"DNR?" Will asked.
"Do not resuscitate," Cathy explained. "And Elena's writing that order instead of conveying her wishes to the attending physician was a significant breach of protocol."
Elena nodded her assent. "The doctor-his name's Matney-the doctor also told me that he hadn't turned off Mark's respirator or authorized withdrawal of life support. He asked me if I'd done it."
Will opened his mouth, but Elena anticipated his question.
"Yes, if I'd done that myself, it would be another no-no. The thing is… I don't know if I did or not. I have no memory of the hour before Mark died."
Will looked up from his notes. "Can't you explain that on the basis of… what do you call it? Did you block out an unpleasant memory? Sort of a selective amnesia?"
"I'd like to accept that, but the story doesn't end there," Elena said.
Will glanced at the notes he'd made. What more could there be to this story? He soon found out, as Elena laid out the story of Chester Pulliam's death. "I'll admit it. When I couldn't convince his wife to authorize removing life support, I wanted to take matters into my own hands. I was alone in that room. I even went through the ways I could end his life so no one would ever know. But I didn't. Or at least I don't remember doing it."
"What about the DNR order in someone else's handwriting?" Cathy asked.
"I've thought about that a lot. I knew the signature on the chart wasn't my usual handwriting. That's why I gave Dr. Matney a sample of my signature and used that to bolster my argument that I had nothing to do with Pulliam's death."
"So what's wrong with that argument?" Will asked.
"What if I was functioning in a dream state? Our knowledge on the subject is still evolving. My handwriting might not be the same under those circumstances."
Will frowned. "What do you mean by 'functioning in a dream state?'
"
Elena leaned forward as though to explain, but Cathy waved her back. "No, let me tell him. Because I see where you're going, and why you might be worried about caring for patients in a situation similar to Mark's." She took a long pull from her water bottle. "Elena is afraid she was in a fugue state."
Will said, "Fugue?"
Cathy smiled, obviously enjoying the opportunity to teach her husband something. "I know you think a fugue is some kind of a musical composition that you don't like, but this is different. It's a neuropsychiatric condition. A person in a fugue state can carry out actions with no conscious volition or subsequent memory of their actions."
"Wouldn't that be self-limited? And couldn't it still be due to the stress of Mark's death?"
"Not necessarily," Cathy said. "We used to think fugue states were part of the psychiatric spectrum, but there's a lot of new evidence that they may be related to seizure disorders. And if you've had one, you could have more."
Will made a few more notes. "I guess you'd know more than I do about confirming that diagnosis." He capped his pen. "So now we have the whole story."
"Not quite," Elena said. She turned to Cathy. "Did Dr. Matney contact you and say anything about my being on probation here?"
Cathy's bewildered look answered the question before she confirmed it. "No, not at all. Why should you be?"
"So that was a bluff," Elena said.
"What's Dr. Matney's stake in all this, anyway?"
"He's in the running for Dean Dunston's job, and he's anxious to avoid negative publicity for his department. That's why he wanted to rush me off the campus."
"You mean he just wanted the whole thing to go away," Cathy said.
"Right," Elena said. "I was worried about Matney and my reputation, but something bigger is at stake now. It's possible I might have taken two patients off life support and not even realized it. Now I'm participating in the care of another patient who might be in the same situation. What if I do it again?"
This time Will didn't reach for his pen. Instead, his mind churned with the legal ramifications of the case. Was ending the life of a patient kept alive only by artificial means subject to prosecution for murder? Or manslaughter? Could a fugue state be the basis for a defense based on diminished capacity? Or was someone manipulating these circumstances to cast suspicion on Elena, bent on wrecking her professional career?
While Elena and Cathy were tossing around phrases like "neurotransmitters" and "subconscious wish fulfillment" and "dissociative reaction," Will tilted his chair back, closed his eyes, and uttered a silent prayer. He certainly hoped God would help out here, because he didn't have the foggiest notion how to proceed.
