Royal Pains

by D P Lyle

  “Thanks for dinner last night,” I said.

  Jill gave me a knowing smile. “Thank you for dessert.”

  “But you made the strawberry shortcake,” I said.

  She punched my arm. “You know what I mean.”

  “My favorite part, too.”

  She propped a fist on her hip and cocked her head to one side. “Are you saying my cooking is second-rate?”

  “Compared to the rest of the night? No contest.”

  “I’ll remember that. Next time I’ll just order in pizza.”

  “That works for me.”

  Divya returned. “That was Maria Mendez. Apparently Oscar is worse. She said he was confused and talking nonsense.”

  “Let’s run over and see him,” I said. “Then you can drop me back at Ellie’s so I can get my car.”

  Jill walked out to the parking lot with us. Divya climbed in her Mercedes SUV and cranked it up.

  “Pizza tonight?” I said.

  Jill laughed. “All of a sudden you’re a pizza fan?”

  “You make it sound so appealing.”

  “Can’t do it tonight. I have a meeting that’ll last until ten or so.”

  “The exciting life of a hospital administrator. Maybe tomorrow, then?”

  “That’ll probably work. Now you go get some work done.” She pulled open the car door for me.

  The sound of a racing engine and then the screech of tires caused both of us to flinch and then turn. A dark blue four-door sedan slid to a stop behind one of the ambulances. A man jumped out, waving his arms and screaming.

  “Help me. Help me. It’s my daughter.”

  I sprinted in that direction. He ripped open the back door. Inside, a young girl, looked to be mid- to late teens, lay on the backseat. Her breathing was labored and erratic and she was unconscious. I immediately climbed in and reached for her neck to check her pulse. Slow and weak and then nothing. Her face and her entire body went limp.

  “She’s in cardiac arrest,” I shouted. I immediately began doing chest compressions. “Get a stretcher out here.”

  Jill ran into the ER just as Divya appeared with her medical bag. She pulled out an Ambu bag and a face mask. She seated the mask over the girl’s mouth and began pumping air into her lungs.

  As I continued the CPR, the man climbed into the front seat, now on his knees, arms resting on the seat back, eyes wide.

  “What happened?” I asked.

  “I don’t know. She had been out for a run and then came home and then . . .” A sob racked him.

  “Relax. Take a deep breath. Tell me what happened.”

  I glanced through the car’s rear window and saw Jill and one of the nurses rolling a stretcher toward us.

  “She had some water. She said she felt dizzy.” He squeezed his eyes shut as if preventing more tears. “Then she gasped once and fell to the floor.”

  While the two nurses stabilized the stretcher, Divya and I lifted the girl out of the car and onto the stretcher. I climbed on top of her, straddling her hips, and continued CPR. Divya led the way, never missing a beat with the Ambu bag.

  Jill and the nurse rolled the stretcher into the cubicle vacated by Nathan Zimmer. I climbed off and stood beside the bed, continuing the chest compressions. One nurse started an IV while another hooked her up to the cardiac monitor. As soon as the final patch was in place and the last cable connected, a rhythm appeared on the monitor screen.

  V-tach.

  “Charge the defibrillator,” I said.

  One of the nurses placed the portable defibrillator on the bed, while the other used a pair of scissors to cut away the girl’s shirt and bra. I smeared electrode paste just to the right of her sternum and to the left of and below her left breast. The defibrillator whined as it charged.

  “Ready,” the nurse said. “Four hundred watt-seconds.”

  I pressed the two paddles against the girl’s chest and rested my thumbs on the red buttons at the top of each. “Clear,” I said, and then depressed both buttons.

  There was a soft pop and the girl quivered slightly as she took in a quick breath. She then began to move around, waving first one arm and then the other. I looked up at the cardiac monitor and saw that she was now back into a normal sinus rhythm.

  “Let’s give her a one-hundred-milligram lidocaine bolus and then start a drip at two milligrams a minute. O2 at one hundred percent. Get an EKG, blood gases, and draw labs for electrolytes, a CBC, and a chem panel.”

