The better to encourage snitches, thought Hamlin, getting up to leave and reaching for Sullivan's chart. Ingram slapped his hand on the document. "Not so fast. There's another issue here that we have to address."
"Pardon?"
"It's whether you should continue your ban on Richard's visiting her. I also see you only allowed her daughter and Richard's son a quick look at her immediately post-op, and nothing since. Hell, it's over seventy-two hours since surgery. Why shouldn't she see those closest to her?"
"Because her vitals go haywire whenever anyone gets near her, including me, and the cauterized vessels won't hold—"
"Hey! Remember who you're talking to here." His boyish crown of curly dark hair did not offset the severity of the expression on his face. "Patients in ICU need contact with loved ones, especially if they're agitated. Lay down the ground rules about what they can and cannot do, so as not to excite her further, but get them in there."
"Gordon, she's my patient. I think I know the state of mind—"
"Don't make me quote the data on ICU psychosis. Also, don't make me officially question the amount of sedation you've been using on this patient. A medical student could see it's the most likely cause of her being so inappropriately agitated. It's time to use family as a sedative, and wind down the drugs."
"But—"
"I can go through channels, and make that an official recommendation, Tony."
The thought of all that scrutiny stopped Hamlin. The OR greens he was still wearing suddenly felt very heavy and hot.
"Now do I tell Steele, or do you?"
"I'll tell him," Hamlin replied, determined not to give the man an additional chance to become any more involved than he already was.
"And you'll speak to the nurses about allowing as much family contact with Sullivan as possible?"
"Yes."
"Good. If you start tapering the doses of midazolam tonight, we should have a sea-change in Kathleen Sullivan's mentation by week's end. Have you arranged for someone to trach her?"Hamlin felt the temperature crank up another few degrees, and a ripple of perspiration broke out under his scrubs. Ingram referred to cutting a hole into her trachea through the front of her neck and ventilating her lungs by that route rather than using the tube down her throat. Patients likely to require long term airway protection or breathing assistance found it more comfortable, and the arrangement also allowed them to talk, recovery of speech often being one of the first functions to return, if it came back at all. But that was a risk Hamlin couldn't take at the moment. "Of course I have," he said, and got up to leave. Retrieving Sullivan's chart, he smiled at Ingram while silently cursing the man. 12:10 p.m. The Hospital Cafeteria
"You're going to tell Steele now, without even waiting to see if she recovers? That's absolute lunacy!" Lockman whispered. He leaned so far across the table toward Hamlin that he almost upset their untouched cups of coffee. "If she dies, which there's a damn good chance she may do, and he knows, he'll turn you over to the cops for sure."
Hamlin hunched forward as well, drawing close enough to catch the sour aroma of the day's NOON SPECIAL, cabbage rolls, off the radiologist's breath. "If you'd kept your mouth shut, she never would have suspected anything."
"What's done is done," interjected Adele Blaine, looking nervously around her and motioning the two men to quiet down. "But you're not thinking straight, Tony honey. Down in Tennessee where I was born and raised we sure believe in letting sleepin' dogs lie. So, if she's going to go, best you let her die with no one the wiser."
"And you're a fool to ignore our usual precautions not to be seen together," Edwards added. "Summoning us all here like this is plain nuts." The large man kept his voice low, but it rumbled the length of the table.
"It's an emergency, for Christ's sake," Hamlin said. "I can't drug her any longer, thanks to Gordon Ingram. The woman's bound to keep on spelling out to Steele what she remembers from the angiogram, and once she's not so sedated, maybe he'll believe her."
Downs said nothing. She kept hoping Norris would walk in the door and bring the others to their senses, the way he always had when they'd clashed before. But back then their problems had been scientific in nature and were solvable. What loomed now seemed as insurmountable as fate.
"So what do you suggest?" Hamlin continued. "Wait until he finds out for himself? Get real! Because if that happens there's no chance he'll listen to our side of the story before going to the police, whether she lives or not."
