Prescription for Trouble - 03 - Diagnosis Death

by Richard L Mabry

  Elena spoke for the first time. "I haven't had time to have cards printed, but I'm entering the practice of Dr. Cathy Sewell. I'll write down my name and number for you. Feel free to call me anytime." She looked at her watch. A little past 1:00 a.m. "I'd suggest you go home, get a little sleep. This isn't a sprint. It's a marathon. We'll call you if something changes."

  An hour later, Elena rubbed her eyes and yawned. Mr. Lambert's condition was stable. What seemed to be an excellent ICU nursing staff was monitoring his status. Maybe she could drive home for a quick nap—at least a shower and a change of clothes—before morning.

  "If you need me in the next few hours, here's my cell phone number." Elena handed a card with the information to the charge nurse.

  "Thanks, Dr. Gardner. We'll call you if there's any change. But we both know that's pretty unlikely."

  Elena wove her way through the dark corridors of the hospital toward the parking lot where she'd left her car. As she stepped through the door, her cell phone chirped. Someone must have called while she was in the hospital and out of cell phone range. She leaned against the doorpost, luxuriating in the feel of the night air against her skin, and pressed the button to retrieve a voice mail message.

  "You have one new call," the electronic voice proclaimed. "Wednesday, 12:01 a.m."

  Elena wondered who could have called this late when she heard a whiskey alto voice that made her shiver despite the late June heat. "Don't think you can escape. I know what you've done, and you'll pay."

  12

  Since you don't have any scheduled patients, you should have slept in a bit," Cathy said. "No need to get to the office this early after a late night."

  Elena gripped her coffee cup like it was the last life preserver on the Titanic. "No, I've pulled all-nighters before. If I skip out every time I get a late-night call, I won't be much good to you, will I?"

  Cathy tried to reassure her new associate. "Listen, you're not on trial here every minute of every day. Relax. Loosen up. You're doing fine."

  "Apparently not in my choice of friends," Elena murmured into her cup.

  "We've discussed that, and as far as I'm concerned, the matter's closed. Just be careful."

  Elena touched the bottom of her cup to the bit of coffee she'd spilled on the break room table and began to form interlocking rings. "There . . . there may be some other problems too."

  "Before I forget about it, this came for you. It must have arrived at the medical school after you cleared the campus, so they forwarded it here."

  The return address on the legal-size envelope grabbed Elena's attention: Texas State Board of Medical Examiners. "This reminds me, I need to give them a change of address."

  "Tell Jane. She'll take care of it for you," Cathy said.

  Elena pulled out the single page, scanned it, and felt a hollowness in the pit of her stomach she hadn't experienced since her first roller coaster ride. "This must be some kind of terrible administrative foul-up."

  "What?" Cathy asked.

  Elena worked to stop the trembling of her hands so she could read. "We have received your request to voluntarily surrender your license to practice medicine. Please reply to this letter, advising in detail your reasons for this request. We must warn you that we are obligated to report any possible criminal activity associated with your actions."

  "I take it you didn't make that request."

  Elena swept her arms wide in a gesture of innocence, sending her coffee cup to the floor, where it shattered. "This is just one more bit of harassment. I thought that when I moved here it might stop."

  Cathy decided that, as usual, her husband had been right. "Want to talk about it?"

  "Not really. But I think I need to. You know about the phone calls I got after Mark's death?"

  "I remember. From your mother-in-law."

  Elena nodded. "That's what I thought. But before I left Dallas I got a letter from a lawyer. Lillian's dead. And she's been dead since shortly after Mark's death. Unless her obituary was some kind of sick hoax, there's no way the calls could have come from her."

  Cathy took a moment to think that over. "So we don't know who was making the calls. Still, they should stop now that you've moved away from Dallas and changed your phone number. You did change it, didn't you?"

  "I had my home phone disconnected. I gave this office as my forwarding address, and limited even that. As for my cell phone, I didn't think it was necessary to change it. Probably . . ." She ticked off numbers on her fingers. "Probably half a dozen people have the number, and I trust them all."

  "So you're through with the calls."

  Elena pushed her cup away and put her fingertips to her temples. "Apparently not. I got another one at midnight last night—the same voice. It said, 'Don't think you can escape. I know what you've done, and you'll pay.' "

  "But you've done nothing wrong."

  "Evidently my caller doesn't hold that opinion."

  "Let me talk with Will," Cathy said. "Maybe the investigator he uses can find out who's harassing you."

  Elena moved her hands to the back of her neck and began to knead the muscles there. "There's more to it than that. I don't think I've done anything wrong. But there's a very real chance that I might in the future. I guess it's time for me to get some help."

  Will made sure everyone was settled comfortably in his office. Elena and he had diet soft drinks, Cathy sipped from a bottle of cold water. He took a seat behind his desk, centered a fresh legal pad on the blotter, and uncapped a fountain pen. "Cathy has filled me in on what you all shared this morning, Elena. Suppose you tell us what it is that makes you afraid you'll do something wrong."

  "I've told you about Mark's death. But I glossed over exactly how he came off life support. I stepped away from his ICU room for a bit. When I came back, they were removing his IV, EKG leads, everything. He was dead. I presumed he'd died in the short time I was gone. But later Mark's doctor, who was the chairman of Neurosurgery, called me on the carpet. I'd waffled about withdrawing life support, and when I finally made up my mind to allow it I wrote the DNR order myself."

  "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 forw
ard 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 español?"

  "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 guess."

  "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 m
ore 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."