Critical Judgment (1996) (9 page)

She put the pack on and buckled the support straps, realizing with dismay that she had blood on her arms, legs, and clothes. She would wash it off as quickly as possible. With a terse good-bye to Lyle Quinn, she walked away.

The barbecue was now in full swing, with a dozen aproned chefs—according to Josh, the officers in the company—serving steak and chicken to their employees. But Josh was not among them, though he had told her he would be. She checked the picnic area and the path to the lake. Not there. Then she walked to the parking lot. The Jeep was gone.

She waited for five minutes but knew he was not coming back. The debate about approaching Lyle Quinn for a ride home lasted only moments. Abby found a pay phone and called a cab. She was feeling as frustrated, worried, and angry as she had at any time since moving to Patience.

Josh would get help or she was moving out.

She glanced back just as the ambulance began its trip to the hospital. There was something surreal about the scene—the magnificent mountains, the perfect ball diamonds, the shimmering emerald grass, the smoke rising from the barbecue pits, the laughter. And at one edge of the perfect scene, an ambulance carrying a woman slashed by her own hand—a woman consumed by the most virulent hatred imaginable. Hatred directed inwardly … at herself.

A
bby parked her three-year-old Mazda in the doctors’ lot and entered the hospital through the ambulance bay. For seven-thirty in the evening the ER was busier than she liked it, but still a notch or two from utter chaos. It was just as well, she thought. A few hectic hours would help keep her mind focused on work.

Five days had passed since the Colstar family outing. For Abby they had been days of tension and turmoil at home, sandwiched around relatively uneventful shifts at the hospital. Shortly after returning by cab from Colstar Park, she had moved her things into the small guest bedroom. And there she had stayed despite Josh’s daily assurances that he would never behave so irrationally again.

Getting away from the stress at home wasn’t the only reason she was pleased to be at the hospital tonight. The day-shift doctor she would be replacing was Lew Alvarez. Their paths hadn’t crossed since the evening of Bill Tracy’s resuscitation. But on her shifts Abby had managed to draw a nurse here or a doctor there into conversation about him. She could not, in all honesty, deny that she found Alvarez intriguing and attractive. But she refused to admit to herself that she had anything like a
crush on him. The deteriorating situation with Josh was simply opening her eyes to other people. That was all.

What she did learn about the man only intrigued her more. He had been at PRH for just over three years and was now a partner in the ER group. Despite George Oleander’s curious irritation with him, not one nurse had anything negative to say, except for the backhanded compliment that because he spent so much time with each patient, the ER tended to get jammed up during his shifts.

He was most definitely single. And although one nurse was certain he was involved with a woman, another felt equally certain he was gay. Abby knew enough of hospitals to be sure there was almost no way an attractive single physician—male or female—could be involved with anybody for long without some colleague getting wind of it. So she labeled him, unofficially and in pencil, heterosexual and unattached. In addition to his ER job he had a small working farm in the hills west of town, frequently moonlighted as the attending physician at the state mental hospital in Caledonia, and coached Little League soccer. His teams hardly ever lost.

Abby skirted the patient area and went directly to the on-call suite—a good-sized office, sleeping room, and bathroom. She changed into a pair of blue scrubs and her clinic coat, and then, as she routinely did when starting a shift, stopped to get centered. She rinsed her face with cold water, headed to the door, then stopped again and returned to the sink. Almost in spite of herself she adjusted the band holding back her hair and put on a dash of lipstick.

Alvarez caught sight of her as soon as she entered the ER, made a theatrical display of looking at his watch, and gave her two thumbs up.

“It’s been like this since we had a code at three this afternoon,” he explained. “Seventy-five-year-old guy with a massive anterior MI.”

“Make it?” Abby sensed the answer to her question
even before Lew shook his head. “Sorry.… Well, listen. Why don’t I get started on that chart rack? Maybe together we can outflank them.”

“I’ll stay until the place is cleaned out,” he said.

“You don’t have to do that.”

“You didn’t have to come in early.”

