Flashback

by Michael Palmer

  "I… I think I'd better get back to my floor," Doreen Lavalley said softly. "Mr. Iverson, my resignation will be in the nursing office tomorrow morning." Without waiting for a response, she whirled and hurried out. "Don, what in the hell's going on here? " Frank asked.

  "Your brother, that's what," Norman answered. "He barges in here, starts examining my patient without even being consulted, badgers the nurse into making some rash statements about the hospital, and then accuses me of causing the woman to fall." He turned to Zack. "You've been trouble since the day you got here, and don't think we don't all know it. This hospital needs team players, Iverson. You're a grandstander.

  Ultramed-Davis ran perfectly smoothly before you showed up, and it will do just as well after you've gone."

  "I'm not going anywhere, " Zack said. "Don't bank on it, " Norman shot back. "Easy, both of you, " Frank said. "First of all, just tell me, is that woman in there going to die tonight?"

  "It was touch and go for a while," Norman said. "But I've gotten things under control. She's a bit disoriented, but she's not in any immediate danger. We'll wait a few days to let her cardiac situation calm down, and then Sam Christian'll fix hey hip."

  "Zack?"

  "What?"

  "Do you think that's the way it is?"

  "I think, " Zack said wearily, still resting his head on his hand, "that Suzanne ought to be called in to take care of Annie. That's what I think."

  "Over my dead body, you arrogant son of a bitch, " Norman rasped.

  "Careful, Don, " Zack said. "That's Frank's mother you're talking about."

  "Will you two please stop it?

  There are nurses and patients all over this place. Now, Don, tell me, did you have Annie on a tranquilizer or not? And for God's sake, keep your voice down."

  Donald Norman was losing what little control he had left. "First of all, Frank, " he said, "I'll thank you not to tell me what to do with my voice. Second of all, I'll thank you and your brother, here, not to go questioning the therapy I choose for my patients. You may be the administrator here, but i'm the chief of the medical staff."

  Frank stepped forward until his face was less than a foot from Norman's.

  His eyes were steely. "Donald, one call from me, one"-he held up a finger for emphasis — "and you'll be lucky to have a job scrubbing bedpans. You should know that. And if you don't think I have that kind of clout at Ultramed, just try me. Now take that chief of staff crap and stuff it. Then tell me what in the hell you were thinking when you put Annie Doucette on tranks."

  "Yeah, Don, " Zack urged acidly, "tell him."

  "Zack, will you please shut the fuck up for a minute and let me get to the bottom of this?"

  Norman was visibly cowed. "Frank, " he pleaded, "I was just trying to follow policy. The woman's DRG payments are about to run out. I have a bed lined up for her at the nursing home. That's just what I'm supposed to do. When I told her what was planned, she went berserk. She demanded more time in the hospital. That was out of the question. You know the rules as well as I do."

  "What rules?

  " Zack asked. Frank ignored him. "So you sedated her, " he said. "Jesus, Don. She worked for my goddamn family. Couldn't you have just called me?" 91… I didn't think to,"

  "What rules? " Zack asked again. "Yes, what rules? " The three men spun toward the voice. Clayton Iverson was just a few feet away, calmly appraising them all. His expression was nonthreatening, but Zack could see anger smoldering in his eyes. "Judge, " Frank said. "You said you were going to wait out there with Mom."

  "I got impatient,"

  "Well… well, good enough. I'm sure it's no great news to you that we can't always agree on everything in a hospital. Right?"

  "Right."

  Frank smiled cheerily, but Zack knew he was shaken. "Don, here, tells us Annie's still disoriented, but that her condition has stabilized. Isn't that so, Zack? Listen, Judge, why don't you get Mom and bring her in.

  It's getting late, and I'm sure you both want to get on home."

  The Judge confronted him in a brief eyeball-to-eyeball showdown, but Frank easily held his own. "All right, Frank, " Clayton said evenly. "As long as things are under control."

  "Don's an excellent internist, Judge, and Annie's getting his best shot.

  Right, Zack?"

  "Right." Zack nearly choked on the word. "Don, come, " Frank said.

  "Let's you and I go over some things before you call it a day."

  Without waiting for an answer, Frank took Norman by the arm and led him from the unit. "How much of all that did you hear, Judge?"

