Lethal Practice

by Peter Clement

  She’d seen enough to spot the reams of numbers and diagnostic codes that were our first ever breakdown of which doctors saw what problems on what shifts and with what outcome. And she’d been right about another thing. All of us were nervous and yet irresistibly drawn to this measurement of our skills, victories, and disasters. It was like a book of judgment, beyond excuses and denial. Some called it quality assurance. Some called it Big Brother.

  It was actually paper shuffling I’d been looking forward to, but my moment with our truths would have to wait. I locked the printouts in my desk drawer to prevent any of the other doctors from taking a premature peek.

  Then I headed for the mess out front. On my way back to the nursing station, I glanced into the resuscitation room and saw Popovitch at the right arm of a very pale woman who was sweaty and having a lot of trouble breathing. He had just threaded a long Swan Gantz catheter under her right clavicle, through the subclavian vein, and on into her heart. It was a more complex version of the technique James Todd had used on my patient Sunday evening.

  As I watched Popovitch’s practiced hands secure the line, the association between skills like his and the skills used by the killer spread over me like a stain of blood. While he was reassuring the gray-faced lady that the tip of the catheter would measure the response of her heart to the medication he’d given her to clear her lungs, I was wondering how many others besides myself would end up on Bufort’s list.

  Popovitch looked up and saw me watching him. Thank God he had no idea what I’d been thinking. “By the way,” he began, “I took care of that matter of Kradic leaving early.” He gave his patient a final check and joined me in the doorway.

  “Michael, am I going to get an angry note?”

  He winked. “I certainly hope so,” he answered, whistling the Godfather theme right after he brushed past me and started down the hall.

  The next hour took all my thoughts away from suspicion and murder.

  The ambulance ban I’d reinstated was helping. The staff could face the pandemonium knowing it wasn’t going to get worse. The surgical beds I’d commandeered and the reinforcements I’d called in cheered Susanne even more.

  “Thank God,” she said. “Oh, and you too, of course.”

  “Good to see you smile, Susanne, even if you are such a smart—”

  “Never mind!” She shoved a file in my hand. It was for a forty-year-old man bleeding from both ends. He’d heard daily aspirin would prevent heart attacks but had given himself a GI hemorrhage by overenthusiastically dosing himself. When I found his stretcher, he was pale and smelled fecal. Black diarrhea poured from his rectum while brown vomit the color of coffee grounds stained his pillows and nightshirt.

  “Oh, God, I’m going, I can feel it. Don’t let me go! I’m going!” His head thrashed around.

  “It’s okay. We got you.” Two IVs raced fluid into his depleted veins. I felt for a pulse at his wrist. Not much, but it was there. “You’ve already got a pressure,” I told him as I jacked up the bottom end of his bed to rush the blood in his legs toward his heart. “This will boost it even more.” His oxygen mask had slipped to his forehead; I slid it back over his nose and mouth. Two sacks of type 0 blood arrived and were being hung up on IV poles. For the moment his pressure was holding, and some IV cimetidine would probably keep him from bleeding. Hopefully. We didn’t have a monitored bed for him if he went shocky again.

  While writing my own orders at a free place on the counter, I could hear Popovitch behind me arguing with a junior neurosurgical resident. “Look, a thirty-five-year-old woman has the most severe headache of her life right after making love and is now slowly losing consciousness. This isn’t a postcoital snooze. She needs a CT of the brain in minutes and most likely neurosurgery in the hour or she’ll die.”

  CT is a specialized X ray used to diagnose hemorrhages of the brain. It had to be done quickly and with a staff radiologist or neurologist present to assure it was interpreted correctly.

  The resident stalled. “My staff man doesn’t like it when I interrupt his rounds upstairs.”

  Popovitch lost it. “Your lady has a subarachnoid bleed. If you don’t get your staff man stat and she deteriorates, he will kill you. If he doesn’t, then I will. If after that there is enough of you left to have a career, we’ll both finish that for you as well.” The CT was under way within three minutes.

