Guarded Prognosis

by Richard L. Mabry MD

  He heard the garage door open, followed by the noise of her Outback pulling in. A moment later, Beth entered through the kitchen. She dropped the bag of groceries she carried and gave him a hug. “Been home long?”

  “Not really.” Caden had a dozen questions but figured Beth would probably tell him all he wanted to know as she unloaded the food.

  “I think I can throw something together if you’re able to wait a bit,” she said over her shoulder.

  “Sure. Is there anything I can do to help?”

  “Nope. This won’t take long.” Beth pointed to a chair at the kitchen table. “Have a seat.”

  One question in Caden’s mind had already been answered. While he had worried about Beth working at the office, she apparently enjoyed it. He pulled out a kitchen chair and listened as she recounted the events of the day from her perspective.

  “I think I’ll catch on easily to the routine of working in a doctor’s office,” she said, as she bustled around the kitchen. “And Rose is a good teacher.”

  “Have you met everyone on staff yet?”

  Beth pulled a package of chicken breasts from the freezer and put it into the microwave to defrost. “I worked mainly with your nurse, Rose. I also met Mona, Dr. Russell’s nurse, and Gary, the nurse for Dr. Sparling, but I didn’t really have much interaction with them.”

  “Were they cordial?”

  “Mona was. Gary seemed a bit . . . I don’t know. He was a little distant.”

  “That’s just Gary’s personality, I think,” Caden said. “He came here looking for a job at about the time Jim Sparling was getting ready to open his practice. I presume Jim checked his background, and he’s worked out fine.”

  The microwave beeped. She checked the meat, hit some buttons again, and turned back to Caden. “I’d already met Donna, one of the two receptionists. I think Mona, the other one, was off today. So I guess that’s everybody.”

  “Sounds like you had a full day,” Caden said. “Did you have any trouble with charts?”

  “No. Rose showed me how to pull them up. You have a few of the old ones in paper form, but not many.”

  Caden nodded. “Did Rose show you how to use the electronic prescription function?”

  “She touched on the basics—the usual meds, refills, things like that.”

  “What about narcotics?”

  Beth shook her head. “She said you rarely prescribe controlled substances, so we didn’t get into that today.”

  “Did she show you where to find my DEA number?” Caden asked.

  “We went to the file room and she showed me the computer all the nurses use to write and send prescriptions. I mainly learned about the regular meds, but I noticed that the DEA numbers for all three doctors are posted on the wall right next to a listing of the most popular pharmacies that accept electronic prescriptions.”

  He nodded but said nothing. Surely the DEA agents saw this too. It was obvious that anyone with access to the office suite could send electronic prescriptions and make it look like they were authorized by any of the physicians. He probably should change this. Of course, that might be locking the barn door after the horse was long gone. He’d ask Neilson about it.

  The other question in his mind was one he planned to investigate without mentioning it to the DEA agents. If this leak in the security of their system was so evident, why had Harwell spent so much time in the office?

  Wednesday was busy but enjoyable for Beth. Dr. Sparling had a surgical case canceled for that morning, but there was room in the suite for both him and Dr. Taggart to see patients. Dr. Russell had also been there for a few minutes that morning, but after receiving an urgent call from the hospital she’d left.

  “What’s up with that patient of Dr. Russell’s,” Beth said to Mona.

  “I think there was a patient in the emergency room who had a bleeding aortic aneurysm,” the other nurse replied. “That was what I gathered as she took out of here.”

  Beth had seen the other side of this scenario—the surgeon rushing in to operate on an emergency case, but never gave much consideration to the juggling of schedules that went on back at the doctor’s office. She had to admire Donna and Mona, both of whom had gone through this often enough that they seemed comfortable. She wondered if she’d ever achieve that level of ease when called upon.

  “Phone call for Dr. Taggart,” Donna said. “It’s Dr. Russell, and I think it’s urgent.”

