Prescription for Trouble - 03 - Diagnosis Death

by Richard L Mabry

  As she paused outside Pulliam's door, Elena heard the rhythmic chuff, chuff, chuff of the respirator. Apparently the patient still had no spontaneous drive to breathe. The machine was keeping him alive.

  Elena tapped lightly on the door and entered the room.

  "Dr. Gardner." Erma Pulliam tried to smile, but Elena saw there wasn't much behind it. "Nice of you to come by."

  The first thing Elena noticed was a plastic tube taped to Chester Pulliam's right nostril, the end plugged to keep a milky fluid from dripping out. There were a couple of vials of pills at the bedside, along with an old-fashioned pharmacist's mortar and pestle. The nurses would use those to grind medicines before inserting them into the feeding tube. No more need for IVs.

  The feeding tube represented an intermediate stage. Surgical procedures came next: a gastrostomy to provide a permanent means of feeding and a tracheotomy to allow unrestricted airway access. These operations were an accepted part of the road to what physicians called a vegetative existence. Nice words, but they failed to describe what would happen to the patient—and to his family.

  Mrs. Pulliam didn't know what lay ahead of her, but Elena did. Once more, she led the woman into the hall for their conversation.

  "Has your family been here yet?" Elena asked.

  Mrs. Pulliam shook her head. "We have two sons, both married and living on the other side of the country. They couldn't get away to come here, but they both said it didn't matter." She nodded toward the room they'd just left. "'That's not my dad in there,' they said. They want to remember him the way he was."

  "And what did they say about taking him off life support?"

  Mrs. Pulliam wiped her eyes with a tissue, then began shredding it. "They think I should do it. But I . . . I can't. It seems so wrong."

  "Do you have religious scruples about it? I can ask the hospital chaplain to talk with you."

  "No, I recognize the difference between taking someone's life and not prolonging the existence of a body with no brain function. It's just that I don't know if I have the courage to do it."

  Elena patted the woman's shoulder. "I know how you feel. I've been where you are."

  Surprise showed on the woman's face. "And what did you do?"

  Elena swallowed hard. When could she stop reliving that awful experience?

  "That's all right. I can see it's hard for you to talk about. I shouldn't have asked."

  Elena shook her head. "No, you need to know that you're not the first person to agonize over this decision. I finally came to the conclusion that it was best for Mark—and for me—to take him off life support and let him die with dignity."

  "I just don't know if I can do that."

  "It's hard," Elena said. "But not doing it can lead to things that are much harder."

  Mrs. Pulliam put her hand on Elena's arm. "Would you mind staying here with Chester for a few minutes? I want to walk down to the coffee shop. I need to get away for a bit. And somehow, I can't leave him alone."

  "Of course. I'll be here when you get back."

  The woman kissed her husband's forehead. She'd taken two steps toward the door when she turned back and kissed his cheek once more. "I love you, Chester."

  Alone in the room with Chester Pulliam, Elena pulled a chair to his bedside. She drew back the sheet a bit to expose his hand. Gently, she covered it with her own.

  A tap on the door jarred her away from her thoughts. Elena turned to see a nurse peek into the room, wheeling a medication cart in front of her. "Oh, Dr. Gardner."

  "I can step out if you like."

  "No, I was just checking on him. Do you think there's any change?" This wasn't the nurse who'd avoided her earlier. This one seemed to care.

  Elena glanced at the woman's nametag. "Not for the better, Ann. And I don't think there'll be any. Do you?"

  "No, I don't." The nurse nodded toward the figure on the bed. "It's pitiful, isn't it? You're so good to stand by Mrs. Pulliam through this. I know it can't be easy. I hope you help her do the right thing."

  A beeping noise issued from Ann's pocket. She consulted her pager. "Oh, they need me stat. I guess the cart will be safe here with you." She looked up and it seemed that her gaze went to the center of Elena's soul. "I'll pray for you." With that, Ann hurried away.

