My gut pinched in recognition of that date. “A victim of the bombing?”
Sydney nodded. “Her injuries weren’t life-threatening, but damned painful all the same. A mild concussion, bruised ribs. Oblique fracture of the left tibia. The decision was made to immobilize the bone with wires and a brace. We kept the patient thirty-six hours to monitor the concussion and her recovery from surgery. Her prognosis was good, so we discharged her into her family’s care, with home service visits for three days.”
“That was a month ago.”
What killed her? was my unspoken question.
“Her father brought her back to GUH two days ago. Clarke exhibited all the signs of organ failure. Vomiting. Elevated temperature. Abdomen distended and tender. The girl died within an hour of being admitted.”
“Any history of drug or alcohol abuse?”
“Her father says no.”
And fathers didn’t always know—or want to know—what trouble their kids got into. Fourteen was damned young, but I’d had friends in middle school who had already started down Trouble Street.
“Her father has asked for an autopsy.”
My attention snapped up to Sydney. “I’m no pathologist.”
“No. Your task is to open the abdomen and record your observations. Gentner will take over from there.”
That was a relief. Gentner was the senior pathologist at Georgetown. Meticulous to the point of fussiness, but that was part of the job, wasn’t it? I pulled back the sheet.
Too damned young was right. Tyonna Clarke was a skinny brown girl just bumping into puberty. Hair braided into tight cornrows. Knobby knees and elbows. The dark smudges under her eyes spoke of those last agonizing hours.
I made the necessary marks on her abdomen, noting a line of sutures not yet dissolved near the upper right quadrant, then took up the scalpel with my left hand. The movements came automatically this time, as though my body and memory had locked together, with Lazarus along for the ride.
All that lasted until I had the abdomen open and I stared down into the cavity of this young girl’s body.
I’d seen any number of mangled bodies in war, and many more riddled with cancer, or wasted and twisted by drugs. But never any organ damage to compare with what I saw today.
“Multiple thrombi throughout all the major blood vessels,” I said to the recorder. “Signs of hemorrhaging . . .” I felt a flutter in my gut, which I’d not since my earliest days in medical school.
“Go on, Doctor,” Sydney said softly.
“Necrosis of the liver,” I said at last. “Signs of incipient necrosis in the large intestines, which accounts for the tenderness and swelling of the patient’s abdomen.”
With an official autopsy ordered, I could not shift the organs to make a more extensive examination, but then, that wasn’t the real point of this eval. I continued to list as many symptoms as I could from visuals alone. When I had finished my observations, I closed the body and stepped back. My right hand was trembling. Lazarus held steady, but the point where flesh met the device’s contacts shivered with a hint of electricity. The electronic version of nerves?
“Any further observations?” Sydney asked.
“Severe organ failure, sudden and painful. I’ve not seen anything like this before. The father was right to request an autopsy.” I hesitated. “I noticed sutures. Was that part of her visit back in January?”
“A medical implant for time-release antibiotics.”
I nodded. A common enough procedure.
“No allergy noted?”
“None.”
So, and so. A mystery for Dr. Gentner to solve. That would make his day.
“How did I do?” I asked as casually as I could manage. The pinpricks of electricity had died off, replaced with a lovely sense of accomplishment. However, it would not do to make any assumptions.
Sydney tilted her head and gave me that wicked smile of hers. “You did well. Very well. I think we can move on to the advanced drills next week.”
***
Friday, lovely Friday, was also the day for our once-a-month M & M conference. Morbidity and mortality, just one of a woman’s monthly joys, Navarette liked to say.
By two thirty, the residents and attendings had collected around the conference table. We had three cases to review today, with Nina Letova as the first resident to present. She had both printed records and her laptop in front of her, which she fussed over until Hernandez gave her the order to begin.
Letova called up the stats on her screen, then tapped the keys to show her display on the conference wall.
