“Did you get up during the flight?”
“Once, to pee. Those damn seats are too small for a normal person, no less someone of my size. I could barely move, doc. I felt like a canned sardine.”
“I’m going to run some tests, Harry, but the odds favor a clot to the lungs coming from your legs. We call that a pulmonary embolus.”
Harry tried to sit up, but Jacob placed his hand on Harry’s chest.
“How dangerous is that?”
“Small clots are bad enough. A large one can be life threatening. If the tests confirm my diagnosis, I’ll give you a clot dissolving medication and start you on blood thinners to prevent more clots.”
“Whatever you say, Doc.” He hesitated. “You’ll explain this to Phyllis...but please, Doc, don’t scare her.”
After the x-ray, lung scan, and a study of the deep veins in Harry’s legs, Jacob talked with Phyllis. He tried to maintain his optimism, but would not mislead her about the seriousness of Harry’s condition.
“This is a dangerous condition, Phyllis. I’m treating Harry aggressively and I’m asking our chief of cardiology, Sharon Brickman, to consult.”
“You’re scaring me, Jacob. Should I be scared?”
“Yes, at least for a while.” He placed his wrinkled, age-spotted hand on her shoulder. “The first few hours are the most dangerous.”
“I’m Dr. Brickman, and this is Ahmad Kadir,” said Sharon as they entered Harry Rodman’s room. “Dr. Kadir is a resident studying intensive care at UC San Francisco.”
Ahmad bowed slightly, and with his Palestinian accent said, “So nice to meet you.”
When Phyllis Rodman stared at Ahmad, her mind flashed on the images of suicide bombers she’d seen on TV. Embarrassed, she looked at the floor, saying nothing.
Harry grunted his greeting and extended a trembling hand.
Ahmad and Sharon examined Harry, and then put his x-ray up on the view box. “See this white area, Mrs. Rodman.” She pointed to the right side of the film. “That’s where the clot went into Mr. Rodman’s lung.”
Sharon sat in a chair opposite Phyllis. “Here’s where we are. If he shows any signs of more clots or if he becomes unstable, we may have to do a pulmonary arteriogram to visualize the clots in his lungs, and go into something much more aggressive and a lot more dangerous.”
They moved Harry to 614, one of the rooms in the step-down cardiac care unit where he’d be on the monitor while he received heparin, an anticoagulant. The laboratory would monitor how well his blood clotted.
Kate Planchette, Harry’s nurse, approached the bedside and turned to Phyllis. “You must be jet-lagged, Mrs. Rodman. That long trip, and now this. Why don’t you go home and rest. I’ll call you at once if anything develops.”
“Are you sure it’s all right? I’m dead on my feet.”
“It’s fine.”
Phyllis kissed Harry. “I’ll see you in the morning, sweetheart.”
Harry grunted something unintelligible, and then closed his eyes.
Luck is with me, I think, as I slip into Harry Rodman’s room.
Not so for you, Harry. This time, we’ll leave it to the fates.
Better make it quick.
Neither the beeping of the cardiac monitor nor the nurses coming and going disturb Harry’s sound sleep.
I reach into my white coat and remove the syringe containing 300,000 units of heparin and flush it into his IV line.
With this massive dose of anticoagulant, Harry won’t need to worry about a blood clot, now or ever and if I’m lucky again, Harry—you won’t have to worry about anything.
Kate had seen Tommy Wells going in and out of Harry’s room all evening to perform bedside clotting studies. He was due back in another thirty minutes when Kate entered the room. She pulled the sheet off Harry’s arm to measure his blood pressure, and then stared. His arm and entire chest wall were purple. Blood oozed from venipuncture sites, the IV site, his nose, and mouth, and when she pulled his lids open, Harry’s eyes bulged bright red.
My God, she thought. He’s bleeding out!
Kate pushed the call button and when the ward clerk answered, she said, “Get Dr. Weizman stat, and have the lab come up to draw a blood count and to do another clotting study.”
