What counted more was the look of fear I’d just seen on his face.
Gil Fernandez was terrified.
* * * *
My guilty pleasure was a log home. I’d found the place years ago. Originally it was a simple cabin more than fifty years old, lovingly constructed on the edge of an isolated mountain lake surrounded by eighty acres of forest. Janet liked to tell people that I had taken her there before I ever took her on the ritual visit to Mom and Dad. We’d modernized it with carpeting, electric heaters, a pool-size bathtub, and, for real luxury, an indoor toilet. Later we added a large addition and ended up with a log and glass home well over a hundred feet long, full of spacious rooms with high ceilings and magnificent windows. Janet had assumed total control over the kitchen and melded a full collection of electrical appliances with the woodstoves. The lady and the lumberjack was what Janet called us when we were there. More important, it was a sanctuary, a place to find intimacy and laughter, a healing place.
It was also where I kept a computer and fax machine, and was the hideout I retreated to if I needed to do more than an hour of uninterrupted work.
I’d gone home to pick up Muffy and then headed south out of Buffalo toward the mountains, all the while trying hard not to think of the mess and horror I was driving away from. I passed through the clutter of junkyards and failed industries that ringed the city. They formed an urban garbage heap tossed farther and farther out. Even when I reached the countryside there was no clear break. From the highway I could see a jumble of trailer homes and cheap new bungalows built up on top of the broken-down farms of the previous generation. In turn, the grandchildren playing on this land in the dusk would only know how to farm welfare. I caught a glimpse of an old man staring out a window at the barren fields. Probably he’d once made them rich with food. I was willing to bet that in the background a TV flickered, showing pictures of starving kids somewhere in the world.
Starving kids. Suffering kids. Corridors full of suffering people. I couldn’t shut out the images or associated thoughts. Hurst. Back in my office I’d figured if he was trying to frame me because he’d murdered Kingsly himself, then the whispering caller had to be someone else. But who? And why? I’d been so sure it was Hurst telling me to back off my attempt to close the ER. Could someone else be that angry about it? One of Sean’s surgeons upset about the loss of income? Or even one of my own doctors? Could any of them be that crazy about money? Perhaps crazy enough to set a pair of Dobermans on me? Dammit! I was starting to let what I didn’t know panic me again. If I was ever going to get out of this mess, I had to stop jumping to conclusions and think clearly.
I reined in my wild thoughts and focused on something familiar. In medicine, when faced with a set of symptoms and signs, we lay out a differential, a list of all the possible diseases that could cause the initial facts of the presenting sickness. Then we do tests to get more data, and in the end we look at which diagnoses fit most of the facts and which don’t. I tried to apply that process to my current problems.
Singling out Hurst had only led to confusion. It was time to do a differential, consider all the other possibilities, including the chance that Hurst was neither the killer nor the person on the phone. All I knew for certain was that he’d made sure the police included me on their list of suspects and he was ramming through an illogical set of bed cuts. The rest I’d assumed. Even about the warning. Now that I was thinking diagnostically, I realized back off hadn’t necessarily meant back off closing the ER. I’d have to keep an open mind there too.
Up ahead I saw some hot-dog stands come into view. Faded and rust-chipped, they cluttered the edge of the highway like litter. They had Drink Coke signs from the fifties that would have been trendy in some downtown establishments, but here they simply marked when the progress had stopped. I couldn’t buy a drink. These concessions had closed for the winter. They looked just as dingy in summer, and I never stopped then either.
I let my mind drift onto other possibilities. Images of Fernandez’s desperate expression returned to blur in with the passing roadside and persisted on the edge of my thoughts. I made a try at including him in my differential. He had looked relieved when Hurst announced Kingsly’s death and not called it murder. Then that relief seemed to vanish when Bufort had revealed it was murder. Again behavior perfectly consistent with a killer whose cover-up initially seemed to work and then failed. Exactly what I’d thought earlier about Hurst’s behavior.
