Lethal Practice

by Peter Clement

  I greeted them all by their formal names, since I remained an intern in their eyes. Three of them nodded, but all I got back from Jack Graham was an accusing silence.

  I passed the very stool at the coffee counter where, as an intern those same twenty years ago, I’d received a hurried cup of coffee and a five-minute orientation from the chief resident. He had raced back to the OR and I walked into emergency for my first shift under Bessie’s ample wing. Now I was at the halfway point of my own journey toward the day when one of my current residents would probably tell me the ride was over, that it was time to go home. Would I blame the younger doctor, or only the bitter irony?

  “Jack still hold you responsible for his old age?” It was Watts, sitting alone at a table, apparently amused at what he’d seen.

  “Hey, for time itself.” I noticed his half-empty cup of coffee and an open sailing magazine by his elbow and invited myself to sit. “How’s your dream machine coming?”

  “Going to be ready when the spring ice goes out, and I’ll be out of here with it.”

  I paused with a spoonful of soup halfway to my mouth. “That’s bad news.” I meant it. I didn’t relish surviving the rampant rise of hospital bureaucrats without his deflating wit and clinical savoir-faire to keep some vestige of sanity. I also knew his term had two more years. “Why?”

  “I’ve had it. My Christmas card this year will include my resignation. They’ll have till spring to find my successor.”

  There was a heaviness about him that didn’t surprise me. He’d vigorously carried the load of being the hospital’s conscience for thirty years. As keeper of the final diagnosis, he had wielded his knife with a passion to improve care and learn from the verdicts: correct or incorrect, right or wrong, unavoidable or avoidable death. There was no appeal, and no one escaped his theater of judgment. Watts had been our gatekeeper.

  All of this had changed forever when his wife died. He still did the job, but his passion and his quiet joy in excellence were mostly gone.

  “Some investments I made came through,” Watts added. “I’m expecting some more final dividends soon. I don’t need the next two years. Enough’s enough.”

  There was a bleakness now to his plan in contrast to the same dream he had expressed to me at a happier time three years ago. He stared at the photo on the open page, a sailboat ad, with a robust gray-haired man and woman at the wheel of a yacht on open seas.

  My bagel tasted dry. “What was bothering you at the end of today’s meeting, Robert?”

  His double-take startled me. “What do you mean?” he asked.

  “Your look. At the end of Bufort’s soliloquy.”

  He shrugged as if he didn’t know what I was talking about.

  “C’mon, Robert, I’ve seen that look before. Your nose was definitely out of joint—and that’s something, considering what your nose puts up with. So what was it?”

  He sat completely still, like a card player weighing his hand, trying to decide whether to play or fold. Finally, he said, “It shook me that an attempt had been made against you.”

  I waited for more.

  “Hey, that’s it! I swear! It’s one thing to do what I do to strangers. It’s another when a pal threatens to become one of my patients!”

  He sounded sincere, but I didn’t believe him. I also knew pushing him wouldn’t help. Over the years I’d seen how stubborn he could be once he decided something.

  “What about the derelict?” I asked instead.

  He seemed relieved to change the subject. "Funny, that. The tox screen was nonsignificant apart from his maintenance level of alcohol, but it was alcohol, not some cocktail better suited for cars.”

  He meant no antifreeze or methanol.

  “I don’t have the trace-element levels yet. We send them out to another lab. The rest was negative, pretty much.”

  “Pretty much?”

  “Yeah. He had hay fever, but some rookie, probably in a street clinic, thought it was a cold.”

  “You might diagnose chronic allergies from tissue samples on a post,” I answered, “but find out the thoughts of people he met too?” I knew it was my expected role to play incredulous. I was going to be taught something.

  ‘Traces of terfenadine and a touch of erythromycin.” He leaned back with a smug smile.