“Patient Javier Arroyo,” she said. “Ten years, three months old. Original diagnosis, acute appendicitis.”
Her voice was cool, precise. Standard doctor presentation. But I’d heard Letova weeping the night the code blue sounded. Don’t blame yourself for anything outside your control, our teachers always said. Hell, they were right. But when you lost a patient, it could be damned hard not to.
Letova went on with an overview of Javier’s first visit to GUH. She recited the patient stats for the operation, what she and Carter had discussed for follow-up care, the scripts prescribed, the lack of complications, and the mandatory visits by medical technicians for any early discharge.
“What did the medical technicians report?” Carter asked.
The two women exchanged the briefest of glances.
“Recovery progressing as expected,” Letova replied. “Temperature normal, blood analytics normal, appetite normal. Surgical site showed no signs of infection.”
“Except the boy died.” That was Hernandez, looking aged and grim. “Review the second visit, please.”
We all knew the details. Letova had ranted about them enough this past week. But we were all professionals. We knew the value of the postmortem, the examination for any flaw. This wasn’t a matter of placing blame. This was how to identify what went wrong so we could do better for the next crisis, the next patient.
“Patient readmitted by their father, exhibiting all signs of sudden-onset infection. After a consultation with the senior attending surgeon, I put the patient on IV with intermittent infusion, twice every hour. Blood tests indicated a bacterial infection. Patient was kept under observation, with the fallback to increase the dosage if their condition changed. Unfortunately, Javier—the patient— The patient went code blue during the night.”
He died. Let’s call out what happened, no dithering. The child died, and his parents are suing the hospital for gross medical negligence.
But we didn’t mention words like negligence or lawsuits. Not in M & M.
I decided to start with a few roundabout questions. “What could we do differently? How can we know a patient is ready for discharge?”
Armstrong, one of the older attendings, swiveled around to stare at me. “It’s not guesswork, Watson. We have any number of procedures that are standard hospital policy—”
“Procedures that predicted nothing about this boy.” That was Pascal. A good point, but everyone knew that Pascal and Letova were close friends.
Arguments broke out between Pascal, Armstrong, and Carter. Letova remained silent and blank. No sign of emotion, unless you counted her pale face, the sudden patches of red when Armstrong and Carter went into full angry attending mode, each one claiming greater experience with complications than the other.
At last Hernandez called a stop to the argument. “Next case, please,” she said. “I have a few things to say after we’re done.”
That lit a fire under the other two residents. They hurried through their presentations, one hit-and-run victim, one alcoholic coma. Nothing unusual about either patient, and we were almost relieved to dismiss any possibility the surgeon could have done better.
We ran through the usual analysis, however. Checked against the usual warning signs. All was good, for all three cases. Really, how much could a surgeon do about the demon infection, or just plain damned bad luck?
Hernandez cleared her t
hroat. “Before we go our merry way, I want to speak about a related topic.”
She tapped the conference tabletop. A panel slid open, exposing a touch-sensitive control pad. Hernandez tapped again. Immediately the lights dimmed, and the screen grew bright. Now a square appeared on the wall behind Hernandez.
Navarette expelled a whispery sigh. “I was expecting this.”
A colorful chart filled the screen—a scatter graph with each dot representing patients who died over the past six months. A red line traced the average of the stats. December showed a spike around Christmas, another spike at New Year’s. Typical stats.
“Look at February,” Hernandez said.
She tapped a few keys. That luminous red line seemed to twitch, like a worm, then reversed and angled upward. Not a spike, like December’s, but clearly higher than usual.
“That’s not all,” Hernandez said. She tapped the virtual keyboard, and a new worm, an ugly greenish yellow, overlaid the red one. “Readmission rates. Those have held relatively steady over the past three months, but we had a jump this past month.”
All of us stared at the graph. The statistics were clear enough, but I had the sense Hernandez was fishing for a particular answer.
