray-haired woman in greens, “Your case is ready. Doctor.”
“Sean, is that Phoebe Saunderson, the gynecologist?” I asked as the middle-aged woman left the lounge.
“Yep.”
“I thought she’d retired from practice years ago.”
He shook his head. “Became the VP medical of a hospital in the east end of Buffalo. After five years she aske
d to come back to St. Paul’s.”
“And she can still operate?”
“Sure.”
“After being away from it for five years?”
“Absolutely. She had to work like crazy to catch up on all the new drugs and the latest in reproductive endocrinology, but apart from a few new techniques and instruments, cutting is cutting. Once you’re a surgeon and know how to operate, it’s like riding a bicycle—you never really lose the technique.”
The same nurse who had summoned Dr. Saunderson now poked her head through the door and called Sean.
“You know,” he said as he got up, “I bet even old Hurst could still wield a pretty mean scalpel.”
My meeting at five that evening with my own staff was brief. By five-fifteen we decided, nearly unanimously, to withdraw our services and shut down emergency in twenty-four hours if the closed beds weren’t immediately reopened. I suggested we should consider issuing a press release warning of our hazardous overcrowding in the ER. It would condemn the administration for its irresponsible action and request that patients use other emergency facilities until we could make our own department safe. I said I was going to sleep on the wording of the press release and we’d take it up tomorrow. Then I explained that I would warn our sister hospitals, since our closing would increase their loads. In spite of the added burden to the other ERs, I expected we’d get support from their staffs. Finally somebody would be doing something. I’d inform MAS what we were up to. They would have no choice but to continue diverting ambulances to other institutions.
Initially, the younger physicians were reluctant to go along with the plan. Not having the established reputations or financial security of the older doctors, they balked at putting their jobs at risk.
“You guys can walk out of here and probably find a new position by tomorrow night,” one of them said pointedly. “We don’t have your options.”
But then I explained about Arnold Pinter’s “pet farms” and excessive lengths of stays upstairs.
“Do the math!” I said. “We admit twenty-five fee-for-service patients a day to medicine, on average. I doubt they all really need to come in, but even if they do, our length-of-stay data show we keep each of them, again on average, two days longer than a managed-care patient with the same diagnosis. That’s sixty beds. Two times thirty. By getting internal medicine off its ass, and these soft admissions out two days earlier. Hurst could close fifty beds and we’d never miss them. And that was just one department. Cut length of stay in the rest of the hospital, maybe we’d have our beds, and he’d have his budget.”
Lethal Practice Page 6