“Yes. I’m sorry. Her oncologist is in Springfield?”
“Yes, but it’s no use calling him. He’ll just increase the morphine.” Fatigue sharpened her voice. “She’s not worth his time. She’s just an old woman.”
“We want to make her as comfortable as possible. I understand you have the DNR request she signed?”
Ivy grew still as her eyes flashed back to his face. Her chin lifted a fraction. “Why?”
“Would you like to sit down?”
“I’ll stand.”
“I know you must be tired. I want to honor your mother’s advance directive, and to do so, I need the DNR sheet. This is all just legalities, and I apologize for having to ask you for it at a time like this.”
“You mean to just let her die?”
Lukas flinched at the harsh tone of her voice and the sudden, angry-suspicious expression in her eyes.
“If her heart should stop,” he said gently, “we wish to honor her request not to restart it.”
“What’s this ‘we’ business? You’re the doctor. You call the shots. I don’t want my mother’s heart to stop, and if it does, I want you to start it again.”
He held her suddenly angry gaze for a moment. She couldn’t know what she was saying.
“Mrs. Richmond, I thought you understood about your mother’s request.”
“My mother is not capable of making that decision now. I have power of attorney, and I don’t want you to just let her die like some worthless old woman. She’s a living human being with a soul.”
“Of course she is.” He hadn’t foreseen this. How could he get through to her? “I’m not talking about euthanasia. I’m talking about allowing nature to take its course, allowing your mother to retain her dignity and keep her from unnecessary pain. I’ve asked a nurse to call your daughter, Dr. Richmond, and she should be here—”
“You did what?” Her dark eyes flashed, and fatigue tightened the tension in her voice.
Lukas blinked at her helplessly. This was not going well. She was clearly, and understandably, irrational from lack of sleep. There had to be some way to make her see, without becoming too graphic.
“I specifically delayed calling my daughter because I wanted to put her through as little heartache as possible,” Ivy said. “She’s been through enough. You had no right to call her.”
“I’m sorry you feel that way, but Mrs. Conn’s condition is getting worse. I felt family needed to be here.”
“Not yet!” She paused with a gasp, placing a hand on her chest.
He stepped toward her. “Are you okay?”
“I’m fine.” Lowering her hand, she took a deep breath and held his gaze. “I don’t care what the DNR form says. I have durable power of attorney, and I want you to do everything for my mother. She’s not ready to die. She’s not…”
“I didn’t mean for this to be so difficult.” Lukas kept his voice gentle, resisting the urge to ask if he could examine her. He’d seen this kind of family reaction before, during his oncology rotation, when a caregiver was so exhausted that they became confused and combative. They often blamed the physician for the pain of their dying loved one. “I will contact Mrs. Conn’s family physician and clarify the matter.” He turned to leave.
“You don’t believe I have power of attorney?” she challenged, her voice rising a decibel.
He paused with his hand on the door. Lord, give me compassion.
But what about Mrs. Conn? She would suffer even more pain if they managed to resuscitate her.
He turned back to face Ivy, and he tried to keep his voice gentle. He knew his words were not. “What I believe is immaterial, Mrs. Richmond. For instance, I believe that to impose heroic measures onto a patient suffering the last stages of advanced carcinomatosis is not only transferring much-needed care from the living to the dying, it is inhumane to the dying.”
“Only if you don’t believe in hell.”
“Mrs. Richmond—”
“Ivy! My name’s Ivy!”
“I’m sorry, Ivy. I do believe in hell. I also believe that your mother is at peace about this. She told me she was ready to go.”
“What do you mean, she told you?” Ivy snapped. “Mother hasn’t spoken in days. What are you trying to pull here?”
Be gentle. Be patient. But what about Mrs. Conn? “Ivy, to try to resuscitate your mother at this stage would only cause greater, unnecessary suffering. And for what? A few more minutes or hours for the family to say goodbye? What about your mother’s feelings? She’s made her decision already.”