  “Good teaching, Michael,” I said over my shoulder.

  “If he reports me, flunk him.”

  I heard the nurses out in the hallway greet Sylvia Green, one of the doctors I’d called in to help. Recently back from her second pregnancy leave, she was another veteran known for her technical skills. She could get an IV line on anyone no matter how flat or inaccessible the veins. Her help was welcome anytime, doubly so today.

  After passing through the confusion and entering the nursing station, she gave a single comment. “Jesus Christ!”

  “Sylvia, a nice Jewish girl like you,” chided Susanne, handing her a chart.

  “Yeah, I know. After ten years in a Catholic hospital, I swear like a shiksa.” Sylvia grabbed the file, smiled hello at me, and went to find her patient.

  Twenty minutes later the resident who’d reluctantly obeyed the ultimatum to get a CT was back in the department, proudly showing everyone the films of the subarachnoid hemorrhage he’d “picked up in the ER.” Popovitch gently handed him the phone and suggested he get on with the transfer to neurosurgery. We got to hear him proudly arrange for life-saving “burr holes” and explain to some wide-eyed students how these would relieve the pressure of accumulated blood on the brain. Popovitch gave me another wink.

  Within an hour the place was calm. Well, relatively calm.

  Jones had even managed to discharge a couple of patients with abdominal pain. Instead of lying in the corridor with nonacute abdomens and borderline blood results while waiting for a trial of oral liquids, they would do their “observation” at home and be reexamined tomorrow morning in a follow-up clinic. Ironically, they were safer out of the ER. Should something go wrong, a vigilant family member would pick up a change for the worse and get the patient back to us faster through the front door than one of our busy nurses might notice them go sour in a rear corridor. With this degree of overcrowding we were in danger of finding patients dead in beds.

  Susanne had a mental filter like mine—get to the important stuff; ignore the crap—and she showed it now. “Oh, I forgot,” she said. “Hurst’s secretary called and left a message. You’re to meet him in the boardroom at ten-thirty.”

  I stiffened. I was going to have to be very careful in my dealings with Hurst. From now on there would be no business as usual, and I’d have to decide whether I should report my suspicions about him to Bufort. I glanced at my watch: 10:40.

  “Susanne!” So much for time to plan. Now I’d have to improvise my way.

  “Hey, we needed you more. You can’t save lives from the boardroom.”

  “I’m in enough trouble—”

  “So what difference does it make? And before you run off,” she added, stopping me as I was halfway out the door, “we got another DOA last night, a bag lady. MAS figured we’d still have room in the morgue.”

  My mind was already preoccupied trying to piece together a way to confront Hurst in front of Bufort, but I tried to pay attention. “Another one?” I asked. Two DOAs in as many days was unusual. “Any idea what killed her?”

  “Probably exposure, alcohol, whatever—like the rest.”

  “Is the paperwork done?”

  “Yeah. We sent her right down to Watts. Funny, he seemed hot to do a full post on this one. Go figure.”

  “Really?” I winced again at the dressing-down I’d gotten from Watts for my stupidity over yesterday’s DOA, then remembered something.

  “Dr. Watts thinks if the numbers of vagrant DOAs really are up all over the city,” she explained, “the medical examiner’s going to push for thorough autopsies to find out what’s killing more
street people than usual.”

  Deaths could be caused by new batches of lethal crack or bad hooch. It was important to find the latest poison of choice and issue a strong warning. If Watts was willing to add another extensive autopsy to his workload when he was already so busy, it was because it was a hell of a lot more legitimate than chasing after moles. Even for autopsies handled in a pretty cursory fashion, many of the DOAs were sent straight to the city morgue.

  “Did he say anything about the one from yesterday?” I asked.

  “Not specifically, but it was getting two within twenty-four hours that seemed to get him so stirred up.”

  Despite the ban, two more ambulances rolled in. Susanne turned to real work, and I headed off to my meeting with Hurst, trying to plan my next move with him and Bufort as I went.