She tried to awaken Harry, but he failed to react. The right side of his mouth drooped and bloody saliva oozed out. When Tommy entered the room, Kate said, “Get a blood count stat and draw a clotting time.”
Tommy looked at Harry. “This guy looks like shit.”
“Tommy,” she shouted, “keep that language to yourself.”
“I’m sorry,” he said inserting a test tube of blood into the automated device.
They waited...stared at the machine awaiting the tell-tale beep that indicated a result. After 10 minutes the machine alarmed and flashed: Infinite. Harry Rodman’s protective clotting system lay in paralysis...he could bleed from anywhere.
Three minutes later, Zoe entered the room. “I was admitting another patient on the fifth floor. What’s happening?”
Tommy studied the clotting device. “His clotting time is infinite. I’ve been doing clotting times every hour or so and they were in therapeutic range.”
“What was his last clotting time?” asked Zoe.
“That’s it. He can’t clot at all.”
Zoe did a rough calculation then gave Harry a dose of protamine to counteract the heparin. “I hope it’s not too much or too little...each has its set of problems.”
After Kate administered the dose, Zoe completed her examination. “The drooping mouth and the flaccid muscles says that Mr. Rodman has had a stroke. We need an emergency brain CT scan.” Zoe paused. “I’d better call Jacob, and someone get me Mrs. Rodman’s number.”
“Should I call the chaplain?” asked Kate.
“Not a bad idea,” said Zoe, “except ask him to leave before Mrs. Rodman gets here. She’ll freak if she sees him.”
Chapter Forty
Jacob had a sixth sense for trouble and it was sounding strong as he walked toward Harry Rodman’s room that evening.
When Jacob arrived, Zoe saw his hair listing to one side and his bow tie askew.
He’s too old for this, Zoe thought. He should be in bed.
Jacob pulled back the sheet to expose Harry and saw the bloodstained bed, the bruising and bleeding, and yelled, “What the hell happened?”
“He has an infinite clotting time, Jacob,” said Sharon. “He’s bleeding from everywhere and clinically he bled into his brain too.”
“Oh, my God...how is he now?”
“Stroked out,” said Zoe. “How much heparin did you order, Jacob?”
“I gave him a standard loading dose of 50 units/kg of body weight then a maintenance dose of 20 units/kg/hour.”
“You adjusted that for his lean body mass?” asked Zoe.
“What are you talking about? I’ve been giving heparin for decades. Of course I adjusted the dose.”
Jacob stared at Zoe and Sharon, trying to read their minds. “His clotting time following the large loading dose was in the therapeutic range and so were the first few follow up readings. I don’t understand your questions and I resent your implications.”
“Take it easy, Jacob,” said Sharon. “We’re trying to find out what went wrong.”
Jacob stared at Zoe. “What are you doing here? I’m on call tonight.”
“I was here anyway, so I decided to come up.”
“Check my orders, Sharon, to your satisfaction...”
“That won’t be necessary, Jacob.”
“If the orders were appropriate,” said Jacob, “then I see only two other possibilities: a dosing error or another process leading to a clotting problem like DIC (disseminated intravascular coagulation). The heparin may have been the wrong concentration or they diluted it improperly. Off hand, I don’t see any reason for DIC.”
“I talked with Kate Planchette and reviewed the set up of the heparin infusion; it’s cookbook. Unless
the heparin itself is mislabeled, I don’t see that kind of error.”
“Even if the Heparin infusion pump went bad and he got too much,” said Jacob, “that wouldn’t explain a massive overdosage.”
Sharon plunked herself down in the easy chair in Harry’s room and stared through the rain-streaked window. She turned to Jacob. “Maybe this isn’t an accident, Jacob. Bad things are happening to patients around Brier, especially your patients: Lidocaine overdose, heroin overdose, and excuse me Jacob, the question of morphine overdose...and now this. Could Brier Hospital have its own serial killer?”
“That’s absurd,” said Zoe. “There’s got to be some other explanation.”