Elena paused outside the examining room door and scanned the information on the page in her hand. Maria Gomez was not only her first patient of the morning; she was her first patient in private practice. Well, her first office patient, at least.
Mr. Lambert was still in the ICU, still dependent on the respirator, still in a coma with no signs of regaining consciousness. Elena was grateful that Cathy had taken over daily rounds on him. She didn't want to be worried about what she might do if another episode came upon her. If there truly were episodes. The jury was still out on that.
Enough. Time to go to work. Elena tapped on the door and opened it. According to the chart, the woman perched on the edge of the examining table was seventeen years old, but she looked twice that age. Her thin arms and legs were in marked contrast to her distended belly. The record sheet listed a chief complaint of "pregnant." Elena figured she could have made that diagnosis at a distance of fifty feet. The challenge now was what to do about it.
"Good morning, I'm Dr. Gardner." Elena moved a step closer. "How can I help you?"
"She does not speak English." Elena's eyes moved to the young man perched on a chair in the corner. His clothes were clean but very worn: faded jeans, a T-shirt, tennis shoes. "?Habla usted espanol?"
" Solo un poco. Just a little."
The man's look of disappointment confirmed to Elena that, once more, her lineage had betrayed her. She could imagine his joy at seeing a doctor so obviously Hispanic fade when he discovered her Spanish was limited.
"Your English is fine," Elena said. "If you don't know a word, give it to me in Spanish. I speak some, just not a lot."
"Okay." He swallowed. "Maria is… embarazada."
"Yes, I can see she's pregnant. What brings you here?" His puzzled expression told her to stop relying on idioms. Try again. "What can I do to help?"
"Her time is coming near. She has the…" Again, a hesitation as he searched. "She has dolor de cabeza severo. And sometimes the things she sees, they are… how you say, not clear."
Elena nodded. Red flags went up immediately. A pregnant woman with severe headaches and fuzzy vision. "Has she been eating?"
Embarrassment colored his face. "Sometimes there is no food. I get work where I can, but…" He spread his hands.
So add poor nutrition to the mix. Elena recognized that getting the entire history would be a slow process. She already had a good idea of the problem, and she was itching to get the pieces of the puzzle that would tell her how severe it was. "I need to do an examination. The nurse will prepare her, and I'll be right back. Do you want to wait outside?"
"Please, no. I am her esposo… her husband." He beamed at finding the word. "And I must tell her in Spanish what is needed."
Twenty minutes later, Elena stood outside the door of the exam room and considered her findings. Blood pressure sky high. Visual symptoms. Headache. Elena could make this diagnosis in her sleep: toxemia of pregnancy. No convulsions- yet-so it was still preeclampsia. But both mother and child were at grave risk without immediate treatment.
Cathy emerged from the next room, and Elena beckoned her over. "Let me ask you about this one," Elena said. "Young woman, probably eight months pregnant, preeclamptic."
"Let's see what you've got." Cathy studied the sheet, now covered with Elena's notes. She raised her eyebrows, and Elena figured she'd seen the blood pressure readings.
Cathy handed the chart back. "No OB, I gues
s."
"Nope. I haven't asked, but I'm pretty sure they're both illegals. She doesn't speak English, but her husband does okay with it."
Cathy nibbled at her thumbnail. "Summers County General is the designated regional medical center. Have Jane call the nurse coordinator there. She'll arrange for care by one of our OB's."
"So we can do this locally? No need to send her to Dallas?"
"Not for this. Sure, if there's something so unusual we can't handle it, we send patients to Parkland. But we have good doctors here. There's some kind of administrative payment deal in place so we're reimbursed for handling indigent care. I don't worry too much about that. That's one way Nathan Godwin earns his pay."
"Good to find that out." Elena scribbled a quick note on the margin of the chart. "You know, I thought I was totally ready to go out into practice. I figured there wasn't anything a patient could throw at me that I didn't have an answer for. But one thing they didn't prepare me for was cutting through administrative red tape to get care for patients. I'd mastered the system at the medical center, but it never occurred to me that I'd have to learn a whole new one here."