  * * * *

  I was surprised to see it was the detective himself who had the floor. He paused politely as I took my seat. From the poleaxed look on a few of the chiefs’ faces, I presumed he’d just announced that Kingsly had been murdered. The others in the room looked appropriately somber, but their lack of surprise probably meant they’d heard the gossip. Hurst, however, was taking a showy look at his watch and all but tapping the dial to make sure none of those assembled missed the outrageously late hour of my arrival.

  “I’m late because emergency’s a mess!” I snarled, unable to control my anger at him. I noticed some of the chiefs exchanging concerned looks, probably afraid that we were going to continue our fight from yesterday morning.

  Bufort seemed kinder. “I was just running through what we discussed in the morgue. Dr. Garnet.” He sounded respectful, as though we were colleagues and I was his chosen confidant. But it was bull. I knew Bufort was mocking me with his politeness. The little smirk playing at the comers of his smile made sure I remembered what he could put me through if it suited him.

  I felt livid with both of them, but took a seat without saying anything more.

  Bufort continued speaking, describing the problems of investigating a homicide in a hospital. Just conducting brief interviews with everyone who’d been on duty Sunday night had taken over twenty-four hours. The site of the actual murder was still unknown. Combing Kingsly’s office for prints or other traces of the killer had been fruitless. It was particularly confounding that the body had been washed. When he got to the autopsy results and how the killer clearly knew how to needle hearts, everyone shifted away from me.

  He advised us his department would issue a brief press release later in the day, but if reporters approached any of us individually, we were to refer them to the police or to the hospital spokesperson. We definitely were not to discuss any details of the case with the media.

  Despite the urgency in his voice as he chronicled all the difficulties they were facing, that annoying little smile kept reappearing. Whatever game he was playing, he looked exceptionally pleased with himself. As if he had an ace up his sleeve.

  On the other hand, Riley was sitting at the back of the room, staring up at the ceiling tiles. Even from where I was sitting I could see his jaw muscles repeatedly quiver and tense. I’d begun to suspect this younger detective had little patience with his boss’s preening. If Bufort was the kind of man who demanded stroking from his underlings, he certainly hadn’t gotten any show of adoration from Riley—at least not in my presence.

  In any case, even without his junior’s encouragement, Bufort built to his climax. “And so, gentlemen, we must expand our investigation, and as you can see, we need your help.”

  He didn’t look very needy to me.

  “Detective Riley will arrange a meeting with each of you to discuss any new information you may have, any further thoughts since our preliminary interview, any rumors you’ve heard about the killing of your CEO. We particularly want to hear about possible motives for Kingsly’s murder.”

  I repressed the urge to shiver. So, Bufort was going to open up the hampers and turn over the carts and spill our dirty laundry all over the place. I felt sick; so did the other chiefs, judging from the expressions on their faces. But Bufort clearly was pleased with himself. I squinted at him. Damned if his hands didn’t seem to be fidgeting as if he were trying hard to keep them from rubbing together in glee. The stocky detective with the big ego could have been funny—if I hadn’t already experienced the menace that accompanied his determination to jump to conclusions. Was he the kind of cop who, right or wrong, was more concerned with getting a conviction than finding out the truth? If so, then my own innocence, or anyone else’s, might not matter much to him. As I watched him stride out the door, I couldn’t help worrying about how thorough or scrupulous his investigation would be once he settled on the first available suspect and saw a chance to keep his solution rate intact— especially if Hurst was trying to feed me to him.

  I decided telling Bufort an anonymous caller had whispered I know it’s you wasn’t a good idea right now. He might agree. Nor was I any more encouraged by the troubled expression on Riley’s face when he looked over at me before he rose slowly from his chair and walked out the door, shaking his head.