  Zack whispered. Clayton Iverson looked over at Annie, who was clumsily picking at the restraint that was holding her to the bed. "Enough, Zachary, " he said. "I heard quite enough. I'm going to have that letter in Leigh Baron's hands tomorrow. Are you going to try and talk me out of it?"

  Once again, Zack rubbed at the burning in his eyes. Even faced with this new reality, it was painful to accept that the promise of Ultramed-Davis-the sparkling physical plant and progressive approach to medicine-was no more than a veneer. Beneath the sheen, beneath the new equipment, the new specialists, and the intense public relations effort, the hospital had no soul. "No, Judge, " he said finally. "Tomorrow I'm going to give you a look at the material Guy had put together against Ultramed. You go ahead and do whatever you feel you have to do. I'm not going to try and talk you out of anything."

  Zack waited until the Judge had left, and then called Suzanne. "Zachary, do you know what time it is? " she said blearily. "Gee, no, " he said,

  "but give me a minute, and I'll see if I can find someone who does."

  "That's not funny."

  "Sorry. You don't sound so hot."

  "I'm not. I have a splitting headache, and sixty milligrams of Dalmane had me barely asleep when you called."

  "Sorry again."

  "I've just got to get some rest. Was there anything special you wanted? "

  "No, " he lied. "Nothing special. I just wanted to see how you were."

  "Oh… well, can you call me in the morning?"

  "Sure."

  "Thanks. I should go before this Dalmane wears off." 4"Good-" The dial tone cut him off. The atmosphere in the shingled ranch Zack had leased from Pine Bough Realty was kept musty and comfortable by the lingering aroma of decades of hardwood fires. It was after one in the morning.

  Seated in a frayed easy chair by the dormant hearth, Zack sipped from a cup of Constant Comment tea, absently scratched Cheap dog in his favorite behind-the-ear spot, and waited. Frank had asked him to stay up to talk, and had promised to be right over. But Zack knew that his brother had never marched to anything other than Frank Iverson's time.

  In truth, it made little difference how late Frank would be. Zack was too keyed up by the events of the evening to sleep. His feelings disappointment, anger, frustration-were strangely akin to those of the dreadful night when Connie had finally leveled with him about her decision to break off their engagement and not to accompany him to New Hampshire. "It wasn't supposed to be like this, Cheap, " be said. "It wasn't supposed to be like this at all."

  So much of him wanted to just pack up and run-load the camper and go back to Muni. For all of its underfinanced, stretched-to-the — limit turmoil, the place at least had heart. The bottom line there was never anything but sick or hurting patients and a crew of nurses, technicians, and docs determined to help them get well. But even as he heard the crunch of his brother's Porsche on the gravel drive, Zack knew that he would stay. For Suzanne and the mountains, for Guy and Toby Nelms and all of the Stacy Millses yet to be in his life, he would see things through. Frank's visit did not last long. He was speaking even before the screen door had shut behind him. "You really stuck it to me tonight, Zack-o, " he said breathlessly. "You really stuck it to me."

  "Have a seat, Frank. You want something to drink? Some tea? A beer?"

  At that moment, Zack caught the odor of whiskey and noted the fine, red flush at the corner of
Frank's eyes. "I don't want anything except a little goddamn loyalty and help from my brother, " Frank said, making no move to sit. "A good nurse has quit, my father, who also happens to be the chairman of the hospital board, is furious, and my chief of staff wants to shoot me, to say nothing of what he wants to do to you. That's great, Zachary. That's a hell of a night's work."

  "Easy, Frank. Okay?"

  "No, damnit! Not okay. Norman's right. From the minute you got back here there's been nothing but trouble. Playing Sir Lancelot all over the goddamn hospital, undermining my authority and Ultramed's policies, even flirting with my wife, for Chrissake."

  "That's ridiculous. Frank, you've been drinking. Why don't we both just sit on this and we'll talk in the morning."

  "I'll talk about it now, " Frank snapped. Having, perhaps, seen and heard enough, Cheap dog growled a soft warning and from somewhere beneath the shag of his face, bared his teeth. Zack glanced over at the animal, but made no attempt to quiet him down. With Frank less than totally rational already, Cheap dog was some insurance against a major blowup. That the dog was basically a coward would remain his secret.

  "All right, " he said wearily, "so talk."