“I am not happy,” Hernandez said. “We need to find the cause for these readmits. More important, we need to find out why these patients come back to us only to die. Find out why and fix the problem.”
“What if there is no cause?”
Hernandez shot Pascal a chilly stare. “That sounds like an excuse.”
To her credit, Pascal did not defend her question. She wilted into her chair and made a pretense of studying her tablet.
“Let me state the situation bluntly,” Hernandez said. “If this trend continues, the hospital must rethink our policy of discharge. We’ll need to implement more checks—more thorough checks—and procedures to ensure our patients don’t return. Especially only to die.”
Everyone went quiet as they absorbed this.
After a moment, Carter cleared her throat. “Perhaps we could institute a higher level of outpatient care, especially during the first week or two at home.”
A higher level of outpatient care came at a higher cost, I thought. Our lovely single-payer health care only covered a day or two at the most. Anything beyond that was charged to the patient.
Hernandez herself was shaking her head. “That’s one approach, but we need a plan to cover all our patients, the poor included.”
Carter had a faintly surprised look, as though she’d forgotten the world included such creatures as the poor. Navarette covered her mouth with one hand. Several others smiled nervously. Only Letova appeared distracted, as though she were still working through Javier’s case.
“Very well,” Hernandez said when no one spoke. “Here is what I want. I want suggestions. I want well-reasoned suggestions that account for our entire patient population, not just a few. Treat this as a diagnosis, with different levels and different angles of attack. I won’t set any deadlines, but I would like to see input from everyone as soon as possible.”
Dismissed at last, Navarette, Pascal, and I headed toward the elevators as quickly as we could without seeming to, with Letova close behind. Navarette and Pascal were discussing the M & M in low tones. I walked quietly beside them. Would these new procedures—whatever they turned out to be—save more patients? Would they have saved Tyonna Clarke or Javier Arroyo?
Maybe. Could be. I had no idea. Death came at you however Death pleased. All we could do was fight the war one day, one patient, at a time.
Nina Letova punched the up and down buttons at the elevator. Her jaw was set. Her eyes narrowed. Was kind and gentle Letova angry?
“I don’t like it,” she said.
“I don’t either,” Navarette replied. “But we both know the probabilities. Patients die. Patients survive but forget to take their meds. Or they go back to old bad habits.”
The doors hushed open and we got into the empty elevator. I swiped the security pad with my ID, then tapped the number for my office floor. Navarette swiped her own ID and punched the number for the outpatient surgery wing. Just as the door closed, she murmured, “I bet I know what has Hernandez all stirred up though.”
Pascal and I stared at her. She shrugged but waited until the elevator hummed into motion before she spoke again.
“It’s not just the patients themselves,” she said quietly. “We have a reputation. We don’t want to lose that, or we might lose the business of people like Senator Blake.” She named the head of the Joint Committee on Health Care, a committee that had only grown in size and influence since the U.S. shifted to a single-payer system. “He was scheduled for a stent implant this June, the new combo type with the timed-release drugs and a remote monitoring component. I hear tell he’s making noises about finding a different hospital. We lose his business, then word gets out why, and we might lose some of that lovely funding.”
“Goddamned politics,” I said.
It was everywhere. Even in death.
***
At last I was free of the hospital and my duties. Not a right and proper attitude for a surgeon, but I had an excuse. It was Friday night. My first Friday night with Adanna Jones.
(Memo to self: Goddammit, girl, you are not a teenager. Get your raging hormones under some kinda control. Friday don’t mean nothing except dinner and some talk. Or were you thinking this woman might offer you some sweet dessert? Settle down.)
I left the hospital early; dropped by the apartment, which was blessedly empty; and changed into what I hoped passed for casual and nice. Black wool trousers. A purple sweater, bought new this past week from a local boutique. Those silver bracelets that Sara had given me last September. A necklace my mother once owned. I spent the last ten minutes fretting over my hair and polishing Lazarus before I dragged on my wine-colored coat and my black gloves, then set out for the restaurant.