  Beth nodded and headed down the hall, where she met Caden coming out of his office. “Call from Dr. Russell.”

  “Usually this is about a patient. Let’s see what she wants.” He ducked back into his office and punched the lighted button for the back line while Beth waited in the hall.

  A moment later, Caden hurried into the corridor. “Beth, get Rose and Donna to help you with rescheduling my morning patients. I’ll be in surgery for the next several hours.” Before she could comment, he pushed open the back door and left.

  Beth thought about what she’d been considering just moments before. Well, I guess it’s time to find out how good a juggler I am.

  Caden scrubbed in as soon as he arrived at the OR, and it didn’t take him long to see that the patient’s aortic aneurysm—the balloon-like dilation of the major blood vessel running from the heart to his pelvis—was leaking blood faster than Ann’s efforts to control it.

  Ann kept her eyes on the operative field when Caden took his place across the table from her. “Thanks for coming. I need to get the graft in place, but I’m not getting anywhere because of the bleeding.”

  “How do you want me to help?”

  “Start with some more retraction.”

  Caden repositioned the instruments that allowed him to expose the area where Ann was working. “Better?”

  “Not much.” Ann looked up at the scrub nurse. “I need more suction. And get someone to adjust the light. Maybe bring in another spot. I can’t see anything in this hole.”

  In situations like this, the surgeon’s full attention was focused on the task at hand. Caden was surprised when he looked at the clock on the OR wall and saw he’d been a part of this procedure for more than an hour. Ann had finally given up on the preferred maneuver of inserting a graft to reroute blood to vital organs before resecting the section of aorta that was bleeding. Instead, she cross-clamped the large vessel to replace it with the graft before there was permanent damage. If she couldn’t restore circulation quickly, the patient would lose his legs, perhaps his kidneys, maybe even his life.

  Ann worked fast and Caden tried to match her speed, all the while keeping a silent count of how long the perfusion had been compromised. Just as Ann and Caden were releasing the clamps that would allow blood to begin flowing again to these areas, the anesthesiologist shook his head. “He’s flat-lined. No pulse. No pressure. I couldn’t pump in blood as fast as he was hemorrhaging. I’ve tried adding plasma expanders and colloids, but it was a losing battle.” He paused. “Sorry. He’s gone.”

  Before he lost his first patient during surgery, Caden somehow imagined there would be silence in the operating room after a patient died on the table. But he discovered that wasn’t the case, just as it wasn’t in this instance. The ambient sounds changed a bit, but the room was far from silent.

  He could hear the muted ringing of a phone at the OR secretary’s desk ninety feet away. Voices, although hushed, still echoed from the tiled walls in the hallway. And in the operating room where he stood, the normal sounds of surgery were replaced by the soft voices of two nurses who were preparing the body of the patient for transport to the morgue.

  Caden leaned back against the OR wall, trying to work the kinks out of his back and relieve the muscle spasms brought on by working in a cramped position for so long. With his mask dangling around his neck, he flipped off his gloves and shucked out of his blood-soaked gown. He tossed them in the bin and looked up at the ceiling. As far as Caden knew, Ann had done everything she could, but he knew she’d be depressed because she’d bee
n unable to save the man. He knew he would be.

  Ann had sounded so confident on the phone, sort of like, “I’ll take care of this, but I sure could use your help.” Now she stood silently at the writing shelf that extended from the OR wall and scribbled notes for the patient’s chart. Later there’d be a full operative note to dictate, all the paperwork that went with an operation, even when the result was the death of the patient.

  Although she was writing, Caden knew Ann’s mind was on what was coming next. She was getting ready to face the man’s family to tell them, “I did everything I could, but he didn’t survive. I’m sorry.” Caden knew it, because he’d been in her position before. And no matter how many times a doctor faced that situation, it never got easier.

  Caden was certain what the answer would be, but he asked anyway. “Would you like me to go with you to talk with the family?”