There. He’d done it again, him and his bad habit of stating his opinion to the wrong people at the wrong time. But if there was the slightest chance Ivy would listen…
She bent her head, her eyes closed for a moment. He watched her hopefully.
She reached into the right back pocket of her jeans and drew out a folded three-page form. “I had hoped it would never come to this.” The strength had left her voice. She unfolded the papers and held them out with shaking hands. “I have the power of attorney. Are you satisfied?”
Beverly caught up with Lukas as he reentered the E.R. proper. “That Mustang’s mine!”
Lukas struggled to work up some enthusiasm. “Don’t tell me you cajoled Dr. Wong—”
“Nope.” She jingled Cowboy’s keys. “Sweet-talked one of the new EMTs to help me. Buck likes animals.”
“Yes, but did you tell him this wasn’t a gerbil?”
She grimaced. “He knows it’s a big animal.”
“Horses are big animals. How will you feel if your helper comes back in here on a stretcher?”
“Awful.” She shrugged. “Dr. Wong’s finished with Cowboy. Got any patients for me?”
“Have I ever.” He gestured toward the charts at the desk. “Enjoy.”
He left her staring at the sudden overload and stepped back into exam room one to check on Mr. Verris. Shelly still sat there beside his bed, and Lauren entered behind Lukas, as if geared to his location by radar.
“Any change?” Lukas asked Lauren.
“Test results are in.”
Lukas checked the printouts. Nothing. Everything was normal. Even the drug screen was not helpful, because all it showed were benzodiazepines, and that was to be expected for someone who occasionally took them to sleep. Lukas could have done a quantitative drug screen, but that would have taken too long.
“BP’s gone up just a little, but not much,” Lauren continued. “Pulse and respiration are the same. They’ve called from upstairs to let us know they’re coming to take him to ICU.”
“Let’s make sure they know he still needs a CT scan.” Lukas did his own assessment. Was it his imagination, or was the man breathing more deeply? As he watched, Frankie’s head moved a fraction of an inch.
Lukas looked up to see if Lauren had noticed. “Has he moved like that before?”
“I don’t think so.”
He watched a moment longer. It was probably just a stimulation of the limbic system, a common event in a coma patient.
Lukas did an auscultation of Frankie’s chest one more time, then shook his head. With a nod at Shelly, he left the room. He was feeling more and more frustrated as the day progressed.
Lauren stepped out of the room behind him. “Dr. Bower? Some of the staff are getting together after this shift over at the cantina across the street. Want to join us?”
“Uh…sure. Yes, I’ll be there. Thank you for asking.” Lukas nodded and continued down the hall, knowing he would be kicking himself tonight when it came time to show up at the cantina. He would be starving when he got off, as usual, and since he always ate out anyway, this would be a good way to get better acquainted with the people who worked here. Unfortunately, he knew that by the time he arrived at the restaurant, he would be feeling so awkward about meeting with a group of near strangers, he would have lost his appetite. Almost.
Moving to a new place was lonely business, especially for him. Funny, he could face patients and
coworkers all day long with no problem, but when his time was not regimented, he had trouble forcing himself to reach out to others. It wasn’t that he didn’t like people, because he did. The youngest of three boys in a loving Christian family, Lukas was the only shy one in the bunch, and he had often been teased about it. The teasing had only made him more self-conscious, turning him inward, and now his family despaired of ever seeing him married. But this was a new place, and no one here knew about his shyness. It was time to dig himself out of the rut—or pray that God would move him out.
He took Mrs. Richmond’s papers to the secretary. “We’ll need copies of these, Carol. Please call Dr. Richmond back and tell her that she needs to be on standby. Her grandmother is holding her own at the moment, but she could deteriorate fast, and she’s now a full code.”
“Yes, sir.” Carol grabbed the papers from him, dark eyes glowering as she spun around to the copier. She muttered something under her breath.
Lukas watched the characteristically cheerful secretary in surprise. “Carol, are you okay?”
