Neisseria gonorrhea.
Streptococcus pneumoniae.
Staphylococcus aureus.
From her studies, Donna knew they were nasty bugs, but nothing out of the ordinary for a hospital.
Campylobacter jejuni.
A commonplace pathogen ingested from undercooked beef or chicken that could cause enteritis, or the runs. Easily treated with ciprofloxacin.
Salmonella.
Shigella.
More serious causes for the runs. Quick to act, would have victims shitting blood, but again, readily treated.
Escherichia coli 0157:H7.
Oh, oh. This one was trouble.
Her memory spit out the pathogenesis. As few as ten organisms could cause an infection. The symptoms were puking and pouring out bloody diarrhea within forty-eight hours. But it was the toxins released by these particular bacteria that could really hit the victim. Ten percent of the time they produced a nightmare condition called hemolytic uremic syndrome by attaching themselves to receptor sites on the inside surface of a patient’s blood vessels. This would cause red cells to rupture, platelets to fall, bleeding to increase, kidneys to fail, and the brain to seize. Once it got that far, the victim had a 50 percent chance of ending up on dialysis and at least a 5 percent chance of winding up on a slab in the morgue. For Escherichia coli 0157:H7 was the organism responsible for what the media called Toxic Hamburger Disease, but it could also be transmitted in water.
At least, that was what she remembered reading in her books.
Troubled, she went over to check out the incubator. Everything seemed in order. But other than going through each culture to see which had had a scoop removed, there was no way of knowing which dish had been sampled, or why, or even if there was anything amiss in what had been done. Perhaps it was only a graduate student doing research who needed a specimen of a particular organism for some project.
One thing was certain, she wasn’t going to say anything. Otherwise, she’d have to explain why she’d been in here.
Her beeper went off, and she jumped, the high-pitched signal splitting through the quiet like a burglar alarm. The tiny message plate indicated the telephone number for ER. They’d need bloods drawn and analyzed or urines spun and looked at under a microscope.
But first, she had to find a bathroom. And her glasses.
Chapter 10
Later that same morning, Tuesday, November 20, 8:10 A.M.
Geriatric Wing,
New York City Hospital
The aroma of a geriatric ward in the morning always got to Earl. It wasn’t just the hint of human waste mingled with the smells of coffee, eggs, bacon, or other offerings on the breakfast menu – he encountered those every day in ER. It was the staleness of the air. It seemed as locked in as the patients, and had both a sour and soapy-sweet odor that hung heavy, a pungent reminder of failing flesh.
As he made his way toward the reception desk through the flow of orderlies, nurses, and elderly patients, a young woman of medium height dressed in a jogging outfit stepped up to him and eyed his identity badge. “Ah, Dr. Garnet. I’ve been expecting you.”
Her shaved haircut made him wonder if she’d either had chemo, treated herself for lice, or done a recent stint in the Marines. Her ID read NURSE TANYA WOZCEK.
“Hi,” he said, shaking her hand. “Are you one of the people taking care of Bessie McDonald?” From her civies he figured she was off duty.
“Yes, I’m also the only staff person willing to talk with you. Want a coffee?”
“What?”
“Do you want a coffee?”
“No, I mean yes, I do. But what’s this about there being no one else-”
“First, I suggest you see Bessie and speak with the resident who was on duty the night she became comatose. He’s with her now.” Without giving him a chance to reply, she led the way down the hallway, navigating between the shuffling men and women in housecoats, most inching along with the aid of walkers. “You and I can speak afterward,” she added, glancing back at him over her shoulder.
“But what about the other nurses-”
“Everyone knows you’re investigating something in connection with Kelly McShane’s murder and that it involves Chaz Braden. They aren’t willing to speak out and risk his reprisals.”
