Prescription for Trouble - 03 - Diagnosis Death

by Richard L Mabry

  All the way to the hospital, she couldn't get away from the idea that perhaps this was more than a simple fever in a post-op patient. But how could someone infect a comatose patient? Material from a contaminated syringe injected in his IV? Bacteria from a lab culture introduced into his lungs via the endotracheal tube? She discarded some of the possibilities as ridiculous, but then again, this whole scenario was ridiculous. Why would someone want to keep an unemployed truck driver from recovering? Had he been hauling illegal cargo, like drugs or stolen goods? Was this an attempt to keep him from talking?

  Or was this another move to discredit her? She was already under a cloud of suspicion for the deaths of two critically ill patients. Would Charlie Lambert's death be the third strike that ended her ability to practice medicine, here or anywhere?

  16

  The OB doctors' lounge at Summers County General was cool enough this morning, but David was sweating. When he'd been in residency, even though he might have gone to a new service or a new hospital, adjustment was relatively easy because things were done with a surprising amount of uniformity in the medical community in Dallas. And most of the town doctors there, except a few stubborn souls, took their lead from what was taught at the medical school.

  Here, he not only had to become familiar with a new hospital with a new cast of characters, but he'd already discovered a couple of things his new partner liked to do that were different from the practices he'd learned. How many more would there be?

  "Don't worry," Milton Gaines said. "I don't expect you to copy everything I do. We'll iron out the differences. I imagine you'll teach me a few things, and maybe I've learned some stuff along the way that will help you. The main thing is that our patients get good care, with as much uniformity as we can offer. That way they feel more comfortable no matter which of us they see."

  David drew a cup from the industrial-sized urn in the corner, tasted what apparently passed for coffee in the lounge, wrinkled his face, and tossed the Styrofoam cup into the trash.

  "I see you've learned a valuable lesson already," Gaines said. "Don't drink the coffee in the OB doctors' lounge unless you have a death wish. I'll buy you a cup in the cafeteria after we finish rounds. It's better than this, which isn't saying much. The best coffee comes from the nurses' break room. Be nice to them, and they'll share."

  "Fair enough." David popped a stick of gum into his mouth, but it was no match for the lingering bite of the coffee. "Ready for rounds?"

  Gaines eased himself to his feet. "Let's go."

  Gaines had two postpartum patients still in the hospital, both doing well after delivering healthy babies, both anxious for discharge. He introduced David to each woman. "This is Dr. Merritt, my new associate. If I'm out or tied up, you'll see him. He's a good man, well-trained and caring. I know you'll like him."

  In the hall, Gaines said, "I have one other patient. She's a Hispanic female, nearly at term, admitted recently with preeclampsia. It's a struggle to keep her blood pressure down, and I'd appreciate any help you can give me."

  David took the chart Gaines offered and studied it. His senior partner had done all the right things: magnesium sulfate, hydralazine, beta-blockers, oxygen, careful control of fluids. The woman—Maria Gomez—had not yet had a seizure, which was in her favor, but her blood pressure remained high despite treatment.

  "I see you estimate that she's at thirty-three to thirty-four weeks gestation," David said. "Are you thinking of inducing her?"

  "Definitely. I figured one of us can manage the induction while the other takes care of the office. Want to handle it?"

  David closed the chart. "Sure. Why don't we examine her?" My first OB in private practice and it's a patient with early toxemia of pregnancy. Welcome to the real world.

  David could see that the girl—and that's what she was, just a girl—was frightened. He could understand why. About to have a baby, lying in a bed in a strange hospital being cared for by people who didn't speak her language; no wonder she was scared.

  Gaines warned David that the husband would be his interpreter, but one of the first things he'd learned in medical school was that in any encounter, especially the first one, the patient should be the focus. He stood at Maria's bedside and lightly touched the back of her hand, careful to avoid the IV there. "Maria? Soy el Dr. Merritt. Cuidaré de usted."

  She nodded and managed a weak smile. The husband offered his hand. "Soy Hector."