  Frank was pacing, elenching and unclenching his fists and then rubbing his hands on the sides of his trousers. "For years now, ever since you fell on that ski slope and I got to go to Colorado, you've been waiting for the chance to get back, to ruin me. Sitting in the stands all those years cheering and clapping with the others, and all the while hating my guts because you couldn't stay on your skis-"

  "Frank, that's crazy."

  Revising upward his estimate of how much Frank had had to drink, Zack could only settle back in his chair and watch. "I told them things were going just fine up here, " Frank ranted on. "I told them we didn't need any goddamn neurosurgeon, least of all you. Well, let me tell you something, Zack-o. Tougher nuts than you have tried to fuck with me.

  Where are they now?"

  He whirled and leveled a finger at Zack's face. From the corner of his eye, Zack saw Cheap dog again stiffen. "Now just listen, and listen to me good, " Frank said. "Things are going to change around here or you're out. I've worked too hard to get this place the way I want it to have anyone screw it all up-especially someone with a twenty-year-old chip on his shoulder. So just back off. Let up on the staff, on the Judge, and on Lisette, or I swear, Zack-o, I'll come down on you like a ton of bricks."

  Without waiting for a response, he spun on his heel and stormed from the house. Moments later, the Porsche screeched away. Zack sat in numb disbelief. A twenty-year-past skiing accident, an innocent, unfulfilled high school romance. Was Frank merely drunk and tired, or was he truly crazy?

  Let up on the staff. The warning would have gone unheeded under any circumstances. But now, there was not even room for dialogue or tact, An eight-year-old boy was drifting toward insanity and possibly death, and, consciously or not, someone at Ultramed-Davis knew why. Zack glanced at his watch. It was after two. He picked up a book of crossword puzzles that were far enough beyond his ability to be soporific, and shuffled to the bedroom. What he needed now, more than anything else, was some sleep, because warning or no warning, Frank or no Frank, he was going to get some answers-beginning in less than seven hours with Jack Pearl.

  CHAPTER FOURTEEN

  The surgical residents at Boston Muni traditionally spoke of exhaustion in terms of the Wall-the moment when a physician ceased to function with any creative effectiveness. Throughout training, one was either approaching the Wall, up against it, or, when operating solely on the gritty-eyed fuel of caffeine and nervous energy, beyond it. At 6,45, when his clock radio switched in on the final two verses of an a cappella version of "Au Clair de la Fontaine, " Zack could distinctly remember seeing three, four, and five o'clock flash on its digital display. His bedside light was still on. The crossword puzzle book with, perhaps, a dozen or so items out of one hundred thirty filled in, rested in his chest. The pencil was still wedged between his fingers. Across the room, Cheap dog, quite ready to begin the day, was perched on his hind legs, his paws resting on the windowsill, the nub of lis tail twitching at the prospect of joining some action in the backyard. It wasn't supposed to be like this. Zack's first thought of the morning was the same as the last he. should remember from the night just past.

  Boards of trustees… hospital buybacks… rules on length of 4@ay … policies on who gets admitted and who doesn't… enemies allies… realty trusts… Golden Circles… interlocking @. Directorates… as if the stresses, pressures, and crises of day-to-day nedicine weren't enough.. 1 Perhaps, he mused, the real villain in the piece wasn't Frank, or the Judge, or Norman, or even Ultramed. Perhaps it was his own naivetehis idealistic notions of illness and injury and the healing arts. Perhaps that was what needed overhauling. Emotionally as well as physically drained, he shuffled to the bathroom to shave and shower, pausing to pull a quarter from behind Cheap dog's ear before letting him out. The Wall, he knew, was just a few hours away. Save for the lone librarian, the Ultramed-Davis record room was deserted. With thirty minutes remaining before his appointment with Jack Pearl, Zack had decided to give Toby Nelms's chart one last go-through. Although he still felt numb and deflated from the madness of the previous night, the morning, at least, had gotten off to a decent start. After getting Cheap dog settled on his run, he had chosen a route to the hospital that took him past a broad field of tiger lilies, lavender, and black-eyed Susans.