  The girl was now becoming combative, swinging her arms and kicking her legs. This often happens after a cardiac arrest. The brain, which has been deprived of oxygen, suddenly receives blood flow and oxygen again. The result is a period of confusion and disorientation. Not unlike waking up from anesthesia. These victims don’t know where they are, or what’s going on, and often feel threatened by the confused images that come at them from the fog. Some can become completely out of control and can harm themselves and others.

  “Get some soft restraints,” I said. “Call radiology and tell them we need a stat chest X-ray.”

  Dr. Weinberg came into the cubicle. “You sure are keeping us busy today, Hank. What have you got here?”

  “Not sure. Young girl was brought in by her father because she collapsed at home and then she arrested in the parking lot. We started CPR immediately. Why she arrested, I don’t have a clue.”

  I moved out of the way to let Weinberg begin his examination. The girl was now his patient. I stepped out of the cubicle.

  “Good job,” Jill said. “Both of you.”

  “Thanks,” Divya said. “I’m glad we were there.”

  I saw the girl’s father, standing at the receptionist’s desk, probably giving them the insurance information. The clerk handed him something, which he stuffed into his pocket. He nodded and stepped away, turning toward us. His face said it all: confused, anxious, terrified. Divya and I walked over to him.

  “I’m Dr. Hank Lawson,” I said. “This is Divya Katdare, my physician assistant.”

  “Tony Gilroy. That’s my daughter, Valerie. How is she?”

  “Better. She suffered a cardiac arrest due to a very dangerous arrhythmia. That’s corrected now and she’s beginning to wake up.”

  He nodded, fighting back tears.

  “Tell me exactly what happened.”

  “Just as I said. She’d been out jogging, came in and had a glass of water, grabbed her chest, and collapsed.”

  “Did she have a seizure or anything like that?”

  He shook his head. “She just fell. Very slowly. I was standing right there. Everything seemed to be in slow motion. I froze. I couldn’t move. I just stood there. I couldn’t help her.” A sob racked him.

  “What happened then?”

  “Her breathing was all raspy and irregular. I shook her. Tried to wake her up. But she wouldn’t respond. I was going to call nine-one-one but decided I could get her here faster.”

  Not always the best call but in this case the right one. Had he waited on the medics and had she arrested at home before they arrived, this could have gone badly.

  “Does she have any medical problems?” Divya asked.

  “No. She’s very healthy. Exercises all the time. Really pays attention to her diet. Runs cross-country. She’s just a freshman, but she made the varsity track team.”

  “Does she use any kind of drugs?” I asked.

  “No. I’m sure of that.”

  I refrained from mentioning that most parents thought that.

  He swiped a hand, fingers trembling, over his mouth. “Is she going to be okay?”

  “I think so. Dr. Weinberg will take care of her here in the emergency room, but she’ll be admitted to the hospital while all this is sorted out.”

  “You’re a doctor. Aren’t you going to treat her?”

  “I don’t practice here. Dr. Weinberg runs the emergency department. He’s very good.”

  He nodded. “Thanks for saving her.” He looked down toward the cubicle where hi
s daughter lay and swallowed hard. “She’s all I’ve got. We lost her mother a couple years ago. It’s been tough on Valerie, but she’s a trouper. Tough as they come.”

  Chapter 25

  Maria Mendez was right. Oscar was confused. Very confused.

  He didn’t know his name. He didn’t recognize Maria. He didn’t know where he was or what day it was, and had no idea who Divya and I were or why we were standing in his living room, looking down at him sitting on the sofa.

  Oscar did not sit quietly. He jabbered on and on, mostly nonsense, occasionally putting together something that sounded like a sentence only to fall apart before he finished. He stared wide-eyed at nothing and waved his arms around as if protecting himself from a squadron of invisible insects. He burst into hysterical laughter and then fell into equally hysterical sobbing.

  “He’s been like this all morning.” Maria sat on the other end of the sofa, out of reach of Oscar’s flailing. Crying had puffed and reddened her eyes, and her face appeared pale and drawn.