Edwards exchanged glances with Blaine, then swung his beefy face around to Hamlin. "Here's how we see the situation, Tony. If you persist in your insane idea to confess all to Steele, then Adele, Francesca, Matt, and I figure it's not just you who'll be arrested, but the bunch of us. That would force us, in the interest of keeping ourselves out of prison, to take drastic measures."
Hamlin tensed. "Meaning what?"
"Either you keep your mouth shut, or we'll approach the cops now, before you give Steele the opportunity to do it for us. And we'll offer them you in exchange for their granting us immunity."
Hamlin looked poleaxed, the color drained from his face, leaving his complexion as white as his hair. "You wouldn't!"
Blaine, Lockman, and Edwards remained defiantly silent.
"Francesca?" he said hopefully. "You can't be serious."
She glanced up at him, as disgusted with herself as she was with the lot of them, but too frightened by the prospect of prison not to go along. Casting around for something to say, she decided anymore words would be futile and, resigned to the trap she was in, simply shrugged. The gesture infuriated Hamlin. His slack features instantly coiled into a show of contempt. "You— you— wouldn't dare." A crimson flush spread over his cheeks, up to his forehead, and down his neck. "You'd all lose your licenses to practice."
"Try us!" said Blaine, her pupils growing wide as buttons and making her small head appear doll-like. "It's better that than jail."
"You bitch!" Hamlin sprang to his feet and towered over the little woman. His high-pitch whisper had been sibilant enough to shush conversations two tables away.
"Shut up, Tony, and sit down!" said Edwards, rising to grab him by the shoulders and plunk him back in his seat. "You're attracting attention. Now listen up. I've got another way to buy us all some time."
"Oh, really?" He tried to shake off the gynecologist's massive grip.
"Yes, really," the big man said, maintaining his hold.
Downs looked around nervously. A half dozen people were staring at them.
Edwards's large face broke into a forced smile, and he released his captive with a friendly slap on the back, as if they were the best of pals. "Why shouldn't I get an operating slot from you? I could do a week's worth of D-and-Cs in the time it takes for one of your brain jobs. Now you're not leaving this discussion until I tell you my plans for dividing up the summer OR schedule in favor of my department." This time his overloud voice carried the length of the room.
The onlookers lost interest.
Edwards brought his head up close to Hamlin's and whispered, "Have Sullivan add a few more features to her story that will make the whole thing so implausible no one will believe anything she says, not even Steele."
"And how do we do that?" said Hamlin, sarcasm curling off his lips.
"Not we," said Edwards. "You."
While passing the cafeteria, Richard spotted Hamlin's distinctive head of hair. He'd been trying to catch up with him all morning to find out how his conversation with Gordon Ingram went, but the man hadn't answered any of his pages. This was his chance, as soon as he had finished talking with the people at his table.
But as Richard watched, the conversation seemed to grow quite intense. "Probably hospital politics," he muttered, recognizing each person at the table as a prominent figure in their respective departments. Knowing from bitter experience that such dustups could go on at length, he bought a coffee and sat down at a table between Hamlin and the exit, intending to intercept him on his way out. He
soon realized that even by New York City Hospital standards, this argument was especially heated. At one point it looked as if Hamlin would throttle Blaine, the rehabilitation specialist, but Edwards settled him down. What could have them so worked up? Come to think of it, they were an odd group. Lockman from radiology and Blaine with her rehab unit would obviously work with Hamlin on neurological cases. Lockman would work with Downs doing coronary angiograms. But why was Edwards, chief of obstetrics and gynecology, with them, and what was he so intent on telling Hamlin that could make the neurosurgeon blanch? Turf battles between those two specialties weren't common.
Ten minutes later Hamlin pushed away from the table and headed for the door, a dazed look on his face.
Richard jumped up and cut him off as he passed. "Tony, can I have a word with you?"
"Richard!" he said, appearing startled. His eyes darted ever so slightly in the direction of the group he'd just left. "Why? What do you want?"