  Ann was shaking her head before he finished his offer. “Thanks, but they won’t know you. Actually, they don’t know me either. There was no family with the man when I saw him in the ER.” She started to turn away, then looked back at him. “But I’d appreciate it if you’d wait around for me. I think it might help to talk about this with someone who understands.”

  “Of course,” Caden said. He made sure the OR nurses didn’t need anything from him, then went to the surgeons’ dressing room to change out of his bloody scrubs into his street clothes. It probably wouldn’t hurt to shower first either.

  After Caden had cleaned up and changed clothes, he looked in the surgeon’s lounge for Ann, but she was nowhere to be seen. He sat on the couch, fidgeting and checking his watch several times. What was taking her so long?

  Caden knew why she didn’t want him with her when she talked with the family of the patient who had just died. As she’d pointed out, they didn’t know him. And undoubtedly Ann was as experienced as he at breaking news of a loved one’s death to the family. But he also understood her request that he stick around. Caden knew after losing a patient it helped to talk through the experience with someone who understood.

  After waiting for fifteen more minutes, Caden began to have second thoughts about his promise to Ann. They probably needed him back at the office. Should he call Beth? He could tell her he was still at the hospital but out of surgery. There might even be a question or two he could answer over the phone.

  Caden had his cell phone out when the door of the lounge opened, and Ann Russell entered. She, too, had changed out of her scrubs, and when she sat down beside him, Caden could smell the soap and shampoo she’d just used in her shower.

  He put his phone back in his pocket and decided to let Ann speak first. They sat in silence for a moment, and when she finally spoke, she surprised him. He thought she’d want to talk about the medical aspects of the operation. What could she have done differently? Was there something she’d missed that could have altered the outcome?

  Instead, she sighed, then said quietly, “There was no one for me to talk with.”

  Caden furrowed his brow. “I don’t understand.”

  “The patient presented to the emergency room with severe belly pain. I found out that he took a bus to the hospital because there was no one to bring him. When I went out to talk with the family, there was nobody in the waiting area. When he signed into the ER, he listed a chaplain at a rescue mission as his emergency contact, so I called there. No one knew anything about him other than his name.”

  “No family, no friends?” Caden asked.

  “No one. That really upset me.”

  “What did?”

  “He didn’t have any friends, anyone who cared if he lived or died. And when you think about it, neither do I.”

  Caden’s response was made without conscious thought. “Of course, you do.”

  “Think about it. I have a few professional acquaintances,” she said. “When you ask me to name my friends I think of you, but I wonder about that. I’ve never been in your home. I know your wife’s name is Beth, but until she started working at the office the other day, I’d met her maybe twice. I wonder if I really have any friends. Does anyone care if I live or die?”

  “What about your parents?”

  “Divorced.” Ann sighed. “Although they’d never say it, I think they thought I was a precipitating factor, so they decided to drop me when their marriage came apart. I haven’t talked with either of them for a couple of months, and when I did, I was the one who called them.”

  Caden started to protest, but Ann wasn’t finished.

  “You’re the only one who cares about me.” She moved even closer to him. “And I don’t want to die alone like that man.”

  “Ann, you’re not—”

  Before he finished his sentence, Ann put one arm around his neck, pulled him toward her, and kissed him.

  12

  Caden knew he was running behind when he finally left the hospital, and spent the rest of the afternoon at the office catching up. But when he had a moment to stop and think, guilt swept over him about Ann’s kiss. She’d immediately apologized, saying her emotions got the best of her. Caden had told her to forget it. But he couldn’t take his own advice. He couldn’t forget, couldn’t stop wondering about Ann’s motivation and feelings for him. Did he return the kiss? He didn’t think so, but was the act a betrayal of Beth?

  He’d known Ann since their days together in residency. There was no question she was beautiful—an attractive blonde who was unattached, a perfect catch for someone. She’d been cool with most men, rebuffing approaches from unmarried and married men alike, yet her relationship with Caden had always been that of friend and colleague. She’d never shown any evidence of wanting to take their connection beyond a professional one—until now.

