by John Godey
The patient on the table in Room D, Papaleo thought wryly, posed no problems in the personal sense. He was obtunded, semicomatose. On the other hand, his inability to respond to questions that might provide helpful signposts into the diagnostic process did pose medical problems. Looking down at the man, Papaleo thought, Overdose, I’ll bet it’s good old overdose. But he put the notion out of mind. Physicians were expected to follow form, especially first-year interns, who were discouraged from making snap judgments. “Even if you turn out to be correct,” one of his professors was fond of saying, “the lightning-flash diagnosis in fledgling doctors—the Kildare syndrome—is either brilliance or dumb luck. Our science is based on neither brilliance nor dumb luck but knowledge.”
So—attend to the symptoms. Cyanotic. Marked hypoventilation—the patient was breathing poorly, although he didn’t seem to be fighting desperately for air, as people usually did who couldn’t breathe. Meaningful? Maybe, but file it away for the moment. Meanwhile, the airway receives first attention. Oxygen. He found a nasal catheter and inserted it. Nostrils filled with heavy mucus—have to check to see that it didn’t clog the catheter.
A nurse came into the room. Kelly, an old hand. It figured. They liked to have someone around to keep an eye on the first-year interns, and if no doctor was available, an experienced nurse was next best.
Without looking at her, Papaleo said, “Blood pressure cuff, please.”
He opened the patient’s mouth—slimy, thick mucous discharge, like the nose—and checked the tongue. No falling back of tongue—takes care of that. Didn’t seem to be any obstruction, either. He sniffed the patient’s breath. No alcohol smell, just a strong bouquet of… what? Chili peppers.
Nurse Kelly was winding the blood pressure cuff around the patient’s arm, her movements deft, practiced. Papaleo said, “Never mind that for a moment. The airway is more important. Will you get the suction apparatus, please?”
Kelly nodded and moved off briskly. Papaleo, suddenly remembering the old yarn about the green intern who had diagnosed a day’s growth of blue-black beard as cyanosis, examined the patient’s fingernails, lips, and tongue. All blue. Cyanosis, not need of a shave.
Nurse Kelly came back with the suction apparatus: a vacuum to suck up the mucus via a tube running into a clear bottle so the matter could be examined. Kelly maneuvered the tube in the patient’s mouth with her right hand, and with her left wiped up the mess on his chin and lips.
Papaleo, his forehead ridged, fitted his stethoscope into his ears, opened a few buttons of the patient’s shirt, and listened to the heartbeat. Fast but fairly regular. The speed was nothing like tachycardia, exertion could even account for it. He picked up the man’s wrist and counted his pulse. Fifteen seconds on the sweep hand of his watch: twenty-four or twenty-five. Call it an even hundred. He finished winding the blood pressure cuff around the patient’s arm and pumped up the auto-valve bulb. He released the bulb, and took the systole and diastole reading. A hundred over forty. Combined with the pulse rate, it was slightly under normal, and it failed to suggest anything of substance to him.
“The oxygen doesn’t seem to be helping his breathing any, doctor,” Nurse Kelly said.
“Yes, well…” She was right. No answer for her. He frowned and said, “Let’s give it a chance to take.”
Nurse Kelly was silent for a moment before saying primly, “Shall I check the catheter to see if it’s clogged?”
“Yes. Will you please do that, nurse?”
He waited until Kelly had removed the catheter. She stepped back from the table and began to clean it. Silently disapproving. Mustn’t let her bother me, Papaleo thought. What now? Neurological check.
“Neurological check,” he said aloud, and stepped back to allow Kelly to reinsert the nasal catheter.
Okay. Test for sensation—pinch and poke and press. Knee reflexes, okay. Bang the tendons—okay. Response to pain, okay. Check head for trauma: lots of black hair, wavy, but can’t feel anything amiss. Okay. Shine flashlight into eyes—pupils normal size and contract under stimulus of light. Heroin out.
The patient’s hand rose feebly, reaching for the mouth. Trying to clear it of mucus. But Kelly had vacuumed most of the mouth clean. She was looking at him sidelong now, and fidgeting. She opened her mouth to say something, but Papaleo intercepted her. “Lungs. Help me to get him into a sitting position.”