  I pulled a chair over near Oscar and sat. “Oscar, how are you doing today, partner?”

  Oscar’s head snapped in my direction, but he didn’t look at me but rather past me toward the front window. “The tangerines have been bouncing all day. Did you see them? I think they belong in the airplane.”

  Maria sniffed, tears welling in her eyes. “See what I mean?”

  “Who am I?” I asked.

  “Don’t you know?” he asked, his eyes widening in surprise, now looking at me. Then his gaze was gone, this time up toward the ceiling. “I think ice cream would be nice. And cherries. Do you like cherries? I do.”

  “Oscar, look at me.” He did. “What did you have for breakfast today?”

  “Tangerines. I saw tangerines everywhere.”

  I turned to Maria. “Anything unusual happen? Like maybe a fall?”

  “No. Everything’s been normal. He actually had a very nice breakfast this morning. Ate more than he usually does.”

  “Tangerines?” I asked.

  A quick nervous laugh escaped her lips. “I don’t know where he came up with that. We haven’t had tangerines in years. In fact, Oscar doesn’t like fruit of any kind.”

  “He’s still taking his medicines regularly?”

  “Oh yes. Like I told you the other day, I take care of that. Make sure he never misses any of them.”

  “Can I take a look at his medicines?” Divya asked.

  Maria stood and left the room, returning a few minutes later with a paper bag filled with prescription bottles and a pale blue plastic pillbox, one of those with three small compartments for each day of the week.

  “Every Sunday morning I organize all of his pills and put them in this.” She handed the box to Divya and sat back down on the sofa. “He takes some of his medicines three times a day, so I have everything set for breakfast, lunch, and dinner.”

  While Divya moved to the kitchen table and began going through Oscar’s meds, I conducted a neurological exam. It wasn’t easy. I couldn’t hold his attention long enough to get through all the necessary tests, but we muddled through.

  “I don’t see any change in his physical status,” I said.

  “There’s no evidence he’s had a stroke or anything like that.”

  “Then what is it?” Maria asked.

  “Most likely a worsening of his dementia. Remember? I told you this is how it usually goes?”

  Her knuckles whitened as she gripped the front edge of the sofa. “This quickly? I mean he’s been up and down for months. But this? I’ve never seen him like this.”

  “It’s unpredictable, Maria. It can happen just this way.”

  “You might want to look at this,” Divya said.

  Maria and I walked to where Divya had Oscar’s pillbox and bottles arrayed on the kitchen table. Oscar began muttering more about tangerines and now began talking about someone or someplace named Rosarita. When I asked, Maria said she had no idea what he was talking about.

  Divya held up a brown plastic medicine bottle. There were only a half dozen pills inside.

  “These pink oval pills?” Divya said. “These are his antianxiety meds. Citalopram. Based on the last refill date, he should still have over twenty-five of these left.” She then pointed to the pillbox, where she had opened each of the twenty-one compartments. “See these same pills here, and here, and here?”

  I saw the problem immediately.

  “Maria, this is a once-a-day medication, but it looks like he’s been getting it three times a day,” I said. “Probably for a week or more.”

  Maria collapsed into the chair across from Divya. Her face tightened as if holding back tears. “I’m always so careful.”

  “It’s easy to do,” I said.

  She looked at Oscar, who was staring at the TV, which was off, and muttering to himself. “I’ve poisoned him.”

  “No, you haven’t. Even if taken correctly, these medications can cause some very strange behavior, particularly in someone who has dementia like Oscar. Taking too many makes that more likely. Now all of his odd behavior makes perfect sense.”

  “What do we do?” Maria asked. “Will he ever be his old self again?”

  I nodded. “He should be fine. We’ll just hold this medicine for a few days and then restart it at the proper dose.”

  I could see the fear and anxiety on her face when she looked up at me. “This is my fault.”

  “It’s an honest mistake, Maria. It happens all the time.”

  “You mean to old folks. Like me and Oscar.”

  “That might be true, but I mess up things like this, too,” Divya said.