  Another factor, and one Caden couldn’t fully figure out, was the relationship of agent Jerry Harwell and Ann. Caden had thought from the first time Harwell laid eyes on her that there was an attraction there—at least on the agent’s part. But Ann had kept things cool. Had that changed?

  At the end of the workday, before he left the office, Beth stopped Caden. “Would you mind if I didn’t cook tonight? I’ve got a headache, and all I want to do is slip into comfortable clothes and sit in front of the TV watching mindless shows.”

  “Why don’t I order a pizza? But before you get too engrossed in TV—or, more likely, fall asleep in front of the set—I need to talk with you a bit.”

  “About something here at the office?”

  Caden shook his head. “Not exactly. But we can discuss this more at home.”

  It was almost time for Beth to get home, and Caden hoped he was ready. He had a large pizza warming in the oven. Although he’d always considered pizza to be finger food, to be eaten directly out of the box or—at least—off paper plates, he’d set the dining room table with real china, as well as knives and forks. Glasses of iced tea sat beside both plates. Too much? He hoped not.

  Beth walked in the door, dropped her purse, kicked off her shoes, and started to collapse onto the sofa next to Caden. Then she lifted her nose and sniffed. “I do believe I smell pizza.”

  “Welcome to Chez Caden.” He chuckled and kissed her quickly, then led her into the dining room.

  “All this for pizza?” She looked at him askew.

  He gestured her to a seat and pulled out the chair for her. “There’s nothing too good for my working wife.”

  She giggled as he fetched the pizza and served it on the china plates.

  Beth asked a blessing that Caden thought was a little too long for carry-out, but he bowed his head and waited patiently for her to finish, even though his stomach churned with hunger.

  After each of them consumed their first piece, he said in a mock-British accent, “I suppose you’re wondering why I’ve called this meeting tonight.”

  Beth smiled, which Caden took as a good sign. “Seriously, I have something I need to tell you.”

  She dropped her second piece of pizza on the plate and looked at him. “Did you hear from your f
ather today?”

  “No.”

  “Is there something new in the DEA investigation?”

  “Not really.”

  Beth shook her head. “Then what is it? Something that has to do with the office? Is there a problem with my work?”

  “No. You’ve caught on to the routine like I knew you would.” Caden drank some of his iced tea, but his throat still felt dry. “Ann’s patient was bleeding from an abdominal aneurysm. The hemorrhage was too fast for us, and he died on the table.”

  “That’s terrible. Is that why you’ve seemed preoccupied all afternoon?”

  “No. I mean, no doctor likes to lose a patient, but Ann and I did everything we could. That wasn’t what I was thinking about this afternoon.”

  “Then what?”

  “Ann asked me to wait around to talk a bit after she notified the family,” Caden said. “But when she came back, she found that the patient didn’t have one—at least, no one who seemed to care. Then she started talking about who might care if she lived or died.”

  “I can understand that reaction.”

  “Then I hope you can understand this.” Caden took a deep breath. “She kissed me.”

  Beth was silent for a moment, staring at him. When she spoke, he could tell she was trying hard to keep her voice level and her tone non-accusatory. “Do you think she was just reacting to the situation and her emotions?”

  “I wish I knew.” He stopped and frowned. “Her relationship with me has been the exception, but in general she’s avoided attempts from other men to get close to her.”

  “What are you thinking? I can almost see the wheels turning in your head. Care to share?”

  Caden looked into his wife’s eyes. “First of all, I’m glad you don’t think I made a play for Ann—at least, I don’t think you do. And what she did could be blamed on the situation and her emotions. But part of me thinks about what’s going on with the DEA and false narcotics prescriptions, and I have to wonder if this signals an attempt to either divert my attention or recruit me as an ally.”