by Robin Cook
“Damn!” Craig blurted with emphasis. He flipped open his phone, put it to his ear, and said hello.
“Doctor Bowman!” a refined voice said. “I’m calling about Patience. She’s worse. In fact, this time I think she’s really sick.”
“What seems to be the problem, Jordan?” Craig asked as he turned to glance back into the bathroom. Leona had heard the phone and was looking at him. He mouthed the name Stanhope, and Leona nodded. She knew what that meant, and Craig could tell from her expression that she had the same fear he had—namely, that their evening was now in jeopardy. If they arrived at the symphony too late, they’d have to wait for the intermission to sit down, which meant forgoing the fun and excitement of the entrance, which both had been keenly anticipating.
“I don’t know,” Jordan said. “She appears unnaturally weak. She doesn’t even seem to be able to sit up.”
“Besides weakness, what are her symptoms?”
“I think we should call an ambulance and go to the hospital. She’s greatly perturbed, and she’s got me concerned.”
“Jordan, if you are concerned, then I am, too,” Craig said soothingly. “What are her symptoms? I mean, I was just there at your home this morning dealing with her usual medley of complaints. Is it something different or what?” Patience Stanhope was one of less than a half dozen patients that Craig labeled “problem patients,” but she was the worst of the group. Every doctor had had them, in every kind of practice, and found them tedious at best and maddening at worst. They were the patients who persisted day in and day out with a litany of complaints that were, for the most part, completely psychosomatic or totally phantom and that could rarely be helped by any therapy, including alternative medicine. Craig had tried everything with such patients, to no avail. They were generally depressed, demanding, frustrating, and time-consuming, and now with the Internet, quite creative with their professed symptoms and desire for lengthy conversations and hand-holding. In his previous practice, after ascertaining their hypochondriasis beyond a reasonable doubt, Craig would arrange to see them as infrequently as possible, mostly by shunting them off to the nurse practitioner or to the nurse or, rarely, to a sub-specialist if he could get them to go, particularly to see a psychiatrist. But in Craig’s current practice setup, he was limited in his ability to resort to such ruses, meaning the “problem patients” were the only bugbears of his new practice. Representing only three percent of his patient base, as reported by the accountant, they consumed more than fifteen percent of his time. Patience was the prime example. He had been seeing her at least once a week over the last eight months and, more often than not, in the evening or at night. As Craig frequently quipped to his staff, she was trying his patience. The comment never failed to get a laugh.
“This is far different,” Jordan said. “It’s entirely dissimilar to her complaints last evening and morning.”
“How so?” Craig asked. “Can you give me some specifics?” He wanted to be as certain as possible about what was going on with Patience, forcing himself to remember that hypochondriacs occasionally actually got sick. The problem with dealing with such patients was that they lowered one’s index of suspicion. It was like the allegory of the shepherd boy crying wolf.
“The pain is in a different location.”
“Okay, that’s a start,” Craig said. He shrugged for Leona’s benefit and motioned for her to hurry. If the current problem was what he thought, he wanted to take Leona along on the house call. “How is the pain different?”
“The pain this morning was in her rectum and the lower part of her belly.”
“I remember!” Craig said. How could he forget? Bloating, gas, and problems with elimination described in disgustingly exquisite detail were the usual complaints. “Where is it now?”
“She says it’s in her chest. She’s never complained of pain in her chest before.”
“That’s not quite true, Jordan. Last month there were several episodes of chest pain. That’s why I gave her a stress test.”
“You’re right! I forgot about that. I can’t keep up with all her symptoms.”
You and me both, Craig wanted to say, but he held his tongue.
“I think she should go to the hospital,” Jordan repeated. “I believe she’s having some difficulty breathing and even talking. Earlier, she managed to tell me she had a headache and was sick to her stomach.”
“Nausea is one of her common afflictions,” Craig interjected. “So is the headache.”
“But this time she threw up a little. She also said she felt like she was floating in the air and kind of numb.”