  The other chiefs continued to look tense, and a few talked quietly together as they got up from the table. Hurst left the room without a glance at me. There wasn’t the slightest hint of the kind of malice I’d felt listening to that whisper on the phone. Still, even if Hurst couldn’t get me charged with murder, he probably was angling to get me to resign. In fact, he was probably tempted to accept resignations to get rid of all of us. With troublemakers like me gone, he could approach the young guys and offer them their jobs back. Then he could reopen emergency with a staff of novices who didn’t oppose him. But even he must know emergency couldn’t survive the loss of all our experienced physicians. At the very least, he’d have to do a lot of explaining, especially when our sister hospitals made him look like an idiot by snatching up our best doctors before the next shift.

  On the way back to the ER, I stopped at the vending machines near the front of the hospital and pushed enough buttons to win myself a hot chocolate. I didn’t have a clue who had killed Kingsly, let alone why. Nor could I figure out what Hurst was really up to, but for the moment I had to stop dwelling on it and try to face my more immediate worries in the ER.

  The machine whirred and sputtered out my order. Trying not to spill the hot brown liquid, I had turned toward emergency when I saw what was left of the Cummings family approaching me in the corridor. Their vigil was finished. A brother supported his brother’s wife. She was clutching one of those obscene plastic bags that hold a patient’s belongings when it’s over. At their side walked two small girls.

  I froze, wanting to escape, but on they came until they were right in front of me.

  Mrs. Cummings tried to speak, failed, and my own mouth went dry. Then she swallowed harder and reached for my hand.

  I flinched and almost jerked it away. I knew what was coming.

  “Thank you,” she managed to whisper. “I know you did all you could.”

  The little girls watched me from behind their mother’s skirt. Despite myself, I imagined first one, then the other of the girls held high in her daddy’s warm, comforting hands. Now Donald Cummings’s hands drooped cold and purple from the stainless gleam of an autopsy table— and we’d put him there. The charts of his case would probably show we were watching his blood pressure while waiting for a bed, because shock was a risk, but an acceptable one, with streptokinase. Yet on this day we hadn’t caught the drop, and two little girls had lost their dad, all within the standards of conventional care—if you didn’t count Hurst’s bed closures as the real reason it happened.

  Mrs. Cummings still held my hand. I gently withdrew it, mumbling words of consolation. Then, I have to admit, I fled.

  I didn’t have the stomach to face the ER at the moment, so I went to my office by a back corridor. Carole had begun storing our interminable memos, minutes, reports, and written recommendations—good intentions on paper—in her computer to save space
, but the changeover had produced more printouts than I’d ever seen before we’d started putting shelves of words on disks. Her desk was scattered with these leavings, but she was out, probably generating even more copies of copies. I was glad for the moment alone.

  I leaned back in my chair and thought about the reams of numbers and coded outcomes of the ER study that now lay locked in my desk. There I would probably find a small number of catastrophes like Cummings, and a few cures. But mostly there would be draws, stabilizing patients by the book and buying them the time they needed for healing.

  I entered Cummings’s name in our mortality review list. The recorded verdict would be “unexpected” and, depending on the size of the guy’s original infarct on postmortem, probably “unavoidable death.” The delay in getting a bed in the cardiac monitoring unit would be noted; the importance of monitoring blood pressure while using streptokinase would be reiterated. Then memory would fade until the cuts exacted another life. In a way, those cuts were as much murder as plunging a needle into Kingsly’s heart. The computer printouts held all our ghosts ... except one.

  * * * *

  Paper wars, paper cuts. The injunction arrived at 11:10 forbidding any organized withdrawal of service.

  Hurst! The son of a bitch had thrown lawyers into our mess. And I’d been stupid enough to be caught by surprise. The injunction would take hours to unravel. Worse, we would need even more lawyers.

  The server, a little man in a big-shouldered raincoat, smirked at me. “You weren’t expecting that, were you?”

  I was stunned; he actually liked his work. As I held the unfolded legal sheets in front of me like a scroll, I realized all at once where he was headed.

  I ran out of the office and into the ER yelling, “Hey, you!” Nurses and patients recoiled as if I were the latest psycho dumped on the ward. But I was too late. The little guy with the Joan Crawford shoulders was disappearing out the far door. Popovitch and Jones, papers in hand, looked as if they were about to have heart attacks.