Was he ever rattled, Richard thought. "How did your conversation with Ingram go?" Hamlin didn't answer. For a second it seemed he was too distracted to make sense of the question. Then he swallowed and said, "Quite well, actually. I got him to agree that no official inquiry into what happened would be necessary."
"Whew. That's a relief. Listen, thank you—"
"I also agreed that you can begin to see Kathleen. Ingram insisted on it, despite it being against my better judgment. He also strongly recommended we taper down her medication, as part of reinstituting family visits, again against my advice. But don't visit her before tomorrow morning. Perhaps by that time, though I seriously doubt it, she'll be better prepared to see you." He then abruptly walked away.
Richard stood speechless watching him go. At the doorway the man paused and stole a backward glance in his direction. He looked frightened. Even stranger, when Richard turned to retrieve his empty coffee cup, he saw scowls on the faces of some of the people Hamlin had been arguing with. But Francesca Downs didn't scowl. She had the puckered look of someone who'd just caught the scent of an exceedingly rotten odor.
Must be the cabbage roll special, Richard thought. From the opposite side of the cafeteria, Gordon Ingram also viewed the disapproving tableau that monitored Hamlin's exit. He, too, found the grouping odd. He made his judgment with a statistician's sense for recognizing things outside the norm, especially their vehement arguing. Trouble, he figured, but what kind could they have in common?
Anyone else might have left the observation at that. But he was a born muckraker. His remarkable clinical skills had not only given him a podium from which he could pronounce on lesser lights, his aptitude for doing things right made it easy for him to spot things done wrong, and he'd made a career of routing out mediocrity wherever he found it. Since his heart attack, he'd become all the more zealous. "If I can't practice medicine, I'll be damned if anyone who's screwing up the privilege will either," he told anyone who complained he was coming on too strong. The truth was he hadn't given up practice altogether, simply curtailed his hours by confining himself to consults. It gave him some satisfaction that those same complainers were almost always among the first to seek his opinion as soon as a case got the better of them. But none of it replaced the exhilaration he'd felt at the helm of ICU. Not a day went by that he didn't chafe at how he hadn't the physical stamina for it anymore.
Within minutes he was in his office unlocking the bottom drawer of his desk and taking out the computer he actually relied on, a black laptop barely an inch thick with a thousand times the power of the puny antique the hospital provided. "It's my book of secrets, just like J. Edgar Hoover's," he used to joke to his wife, before she got fed up with his long hours at the hospital and left him.
Over the next hour he ran a morbidity-mortality analysis for the last few years of each physician at the table, including Hamlin, looking for any patterns suggesting a higher rate of complication or death than was acceptable.
"Interesting," he muttered.
Lockman's record was littered with mistakes, as Ingram expected. All the other numbers were within normal limits, except Hamlin's and Downs's. Their rates of adverse incidents were far below national standards, indicating the two physicians were much more successful in treating their patients than most other U.S. doctors in their respective fields, Downs even more so than Hamlin.
So why would these two superstars be so unhappy with their colleagues in the cafeteria? Judging from the expressions on their faces, they appeared the most upset by whatever the group was arguing about. Come to think of it, Hamlin also seemed rather unusually defensive during their meeting over his problems with Kathleen Sullivan. And his medicating her so heavily, especially in the context of a clear-cut ICU psychosis, was of questionable judgment, to say the least.
Ingram used his authorization to access the hospital's computerized records of prescribing patterns by physicians and punched up Hamlin's profile for ordering narcotics and tranquilizers.
It seemed in order. His overmedicating Sullivan was an isolated event.
So why the scene in the cafeteria?
He went after another indicator that often signaled trouble, pulling out the incidence of unexpected patient readmission back into hospital shortly after discharge for the two physicians. Again, they both had exemplary records. Two entries for Hamlin, however, caught his attention, because they were both similar and relatively recent. Both were men who had been readmitted to emergency with fatal hemorrhagic strokes, but more than a year had elapsed since their previous surgery. The neurosurgeon couldn't be faulted for that. Especially since the initial diagnosis in each case was a hereditary vascular malformation, one being a Berry aneurysm, or sacular weakening of an artery that was leaking blood, and the other a capsular angioma, same as Kathleen Sullivan had. Whatever led to their second bleeds couldn't have had anything to do with the first. Once congenital malformations were removed, they didn't reoccur.