Cathy smiled. "Don't worry. You'll find your way through the jungle pretty quickly. Meanwhile, just keep on taking care of the patients."
Elena was about to re-enter the exam room when Cathy called to her. "Oh, and Will wants us to get together again this evening. He has a suggestion about shedding some light on your mysterious caller and the circumstances of Chester Pulliam's death."
Elena froze. She wished she could ignore the whole problem, let it go away. But in her heart, she knew she had to face it. And she was afraid of what she might find.
Elena wasn't really hungry, but the dictum of "eat when you can, sleep when you can" was deeply ingrained. It probably wouldn't hurt her to grab a bite of lunch in the hospital cafeteria. She might even have the opportunity to meet more of the staff.
She saw a familiar face alone at a table for two in the corner. Elena wove through the cafeteria balancing a tray with a ham sandwich and a glass of iced tea. When she arrived at the table, its occupant looked up, smiled, and said, "Dr. Gardner. Would you like to join me?"
"I'd love to." As Elena unloaded her tray, she sneaked a peek at the nametag pinned onto the woman's scrub top. In the ER, Elena hadn't picked up the nurse's last name. The tag gave her that information: Glenna Dunn, RN.
"So are you settled in?" Glenna asked.
"Pretty well," Elena said. "And I want to thank you again for telling me we have an interventional radiologist here. There are so many things to learn when you come to a new hospital- especially when you're thrown in suddenly."
Glenna waved it off. "No problem. And I hear Mr. Nix is doing well."
"How long have you been working in the ER?"
"About five years now. I planned to quit work and be a stay-at-home mother after Bill and I had children, but-" She bit her lip and stared down at the remains of her salad.
"But you can't have children? Is that it?"
"You might say that," Glenna said. "Bill and I were married less than a year ago. He thought our little apartment was too small, especially if a baby came along. He was driving a truck on weekends to make enough money for the down payment on a house. And then… then, about six weeks ago, he was in an accident. Head-on crash. It was terrible." Tears welled up and spilled onto the table.
Elena pulled a tissue from her purse and handed it to Glenna. "I know how you must feel. My husband died recently too."
Glenna looked up with an expression of pure anguish. "Bill didn't die. He had a severe head injury with a massive amount of intracranial bleeding. The neurosurgeon operated, but there was too much damage. Bill's been in a coma ever since. He was in ICU for a week. When he was finally able to come off life support they put him on a regular ward. Now he's in the south wing, the old part of the hospital. They call it 'extended care,' but it's not like he gets a lot of care. The doctor says he won't ever wake up, but he could live for years like this. I don't know what I'll do when the insurance benefits run out. I can't even think about it right now. No, Bill didn't die. But every day I find myself wishing he had."
Elena felt a lump the size of Kansas in her throat. She swallowed hard. "I'm so sorry. I didn't know."
Glenna dried her eyes, excused herself, and hurried off.
Elena was still at the table, her sandwich forgotten, when she felt a gentle touch on her shoulder. She turned and saw Marcus Bell behind her. "I saw Glenna rush out. Did she tell you about her husband?"
Elena gestured for Marcus to sit. "Yes, I'm afraid I put my foot in my mouth. Poor lady dissolved in tears." She sipped her tea, then shoved it aside. She suspected her lunch would remain uneaten today.
"It's a sad story. And every patient who comes into the ER with a head injury seems to freshen the wound. I've asked Glenna if she wanted to transfer to another unit. Her answer's always the same. 'If I can keep another family from facing what I have to live with every day, my work will be worthwhile.'"
Elena wondered if she might have discontinued Mark's life support while in a fugue state to avoid the living death now experienced by Glenna's husband. Had she been fulfilling a subconscious wish? And could she have done the same thing with Chester Pulliam?
"Penny for your thoughts," Marcus said.
"Sorry. Glenna's story just brought back memories of my own husband's death."