“Those are new ones!”
“I’m telling you, this is altogether different.”
“Is the pain visceral and crushing, or is it sharp and intermittent like a cramp?
“I can’t say.”
“Could you ask her? It may be important.”
“Okay, hold the line!”
Craig could hear Jordan drop the receiver. Leona came out of the bathroom. She was ready. To Craig, she looked like she belonged on the cover of a magazine. He indicated as much by giving her a thumbs-up. She smiled and mouthed: “What’s happening?”
Craig shrugged, keeping the cell phone pressed to his ear but twisting it away from his mouth. “Looks like I’m going to have to make a house call.”
Leona nodded, then questioned: “Are you having trouble with your tie?”
Craig reluctantly nodded.
“Let’s see what I can do,” Leona suggested.
Craig raised his chin to give her more room to work as Jordan came back on the line. “She says the pain is terrible. She says it’s all of those words you used.”
Craig nodded. That sounded like the Patience he was all too familiar with. No help there. “Does the pain radiate anywhere, like to her arm or neck or any other place?”
“Oh my word! I don’t know. Should I ask her?”
“Please,” Craig replied.
After a few deft maneuvers, Leona pulled on the looped ends of the bow tie and tightened the knot she had made. After a minor adjustment, she stepped back. “Not bad, even if I say so myself,” she declared.
Craig looked at himself in the mirror and had to agree. She had made it look easy.
Jordan’s voice came over the phone. “She says it’s just in her chest. Are you thinking she’s experiencing a heart attack, doctor?”
“It has to be ruled out, Jordan,” Craig said. “Remember, I told you she had some mild changes on her stress test, which is why I advised more investigation of her cardiac status, even though she was not inclined.”
“I do remember now that you mention it. But whatever the current affliction, I believe it’s progressing. I believe she even appears rather blue.”
“Okay, Jordan, I’ll be right there. But one other quick question: Did she take any of those antidepressant pills I left this morning?”
“Is that important?”
“It could be. Although it doesn’t sound like she is having a drug reaction, we have to keep it in mind. It was a new medication for her. That’s why I told her not to start until tonight when she went to bed, just in case they made her dizzy or anything.”
“I have no idea if she did or not. She has a lot of medication she got from Dr. Cohen.”
Craig nodded. He knew very well that Patience’s medicine cabinet looked like a miniature pharmacy. Dr. Ethan Cohen was a much more liberal prescriber of medication than Craig, and he had originally been Patience’s physician. It had been Dr. Cohen who had offered Craig the opportunity to join his practice, but he was currently Craig’s partner more in theory than in fact. The man was having his own health issues and was on an extended leave that might end up being permanent. Craig had inherited his entire current roster of problem patients from his absent partner. To Craig’s delight, none of his problem patients from his previous practice had decided to pay the required fee to switch to the new practice.
“Listen, Jordan,” Craig said. �
��I’m on my way, but make an effort to find the small vial of sample pills I gave Patience this morning so we can count them.”
“I will give it my best effort,” Jordan said.
Craig flipped his phone shut. He looked at Leona. “I’ve definitely got to make a house call. Do you mind coming with me? If it turns out to be a false alarm, we can go directly to the concert and still make the entrée. Their house is not that far from Symphony Hall.”
“Fine by me,” Leona said cheerfully.
While pulling on his tuxedo jacket, Craig went quickly to his front closet. From the top shelf, he got his black bag and snapped it open. It had been a gift from his mother when he’d graduated from medical school. At the time it had meant a mountain to Craig because he had an idea of how long his mom had to have squirreled money away without his father knowing to afford it. It was a sizable, old-fashioned doctor’s bag made of black leather with brass hardware. In his former practice, Craig had never used it since he didn’t make house calls. But over the last year he’d used it a lot.