  “You’re just being nice.” She sighed heavily, her shoulders slumping. “I know you’re both wondering if I’ll do this again. If maybe next time something bad will happen to Oscar.”

  “You’ll have to be more careful,” I said. I laid a comforting hand on her shoulder. “Maybe you should reconsider what we talked about before. Some assisted-living arrangement.”

  Maria tugged a napkin from the green plastic holder that sat in the middle of the table and dabbed her eyes. “I don’t . . . we don’t want to do that.” She looked up at me. “Unless we have to.”

  “You don’t have to make that decision right now, but I do wish you would consider it.”

  Again, she looked toward Oscar, her gaze resting on him for a full minute before she spoke. “I owe him so much.” She sniffed back tears. “Like swallowing my pride and doing what’s best for him.”

  I sat in the chair next to her and took her hand. “Let me talk to Jill Casey. She’s the administrator over at Hamptons Heritage. She’ll have one of the hospital social workers come talk with you. Show you the options. Even take you around to look at some of the places. Then you can make a decision.”

  Maria nodded, and took in a deep breath, letting it out slowly. “I guess I should do that.”

  Chapter 26

  Divya dropped me at Ellie’s estate to pick up my car. She headed back to my place to work on her notes and to have some sort of quasi marketing meeting with Evan. His idea. Not something she looked forward to.

  Better her than me.

  I drove to Hamptons Heritage.

  I walked into the emergency room and immediately ran into Jill.

  “Looks a lot quieter around here now,” I said.

  It did. Where there had been disorder earlier, everything was now calm. No one was in the trauma room or either of the two major treatment rooms, and only a handful of people sat in the waiting area.

  “Probably the calm before the next storm,” she said. “What’re you doing here?”

  “I came to see you.”

  “Liar.” She laughed. “I know you too well, Hank Lawson. You’re here to see how all the patients you brought us today are doing.”

  “That, too.”

  “Come on. I’ll go upstairs with you.”

  “Is that because I don’t have privileges and shouldn’t be wandering around
the hospital or because you just want to hang out with me?”

  “Let’s go with the former.”

  “Maybe both?”

  “Maybe not.” She smiled.

  “Now look who’s lying.”

  We first stopped by to see Jesus Morales, who was light one spleen but otherwise doing well. ICE hadn’t been called, at least not yet, so he was happy and anxious to go home.

  “It’ll be a few days yet,” I said.

  “I’m fine. A little pain, but I can handle it.”

  I was sure he could. “See that bag of yellow fluid?” I pointed to the IV bag that hung above his head. “That’s fluids and vitamins and antibiotics so you’ll heal properly. Can’t shortcut that stuff or bad things might happen.”

  He held out one of his hands, palm down. A large scar ran diagonally across its back. “See that? Piece of sheet metal. Know what I did?”

  “What?”

  “Nothing. No doctor. No hospital. I washed it with whiskey every day.” He made a fist. “I’m a fast healer.”

  “This is a little different, Jesus. Be patient.”

  We then visited Nathan Zimmer in the cardiac ICU. He was sitting up in bed, stacks of paper on his tray table, half-glasses resting on his nose. Todd sat in an adjacent chair, his MacBook Pro on his lap, fingers struggling to keep up with Nathan’s rapid-fire dictating.

  “Does Dr. Edelman know you’ve turned his cardiac unit into an office?” I asked.

  Nathan didn’t look up, his eyes racing across the page he held. “They took my phone. Some BS about it interfering with the electronics in here. I think it’s a power play.”

  “Actually, it’s true. Cell phones can interfere with the monitors.”

  “Pardon my skepticism.”

  “You should be resting, not working.”

  “I told you I didn’t have time for this,” Nathan said. Now he looked at me and then to Jill. “Who is this lovely creature?”

  I started to answer, but Jill beat me to it.

  “This creature is the hospital administrator,” she said.

  Nathan perked up. “I’m glad they sent the big boss to see me.”

  Jill laughed. “I’m simply trying to keep Han—Dr. Lawson—out of trouble.”