"You know, I'd like to offer you that non-date I mentioned earlier. Why don't I buy you dinner on Saturday night? You can talk, we can commiserate, and I assure you I'll be a perfect gentleman."
Elena felt herself tugged in two directions. She'd love some companionship, especially that of someone who'd also lost a spouse. But she got the definite impression that Marcus wanted a relationship that could move beyond the "non-date" phase. Was she ready for that? And if so, was Marcus the one? No, she couldn't make that decision. Not yet. She looked him full in the face. "Marcus, I appreciate the offer, and someday I may be able to take you up on it. But not right now. I hope you'll understand."
The three people gathered in Will's office showed signs of a hard day. Will slouched in his office chair, his collar unbuttoned and his tie askew. Cathy had her feet propped on an extra chair and kept poking at her ankles, apparently trying to decide if the swelling was significant. Elena did her best to look cool, but she couldn't get away from the phone call that had come before she left the office.
"Elena, it's Frank Perrin."
The sound of his voice had made her feel like a schoolgirl again, thrilled that the captain of the football team had called her and a little nervous that she might say the wrong thing. "Frank, it's good of you to call. I'm sorry we had to cut our lunch short the other day. And I really appreciate your using your lights and siren to get me to the hospital quickly. That made a big difference to the patient."
"'Protect and serve,' that's us," Frank said lightly. "I was wondering if we could make up for that shortened lunch by having dinner together this evening."
Elena almost laughed. Two dinner invitations in one afternoon. Her social life was picking up, and she was nowhere near ready for it. She was exhausted, both physically and emotionally. And she still had the meeting with Will and Cathy.
"If you have to think about it that long, maybe I shouldn't have called." Frank's voice was even, but she sensed an unpleasant undercurrent there.
"No, I was just going over my schedule. Actually, I have a meeting tonight. After that, all I want to do is go home and crash." Keep it simple. Let him down easy. "Can I get a rain check?"
"Sure. We'll try again later. Have a good evening."
"Hey, are you with us?" Cathy's voice brought Elena back to the present. "You looked like you were a million miles away."
"Sorry. I can't get my mind off that pregnant girl I saw this morning. Think the OB assigned to her case would mind if I dropped by to check on her?"
"Not at all," Cathy said. "In the morning, call and see which doctor it
is. If you go about the time he usually makes rounds, you can introduce yourself."
"If you two doctors are through talking shop, I'd like to get going. We've all had a hard day. Elena, I need your permission to have an investigator look into both the deaths of your husband and Mr. Pulliam. I'll employ him, and if you engage me as your counsel, anything he finds will be privileged and protected."
"You mean that if he discovers I actually did discontinue life support in both cases, that won't necessarily make me end up in court," Elena said. "Is that it?"
"Yes. The guy I want to use-Ramon Campos-is based out of Dallas. He's discreet, very trustworthy, and does a great job of staying under the radar. I can pretty much guarantee that no one will ever know he's investigating these matters."
Elena bit her lip. She hated to open what could be a Pandora's box. "What about the midnight phone calls?"
"That's part of the package. I want him to find out who's been calling you and why."
"How much would this cost?" Elena asked. "I haven't drawn a paycheck yet, and my financial situation isn't very good right now. Between my student loans and the expenses of Mark's death, I'm pretty far in the hole."
Will waved that away. "I'm going to take this on pro bono, and I'll handle the expenses of the investigation. You can pay me back after you're on your feet."
Elena felt like she was poised on the edge of the high board. She could jump or back down the ladder. The only sound in the room was a faint click followed by a low whoosh that signaled the air conditioner starting to combat the evening heat.
"Your choice," Cathy said. "But I think you're going to regret it if you don't confront this issue."
"I'm willing-no, I'm anxious to find out who's been calling me. But I don't know how your investigator can talk with the ICU nurses and staff and discover anything about the deaths of those two patients without making a lot of people suspicious. And if Dr. Matney gets wind of this, I can guarantee he'll reach out and do something to get back at me for stirring the pot again."
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