  I saw what he meant. Terfenadine was a hay fever medication, but alcoholics living on the streets usually spend what little cash they scrounge on booze. The John Doe must have gotten a clinic sample. Erythromycin was a form of penicillin especially for people with a penicillin allergy. It took a prescription, and only a rookie would have given antibiotics for hay fever or been browbeaten by a patient into prescribing them for the symptoms of a viral infection that hay fever might mimic. Worse, a precautionary had been issued against giving the two together. Fatal arrhythmias had occurred with little more than therapeutic doses.

  “Do you think it’s a drug-induced dysrhythmia?”

  “No. But you’re right to think of it. These things rarely leave footprints. His anatomy and conduction pathways were normal, and the rest of the drug screen was negative. However, you’re forgetting another little feature in this guy’s heart that was a lot more obvious cause of death.”

  He made a stabbing motion with his finger over the left side of his chest. “The slides of tissue samples along the needle track show extensive intracellular bleeding and none of the degenerative changes I’d expect to see if the needle went in postmortem.”

  In his own inimitable fashion Watts had made a clinical description of the stark way the DOA had died. The needle had gone into the beating, healthy heart of a very live man and then killed him, fast. The mechanical effect of the tip or something injected had stopped his heart cold. Either way, it was murder. The needle definitely hadn’t gone in after he was dead. He had been killed just like Kingsly.

  “Did you tell Bufort?”

  “After our last encounter? Fuck him. I’m submitting my written report as required.”

  He surprised me; revealing nasty news to people bent on keeping their illusions was Watts’s specialty. Besides, this morning Bufort had seemed pretty resigned about what Watts was going to find.

  “Do you mind if I do?” I asked. Bufort needed to know as soon as possible.

  He hesitated, then replied quietly, “Be my guest. By the way,” he added, “I’ve called a few of our sister hospitals to see if anyone found cardiac needle tracks on any other DOAs, and I suggested that they keep their eyes open.”

  “My God! And did they?”

  “They haven’t had the chance. It seems the run has dried up for now.” He gathered his magazine, stood up, and said, “Well, back to work.” I watched him carry his tray to the rack by the door. He found a slot for it there, then smiled and gave me a parting wave. Always a teacher, he should have been restored from enlightening me. Instead, he looked worried.

  * * * *

  Fernandez wasn’t in his office. His secretary, dressed like Elvira, thought he’d gone home but wasn’t sure and obviously didn’t care.

  My tactical plan exhausted, I decided to head home myself for an early dinner and movies with Doug’s boys. I rescued my coat, which wasn’t any drier, except now it smelled bad and hung on me like a wrinkled foreskin.

  I peeked into emergency on my way out. I immediately wished I hadn’t.

  Sylvia Green’s eyes were brimming with tears. The nurses went quiet at my entrance. Everyone focused on the floor. It was embarrassing. I waited. No one spoke. Sylvia started to look more mad than tearful, and for that I was grateful. But it was clear that I had to be the one to break the silence.

  “Okay, everyone, what the hell is going on?”

  The nurses looked at one another, but still no one said anything.

  I turned to Sylvia. “Syl, are you all right?”

  She looked at me and decided on angry. “No, I’m not all right!” she answered, her eyes flashing. Wrenching a chart off the wall, she strode down the hallway to
her next patient.

  The silence only got worse after she left.

  “Look, I need to know what happened.”

  Lisa Gray, sheepish, offered, “It’s the killings.”

  “What do you mean?”

  She glanced at her friends for support. They continued to keep the floor under observation. Nevertheless, she went on. “Those two detectives, they got us all in a room and started asking a lot of questions.”

  Everybody got more intent on studying the floor, and I got angry. “What the hell’s going on here?”

  Silence.

  “Lisa!” It was a plea.

  “Okay. But promise you won’t be mad.”

  “Lisa!” More like an order this time.

  “Okay, okay! Like I said, they asked a bunch of routine questions. You know, how we work, how the shifts are arranged.” She shrugged. “They asked about the doctors. At first it was innocent, how you guys work your shifts, who works when ... that kind of stuff. Then they wanted to know who was really good with procedures, lines, that kind of thing.”