She put the first sheet into the copier and pressed the button. “Fine, just fine,” she mumbled. “We’re swamped, we’ve got patients dying back there, and all I hear are complaints that we’re not seeing people fast enough.” She indicated the waiting room. “Griping because you haven’t looked at their scalps yet. They’d be in here right now, except one of them had to step outside for a smoke. I get so tired—”
“Have they been signed in?”
“No, I’ve been too busy with these other—”
“I’ll take care of them.” Lukas glanced out the door, where one of the women he’d seen earlier stood smoking, talking to the other. He strolled out to join them.
“Hello, ladies, I’m Dr. Bower. I hear you’re unhappy about our service. What’s the emergency?”
The smoker quickly shoved her half-smoked cigarette into the receptacle like a school kid caught by the teacher.
“We need to be treated for head lice,” the nonsmoker said.
The patio was deserted, Lukas noticed. He took another step forward, carefully looked at first one over-permed head of hair, then at the smoker’s long, stringy brown hair.
He took out a notepad and a pen and wrote the name of a shampoo. He held it out toward the smoker. “Wash with it once, then wait a week and wash again. You can buy this at your local pharmacy.”
She stared at the note in his hand. “No prescription?”
“You don’t need a prescription for this. The two of you can share a bottle.”
“But we’ll have to pay for it.”
Lukas felt his skin tingle with growing irritation. He inhaled slowly, counting to ten as he placed the note on the top of a trash can nearby. It had suddenly become a stressful day, the worst he’d had in a long time. He couldn’t blame it all on these two misguided souls.
He turned and opened the heavy glass door. “Ladies, the shampoo costs less than a pack or two of your favorite brand of cigarettes.”
“But we have Medicaid cards,” the smoker called after him. “We can report you for refusing to treat us!”
He stopped midstride and slowly turned back toward them. “Feel free,” he said, keeping his voice calm. “I feel I should warn you, however, that when a card carrier tries to use the card in the E.R. for nonemergency care, she can lose her card. It’s called Medicaid abuse. I think you’ll find that shampoo works very well as long as you follow the directions.” He stepped inside and let the door close silently behind him.
There were other Medicaid cardholders—for instance, the little baby in exam room three—who needed treatment today, not next week, and Lukas saw to it that they received good care. Lots of Medicaids used the emergency room here because many family practitioners refused to take assignment. Those who did still limited their patients. Medicaid paid so little that a physician who took too many could go broke. The system didn’t work. Many times the people who behaved with integrity got left out entirely—both the honest Medicaid recipients and the honestly compassionate physicians. Greed was the culprit on all sides. Lawmakers spent their time writing more laws because people kept figuring out ways to take advantage of the system. It was frustrating. Lukas had to keep reminding himself not to blame the patients who sometimes misunderstood the constantly changing rules.
Lukas glanced around at the emergency department. He liked this little ten-bed setup. The exam rooms surrounded a large central station. Each room was well equipped. Five of the ten rooms had excellent cardiac equipment. There was a separate ambulance entrance and two physician call rooms.
Mrs. Estelle Pinkley, the hospital administrator, had done a remarkable job when she’d convinced the county to pay for this upgrade. Lukas had jumped at the chance to receive a dependable salary with benefits so far away from the congestion and stress and corruption of the city. Yes, he knew corruption was everywhere, but right now, with specific, damaging events so fresh in his memory, Kansas City represented everything painful.
Carol met Lukas as he entered the E.R. proper. “Dr. Bower, Mrs. Conn is getting worse. Lauren said to notify you.”
“Thanks, Carol. Please call Dr. Richmond back.”
“Lauren already did so.”
“Get ready to call a code if necessary.”
“Dr. Richmond will have a fit about that, you know.”
“Maybe she can do more about it than I was able to.”
Chapter Three
Mercy Richmond ran the block from her medical office to the hospital, not bothering to remove her lab coat. Mom had promised to call when the time came, but she hadn’t done so. Instead, Lauren had been the one to break the news.
Shoving open the glass doors into the emergency room reception area, Mercy barely slowed her stride. “Carol, where’s Grandma?”