But why had they rebled? Intracranial hemorrhages only comprised 20 percent of all strokes, whatever the cause, and vascular malformations were way down that list. Yet here were two men who'd both had two bleeds. Perhaps they also suffered from hypertension, he thought, identifying the most common reason for strokes of all kinds. But he couldn't tell without pulling their charts, the computerized record listing only their principle admission diagnoses. Any contributing secondary problems, such as high blood pressure, should have been added as well, but staff pressed for time often failed to enter such data. Even for a suspicious mind like his, the absence of the secondary diagnosis on a couple of charts didn't seem much of an indicator for something being seriously wrong.
Still, attributing a pair of hemorrhagic strokes in the same patient to more than one disease process bothered him. To explain away two patients that way left him even more uneasy, because he knew the statistics. When doctors resort to more than one diagnosis to account for a recurrent sickness, they're usually wrong.
He shoved back from his desk and rubbed his eyes, the glare from the computer screen along with the harsh white light from the overhead fluorescent tubes giving him a headache. But he continued to puzzle over what he'd learned.
Years of uncovering bad practices had taught him another important lesson in the quality assurance business. The more successful things appeared to be, the less critical attention people pay to what's going on, and the greater the possibility that a serious problem could escape detection for a long time.
Maybe one of our two superstars warrants a closer look, he thought, shutting downhis computer. The trouble would be finding the time. Today alone he had three disciplinary hearings to chair. 8:20 p.m.
Silver needles of rain danced off the asphalt as Richard ran for his car, his coat pulled over his head.
"Hey, Richard," called a voice from behind, barely audible above the noise of the downpour. "Wait up."
He turned and recognized the sleek form and familiar slow walk of the man approaching him carrying an umbrella. "Evening, Gordon," he said. "Have you
got room for me under there?"
Ingram grinned. "Come on in."
Richard hurried up to him and stepped beneath the black brim. As they both were tall, he didn't have to duck. He did have to reduce his pace a little, so as not to pull ahead of Ingram, who had the measured step and slightly labored breathing of an old man.
"Everything straight between you and Hamlin now?" he asked, puffing a little. "Yes. I was going to thank you tomorrow for smoothing things out for me—"
"My God, Richard. What's the point of sorting out ethics all day unless I enforce a few of my rulings now and then? You know, win one for the good guys and all that. You're certainly one of the 'good guys' around here, and among the few I can talk with equal to equal. Think nothing of it. Just take care of Kathleen. How's she holding up?"
"As to be expected, I guess. She's pretty dazed."
"Well, that ought to improve quickly. I remember how I felt as a patient in ICU. Like I'd had my teeth kicked in."
Richard thought back to the night three years ago when the man had arrived at ER in cardiac arrest with a massive heart attack. "Half the battle in saving your sorry ass was getting the residents and nurses settled down," he'd told him weeks later. "They were already freaking out at having to resuscitate one of our own, but after coming around, you started giving orders on yourself. Everyone was so intimidated and used to taking what you said as word of law, they very nearly carried them out." Richard now chuckled at the memory. "You were a real son of a bitch as a patient, I seem to remember."
Ingram's normally ascetic expression burst into a smile. "I was, wasn't I?" he said, beaming with pride.
"The worst."
"Well, I wouldn't wish the experience on anyone, but it taught me a ton about being a doctor. Having someone around to hold your hand can count for a hell of a lot."
The sudden edge in his voice made Richard wince. It had been the talk of the hospital how lots of colleagues and residents dropped by to wish him well or sent him flowers, but the man's wife barely managed to visit him a half dozen times. Even then, according to gossip from the nurses, the woman barely touched him. A year later she had filed for divorce.
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