  Elena tried to recall all the people who'd told her they'd be praying for her. Most of her recent thoughts had been questions, not supplications, but surely God would count them as prayers. Other than that, she hadn't prayed since Mark's death.

  She closed the door and began to look around the room. Everything she saw reminded her of a way to end Pulliam's marginal existence.

  The most obvious action would be to disconnect the respirator from his endotracheal tube. Two or three minutes, and it would be over.

  She scanned the medication cart. Pills? It would be difficult to get them down the feeding tube. Something injected? The IV had been removed, but there were needles and syringes on Ann's cart along with vials of various medications. One intramuscular injection would release Chester Pulliam from his prison.

  She looked down at the frail figure on the bed and located the pulsations of his carotid artery. Enough pressure on one spot—a spot she could easily find—and his heart would slow and stop.

  Elena knew how to spare Chester from a living death. If she did that, Erma Pulliam would be spared too—spared the guilt that comes from making the decision that ends the life of a loved one. Sure, she'd grieve for a while, but eventually she'd move on. She wouldn't be tied for who knows how long to a husband whose brain no longer functioned, whose body shriveled with contractures and wept with bedsores.

  Mrs. Pulliam was waffling. Elena recognized all the signs. And delaying the decision would just bring about a host of problems. Chester would have recurring kidney infections because of his catheter. Despite frequent suctioning through his tracheotomy, pneumonia would finally come. The staff would turn him frequently, but eventually he'd develop decubitus ulcers—ugly sores that smelled foul and ran pus, poisoning his system. He'd shrink to a husk of the man Erma Pulliam had known. And thanks to the miracles of modern medicine, his life—if you could call it life—would go on.

  Elena could prevent all that. And that knowledge was what made her heart sink, as she stood alone at the bedside, pondering what to do.

  Twenty minutes later, Elena tapped the keys of a computer in the hospital library to call up the last of the articles and research papers she needed. She snatched the papers from the printer as quickly as it spit them out, turned, and moved toward the elevator. Had she done the right thing? Well, what was done was done. From here on, it was out of her hands.

  Her pager went off as she stepped off the elevator. Elena pushed through the doors of the ICU and stopped. Something was going on in Chester Pulliam's room. A resident, one whose name she couldn't recall, bent over the bed. He listened for a few moments, then straightened and looped his stethoscope around his neck. The nurse, Ann, stood next to him. He murmured something to her. She nodded assent and pulled the sheet over Pulliam's face.

  As the doctor edged through the door, he saw Elena. "I didn't expect you to be around for this."

  She plucked at his sleeve, but he kept walking. She hurried after him, matching his long strides. "What do you mean? I got a page and came in here to use the phone."

  He ducked into the head nurse's office and closed the door behind them. "We told Mrs. Pulliam it was time to take him off life support, but she couldn't bring herself to do it. The nurses saw you talking with her this morning. They figured you told her about Mark."

  "I did, but the decision still had to be hers."

  He grunted. "Pulliam's nurse had to help when one of the other patients in the unit went sour. Half an hour later, when Ann went in to check him, Pulliam's respirator was turned off. His wife was at his bedside, holding his hand."

  Elena couldn't believe what she was hearing. "Maybe Mrs. Pulliam decided to do it herself. Say good-bye, flip the switch, sit the
re with him while he died."

  "No, she said it was off when she returned to the room. The nurse figured you did it to save Mrs. Pulliam from having to make the decision. That's the way I see it too." He frowned as his pager beeped. "I'm going to sign it out as death due to his stroke." He thumbed the pager button, looked at the display, grimaced. "For the record, I think it was probably all for the best. I saw the DNR order you wrote on his chart today. I hope Dr. Clark is okay with it."

  The resident rose from his chair. "Gotta answer this page. See you around."

  "Wait!" she called. But the young doctor was already out the door, on his way to handle the next emergency.

  Elena slumped into a chair and buried her head in her hands. What next?

  Elena stumbled through her clinic duties that afternoon. Time after time she had to ask patients to repeat themselves, their answers drowned out by the words that still rang in her ears: "I saw the DNR order you wrote on his chart today."