“She was in exam room eight, but they called a code and moved her to trauma room one.”
Mercy stopped and wheeled back. “What? There’s not supposed to be a code!”
Carol shook her head in sympathy. “I’m sorry. Dr. Bower called it. He had to.”
“We’ll see about that.” Mercy swung back on course. First, administration had arbitrarily decided to bring in a full-time E.R. doc from Kansas City, and now this hotshot doc had decided to ignore a perfectly legal DNR request. Perhaps he’d never learned to read.
She pushed through the swinging double doors that pretended to lend privacy to the open emergency room. A secretary manned the central station. All other hands were gathered in the trauma room, six people altogether, including Grandma’s frail, still body on the bed. Others worked with quick efficiency, responding without question to the soft-spoken commands of a slender, brown-haired man in green scrubs. He knew the drill well.
“Get me a blood gas…. Push the epi now, Lauren…. Any pulse…? Continue CPR.”
Mercy stopped just inside the doorway as a nurse from upstairs pushed methodically against Grandma’s chest and another bagged her.
“What’s going on here?” Mercy demanded. “Doctor, what are you doing to my grandmother?”
He looked up, his blue eyes behind gray-framed spectacles holding her with gentle concern. “You must be Dr. Richmond. I’m sorry, but as per your mother’s request, we are attempting resuscitation.” He turned back to the table.
“Stand clear,” he called as he prepared the paddles to send a jolt of electricity through Grandma’s chest. He placed one paddle above her right breast, and the other paddle he placed to the side below her left breast.
Mercy stood in stunned horror as the frail body jerked, arms flying out, legs up. Mercy had done the same procedure herself many times during her shifts in E.R. but not on someone she loved like Grandma.
“Check pulse,” Dr. Bower said.
Lauren gently felt the carotid artery for a moment, then shook her head. “Nothing, Doctor.”
“Continue CPR. Prepare more epi, and I need lidocaine, 1.5 milligrams per kilogram. What’s that blood gas?”
<
br /> “Not back yet, Doctor.”
Mercy stepped toward him. “Dr. Bower, I’m her granddaughter. Stop this code.”
He was barely taller than her five feet eight inches, but his expression held calm authority. “As I said, Dr. Richmond, your mother—”
“I heard what you said, but my grandmother signed a DNR form weeks ago. Surely that has some bearing on this case.”
“You know that form does me no good. Believe me, I wish it did.” Dr. Bower’s voice betrayed frustration. He lowered his voice. “Your mother showed me her papers for legal power of attorney. Her order is to resuscitate.”
“Forget that order. As a fellow physician—”
“I can’t break the law, Dr. Richmond.”
“Don’t abuse this patient any more than she has already been abused!”
Dr. Bower grimaced at her words, sighed and shook his head. “I’d love to comply, but I can’t. If you want to sway the decision, please talk to your mother. I tried.” He turned back to the table. “Stop CPR.”
The monitor showed an irregular, sawtooth pattern. Grandma’s heart was in ventricular fibrillation. Mercy hoped it would not change back.
“Where is my mother?” she asked, her voice heavy with frustration.
“She was in the private waiting room when I left her.” Dr. Bower shook his head at the monitor. “No change. We need to shock again.”
He charged the defibrillator to 360 joules. “Clear.”
Mercy stepped back and almost turned to leave, but she couldn’t. A sort of morbid amazement held her there, watching the scene of horror play out before her. She gripped the door frame. A loud pop and flash preceded the stench of burned flesh. An electrode had blown. Lauren and Dr. Bower checked for signs of life while another nurse replaced the electrode.
“No change,” Dr. Bower said.
Mercy felt sick. Mom should be here to see what her crazy order was doing to Grandma. But then, Mom, too, had suffered enough.
Again they shocked, and Mercy could not bring herself to leave. CPR resumed. The longer they worked, the more convinced she became that Grandma was already far past their so-called help. And that meant she was also past any more pain.
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