Critical Judgment (1996) (28 page)

“Joe, you said the hospital bylaws were established to protect patient confidentiality. Well, I violated those laws because I believe those same patients’ lives may be at stake. And I believe Colstar may be at fault.”

Henderson sat forward and pushed aside his putting green.

“Then why in the hell didn’t you talk to someone?” he asked.

“Who? Dr. Oleander almost jumped down my throat for ordering cadmium levels on a couple of his patients.”

“All negative, I’ve been told.”

“See? That’s a perfect example of how there are no secrets in this town at all. The things I believe Colstar might have done are crimes. People may even have died because of them. The company could be heavily fined and even shut down. If there’s been a deliberate cover-up, people could be sent to prison. So who am I supposed to talk to? Do you want me to ask permission from the records committee to investigate? Well, Martin Bartholomew is the head of that committee, and he’s also the head of the employees’ clinic at Colstar.”

“I see.”

“So I just decided that the welfare of my patients—
your
patients, too, incidentally, since they all have been inpatients or outpatients here—was worth breaking that bylaw for.”

“Abby, how can you believe the company is responsible for exposing people to cadmium when there is absolutely no proof? No positive tests. Nothing!”

“I’m waiting for an independent lab in San Francisco to call with the results on some samples of blood I brought to them.”

“You don’t trust our lab?”

“Quite frankly, I don’t trust anyone right now.”

“What patient was it?”

Again Abby resisted any knee-jerk response. Was there any way she would be putting Cardoza at risk by revealing that it was his blood? Considering her encounter with the man in the ski mask and his pickup, it seemed clear that nothing she could say was going to be hot-off-the-press news.

“Willie Cardoza,” she responded.

Henderson’s attempt at looking surprised missed badly, she thought.

“You think he was poisoned with cadmium?” he asked.

“I do, actually. That would explain the violence, the insanity inherent in what he did. I’ve researched the subject
quite thoroughly. Violent, psychotic behavior has been reported from cadmium, especially with high-dose exposure. Cardoza has some physical findings in his eyes, as well, that I think may quite possibly be due to some sort of heavy-metal poisoning. And cadmium is a heavy metal. It would certainly make me feel better to know that he wasn’t responsible for what he did, although no matter how the tests turn out, I still defend my decision to work on him and not Peggy Wheaton. I did what every ER doctor is trained to do in a triage situation—treat those who have a chance of making it.”

“Chance of making it
in your opinion.”

“Dammit, Joe! All right, all right. If it would make you any happier, I’ll say it. In
my
opinion. Now, let’s just drop it.”

“Did anyone else see these findings in Cardoza’s eyes?”

“Not yet. But anyone who wants to can do it anytime.”

“It won’t be quite as easy as that. Cardoza was transferred to a prison hospital early this morning.”

“Which one?”

“I’m afraid I’m not permitted to give that information to anyone.”

Abby sighed.

“What a carnival.”

Henderson clearly found her remark offensive.

“We don’t think so, Doctor,” he snapped. “This hospital and the Colstar corporation take the health of the people in this area very seriously. Two and a half years ago, when the community first raised health concerns about the company, investigators from the Environmental Protection Agency and the Occupational Safety and Health Administration were welcomed up on the hill and given free rein. The two teams were each here for almost a week. They found a few minor violations, which were dealt with immediately, but nothing that could have caused any health danger in the valley or to
the plant workers. You were up there. You saw how they operate that plant.”

Another nonsecret
.

“How do you know I was up there?” she asked.

“Abby, what difference does it make? The problem is that you have gone out of your way to create conflict where none existed. It seems to us that your temperament, your way of doing things, is much more suited to … to a place that’s not as … tightly woven as our valley. The letters of recommendation from your directors at St. John’s were glowing. Superb. Perhaps you should consider returning to some sort of academic environment, where controversy is more a way of life.”