But now I wanted to think critically and avoid easy conclusions. I was going to have to get used to thinking about murder in this familiar, clinical way.
I continued my new application of an old skill, more for the practice than any real hope it would get me anywhere. There could be other explanations for Fernandez’s symptoms. His apparent mood changes could have been coincidental and stemmed from some other unrelated nightmare. His wife might have announced she had a lover, or one of his kids been diagnosed with cancer, or even a malpractice suit been threatened against him. And some things about Fernandez didn’t fit the diagnosis of him being the killer. Even though his initial calm had vanished, he still hadn’t seemed more obviously upset than the other chiefs when Bufort finally did say Kingsly had been murdered. And why was he panicking now, after Bufort had clearly indicated suspicion was primarily on the ER and those few doctors in other parts of the hospital who could needle hearts? Fernandez might have gotten some rudimentary training about how to administer an intracardiac injection during medical school, but as Sean said, that would hardly be enough to give him the means of murdering Kingsly now.
Occasionally mist drifted across the liquid mud fields on either side of the road. Sometimes it glared in my headlights and hid the dirty pavement snaking out in front of me.
There was hardly any traffic. In my rearview mirror I could see only a single pair of headlights keeping a steady distance. I was glad the driver was being cautious; I didn’t want any tailgater humping my car in a fog patch.
By this point in the familiar drive, I’d usually left thoughts of the hospital far behind. But I kept obsessively turning over why I had an uneasy feeling I was missing something about the murder, a connection I was sure was there but had eluded me so far. About Fernandez? I didn’t seriously think he could be the killer. But had I forced a case against Hurst to avoid adding the real night-mare possibility to my differential diagnosis—that the killer might be a member of my own department? Again the thought of unchecked suspicions about my staff that I couldn’t control sent a chill down my back.
Finally the road left the sodden flatlands for some real rock and pine turf. Climbing one interminably long hill, I was suddenly above the fog. A full moon rippled the mist lapping around the bases of floating hills. It was the first sky I’d seen in more than a week. I opened the window and inhaled deep breaths of clear, frosty air. I laughed and woke up Muffy, who immediately scented the wild. She sat panting expectantly, ready to run out her hunting fantasies in the night woods. I ruffled her ears and got licked in return. Thoughts of murder started to subside.
Soon I slowed for our turnoff. It was foggy again, and remembering the pair of lights behind me, I quickly left the highway for the narrow dirt road leading up to our lake. As I started the climb into the deepening mist, I saw in my rearview mirror the passing taillights of a large square-ended van continuing north through the night.
The road was rutted hard in the mountain frost, but I preferred it to the mush we had left behind. Pointing up the incline, my lights tunneled through swirls of bare tree branches awaiting winter. The beams exaggerated the bouncing motion of the car and gave our progress the feel of a boat plowing seas.
A few minutes later I pulled into the graveled parking area and was met with the glare of the automatic floodlight snapped on by movement sensors picking up our arrival. Muffy was unrestrainable. As soon as I got my car door open, she bounded out and happily ran into the woods. I struggled with the computer printouts and made it to the front door before the t
imed light went out and left me juggling keys in the dark. Door open, I plopped the paper stack on a rickety antique entrance table more suited to delicate riding gloves than the pounds of data encumbering a modern man. But the table was a favorite of Janet’s, so there it stayed. Then I switched on the lawn lights and stepped back outside.
The grounds were a lacy mélange of vapor and backlit trees. The only sound was from the distant creek, the rush of its swift currents defying the coming winter to turn it into ice. Muffy trotted up and put her head under my hand for an ear kitzle.
Our breath joined the general haze. As I turned to put her in the house, the first flakes of a light snow began to fall. In minutes I’d chucked my intentions to work and was asleep under a skylight framing diamonds and mist.