He started unbuttoning the rest of the man’s shirt. Unbutton? He remembered what another professor had said: “Don’t waste time with buttons, cut the garment off or rip it off—the moral being that saving a shirt is no substitute for saving a life.” Balls. All he had to do was push the shirt up over the patient’s back. Two birds with one stone—save the life and the shirt. Maybe.
The patient was dead weight as they tried to sit him up. His head lolled forward against Papaleo’s chest. Kelly held him steady and Papaleo leaned over him, placed his ear against the smooth brown skin and tapped. Sounded all right, but what could he really tell with the patient unable to breathe deeply?
“Let’s get him back down, nurse, shall we?”
“Doctor, I think we—”
He cut her off with a frown. Got to keep them in their place, especially the old-timers, mustn’t let them get ahead of you.
He picked up the patient’s arms and studied them. No needle tracks. Well, the normal pupils had told him that. Overdose of some kind of pill? a possibility. Do a gastric lavage? He realized that he was sweating profusely. He wiped the sweat from his face with his forearm. Kelly watched, her lips pursed.
He said, “Who brought him in?”
“The police. I think they’re still around.”
“I’ll step outside for a second and talk to them.” Should have thought of that earlier, dammit. He started away from the table, then returned. “Maybe some kind of overdose, though the signs are absent. Still… get some Narcan, will you, please? Yes, and set up an I.V. with five percent dextrose and saline.”
Nurse Kelly nodded her head and her lips softened. Good, Papaleo thought, I’m on the beam, Kelly approves.
“Oh yes, let’s protect against an insulin overdose. Add fifty percent glucose.”
***
He found the cops in the anteroom, drinking coffee and chatting with the security guard. They told him what they knew. No help.
“What about his movements. Was he jerking? You know—you’ve seen epileptics.”
The cops agreed that although he had been staggering he hadn’t appeared to be convulsed.
“It looks like overdose to me,” one of the cops said. “A lot of Hispanics overdose these days.”
Kelly maybe, but a dumb cop no. Papaleo returned through the reception room to Room D. Kelly had already hooked up the I.V. and she was back working with the suction apparatus, picking away at the mucus in the patient’s mouth.
“Not alcohol,” she said. “No odor.”
“I’m well aware of that. I have a nose, too.”
Kelly’s lips tightened up again. Papaleo looked down at the patient blankly. What else was there, chrisesakes? Take a blood sample, check for sugar? But it would take at least a half hour. Some kind of GI hemorrhage?
“Could be inapparent bleeding,” he said aloud.
“Doctor,” Kelly said, “I think we’re in trouble.”
He thought so himself, but the declaration would have to come from him, not from a nurse. What the devil could it be? He ticked off items in his mind. Alcohol, no. Overdose, none of the signs. Trauma, no. Stroke—who knows? He decided to listen to the heart again. There was some change, and it was for the worse—beat more rapid now, and weaker. The patient’s chest barely seemed to be moving. Paralysis, some kind of paralysis?
Kelly said, “Doctor, I think we want a Code Blue.”
Code Blue was the emergency call that mobilized a surgeon, an anesthetist, the Chief Resident, extra nurses. It was clearly indicated, Papaleo thought, but suppose they all piled in and made a sure, quick, easy diagnosis? Chr
ist! Better hold the Code Blue for another minute or two.
“Presently,” he said to Nurse Kelly, and studied the patient hopelessly. Why should he resist just because they might think he was a dunce? That’s what everybody thought of first-year interns anyway. They would come in, fire questions at him with the same sort of hauteur he had used with the two cops outside….
“Well, doctor?” Kelly looked grim. “I think we’re about to lose him.”
Sweat was pouring down the sides of Papaleo’s face. “Very well. Let’s do a Code Blue.”
Dr. Shapiro, the Chief Resident, was down in less than a minute. He ran his hands over the patient’s chest, almost abstractedly, while Papaleo, earnest, sweating, filled him in. Shapiro’s face was a mask. Before Papaleo was quite finished, Shapiro interrupted.