  "Mrs. Murchison," Elena said, "Your blood pressure is creeping up a bit, but so is your weight. Are you following that diet I prescribed?"

  "Well, doctor . . ."

  Elena knew what the answer was before the woman was halfway through her detailed justification for ignoring her diet. High blood pressure was truly the silent killer. Until the symptoms were severe enough—headaches, dizziness, shortness of breath—people tended to ignore the warnings of their doctors. Mrs. Murchison was no exception.

  "I'm going to ask the nutritionist to talk with you again. Meanwhile, let's add this to the blood pressure medication you're already on." Elena filled in the prescription as she talked. "Let's see you back in two weeks. I want you to be two pounds lighter by then. Will you try?"

  Mrs. Murchison left, trailing promises and good intentions behind her. Elena wrote a note and tossed the chart into the basket beside her desk. She wondered if she'd be here in the clinic in two weeks when Mrs. Murchison returned.

  The clinic nurse stuck her head through the door. "That's your last patient."

  "Thanks, Mary." Elena sat for a moment, torn between going home to lick her wounds and picking up the phone to make a call that would either resolve her problem or make it much worse. The strident bleat of her pager put an end to her indecision.

  The number included the medical school prefix. She felt that she should recognize it, but the identity danced in her head just out of reach. She dialed it, and the voice that answered reminded her why it seemed familiar. It was one she'd heard on a daily basis while Mark was in the ICU.

  "Dr. Matney."

  "This is Elena Gardner. You paged me?"

  The chairman of neurosurgery cleared his throat. "Elena, I believe we need to talk. How soon can you come to my office?"

  "I'm at St. Paul, but I can be there in fifteen minutes. Is that okay?"

  "Come as soon as you can. We'll be waiting."

  Dr. Matney's call set alarm bells ringing in Elena's head. His use of the word "we" increased the cacophony a dozen-fold. What "we"? Who else would be waiting for her? She thought she knew, and the prospect was far from pleasing.

  No condemned man ever walked his last mile any more slowly and unwillingly than Elena trudged down the hallway to enter Dr. Bruce Matney's outer office. His secretary gave two sharp raps on the closed door of the chairman's inner sanctum, opened it, and motioned Elena in. The closing of the door behind her made Elena want to bolt, but there would be no escape from this meeting.

  It was his office, his meeting, and Matney held center stage. He sat behind his desk, flanked by Dr. Amy Gross on his right and Dr. James Clark on his left. Matney motioned Elena to the straight chair across from him.

  "Elena, thank you for coming."

  She wanted to say, "I had no choice," but decided that silence had served her well before so it was worth a try here as well. She simply nodded.

  Matney picked up a thick manila folder. "This is Chester Pulliam's chart."

  Elena felt her heart creep into her throat. Droplets of sweat trailed down her backbone. She hunched her shoulders, but the muscles remained tense as bowstrings.

  Clark took the chart from Matney's hand and flipped it open. This time the page was marked with a paper clip, but otherwise the feeling of déjà vu was complete. "I believe I intimated that Chester Pulliam had virtually no hope of recovery. I know you communicated this to his wife, and frankly, I appreciate that. It's difficult to break this kind of news. But there are some questions about the way he met his end, and we think you can answer those questions." He tapped the page with a manicured fingernail. "Here is a DNR order you wrote—an order about which I knew nothing. And Pulliam was found dead, disconnected from his respirator, immediately after you were alone in his room. The inference is obvious."

  Elena licked her lips but remained silent.

  Matney frowned. "If it were not for the similarities between this case and that of your late husband, this might have gone unnoticed, or at least been ignored. As it was, because of your involvement in the case, Dr. Clark brought this to my attention. We thought it best to deal with the matter in this setting, rather than mounting any kind of official inquiry."

  Amy leaned forward. "Elena, you're about to finish your residency. I don't want you to go out under a cloud of suspicion. It's possible that what you say in this room can stay in this room, but the three of us need assurance this sort of action won't be repeated."