“Joe, I don’t think patients like Bill Tracy and Hazel Cookman and a number of others I’ve cared for would say that I foster controversy and conflict. I know I’m having trouble adjusting to some aspects of living in this community, but once I step through the doors of the emergency room, I feel totally at ease. Before I came here, I was dreading having to work with no backup in the hospital. Now I’ve discovered that I actually enjoy the challenge. I don’t want to leave. At least not right now.”

Henderson shook his head.

“I heard there are some nurses and doctors who aren’t even speaking to you anymore.”

“They’re upset about Peggy Wheaton. That’s understandable. Just about everyone is. But they’ll come around. And those who don’t, still have to take care of the patients.”

“Abby, I’m sorry. It just isn’t working.”

She took a deep, calming breath.

“Joe, after you called this morning, I read over my contract. It spells out very clearly what I can be fired for. I don’t believe that anything you’ve said this morning about me and my job performance qualifies.”

“I don’t want to fire you, Abby. I want you to consider resigning.”

“And if I say no?”

Henderson drummed his fingers on the desktop, then removed a folder from his desk.

“I believe that one of those reasons spelled out in your contract has to do with demonstrating flawed judgment in critical situations. I have here the autopsy report on Peggy Wheaton.”

He opened the report to a specific page, studied it for a very dramatic ten or fifteen seconds, and then slid it and another page across to her.

Abby looked at him quizzically.

“I was present for the autopsy,” she said. “The whole thing. Start to finish. I don’t understand what—”

“Just read those pages, Abby.”

The first page in the technically written document was the description of the removal of the top of Peggy Wheaton’s head, and the examination of the trauma to her skull and brain. The single-spaced, computer-printed paragraph covered most of the sheet. Abby read it in shocked disbelief. The injury described was far less serious than the massive fractures and brain damage that Abby had diagnosed in the ER and confirmed through her observation of the autopsy. In fact, as described, the trauma was minor enough to have easily
not
caused Peggy’s death.

“This is a lie,” she said. “Every word of it.”

“I think you should read the next page as well.”

The second sheet described the findings in Peggy’s chest—a contusion to the heart with a traumatic hemopericardium—a constricting accumulation of blood between the heart muscle and covering membrane. If the finding was true, and Abby knew from having seen Peggy’s perfectly normal heart that it wasn’t, she would have been guilty of missing the very treatable cause of the woman’s death.

“You’re crazy if you think you can get away with this. I’ll just insist that the tissues be reexamined.”

“Feel free. I believe what tissue remains will conform
completely with this report. The report is official, signed by the medical examiner, Dr. Barrett.”

Abby groaned. Barrett was the chief of pathology at Patience Regional. He also ran the laboratory that had never found cadmium in anyone.

“I can’t believe you all would sink to this.”

“Abby, I assure you that no one wants this report to become public knowledge. It would reflect badly on the hospital, and terribly on you. In fact, I wouldn’t be a bit surprised if Gary Wheaton and his attorney choose to pursue the matter in court. That would tie you up indefinitely.”

“Am I that great a threat to Colstar, that you all would do this? What in the hell is going on here?”

“We would like you to give us two weeks’ notice.”

“If I refuse?”

“Then I’m afraid we’ll just have to decide what’s in the best interests of this hospital and this community.”

At that moment Abby’s pager went off, and at almost the same instant the loudspeaker outside Henderson’s office sounded.

“Code ninety-nine, X ray. Code ninety-nine, X ray.”

Abby glanced down at her page.

“It’s the ER, and it’s urgent,” she said, pushing back from the desk. “They need help at the code.”

“We can complete our conversation later,” Henderson replied icily. “Perhaps we’d better see what’s going on in radiology.”

“Tell your secretary to call and say I’m on my way. And in case I forget to say it later, Joe, you’re a son of a bitch.”

The overhead page was continuing to broadcast the location of the code ninety-nine as Abby sprinted down the hall to the stairway. The radiology department was on the ground floor, not far from the ER. She tried to recall what doctor from her ER group was on the schedule
for today. Whoever it was would certainly be there running the code. Just as she raced through the open doors to radiology, she remembered that the ER doc on duty was Jill Anderson. And that, she knew, could mean trouble. Jill was skittish and insecure, and prone to bursts of temper.
Talk about impaired critical judgment!
Abby had wondered more than once what Jill was doing in a specialty that required nothing if not a cool head. She was a disaster waiting to happen every time she put on her clinic coat.