Caught off guard, Earl reflexively went on the offensive. “Who told you such nonsense?” Damn that talkative Lena Downie. She must have spilled the beans after all. So much for keeping his interest in the case on the quiet side. But maybe he could still bluff it out. “That kind of rumor is far from helpful-”
“Come off it. We figured it out as soon as the request to see Bessie’s charts for 1974 came through. Since Chaz Braden was her doctor at the time, and the coroner who made the application for the files is the one investigating the killing – it wasn’t hard. What we can’t put together is the tie-in between Kelly’s death and Bessie.”
“Oh?” It was all he could think of to say.
She punched in a code on an electronic lock and let them into a small kitchen. Within minutes he had a styrofoam cup filled to the brim with steaming black sludge – what his residents would have called a real stomach-stripper. Not even a triple milk and double sugar helped tame it any. He took a sip to be polite, trying hard not to wince.
“I want you to know Bessie was fine when I went off duty that night,” she said, pouring a coffee for herself.
“Okay,” he said, indicating with a shrug she should elaborate as they continued down the corridor.
“It doesn’t strike you as odd? The newspaper article confirms that Kelly’s remains are found, and within twenty-four hours, Bessie is in a coma.”
“Now wait a minute. Surely you’re not insinuating-”
“I don’t like coincidences!” She ran a hand over the stubble on her scalp. “Especially convenient ones.”
Earl didn’t like coincidences either. Most doctors didn’t. But he’d also an ingrained aversion to melodrama. “If you’re suggesting what I think, isn’t it a little over the top?” He’d lowered his voice, passing a couple of nurses who seemed to have stopped what they were doing and grown very quiet. “Could we perhaps have this conversation where it’s a little more private?”
Tanya’s drawn face relaxed into a smile. “Of course. Sorry.” She turned her attention to the gray, loose-skinned inhabitants who wandered the place like ghosts, greeting them by their first names as she made her way along the corridor.
An old lady, drooped over in a wheelchair and mumbling to herself, lifted her head and responded, “Morning, Tanya.” A food-spattered hospital gown lay draped over her like a drop cloth.
An elderly man wearing oversize trousers held up by red suspenders leaned against the wall, his hands resting on the head of his cane. He gazed blankly at her, clearly not recognizing who she was, or perhaps it was the sound of his own name he found perplexing.
All along the hallway wrinkled features brightened into wispy, almost hopeful smiles, as if the sound of someone calling them had penetrated the gray limbo where they lived and ignited the flicker of a shared dream. At last someone they knew had come here and would take them home, back to where they could remember.
Heartbreaking as this was to witness, Earl liked Tanya’s tenderness toward her patients. She could engage the remnants of whoever they once were with a warm hello or bestow a moment of dignity on them simply by addressing them with respect. Too many doctors and nurses burned out in what the cynical called “exit medicine.”
“As to what I’m suggesting,” she whispered, once they reached a section that was free of her coworkers, “I know it sounds off the wall, but I’m just so upset. She was my patient for the last three months, and I really grew to like her. We don’t get many who can actually make it out of here, and she had a chance to end her days in style, compared to the dead ends that await these other lonely souls. Around here, that’s like a little miracle, and I got caught up in it.” She turned and stared him right in the eye, her
intensity startling him. “So let’s just say I want to make sure you consider all the possibilities before you conclude what happened to her.”
Strange woman. Intense, even a touch paranoid perhaps, but sincere. Maybe she thought she’d missed a subtle clinical sign or dismissed something Bessie McDonald had said that might have warned of another stroke being imminent. Sometimes grasping at impossible scenarios was easier than admitting a mistake, especially a near-lethal one. “You’re positive Mrs. McDonald was okay? The harbingers of throwing off emboli can be very subtle, as I’m sure you know – a little shadow on the visual field, transient numbness or weakness in a limb-”
“She would have told me. She was a physician, a GP.”
The news took Earl by surprise. “Nothing on her chart indicated she was a doctor.”
“She wouldn’t allow it, nor us calling her doctor.”