“You’re not party to the detail of these cases, Zoe,” said Sharon, “but the more I think about it, the more obvious seems the explanation.”
On their way to view Harry’s CT scan, Zoe turned to Jacob. “I’m sorry. I wasn’t thinking straight. I was reaching for an explanation. I’d never...”
“Forget about it, Zoe. I know all too well the effects of stress and uncertainty on the human mind and its rationality.”
“But, you’ve done so much for me...how can I have thought...?”
“Forget it.”
The chief of radiology, Bernie Myers, stood before the high-resolution screen paging through slices of Harry Rodman’s brain. “He’s lucky, Jacob. It’s a small frontal lobe bleed.”
“The last thing I’d call this man,” said Jacob, “is lucky.”
“Well,” said Bernie, “I’ve seen a lot worse. If Harry has no further bleeding, he might just pull through.”
When they returned to Harry’s room, Phyllis Rodman sat next to her husband, holding his hand and crying. Her daughter Carol stood at her side stroking her mother’s hair.
Jacob entered the room. Phyllis rose and embraced him, tears running down her cheeks.
“My God, Jacob! What happened?”
“Something happened with his anticoagulant...I don’t know what. His blood couldn’t clot. He’s bleeding everywhere, including, I’m afraid, into his brain.”
“His brain?”
“We just looked at the brain scan. Thank God it’s a small bleed. I think he’ll recover, but it’s going to be iffy for a while.”
Carol turned to Jacob. “I thought he needed the blood thinner to prevent another clot to his lung.”
“He does,” said, Jacob, “but I see no way we can give him a blood thinner now. It might make the bleeding in his brain worse.”
“What are you going to do, Jacob?” asked Phyllis. “You must do something.”
“I’ll talk with Sharon Brickman about putting a filter inside the large vein in the lower part of his abdomen ( the inferior vena cava ). That way, if more clots break off, we can catch them before they reach Harry’s lungs.”
“Whatever you think best, Jacob,” said Phyllis. “We trust you. We’ve come this far with you. We might as well go all the way.”
“I’ll never have that kind of loyalty...that kind of respect,” murmured Zoe. “The best of medicine will die with the departure of men like Jacob Weizman.”
Jacob turned to leave. Carol caught him by the arm. “You don’t know how this happened?”
“No,” said Jacob, “but I’ll find out!”
Chapter Forty-One
When Mary Oakes, the charge nurse on the fifth floor medical unit, looked at the skeletal Angelina Cass, she felt her eyes moisten then she flushed with anger.
This is a total waste of our time, she thought. We’ll never get to her.
This was the sixth admission for this thirty-year-old woman in the last six months, each time for the same sequence of problems: anorexia nervosa, a severe anxiety disorder, with malnutrition and dehydration leading to multiple electrolyte abnormalities, often life threatening.
Mary pushed aside the standard blood pressure cuff at the bedside, too large for Angelina’s twig-like arm, and grabbed the pediatric one. After she completed her assessment of the brooding, angry young woman, she saw Joanna Cass, Angelina’s mother, in the hallway talking with Arnie Roth, her daughter’s physician.
“What more can we do, Doctor? Angelina’s seen dozens of shrinks, psychiatric social workers, and participated in three eating disorder inpatient programs. Nothing worked.”
Arnie shook his head. “I don’t know. Let’s first get her out of trouble.”
“I’m so sick of this,” said Joanna. “I have a life too, you know.”
“I’m sorry,” Arnie replied. “I’ll try to find another program after she’s stable.”
“I don’t want her to have any visitors. Her friends are nearly as bad as she, and her son-of-a-bitch husband Milo, he’ll only upset her more.”
“I’ll write the orders for no visitors.”
When Arnie entered Angelina’s room the next morning, her eyes bored into him. “It’s you again, damn it. I told you I don’t want your help.”
“I don’t think you’re competent to make that decision, Angelina. You almost succeeded this time in killing yourself.”