  "Hector, I've used up most of the Spanish I know to introduce myself to your wife and tell her I'll take care of her. Can we speak English?"

  "My English is not so good, but I will try."

  David explained that he and Dr. Gaines needed to examine Maria. "We think that it may be best to help the baby get here as soon as possible."

  "I understand. Do what is needed, and I will share what you tell me with Maria."

  Thirty minutes later, the three men stood at Maria's bedside. In simple English, augmented by the few Spanish words he had picked up during his residency, David explained what was planned. Medication given in Maria's IV would stimulate labor. He would be at the bedside or nearby during the process. The baby was old enough to safely come into the world, and that was necessary to lower Maria's blood pressure and prevent such complications as convulsions. David stumbled on the last word, but Hector assured him it was the same in Spanish.

  Maria was nodding even before David finished. "Si, comprendo." Obviously, she understood more English than he or Gaines realized.

  "If you're okay to stay here and handle this, I'll get back to the office," Gaines said. "I'll check with you later today. If you need me to relieve you, we can switch."

  David took the chart Gaines handed over, feeling like a runner who'd just been handed the baton for the final leg of the race. He prayed he wouldn't stumble.

  Elena handed Jane the chart and yawned for what seemed like the fiftieth time that morning. Her jaw popped. "Excuse me."

  "Tough night?" Jane asked.

  "They called me about four. Mr. Lambert was running a fever."

  "Anything serious?"

  "Nope. Just a urinary tract infection."

  "Glad it wasn't anything worse," Jane said.

  Elena thought again about the dictum she'd heard repeatedly since her first physical diagnosis class in med school. When you hear hoofbeats, think horses, not zebras. But last night she'd focused on zebras as soon as the call came.

  All the way to the hospital, she'd imagined all the worst possible causes for Charlie Lambert's fever. As it turned out, a third-year medical student could have made the diagnosis and started treatment. Elevated white blood count and pus cells in the urine added up to a urinary tract infection, the most common cause of fever in a patient with an indwelling urinary catheter, and one that was easily treated.

  After ordering the appropriate antibiotic, with a mental note to adjust it after the urine culture results were available, Elena carried out a thorough neurological evaluation. Although his endotracheal tube was still in place, Lambert hadn't required ventilator assistance for thirty-six hours. He was moving all four extremities in random fashion, occasionally bucking against the breathing tube in his throat. He uttered a few groans, although the presence of the tube prevented him from talking. Time to take out the endotracheal tube. She left a note for Shelmire, letting him make the final decision.

  Jane's voice brought Elena back to the present. "That's the last patient until this afternoon." The nurse strode off toward the front office to file the morning's charts.

  Elena was barely through the door to her office when her cell phone vibrated. She pulled it from the pocket of her white coat. The Caller ID showed "anonymous caller." What now?

  "This is Dr. Gardner."

  "Elena, Sam Shelmire."

  She closed the door, dropped into her chair, and leaned back. "Are you a mind reader? I was thinking about you."

  "No psychic powers. Just responding to your note. I'm on my cell, headed back to Denton."

&
nbsp; They spoke for a few minutes, ironing out details of treatment. Shelmire agreed with her suggestion to remove Lambert's breathing tube. Elena said she'd take care of that on rounds this evening.

  "How long do you think it will be before he can go to a regular room?"

  Shelmire paused, apparently measuring his words. "Don't quote me on this, but the moment Lambert leaves the ICU, your martinet of a hospital administrator is going to be all over me to get him to another hospital. He's still upset that there's no insurance coverage in this case. Frankly, I don't think a long ambulance ride up the road to Parkland is in Lambert's best interest quite yet. Do you?"

  "You're the surgeon," Elena said. "But I think you're right. So, what you're saying is that we need to be very slow in moving Lambert out of the ICU."

  "We won't make up anything, but I'll bet you can find a reason he needs skilled nursing care, even after he regains consciousness."

  "If he regains consciousness," Elena said. "Just because he moves and groans doesn't mean he's going to wake up again."