  “ ‘That kind of thing’ include intracardiac injections?”

  “Yes, but we didn’t know they’d use any—”

  “And you gave Sylvia’s name.”

  “Well, you know how good she is,” Lisa said defensively. “We’re proud of her.”

  “Any other names you were proud of?”

  “A few.”

  “Oh, Jesus, who?”

  She hesitated.

  “Lisa!”

  “Popovitch, Kradic, Jones, and”—she took a breath— “and you.”

  Now I knew what had been bothering Susanne.

  “It’s okay about me. They’re not interested anymore, but do the others know of the high honor you’ve accorded them?”

  “No, just Sylvia.”

  “Why?”

  “I guess she’s the only one they questioned.”

  “Questioned! Here? While she was on duty?” I knew the interviews would be scheduled at the convenience of the police, but I’d naively assumed they’d start with off-duty doctors and conduct the sessions in private, not ambush a doctor trying to run the ER at the same time.

  “No, not here. They took her to their interview room before her shift started. She told us what they asked about when she got back. That’s the worst part—they asked about her mother’s death.”

  I couldn’t have heard right. “Her mother’s death?”

  She nodded, and the incredulity of the other nurses matched my own.

  A year ago her mother had been admitted over Christmas with severe flu and aggravated heart disease. She’d come in with acute respiratory distress, cardiac failure, and chest pain. She was eighty-seven, and we prepared for the worst. To our surprise, she recovered and went home in a couple of weeks. Two days after that, she collapsed at home in acute pulmonary edema and arrested in the ambulance on the way back to the ER. When she got here, it was too late.

  It wasn’t that anyone had been negligent on discharge, but more could have been done. An echocardiogram to better assess the function of the heart and the use of an ACE inhibitor to reduce the load on the heart were options available but not taken.

  The echo had a waiting list from budget cutbacks. The additional medication simply hadn’t been thought about at the time.

  While neither omission was cause for a lawsuit, Sylvia had been bitter. I’d held her hand while we sat together in the nursing station. She’d told me how her family had been prepared for her mother’s death but gained hope again when she’d recovered, been discharged, and seemed to have beaten the odds.

  At that moment Kingsly had gone stumbling by. Sylvia had looked at his lurching backside and started to sob. “That’s the son of a bitch who cut the very echo time that might have made a difference. Maybe I could have had her a while longer. Just a little while.”

  I’d been unable to say anything then. Now I was furious that this moment would be used against her. And how did they know?

  I spun out of the room and went down to the examining cubicle, where I found Sylvia dutifully preparing to repair a gaping facial cut on a young girl.

  I waited until she finished replacing a dressing pad, then excused myself to the patient and led Sylvia out to the hall.

  “Syl, I’m furious. Those cops were way out of line!”

  “Damn right they were.”

  I put my arm around her shoulder and gave her a hug. “Listen, for what it’s worth, I’ll scream bloody murder to stop those jerks from harassing you and any of us around here.”

  She looked a little mollified. “Us?”

  “Yep, they’ve been on my case since Monday. At least they were until someone tried to run me over yesterday.”

  “Oh my God! I thought it was an accident. Who was it?”

  “I’ve no idea.”

  A slow, sardonic smile transformed the horrified expression on her face. “If that’s what it takes to get clear, I’ll settle for staying on the list”

  “I need to ask you something. When your mom died, who else did you mention Kingsly cutting the echo time to?”

  Her mouth became a hard, thin line before she spoke. “Hurst!” she snarled.

  * * * *

  I only half heard the PA as I walked out of the building. A code 44 was being called for nine west. Nothing unusual, a code 44 means a psychiatric disturbance and brings a gang of orderlies to restore peace, one way or another. I hear it announced a dozen times a day and never really pay attention.

  It was 5:10, and the parking lot was already dark. In the distance, low rolls of thunder mixed with the drone of commuters heading home. The resultant grumbling noise made this daily evacuation seem more desolate than usual. The air was something to be chewed before breathing.