Craig tossed a bunch of supplies he thought he might need into the bag, including a bedside assay kit for myocardial infarction or heart attack biomarkers. Science had advanced since he’d been a resident. Back then it could take days to get the results back from the lab. Now he could do it at the bedside. The assay wasn’t quantitative, but that didn’t matter. It was proof of the diagnosis that was important. Also from the top shelf he pulled down his portable ECG machine, which he handed to Leona.
When Craig had formally separated from Alexis, he had found an apartment on Beacon Hill in the center of Boston. It was a fourth-floor walk-up duplex on Revere Street with good sunlight, a deck, and a view over the Charles River to Cambridge. The Hill was central to the city and fulfilled Craig’s needs superbly, especially since he could walk to several good restaurants and the theater district. The only minor inconvenience was the parking problem. He had to rent a space in a garage on Charles Street, a five-minute walk away.
“What are the chances we can get away in time for the concert?” Leona asked when they were on their way in Craig’s new Porsche, speeding westward on Storrow Drive.
Craig had to raise his voice against the whine of the engine. “Jordan seems to think this might be legit. That’s what scares me. Living with Patience, he knows her better than anybody.”
“How can he live with her? She’s such a pain in the ass, and he seems like quite a refined gentleman.” Leona had observed the Stanhopes in the office on a couple of occasions.
“I imagine there are benefits. I have a sense she is the one with the money, but who knows. People’s private lives are never what they seem, including my own, until recently.” He gave Leona’s thigh a squeeze.
“I don’t know how you have such patience with such people,” Leona marveled. “No pun intended.”
“It’s a struggle, and between you and me, I can’t stand them. Luckily, they are a distinct minority. I was trained to take care of sick people. Hypochondriacs to me are the same as malingerers. If I had wanted to be a psychiatrist, I would have studied psychiatry.”
“When we get there, should I wait in the car?”
“It’s up to you,” Craig said. “I don’t know how long I’ll be. Sometimes she corners me for an hour. I think you should come in. It would be boring to sit in the car.”
“It will be interesting to see how they live.”
“Hardly the average couple.”
The Stanhopes lived in a massive, three-story, Georgian-style brick house on a sizable wooded lot near the Chestnut Hill Country Club in an upscale area of Brighton, Massachusetts. Craig entered the circular drive and pulled up to the front of the building. He knew the route all too well. Jordan had the door open as they mounted the three steps. Craig had the black bag; Leona carried the ECG machine.
“She is upstairs in her bedroom,” Jordan said quickly. He was a tall, meticulous man dressed in a dark green velvet smoking jacket. If he marveled at Craig and Leona’s formal attire, he didn’t let on. He held out a small plastic vial and dropped it in Craig’s hand before turning on his heel.
It was the free sample bottle of Zoloft Craig had given Patience that morning. Craig could see immediately that one of the six pills was missing. Obviously, she had started the medication earlier than Craig had suggested. He pocketed the vial and started after Jordan. “Do you mind if my secretary comes along?” Craig called out. “She can possibly lend me a hand.” Leona had demonstrated a few times in the office her willingness to help out. Craig had been impressed by her initiative and commitment from the start, long before he thought of asking her to a social event. He was equally impressed that she was taking night courses at Bunker Hill Community College in Charlestown, with the idea of eventually getting some sort of medical degree as a technician or nurse. For him, it added to her appeal.
“Not at all,” Jordan responded over his shoulder, waving for them to follow. He had started up the main staircase that skirted the Palladian window above the front door.
“Separate bedrooms,” Leona whispered to Craig as they hurried after Jordan. “It kind of defeats the purpose. I thought that was only in old movies.”
Craig didn’t respond. They quickly descended a long carpeted hallway and entered the feminine master suite upholstered in a square mile of blue silk. Patience, her eyelids heavy, was lying in a king-size bed, semi-propped up with overstuffed pillows. A servant in a demure French maid’s outfit straightened up. She had been holding a moist cloth against Patience’s forehead.