I have no idea what time Muffy went on alert and roared out of the bedroom down to the front door. But the ferocity of her bark told me we had a night visitor. Raccoon most likely. The barking raged on. I mumbled, “Good girl.” and went back to sleep even before she finished her tirade to scare them off. Good riddance. Raccoons made a mess of the place.
* * * *
I wouldn’t call it first light. This time of year it was a lighter shade of gloom. But it was enough to signal my sleep-sogged brain it was time for coffee and a start on the computer with my stack of stats. The coffee was easy—a form of yuppie instant that involved pouring boiled water on fresh grounds, waiting a few minutes, then pressing down on a plunger. It was the only piece of kitchen equipment Janet let me use. She considers me so technically challenged, I’m banned from cooking.
My first sip coincided with a glimpse through the large windows that surrounded the oversize kitchen. The lake was black, but covering everything else was a powdering of snow. In a magic instant the brown month had been banished and made over. It was one of the annual landmarks of life, the first snow. It never failed to lift me from adult routine back to childhood, inspiring me to play and infusing me with a sense of sweet freshness in which all was possible again.
I was still wearing a smile as I lit some kindling in the kitchen woodstove. It performed like a furnace and was the fastest way to cozy up this end of the house. My computer room was directly above on the second floor, and I wanted it warm up there. When the crackle and scent of wood smoke assured me the fire was well started, I went to the front entrance mudroom to get the printouts. Muffy, monitoring me out of a half-raised eye, saw this move as interesting to her. She arched in a leisurely poodle stretch, then pranced to the door to be let out.
Absently, I reached for the knob, then stopped. Outside on the wooden stoop and stone pathway the white dusting was already beginning to fade. Still visible was a set of footprints. They came up to the door, turned, and retreated back down the path.
Chapter 8
I held my breath. Muffy, sensing my alarm, went still, listened, but didn’t growl. I let myself slowly exhale and tried to rationalize. My prints from coming in? No, the snow had started just after we arrived. Hunters were a constant nuisance, but they stayed away from the cabin, out of sight.
The chill of the simple truth sank in. Someone had tried to break in on me. Only Muffy had made the difference.
Her lack of concern now was reassuring. Whoever had been here was gone. But the footsteps were a slash across my earlier mood. Isolation was stark and beautiful, but the wilds were also a place of menace and natural violence. Yet in nature there was reason, usually. Bears lived in the next valley over, but, unspoiled, they stayed away. I’d always felt more people were killed in gun accidents than bear attacks, and so I never considered arming myself. Against human menace, the long drive in was both protection and a trap. Shutters on the windows and a chain gate over the road discouraged casual vandals. To a real creep intent on trucking the furniture away, however, we were vulnerable. But they were cornered if seen. Our defense had come down to a couple of BEWARE OF DOG signs and letting Muffy roar her head off at unwanted guests. Sort of security by the Wizard of Oz. It was damned effective too. I even left the chain down most of the time. It fooled hunters into thinking we were there, and Muffy had actually chased them off enough times that they were too scared to find out for sure. Those prints, however, already fading with the melting snow on the darker stones, were mocking me. A hunter wouldn’t come to the door. A kid looking for a place to throw a party, or an intruder with a more sinister purpose?
I know. Doc. I know it’s you. You’ve had your warning. Back off! I felt a chill again, remembering the dogs. But there were no paw prints anywhere.
Why would I be a target? I didn’t know who had killed Kingsly, or why, and I hadn’t a clue how the murder had anything to do with me. That hadn’t meant much to the cops so far, thanks to Hurst, but it sure should have been clear to the killer, and keeping me alive would be what made sense, as long as whoever it was knew I was a suspect.
I was probably overreacting again. It was pretty farfetched to think the footprints had anything to do with the murder at all. Maybe they were made by a common thief here to steal a VCR.
Nevertheless, I put Muffy on her leash to keep her near me until I made sure no one was still hanging around. We stepped outside. It was frosty, but the footprints disappeared where the graveled parking area ended, and the darker cinder road had already melted the snow. Muffy showed little interest. The hard surface refused to even hint where the intruder had headed. I shivered, this time because I was still in a robe and slippers. I let Muffy off her chain. Me, I needed the warmth of indoor plumbing.