  After she ended the call, Elena sat for a moment and stared at the ceiling. She would love nothing more than to head home and fall into bed, but she had a full schedule of patients this afternoon. Or rather, Cathy had a full afternoon, and now these patients were Elena's.

  She was about to slip out and grab a sandwich when Jane tapped on the door and opened it halfway, her expression apologizing for the interruption. "Frank Perrin's on the phone for you. Do you want to take the call?"

  Elena noted that when Jane spoke Frank's name, she looked like she'd bitten into a persimmon. "I'll take the call," Elena said. As Jane was withdrawing, something made Elena add, "And I'll be careful."

  Elena lifted the receiver and hesitated with her finger over the blinking button. How should she handle this? Chummy? Distant? Formal? She settled for neutral. "Dr. Gardner."

  "Hey, Elena. This is Frank Perrin." Chipper, perky, just a friend calling another friend.

  Elena adjusted her tone accordingly. "Good to hear from you, Frank. What's up?"

  "I was wondering if you could break free for lunch. I know you're snowed under, what with Cathy out of the office for a while."

  How did he know that? Was she the only person in town not on that grapevine? She shrugged. "I . . . I guess so. But I'll have to be back here by one. Will that work for you?"

  "Grab your purse and walk out the back door. I'm sitting out here waiting for you."

  Elena wasn't sure how to react to that news. How long had he been sitting out there? And how many times before that had he sat outside her office or home? Get a grip. Now you're being paranoid. Still, despite the bright summer day, she felt a shiver move up her spine as she climbed into Frank's patrol unit.

  The vehicle must have been here in the sun for quite a while. The vinyl seat was searing, so Elena hunched forward.

  Frank started the SUV and flicked the air conditioner to high before he lifted the microphone off its hook. "This is Frank. I'm out of service for lunch, but I have my radio on." He replaced the microphone and put the SUV in gear.

  "I thought you'd say something like 'Base, this is Unit 3. I'm ten-ten.' What happened to those codes?" Elena asked.

  Frank shrugged. "You've watched too many police shows. We did away with those a few years ago. This is more direct. If we want to say something without it going out over the air, we have cell phones."

  "You're taking all the mystery out of police work," Elena said. "I've always pictured what you guys do as exciting."

  Frank half-turned his head and shrugged. "Do you like burgers?"

  The abrupt change of subject caught Elena off guard. It took her a moment to process the question. "Sure."

  "Got anything against eating them in a hole-in-the-wall?"

  "I've done that before and survived. I'll bet I can do it again."

  He flicked his turn signal. "Then prepare for a taste treat."

  This time Elena paid close attention to the route Frank took. She was never going to be lost in this town again. The unit rolled to a stop in a gravel parking lot before what could charitably be called a house, although Elena's description leaned toward "shack." The paint had at one time been blue, probably at least three shades of blue, but now the building was a uniform gray. Two windows, one of them covered with plywood, flanked a front porch that leaned at a precarious angle.

  Frank followed her up the rickety steps and opened a warped front door with a loud scraping sound. Inside, Elena stepped into a room filled with picnic-style tables and benches. It seemed to her there was hardly room to maneuver around the tables and through the people who stood waiting for a place to sit. Frank's entry parted the standees like the Red Sea before the rod of Moses, and in a moment he and Elena were standing at the counter that ran across the back of the room. A black woman, her gray hair barely contained by a net, stood sweating behind the counter. Behind her, a man of similar age and coloration was flipping patties and assembling hamburgers at a record pace.

  "Two, please, Hattie," Frank said. He turned to Elena. "Everything?"

  "No onions."

  "One no onions. Two iced teas."

  Hattie barely nodded. "Two—one, no onions—for Frank."

  Frank pointed toward a middle-aged couple leaving one of the tables, and Elena followed him. Two men moved toward the spot, but when they saw Frank, they veered off and headed toward the wall where stools and a chest-high shelf afforded a place for the overflow.

  Frank pulled a couple of sheets of paper towel off the roll in the middle of the table. He shoved a squeeze bottle of mustard, another of catsup, and shakers of salt and pepper toward Elena. "Not the Ritz, but I'll bet you've never had a better burger."