With a quick glance at Patience and without saying a word, Craig rushed over to the woman, dropped the bag on the bed next to her, and felt for a pulse. He snapped open the bag and pulled out his blood-pressure cuff and stethoscope. As he wrapped the cuff around Patience’s right arm, he barked to Jordan: “Call an ambulance!”
With only a slight elevation of his eyebrows to indicate he had heard, Jordan went to the nightstand phone and dialed 911. He gave the servant woman a wave of dismissal.
“Good Lord!” Craig murmured as he tore off the cuff. He snapped the pillows from behind Patience’s body and her torso fell back onto the bed like a rag doll. He yanked down the covers and pulled open her negligee, then listened briefly to her thorax with his stethoscope before motioning to Leona to give him the ECG machine. Jordan could be heard speaking with the 911 operator. Craig fumbled to unsnarl the ECG leads and quickly attached them with a bit of conducting jelly.
“Is she going to be all right?” Leona asked in a whisper.
“Who the hell knows,” Craig answered. “She’s cyanotic, for Christ’s sake.”
“What’s cyanotic?”
“There’s not enough oxygen in her blood. I don’t know if it’s because her heart isn’t pumping enough or she’s not breathing enough. It’s one or the other or both.”
Craig concentrated on the ECG machine as it spewed out a tracing. There were only little blips, widely spaced. Craig tore off the output strip and took a quick, closer glance at it before jamming it into his jacket pocket. He then snapped the leads off Patience’s extremities.
Jordan hung up the phone. “The ambulance is on its way.”
Craig merely nodded as he rapidly rummaged in his bag and pulled out an Ambu breathing bag. He placed the mask over Patience’s nose and mouth and compressed the bag. Her chest rose easily, suggesting good ventilation.
“Could you do this?” Craig asked Leona as he continued to ventilate Patience.
“I guess so,” Leona said hesitantly. She squeezed between Craig and the headboard and took over the assisted breathing.
Craig showed her how to maintain a seal and keep Patience’s head back. He then glanced at Patience’s pupils. They were widely dilated and unreactive. It wasn’t a good sign. With the stethoscope, he checked Patience’s breath sounds. She was being aerated well.
Back in his black bag, Craig pulled out the assay kit for testing for the biomarkers associated with a heart attack.
He tore open the box and pulled out one of the plastic devices. He used a small, heparinized syringe to get some blood from a major vein, shook it, and then put six drops into the sample area. He then held the device under the light.
“Well, that’s positive,” he said after a moment. He then haphazardly tossed everything back into his bag.
“What is positive?” Jordan asked.
“Her blood is positive for myoglobin and troponin,” Craig said. “In layman’s terms, it means she’s had a heart attack.” With his stethoscope, Craig ascertained that Leona was ventilating Patience appropriately.
“So your initial impression was correct,” Jordan commented.
“Hardly,” Craig said. “I’m afraid I have to say, she is in a very bad situation.”
“I was trying to communicate as much on the phone,” Jordan said stiffly. “But at the moment, I was referring to the heart attack.”
“She is worse off than you led me to believe,” Craig said as he got out some epinephrine and atropine, along with a small bottle of intravenous fluid.
“I beg your pardon. I was quite clear she was progressively getting worse.”
“You said she was having a little trouble breathing. Actually, she was hardly breathing at all when we got here. You could have let me know that. You said you believed she was rather blue, whereas I find her totally cyanotic.” Craig deftly started an intravenous infusion. He taped the needle in place and gave the epinephrine and atropine. He hung the small IV bottle from the lampshade with a small S hook he had made for that specific purpose.
“I was doing the best I could to communicate to you, doctor.”
“I appreciate that,” Craig said, holding up his hands in a conciliatory gesture. “I’m sorry. I don’t mean to be critical. I’m just concerned about your wife. What we need to do now is get her to the hospital as quickly as we can. She needs to be ventilated with oxygen, and she needs a cardiac pacer. On top of that, I’m certain she is acidotic and must be treated for it.”