  Lightning danced up the hospital walls, then left them invisible again in the black, but not before I glimpsed a lone bowed figure, like a cathedral gargoyle, on the roof of the west wing—the wing that had only eight floors.

  Nine west was the roof.

  The next flash caught a huddle of white figures creeping up behind the figure in the dark suit. In the dying illumination I saw the man step forward as calmly as if entering an elevator. The return to black enveloped his drop, but not even thunder could mask the wet, soft thud of his impact on the pavement ahead of me.

  Fluttering down after him in the soft descent of a wounded cardinal was a wisp of scarlet. A flicker of lightning caught its brilliance until it landed and disappeared in the spreading ooze of mud and blood.

  Chapter 13

  The chief of psychiatry leaping off the roof of his own hospital was the lead story in all Buffalo’s TV, radio, and newsprint media. Even the trashy tabloid Police News out of New York City, which usually focused exclusively on their own body count, led off page three with a wire photo of poor Gil’s remains—only the feet poking from under a sheet, of course.

  “Psychiatrist Jumps!”

  “Suicide!”

  “Killed!”

  The stories underneath contained a spatter of quotes.

  “He’d seemed distracted lately.”

  “He’d stopped caring about how he dressed.”

  “He hadn’t looked well recently.”

  Now everyone was saying they’d known something, but no one had done anything. In medical circles we called it the retroscope, perfect hindsight.

  I couldn’t read the stories. I kept imagining that moment when his brain was still cognizant of onrushing cement and inevitable death was milliseconds away. Was there time for a final no?

  Immediately the media recounted the details of Kingsly’s murder they’d been reporting for nearly four days. Most of them hinted at the possibility of a connection between the two deaths and left the question tantalizingly up in the air. There was no mention of embezzlement so far, but it would be a while before our story even got off the front page or was relegated to the end of a newscast.

  We buried Dr. Gil Fernandez that Sunday, and wit
h him, Bufort buried his murder investigation.

  The cemetery was a large green oasis around which the rest of the city sprawled. Covered with trees and slopes of mowed grass, it would have been the perfect place for families to have picnics—except there were a few centuries’ worth of tombstones. Rich and poor, black, brown, and white, people whose ancestors had come from far continents; all lay at peace together. It was the inverse of the American ideal—men and women equal in death, not quite having managed it in life.

  The questions I’d not had the chance to ask Fernandez thudded into my thoughts with each ritual toss of earth on the closed casket.

  Was the money in the unexplained account that Bufort found actually the surplus that Fernandez had bragged about so often? Was that what Fernandez meant when he’d boasted that psychiatry paid its own way?

  Was it dirty money, Gil? Otherwise, you would have stood up and proudly claimed responsibility for it and pulled Bufort back from a false lead. That’s what I finally realized was missing from our last meeting together.

  I also remembered Voyzchek requesting the emergency psych roster for last July. I’d thought it peculiar that she would ask us, because Fernandez drew up the psych on-call schedule. But had she noticed something, Gil, and wanted to check it out behind your back? Obviously Bufort had, and when he announced he was looking closely at the salary pools, you knew you were going to get caught. For fraud.

  A man of God started some words. Some more dirt hit the coffin.

  I thought I knew how it was done. It had to be with fee-for-service patients, and their care had to be government funded. Psychiatrists in a teaching center can bill both for patients they see themselves and patients the residents see in their name under their supposed supervision. So even legitimate billings to Medicare or Medicaid might not seem familiar to a psychiatrist looking at computer records six weeks later. They’d just put an unremembered session down to an uneventful supervision signed off to them by a resident. This happened a dozen times a week per psychiatrist. When billing records showed increased claims, no one would remember enough about the exact amount of their supervision activity to suspect an error. Supervision was sometimes done too much at a distance anyway, but residents liked the apparent autonomy. They got to play real doctor and erroneously rated staff who kept out of their way as “good teachers.” And it suited the staff. If their billing statements showed they did a lot of this “teaching,” in a university center it was the currency of tenure.