  "I'm sure it'll be great. But—"

  A young black man hustled up to the table and set two plates before them. "The one with the toothpick in it's the one without onions," he said, his eyes never meeting theirs. "I'll bring your tea."

  "That's Sam. He's Hattie's grandson. She's raising him."

  "Shouldn't he be in school?" Elena asked.

  "He dropped out after tenth grade. He wasn't an athlete, so there was no way he'd ever get into college. Hattie figured he might as well go to work."

  The young man was back with teas before Elena could speak. Again, he kept his eyes downcast, as though afraid to meet the gaze of the deputy.

  They ate in silence, partly because of the din surrounding them and partly because the food was so good that bite followed bite without interruption.

  Back in the parking lot, Elena said, "Thanks for lunch, Frank. I'm glad we had an uninterrupted meal this time. And I'll certainly come back here again. That was probably the best hamburger I've ever tasted."

  "I hope those return trips will be with me. Next time, though, I'd like to take you out in the evening to a nicer place."

  Elena said something noncommittal. She wasn't sure about the vibes she was getting from Frank Perrin. She was noticing little things: the way the help at the café looked at him, the two men who almost fell over themselves getting out of his way, the fact that he hadn't even offered to pay for his meal. No, the more she learned about Frank, the more she understood the warnings she'd received. She needed to be careful around him.

  "Time for a break, Dr. Gardner." Jane motioned to Elena's office, where a cold Diet Coke and a package of mini-Oreos were centered on her desk blotter. "I think this is what you like."

  "Jane, you're an angel. How did you know?"

  "I pay attention. You've got half an hour before your next patient. Now sit down and relax. You've done a great job today, but I don't want you to wear yourself out." Jane grinned. "I'm pretty sure Dr. Sewell's going to want you around for a good while."

  "I hope so." Elena eased into her chair and motioned Jane to the one opposite.

  Jane remained standing in the doorway. "Thanks, but I've got things to do." She started to close the door.

  "One thing," Elena said. "The office is closed tomorrow afte
rnoon . . . right?"

  "Right." Jane eased the door closed.

  Elena extracted a wrinkled post-it note from her desk drawer. If she did this, there was no turning back, and the results might change her life. On the other hand, she couldn't go on this way. She pulled the phone toward her and tapped out ten digits.

  A man's voice answered on the second ring. "This is the office of Dr. Josh Samuels. I'm probably with a patient, but if you'll leave your name, number, and a brief message, I'll call you back, usually within an hour. In the meantime, relax. Together, we can get through this."

  Elena smiled. She could see what Cathy meant. This wasn't your ordinary psychologist.

  "This is Dr. Elena Gardner. I'm a new associate of your former patient, Dr. Cathy Sewell. I need to see you tomorrow if at all possible about an urgent matter." She added the numbers of the unlisted office line and her cell phone, and hung up. She hoped she was doing the right thing.

  She'd eaten one cookie and drunk half her Diet Coke when the back line rang. She snatched up the receiver. "Dr. Gardner."

  "Elena, this is Will. I was hoping I'd catch you between patients. Do you have a moment?"

  She tried not to let her disappointment show. "Sure. What's up? Is Cathy okay?"

  "She's fine. She's at home and champing at the bit to get out, but Milton Gaines wants her on bed rest for a bit longer. We can talk more about that when I see you. Can you come by our house this evening about six?"

  Elena did some rapid calculations. Finish with office patients, make rounds and pull Mr. Lambert's endotracheal tube, pick up her dry cleaning. "Sure. Can I bring anything?"

  "No, we're fine. I'm going to get some Chinese takeout. Will you eat with us?"

  "Sounds good." Tex-Mex, Chinese, American. The cuisine in Dainger was a veritable United Nations. "I'll see you at six."

  She'd just hung up the phone when it rang again. The blinking light told her the call was on the private line. Dr. Samuels? She felt a mixture of hope and fear wash over her as she lifted the receiver and answered.