“But why?” Any patients he’d ever had who were physicians usually trumpeted the fact to everyone and anyone who came near them, as if it was a Visa or MasterCard for special treatment.
“ ‘Makes people nervous, and that’s why things always go wrong when an MD is the patient,’ she used to say.”
Earl shook his head. He felt the same way, but had never prevented his profession from being stated in a medical file.
“She was so set on getting to her son’s,” Tanya continued, “she never would have ignored any warning symptoms.”
Earl nevertheless resisted joining her flight of fancy. “There also might not have been any warning symptoms.”
“I know.”
“And she had a lot of risk factors. Another stroke isn’t improbable.”
“I know that, too.”
“So why the suspicions?”
She quickly glanced around. A few steps away a woman stood with a blank, dark-eyed stare on her face and her gray hair in wild disarray.
But no staff were in sight.
“Because I think Chaz Braden is a slimeball who’s capable of anything,” Tanya said, and continued down the corridor.
Earl hurried after her. “Care to elaborate?”
“Not really. If I get caught bad-mouthing the bastard, I’ll be out on my ass.”
“Then will you answer some specific questions by ‘yes’ or ‘no’?”
“Depends on the question.”
“Did Mrs. McDonald indicate she knew anything about Kelly McShane’s death?”
“No.”
“Did she insinuate anything incriminating about Chaz Braden?”
“No.”
“Did she ever express having any fear of him?”
“No.”
“Did she indicate to you she had anything at all to tell about her admission under Chaz Braden in ‘seventy-four?”
Tanya spun about to face him again. “Yes. She said she didn’t like the man, and wanted to talk about it, but I was too busy at the time. And I repeat, when I left her that last night she was fine.”
Sounded as if Tanya did feel a tad guilty. “So you didn’t listen to an old lady go on about a former doctor she’d disliked twenty-seven years ago – not exactly a cardinal sin.”
“If I had taken the time-”
“She still would have had her stroke. I don’t see why you’re so quick to suspect foul play.”
Her shoulders rose, a sign that he had irritated her. She stopped at a closed door and gestured that he should enter. “See Bessie McDonald for yourself, Dr. Garnet,” she said through clenched teeth. “Then let’s talk about what you think happened.”
They walked in on an elderly woman laid out still as a corpse in a hospital gown. An orange tube stuck out of her mouth from which intermittent gurgling noises came as her chest rose and fell. An IV tube ran from a clear bag of fluid into her left arm. A transparent catheter protruded from between her legs and carried urine to a bag strapped on the railing at the side of the bed. A multiscreened monitor flashed continuous readings of her vitals.
At a glance Earl took in that she was breathing on her own, had been receiving sufficient hydration to keep her kidneys functioning, possessed a normal heart rate, rhythm, and blood pressure, and, according to the information relayed from a clip on her finger, just about perfect oxygen levels in her blood.
So why wasn’t she sitting up and waving at him?
A young man in a white coat looked over from where he’d been methodically tapping at her knees with a reflex hammer. He had bushy red hair, and his name tag read DR. P. ROY. When Tanya made the introductions, he practically clicked his heels.
Earl got down to business. “So what happened?”
“The night staff found her unresponsive on the floor at the entrance to her room around 4:00 A.M.,” Dr. P. Roy began. “They immediately called me.”
“She was seizing when you found her?”
“No, but there was a lot of blood in her mouth and tooth marks on her lips and tongue. Grand mal was obvious.”
“Vitals?”
“As you see now.”
“Did you do the DONT?”
“The what, sir?”
“The DONT. Dextrose, oxygen, narcan, and thiamine.” He was stating an anagram he always used to teach residents the basic ER approach to coma, listing the first variables to be thought of whenever a patient presented with an altered level of consciousness. An IV bolus of dextrose, or sugar, would have corrected hypoglycemia. A measure of her O2 saturation would have signaled any respiratory causes for the coma, and the administration of oxygen possibly turned them around. Narcan would be the antidote to reverse a narcotic overdose, and thiamine administration treated a deficiency of the vitamin that sometimes caused persistent confusional states in malnourished individuals, such as alcoholics.