  For years Annie Doucette had allowed scarcely a day to pass without setting fresh flowers on the dining room table and mantel of the Iverson home. During her hospitalization, the family had done its best to repay her in kind. Gathering up an armload bouquet, Zack had amused himself by composing cards he would have liked to have propped up by the vase in her ICU cubicle. To Annie, with deepest apologies. Ultramed… To Annie, my temporary patient, from Don, your temporary doctor. In repayment for your humiliation, heart attack and broken hip. In sharp contrast to the surreal chaos of the early morning hours, the unit had been bright and tranquil. Annie, the Haldol largely out of her system, was fully oriented and even a bit feisty. Although she was sluggish from the analgesia she was receiving for her hip, she had talked in detail of her son and grandchildren, and of Zack's family. Of the thirty-six hours preceding her fall, she remembered nothing, except to reiterate her determination not to be sent to "any death-trap nursing home."

  Donald Norman's cookbook cardiology had, for the moment at least, proven adequate, and while Annie's cardiac status remained shaky, it was not critical. All in all, Zack had left the unit sensing that if anyone her age could make it through the ordeal she was facing, Annie Doucette could. The record room librarian, an alert young brunette who was nearing the end of a pregnancy, seemed grateful to have company. Zack signed for Toby's chart and brought it to one of several Formica-walled dictation carrels, The manila folder he set to one side contained the notes and the trickle of articles he had begun to amass on the more obscure complications of the two anesthe ics the boy had received. None of those sources had offered so much as a clue to his bizarre condition.

  Word by word, more meticulously even than on previous efforts, he picked through the chart. Family history-unremarkable, past medical history-usual childhood immunizations and diseases, nothing else of consequence, physical exam-normal except for an incarceratedinguirial hernia, operative and anesthesia notes-routine. Nurses' notes, "patient brought into recovery from O. R. awake, alert, and smiling, vital signs normal, no evidence for respiratory depression, pupils equal and reactive, lungs clear."

  Remarkable. Absolutely remarkable. Zack read the notes once, and then again. Toby's total stay in the recovery room was less than thirty minutes. He asked for Suzanne's chart. Her anesthe ics and doses, when adjusted for weight, were virtually identical to Toby's, so were her recovery room nurses' notes. Total time in the recovery room, forty-five minutes. The g I'm of an idea began to take root. Zack checked the time.

  Thirteen minutes u
ntil he met with Pearl. "Excuse me, " he called over to the librarian, "are these records completely computerized? "

  "For the last five years, yes, " she said, setting aside the romance saga she was reading. "I think they're working on the five years before that."

  "Well, supposing I wanted to get, say, a list of all the gallbladder patients operated on in the last three years?"

  "No problem. Cholecystectomy is one of our codes, 3982, I think."

  "How about just the ones where Dr. Pearl was the anesthesiologist?"

  The woman checked her manual. "Dr. Jack Pearl. Physician 914. I can get the printout for you in just a minute, but it will take a while if you want me to pull the charts." She patted her belly. "As you can see, I'm walking for two."

  "Your last month?"

  "Last two weeks, I hope."

  "Well, if it's too much trouble-"

  "No, no. We both need the exercise."

  "I hate to make it harder on you, but could I have the first few right away, and then come back in, say, an hour to check on the rest?"

  "Sure. At this hour of the morning, this place isn't exactly humming."

  She was already typing commands into the computer. By eight-thirty, Zack had scanned nine charts out of thirty-one. He slipped the notes he had taken into his folder and promised to return for the rest. Despite his lack of sleep, he felt energized-keyed up and very sharp. His idea had provided no definite answers. But now, at last, he knew he had some damn good questions. If Jack Pearl had made any attempt to straighten up his office before Zack's arrival, he had failed miserably. The small, windowless space between the O. R. suite and the recovery room was cluttered with journals and scraps of paper, and smelled heavily of coffee and stale cigarettes. Half-filled ashtrays, one with a butt still smoldering, graced two corners of the desk, and opened, cellophane-wrapped packets of Kleenex were everywhere. Pearl himself, sporting a wrinkled green polo shirt, was nearly dwarfed behind the pile of reprints, texts, and notebooks on his desk. The hand he extended was cadaverous. Regardless of how skillful an anesthesiologist Pearl was, it was difficult for Zack to imagine his fastidious brother hiring such a man. "So, " Pearl said, his voice an annoying cross between Peter Lorre and, perhaps, Carol Channing, "I see you are an early morning person, too."