“Let’s tube him,” Shapiro said. “He needs air. Nurse, get hold of a respirator.” Nurse Kelly, looking righteous, moved away from the table. “He can’t breathe because his muscles aren’t functioning properly. We want a mechanical aid to help the chest muscles do their work.”
Should have thought of it, Papaleo told himself, when I noticed that he didn’t seem to be fighting for breath. Mechanical respirator: endotracheal tube pushed into the windpipe, attached to a cock on wall that pumped oxygen directly into lungs.
Shapiro removed the nasal catheter when Kelly arrived with the respirator. He had some initial trouble intubating the patient, and Papaleo thought, Christ, if he has trouble, what would have happened to me? Other members of the Code Blue team had arrived, but there was nothing for them to do, as yet.
With the tube emplaced in the patient’s trachea, Shapiro stepped back a pace and shook his head. “I don’t know.” He looked worried. Then, frowning, he stepped forward to the table again. “What’s this, on his thigh?”
The light summer trousers were stained with a scuffing of grime, sweat, and a little blood. Papaleo hadn’t noticed it before.
“He must have scraped it when he fell. The policemen who brought him in said he collapsed in the street.”
“Hand me a scissors. We’ll cut them off.”
But, abruptly, Shapiro bent over the patient with his stethoscope.
“I swear,” Papaleo said, “I can’t figure out what’s wrong with him,” and then shut up because Shapiro was still auscultating.
Shapiro straightened up. “I can’t raise a heartbeat. Let’s get going.”
The entire Code Blue team pitched in. Everyone worked with great intensity, injecting, kneading, pounding—Papaleo, with a shudder, felt a rib break under his fist—but to no avail. The patient’s heart refused to start up again.
“You can all go,” Shapiro said. “We’ve lost this one.”
Before he left, Shapiro reminded Nurse Kelly to phone the Medical Examiner’s office and ask them to send the death wagon around to pick up the body for autopsy. In death from an undiagnosed cause, Papaleo recalled, no permission from next of kin was required.
“Death from cardio-respiratory failure due to unknown causes,” Shapiro said to Papaleo. “Don’t forget, the M.E. gets a duplicate of your report.”
“I should have thought of the mechanical respirator earlier,” Papaleo said. “I’m sorry.”
“Well, you’ll think of it next time.” Shapiro took a last look at the corpse on the table, said “Good night,” and left the room.
***
The surgical resident, wearing white ducks and a dirty sweatshirt, shuffled into Room D. His yawn turned to a scowl when he was told that the patient had died and that the Code Blue had been canceled. He charged Papaleo and Nurse Kelly with wantonly disturbing his sleep.
“I’m doing a very difficult abdomino-peritoneal resection at seven o’clock and if I’m not at my best during the operation… Christ!”
Nurse Kelly flushed and said defensively, “Well, I’m sorry doctor. The patient’s condition indicated a Code Blue, and we didn’t know he was going to die.”
“Well, somebody should know those things,” the surgical resident said, giving Papaleo a dirty look. He turned abruptly and shuffled out. He was barefooted.
“Five minutes late for a Code Blue, and he’s mad,” Kelly said. “Surgeons, they’re born that way.”
Papaleo had once heard someone say that surgery residents begin getting difficult in their third year so that they could open their own practice with their arrogance at full bloom. But he had seen plenty of arrogant first-year interns who were preparing for surgery, so Kelly was probably right, they were born that way.
“It’s a fact of life,” Kelly said, “the way heart specialists are dangerously overweight and plastic surgeons are handsome, and orthopods are built like football players.”
And radiologists are shy of people, Papaleo thought. While Nurse Kelly picked up the pieces—phoned the M.E.’s office for the death wagon, and got an orderly to wheel the body to the hospital morgue near the truck exit—Papaleo went to another room, where he put a butterfly suture under the eye of a man who had been kicked decisively in a brawl. After that, his tour of duty was finished. But instead of going to bed, he went down to the morgue.
The patient’s eyes were open, and they seemed to Papaleo to be bewildered, as if he too was trying to fathom the cause of his death. Papaleo closed the eyes, not from sentimentality but because—he told himself with a nervous smile—he preferred working without anyone watching him.