Dr. P. Roy flushed. “Well, no, not exactly, sir. I did make sure her airway and O2 were okay. But it seemed pretty obvious she’d had another stroke and seized.”
“Really? Any focal signs in your neurological exam, now or then?” Earl referred to the abnormalities of sensation, movement, and reflexes that would have occurred in the specific region of her body controlled by whatever part of the brain a recent embolus might have injured.
“No, at least not any new ones that I could tell. She did have some minor abnormal reflexes from her previous event.”
“Shouldn’t there have been at least a change in those, if you attributed her seizure to another massive embolus? And it would have to have been massive to leave her comatose, wouldn’t it?”
“Well, yes-”
“Did you do bloods at all that morning?”
His face brightened. “Of course. They were all normal, including her sugar.”
“Was that sample drawn before or after you gave her an IV?”
Roy grew red in the face again. “After.”
“How long?”
He swallowed. “About an hour later.”
“An hour?”
“I ordered they be taken stat, but, well, on this ward, especially at night, we aren’t given much of a priority by the lab-”
“Could you excuse us a minute, nurse?”
Tanya nodded, then slipped out the door.
Earl closed it behind her. “You should have insisted they make it a priority, Dr. Roy.” He had no patience for that kind of passivity in his own department, and always taught his residents to stand up to it.
“Why-”
“Had she signed a do not resuscitate order?”
“No, but I figured-”
“Figured you were her last stop before she got to God, and she deserved your best shot at bringing her around.”
“But-”
“What was in the IV?”
“Two-thirds, one-third,” he answered, referring to a common intravenous mixture of sodium chloride and glucose.
“So even if she was hypoglycemic when she’d seized, you’d expect a normal level of glucose afterward, since you had been infusing her with it.”
Roy flushed some more. “Yes, I guess, except why would this patien
t be hypoglycemic in the first place? She didn’t have a history of diabetes, let alone diabetic medications.”
“Ever hear of a medication error?”
Roy went an even deeper shade of red.
“The point is,” Earl continued, “at the time of finding someone comatose, you can’t presume anything about how the person got that way, especially since they can’t tell you what happened. So you ‘do the DONT’ as we say, running through all the possibilities beginning with checking her serum glucose. And if you haven’t got a dextrose stick handy, you still can figure that a single rapid bolus of concentrated IV glucose never hurt anyone, even a diabetic.” Untreated, nerve cells die by the millions for every second hypoglycemia is allowed to persist, and the patient is at risk to seize, choke to death, or lose enough brain tissue to end up a living vegetable. Every first-year medical student knows this, so Earl saw no need to point it out to Roy. “It’s good you at least gave her some sugar,” he continued, “but it was too slow and too little, as far as being any therapeutic benefit to her. All you accomplished was to wipe out any evidence that her level had been low in the first place.” Any medical student would also know that if Dr. P. Roy had acted properly, Bessie McDonald might not be in her current state. No point to rubbing it in. This guy looked sunburned enough already, and no one could ever prove it. But that’s what he would have trouble living with, once he digested all the facts. He’d never be able to disprove it either.
“Hey, I did do an O2 sat, and it was fine just as it is now, and if she mistakenly got a narcotic overdose, her respirations would have been suppressed,” he said, beginning to sound more annoyed than defensive. “As for thiamine, she sure as hell hadn’t been malnourished or gone on a recent bender…”
Earl ignored whatever lame excuses the kid offered up – chances were good he wouldn’t screw up his next coma case – and refocused on what bothered him most about Bessie McDonald – her lack of focal signs. “What’s her level of consciousness today?” he asked, referring to a scoring system by which a patient’s response to verbal and painful stimuli was measured.
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