“It’s my life,” she snarled, pulling on her restraints. “I can do what the fuck I like with it. I want you to remove this stomach tube and IV. And get these damned restraints off me.”
“Not a chance.”
Angelina’s eyes bulged as she strained to sit upright. “You fucking bastard! You can’t do this to me. I’ll sue the shit out of you and this damn hospital.”
Arnie had the foresight to step back from Angelina’s bed as a large wad of mucoid spit flew across the room landing on the wall.
He watched the thick saliva sliding downward. “I’ll have the nurse give you something to calm you down. Maybe sometime soon we can talk about a future for you.”
Arnie left the room. When the closed door muffled her profanity, he sighed with relief.
I’m getting too old for this crap!
The intruder ignored the large ‘No Visitors’ sign and entered Angelina’s room.
Even in sleep, her mouth formed into a smirk.
Grabbing the end of the feeding tube, the intruder attached a large syringe and pushed in the thick, green fluid. After the third syringe-full, the intruder smiled, caressed Angelina’s cheek.
Maybe this will end your smirk, the intruder thought, then departed.
At 4 a.m., the voice of Angelina Cass boomed through the intercom. “You got to help, my stomach is killing me.”
“I’ll send your nurse right in,” said the ward clerk.
When Patti Sax, the night nurse, entered the room, Angelina was bent over clutching her stomach and retching. “I never felt this bad before...these cramps are killing me.”
Patti wiped off the vomit, and then checked Angelina’s vital signs. Except for a racing pulse, they were stable. She felt Angelina’s abdomen which felt soft and wasn’t tender.
“I’ll call Dr. Roth.”
Arnie listened to Patti’s description. “It might be an ulcer or possibly pancreatitis. Give her a shot of Compazine and have the lab draw her morning bloods right now. Ask them to add an amylase and lipase to rule out pancreatitis. I’ll be at Brier in a couple of hours. Call me if she gets worse.”
When Arnie arrived for rounds, the morning nurse raced to meet him. “She won’t wake up, Dr. Roth.”
Angelina groaned when Arnie examined her, but except for deep breathing, he noted no other abnormalities. Back at the nursing station, Arnie turned to the ward clerk. “Where’s today’s lab?”
The ward clerk handed him the printout. “It just came up.”
Arnie stared. He’d rarely seen so many abnormalities of a patient’s chemistries with a pattern of too much acid in her blood.
Now I know why she’s breathing that way.
“Transfer her to ICU stat. I want a set of blood gasses, a chest x-ray, a new set of electrolytes, and get Jack Byrnes to consult.”
Two hours later, Arnie sat with Jack looking over Angelina’s laboratory tests.
Jack st
ood. “Come with me, Arnie.”
They walked to Angelina’s bedside.
Jack looked at Arnie. “Turn off the lights.”
“What’s going on?” asked Arnie.
“Just turn them off.” Jack grabbed a peculiar shaped lamp. When the room became dark, he shined the purple light on the bag of urine collected from the catheter in Angelina’s bladder. At once, the urine glowed green.
“What the hell?” said Arnie.
“Somebody poisoned her,” said Jack. “The chemistries, the pattern of electrolytes, the severity of the acid in her blood, and the green glow, says one word to me: antifreeze.”
Arnie stared at Jack. “Antifreeze!”
“I sent out a sample to our reference lab, but we can’t wait for the results. I think we need to pull out all the stops.”
“Whatever,” said Arnie.
“Where’s her husband? I’d prefer him to sign the permit for dialysis.”
“We called their home, but nobody answered.”
“I’m starting an intravenous alcohol infusion, until I get the dialysis machine ready. The alcohol competes with antifreeze for its metabolism. That should help until we remove it.”
“I have a few alcoholics who’ll line up for that IV anytime,” said Arnie.
“Once they get the whole picture, I don’t think they will.”
After four hours of dialysis and with the continued alcohol infusion, Angelina was in a cheery mood. With speech slurred, she giggled, “I really like you, Dr. Roth...you’re my favorite doctor.”
No Cure for Murder Page 18