A technician stationed by the doors pointed down the brightly lit corridor.

“The MRI suite, Dr. Dolan!” she called out. “Please hurry!”

The magnetic resonance imaging suite consisted of a small waiting/reception area, a dressing room, and the room housing the massive MRI unit itself. The code ninety-nine was being conducted in there. Several people, including two nurses, were standing outside, craning to see through the thick glass walls.

“Just bump someone out and go right in,” one of them said.

Over her years as a med student, resident, and then emergency specialist, Abby had been involved in hundreds of code ninety-nines. But the bizarre scene in the crowded MRI room was one she would never forget. Jill Anderson, tears streaming down her face, muttering to herself, was fumbling with the equipment to do a subclavian IV insertion in a woman who was kicking and flailing her arms about desperately. Every bit of the patient’s skin that Abby could see was flaming red. Standing across from Jill, Dr. Del Marshall, a radiologist in his sixties, was trying to ventilate the patient with a black Ambu breathing bag. Even from the doorway Abby could tell he was doing an ineffective job of getting air into her lungs.

“What’s up?” Abby asked as a nurse stepped back to give her room by the stretcher.

“Anaphylactic shock,” Jill said. “She went into it while she was inside the MRI cylinder. Her jaws are clenched too tightly to get a tube in. She’s hardly breathing.”

Why in the hell didn’t you wheel her out of this closet and back to the ER?
Abby wanted to scream. The forty-five seconds or so that such a move would have taken would have been repaid a thousandfold with the space and equipment at their disposal in the ER. Now Abby couldn’t tell if time was too precious for that.

She moved behind Del Marshall to get a better look at the patient, and at what the radiologist was doing. Above the black rubber face mask, she saw the patient’s bright-red hair. Marshall backed away and let Abby handle the breathing bag. She lifted it from the woman’s face. Lying there, her eyes wide with panic, fighting desperately and futilely to get air past the swollen tissues in her throat, was Claire Buchanan.

C
laire Buchanan’s face, puffed and crimson, was barely recognizable. She was thrashing about as if someone were smothering her with a pillow.

Jill Anderson looked only marginally better. Her mascara was beginning to smear beneath both eyes, and her normally pale complexion was bloodless.

“I’ve got to get this line in so we can paralyze her with some Anectine,” she said. “Once her jaws are relaxed, maybe I can get a tube in.”

Paralyze. Tube
. From what Abby could tell, Claire Buchanan was still conscious. The use of such words in this situation was totally inappropriate. To make matters worse, the time that was being lost as Jill struggled to get an IV in could prove fatal. The lactic acid that was rapidly building up in Claire’s bloodstream from her low oxygen levels could cause a cardiac arrest at any moment.

By the accepted rules of practice Jill was in charge of the code ninety-nine. But there was no way Abby could allow things to continue as they were. Besides, what did she have to lose? Henderson had more or less just fired her.

“Jill,” she said with undisguised firmness, “let me help.”

At that moment Jill looked like a frantic, treed animal who had just realized there was no place else to run.

“Take over,” she said.

Thank God
.

Abby was already experiencing the familiar slowing of movement and muffling of sound as her mind and body homed in on the critical elements of the situation at hand. In just a few seconds she understood the crisis and what she and the others had to do to reverse it.

“Jill, please get a tourniquet on that arm,” she said. “Someone else keep a couple of fingers on her femoral pulse until we can get our portable monitor hooked up.”

She next turned to the nurse, Mary Wilder. Before Peggy Wheaton’s death they had been on a first-name basis—allies in the ER war. Since the triage episode the nurse hadn’t spoken a kind word to her.

“Mrs. Wilder, please give Dr. Anderson point eight of epinephrine on a twenty-seven needle.”

Wilder looked at her dispassionately.