He ran his hands over the torso absently, as Shapiro had done earlier. The skin had begun to cool, and to gray down from the smooth brown of a young man who had been, Papaleo guessed, in quite good health. The mouth was open in a crooked gape, and the lips and chin were smeared with hardening mucus. He ran his eyes down the body from top to bottom, as if taking inventory. Then his eyes traveled upward again to the thigh, to the patch of bloodied grime on the trousers.
After a moment’s hesitation he opened the belt buckle and started to roll the trousers down, but changed his mind. He took a scissors from the pocket of his jacket, and firmly slit the trouser leg up from the cuff to the hip. He spread the material carefully to the side and bent over the thigh. The skin was abraded and slightly stained by blood. Bending still closer, he noticed four small perforations in the skin, partially obliterated by the abrasions. So it was overdose after all, despite the contraindicative symptoms!
But his certainty was short-lived. Why would an addict use his thigh when his arm was clear? And how could he be thought of as an addict if there were only the four marks, and no signs of needle tracks? And why four marks, of equal freshness? The four perforations seemed to be in two sets: one pair about six inches above the knee, the other two or three inches higher. The perforations in each set appeared to be about twelve millimeters apart.
With his nose almost touching the thigh he studied the marks. They certainly could be an injection of some sort, though with a rather large needle. But who would inject in pairs? Bites of some kind? Fang marks? But fangs would make much bigger and more ragged holes. Insect bites? Too large, and not with that spacing. No insect he had ever heard of bit that way, in pairs. Besides, who would stand still for four such bites or stings?
Fangs, then. What had fangs? Dogs, cats, lions, tigers… come on, Papaleo. Snakes? A poisonous snakebite in Manhattan? Anyway, snakes didn’t strike that high. They might bite a hand or finger if they were held, but they usually struck the foot or lower leg. Besides, so far as he knew, snakes secreted a hemotoxic poison, which destroyed the red blood corpuscles and resulted in discoloration and swelling of the affected area due to local hemorrhages. Nothing like that here. Snakebite? Forget it, Papaleo. Still, shouldn’t he tell Shapiro about the perforations? Yeah, sure, wake him up, wake up the boss and face that curled lip and those glittering eyeglasses…. Forget it, Papaleo.
Nevertheless, he decided to read up on snakebite in Beeson and McDermott before he hit the sack. But by the time he got back to his room he was feeling too damn exhausted to start rummaging for a book. Instead, he fell on his be
d fully clothed and went to sleep.
***
A half hour later the M.E.’s death wagon backed into the receiving bay. The attendant signed a receipt for Torres’s corpse, and took it away for storage in the city morgue until the M.E.’s office could schedule it for postmortem examination.
THREE
The snake woke shortly before dawn. At once, its long tongue began to flick in and out through a rostral opening in the margin of its upper jaw that allowed it to emerge even when its mouth was shut.
The two tips of the forked tongue fitted into ducts communicating with the snake’s Jacobson’s organ, which lay in a depression in the roof of the mouth. The sensory epithelium of the Jacobson’s organ responded to odor substances conveyed to it by the tongue, and interpreted them as a chemical computer might do, in terms of the quality of the atmosphere, of the presence of another animal, of prey.
The findings of the Jacobson’s organ disquieted the snake. And so, when it slipped through the branches of the tree and down the trunk, it chose not to wander off in search of water. Instead, moving in slow ripples, it drank the dew from the grass. Then, despite its hunger, it did not go in search of food, but wound back up the tree until it found the place where it had been before.
It slept again.
***
At much the same moment, Arthur Bennett stumbled on a body. His first thought, when he saw it lying on the walk, was that it was some other wino sleeping it off. But when he saw its size, he decided that it was that big bastard who had beaten him up a month ago and damn near punched his eye out.
His immediate impulse was to cut out, but when he touched his eye, still scabbed in the process of healing, he got mad. Stepping forward a pace, he launched a thudding kick to the ribs. He was bringing his foot back for a second kick—although by now he had remembered that the bastard who had punched his eye was a black guy—when he saw the dark blood staining the front of the T-shirt and the linen jacket.