  Elena cleared her throat. "Could . . . could I have some water, please?"

  Matney swiveled in his chair and plucked a bottle of water from a mini-fridge behind him. Elena took it and drank deeply. "Thank you."

  Matney came right back on point. "Can you give us the assurances your chairman has asked for?"

  "I can give you assurances, but not the ones you want," Elena said. "I can assure you that I neither wrote that DNR order nor disconnected Chester Pulliam's respirator."

  7

  Elena's words hung in the silent room like the last notes of a grand symphony dying away in a concert hall.

  Clark pinched his lip and furrowed his brow. Matney leaned forward and opened his mouth, but Amy Gross spoke first. "Elena, I recognize how difficult it must have been for you to be involved with a patient whose situation so closely mirrored Mark's. Are you sure you're not simply denying—even repressing—an action you regret?"

  Elena scanned the tribunal before her. She realized that's exactly what they represented: a tribunal. As surely as Caesar and his buddies decided the fate of a gladiator, these people held her professional life in their hands. Thumbs up or thumbs down. Well, she wouldn't go without a fight.

  "I've admitted that I wrote the 'do not resuscitate' order on Mark's chart. After I made up my mind, I decided to write the order before I backed out." She fixed her gaze on Dr. Matney. "I didn't think it would matter whether I told you or the resident about it or wrote it myself. Obviously, that was a bad decision, a breach of protocol, but I wasn't exactly at my best after practically living in the ICU for two weeks waiting for Mark to show some sign of recovery."

  Matney raised a hand like a sixth-grader trying to get the teacher's attention, but Elena plunged ahead. "I don't think I was the one who disconnected Mark's respirator. I have no memory of doing so, but it's possible that I did and repressed it. I've told you—at least, two of you—all that before." She picked up the water bottle and finished it in two greedy gulps.

  "But—" Amy said.

  "But in this circumstance, I'm absolutely clear about my actions."

  "You don't deny you were alone in Pulliam's room," Matney said.

  "Why deny it? It's true. There was even a witness. A nurse—Ann was her name—came in after Mrs. Pulliam left. We talked briefly before she left the room to help with another patient."

  Matney bored in for the kill. "Turning off the ventilator would only take a few seconds. How long were you alone in the room?"

  "I don't know. Maybe five minutes." She read the doubt in their eyes. "Yes, long enough to do any num
ber of things to end Pulliam's life. And I thought about every one of them. But I didn't."

  Amy pushed Pulliam's chart across the desk and pointed to a line on the order sheet. "This is the order not to resuscitate Pulliam. There's your signature. Do you deny writing it?"

  Elena didn't even look at the chart. Instead, she pulled a blank sheet from the notepad on Matney's desk and scribbled on it. "This is my signature. Does it match?"

  Amy took the sheet of paper and the chart. Her gaze ran back and forth a couple of times before she passed them to Matney. He scrutinized them and handed them to Clark, who spent almost no time comparing the signatures before he dropped the chart on the desk, saying, "They're not the same."

  Elena scanned the group. "Get a handwriting expert to compare them if you want to."

  "That won't be necessary," Amy said. "It's pretty obvious that someone else wrote this."

  Matney tapped his fingers absently on the chart cover. "If you didn't write that order, who did?"

  "I think there's a more important question," Elena said.

  Amy was the first to voice it. "Who took Chester Pulliam off his respirator? And why did they want the blame to fall on you?"

  David waved to Elena and motioned her to the corner of the hospital cafeteria where he sat with the remains of his breakfast. She shuffled over and slumped into the chair opposite him.

  "Bad night?" he asked.

  "Bad week. Bad month. Bad year." She drank deeply from the coffee cup she held. "Bad life, I guess."

  "Do you want something to eat? I'll get it for you?"

  Elena shook her head and emptied her cup. "Just coffee for me this morning. If I ate anything, I'm afraid it would come right back up."