The restaurant—Adanna’s choice—was an old, established Vietnamese restaurant in the SW quarter. For all my years at Howard and then Georgetown, I’d never come across this place.
I was twenty minutes early. I settled into the booth the waiter showed me and spent a few minutes glancing over the menu. This was no trendy uptown spot, the kind Sara Holmes liked for our occasional nights out. Inexpensive, with only half a dozen main dishes. I turned over the menu to the wine and liquor selection, which was even shorter. Three white wines, one red, a couple fashionable martinis, and a list of draft beer.
“You got here early.”
Adanna Jones slid into the seat opposite me. She wore her usual black wool coat, a voluminous sweater knitted from jewel tones, and two enormous silver discs suspended from her ears.
“I like to plan ahead,” I told her.
Her mouth tilted into a smile. “Do you, now?”
My mood lifted even higher, if that were possible, at her teasing. “When I can,” I said. “When it’s right.” Then, because I feared I had overstepped some invisible line, I quickly added, “So. How was your day?”
Her face took on that smooth expression I had come to classify as Too damned bad to talk about. But all she did was shrug and smile. “Worse than I liked, better than I feared. Mostly boring shit about accounts and shipping charges. How about you?”
We talked about death and disease. And politics.
Not the best topic for a Friday night date.
“Oh,” I said lightly. “The usual, nothing more. My interns. My committee meetings. Pretty boring stuff.”
Her expression didn’t change, but I caught the flash of her gaze, the almost inaudible sigh as she leafed through the three-page menu. She looked weary, distracted, as if she wanted to be elsewhere.
Come on, Watson. You are not making a good impression here.
“However, I did have my first official evaluation today.”
That caught her attention.
“I told you about my arm.” I lifted Lazarus and twisted my arm around so that lamplight r
an in silver rivulets along the mesh. “I’m going through the usual physical and occupational therapy. Plus, I need to learn how to use all the special features Lazarus has for surgery.”
Her mouth quirked in a half smile. “Lazarus?”
“Ah. Yes.” My face heated up with embarrassment. “That’s what I call my friend here.”
“I like that.” Her voice was no longer weary, her expression no longer distracted. “So, tell me. What happens when you pass all your evaluations?”
She said when, not if.
“It means . . . everything. It means I can be a real surgeon again. It means I’m not stuck with a meaningless title, doing meaningless work, for far too much money—”
I stopped myself. My pulse was jumping, and I realized I was babbling. Trigger words, I told myself. Damned poor time for them to show their ugly faces.
I gulped down a breath and offered Adanna a shaky smile. “I’m sorry. It means so much to me. My therapist—my other therapist—says it’s because I feel I’ve lost a part of myself. And more than just my arm.”
There, I’d said it. I waited for her to reply.
“You are a brave woman,” she said simply, no trace of pity in her voice or her expression. I felt a release of tension I hadn’t realized was there.
Our waiter appeared in this moment, with an electronic pad and stylus in hand. I wanted to curse his timing. We both glanced over the menu and gave our orders, including a bottle of wine.
He returned within moments with the wine. Adanna and I touched our glasses together.
“To victory, however we define it,” she said.
“To the best of all possible weeks,” I replied.
We drank. I was about to mention how good the wine tasted, when the restaurant door swung open and Sara Holmes appeared in the doorway. She wore her rattiest brown leather jacket, tight worn jeans, and a knitted cap pulled low over her forehead. Her locs tumbled down her back, thick and wild, and she had that strange manic air I’d come to dread.
Her gaze locked on mine and she made a direct line toward our table. “Janet, my love. Do you have a moment?”
I glared at her. I had told her about Adanna Jones. Not all the particulars, but enough that she ought to have known how much this evening meant to me. I had not, however, told her the location for tonight’s dinner, and part of me wondered how she had ferreted out that data point.
The Hound of Justice Page 8