* * * *
I refused to let my paranoia chase me back into the city after coming all the way out here to work.
Besides, the respite offered by working on the QA data for the next three hours was the only remedy I had at the moment for my paranoia.
Carole had saved me days by entering the data for our major diagnostic categories on a floppy disk. It was pretty routine stuff, and if I needed anything more esoteric, I could still refer to the original printouts.
Studies of lawsuits had identified that two-thirds of screw-ups came from six types of problems: chest pain, abdominal pain, missed fractures, nerve injuries, intra-cranial bleeds, and meningitis. Knowing where to look before going in always makes the odds better to find our flaws and to learn.
These major categories were behaving as they should. The classic—chest pain—presented about a hundred and twenty times a week. In this group, only four, statistically and on average, would be real heart attacks, but the trick was to know which four, and which weeks were not average. Sixty would be cleared right off, and be sent home with acetaminophen for sore muscles or antacids for indigestion. But in the remaining sixty, there would be four heart attacks and four unstable anginas about to become heart attacks, statistically speaking. To find one MI, it takes a workup on fifteen suspicious chest pains, according to studies on centers that get it right ninety-five percent of the time.
Out of more than two hundred proven MIs, we had mistakenly sent home only five in the last year. One died at home. The other four, each feeling increasingly worse after discharge from the ER, had made it back to our door. One arrested in the hallway and failed to respond. The other three had survived.
Each case was a different physician. The chart review had revealed an error in judgment, not negligence, in all five cases. Statistically, this was all acceptable. Individually, I felt pretty disgusted knowing we probably would miss another five this year.
Abdominal pain shaped up miserably, as expected. Our initial diagnoses were wrong, or right, fifty percent of the time. This was a national average no one seemed able to better. It just was a reality that initial presentations of abdominal pain were hard to pinpoint and required repeated reassessments and follow-up to finally nail the problem. Knowing this, we could act with appropriate care. Two physician numbers popped out of the norm here. I had no idea who; a code kept identities unknown in the raw data prepared by medical records and submitted to the state health department. An individual physici
an’s performance would then be known only to that doctor and myself, after I analyzed the statistics.
While one doctor had been correct in diagnosing appendicitis one hundred percent of the time, another was only sixty percent accurate. The first physician was actually the more dangerous of the two. Every patient this doctor had diagnosed as a possible acute appendicitis actually had an acutely inflamed appendix when they were opened. That pattern meant only the most obvious cases had been diagnosed and the subtler presentations had been sent home. In a good center where appendicitis was not usually missed, a competent surgeon would usually have to open five bellies to find four acute appendixes, and would take out a perfectly normal appendix twenty percent of the time. The doctor whose initial diagnosis was always right had not been referring enough patients to surgery. Sure enough, further down in the study, this same physician had a disproportionately high number of unscheduled return visits with a ruptured appendix attributed to his or her code number.
The second doctor was calling everything acute appendicitis. As a result, he, or she, wasted time, tests, and money, and had subjected too many patients to the dangers of unnecessary surgery. Of course, an overeager surgeon was partly to blame here too.
I also noted another problem. Too often the diagnosis for abdominal pain was constipation. Repeatedly, I’d stressed to staff and residents that constipation was a symptom and not a diagnosis. It could be caused by anything from colon cancer to not enough fiber in the diet and, if it was unusual for the patient, indicated the need for further investigation in a follow-up exam. Obviously, the message bore repeating.
And so it went—injuries and deaths caused by our mistakes and errors dulled to the dry stuff of tables and numbers. Even then, whatever harm we did was statistically rare enough that we were no worse than physicians in other ERs. In other words, as long as we screwed up within national norms, we could claim enough competence to still go out there and perform.
Lethal Practice Page 12