The first patient Abby dealt with was another of the
I don’t know what’s wrong with you
group. He was a thirty-eight-year-old father of three with profound fatigue. In Abby’s experience fatigue and headaches were two of the most difficult complaints to evaluate and diagnose. And she had seen a significant number of both since starting at PRH. There was an almost limitless number of causes for each symptom, with perhaps the most common of those being stress—psychosomatic illness. Abby had never doubted the power of the human mind to cause
or
cure disease. The problem was that psychosomatic illness was a diagnosis of exclusion, to be made only when all other reasonable possibilities had been systematically ruled out. To assume an emotional etiology for a symptom like fatigue was asking for trouble.

Abby sent off what she considered to be a reasonable battery of tests and was launching into her “I don’t know …” speech, when the nurse, Bud Perlow, motioned her over to the minor trauma room and handed her a chart. The patient’s name was Hazel Cookman. She was eighty-four years old and a widow. Her presenting problem read simply, “Fell.”

“I know you’ve got about ten things going on at once,” Perlow said, “but I just needed you to take a quick look at her arm and tell me if you want films. I don’t think they’re necessary. You’ll love her. If she wasn’t a schoolmarm, she should have been.”

The woman, propped up on the stretcher, wore a navy-blue short-sleeved cotton dress with a lace collar. She had on pearls and an extravagant amount of rouge, and overall looked as if she were dressed for a church
social. The glint in her eyes and the set of her jaw were defiant.

Abby introduced herself.

“I assume you are well qualified to fix my arm, young lady,” Hazel said, her voice strong.

“I am. Could you tell me what happened?”

“Why, I fell. Doesn’t it say that there?”

“It does. But
how
did you fall?”

“I just fell. Nothing complicated about it. I was cooking some chicken and I fell. I think I must have hit the edge of my kitchen table. I checked my arm in the mirror and knew that I would need some stitches.” She eyed Abby sternly. “Now, Doctor, I would like you to tend to my injury and let me get home. I left my house in such a lather that I forgot the chicken simmering on the stove.”

“How did you get here?”

“Why … why, I drove, of course.”

“Of course,” Abby said, smiling toward the nurse.

Hazel Cookman’s injury was one common to older people with “tissue paper” skin. Just below her elbow a flap of delicate skin had peeled back. It would need to be stretched out again and tacked in place with some fine stitches and Steri-strips.

“Well?” Hazel asked. “Can you fix it?”

“I can.”

“And?”

Abby was checking the left and right carotid-artery pulses in the woman’s neck as she kept two fingers on the radial artery pulse at her wrist.

“I’d like to examine your heart and check over your nervous system,” she said. “And I think you should have an electrocardiogram and a blood count.”

“My lord, it’s just a cut arm. I simply have no time for all this rigmarole, young lady.”

“Mrs. Cookman, I may be a young lady to you, which is fine. I’m pleased you think me one. But I am also a doctor. And I worry a lot about missing things in
my patients. Right now I’m very worried that you don’t know precisely why you fell. Now, these tests won’t take long. And I promise as soon as they’re done, we’ll fix your cut.”

“But—”

“Thank you.” She turned to the nurse. “We’ll need postural blood-pressure checks, lying, sitting, and standing, but not until I’ve seen the EKG.” She waited until they were out of earshot, then added, “I don’t know why, Bud, but something doesn’t feel right. I don’t think she just tripped. I think she lost consciousness and fell. In fact, before you do anything else, hook her up to the monitor.”

“She’ll bite my head off.”

Abby patted him on the arm.

“Charm her with one of those great faces you use to win over the kids.”

Abby saw one more patient, a straightforward splinter removal, then met Lew by the chart rack. There was no question that together they were getting ahead of the backlog.

“Anything interesting?” he asked.

“Not really. A cute LOL with a flap of skin pushed back off her forearm. Listen, Lew, why don’t you go on home?”

He glanced about at the beds, which were still almost all filled.

“Another half hour, forty-five minutes. All I had planned for tonight was paying bills. The more tired I am, the easier that job is to take.”

Not a team player?
Abby wondered what could possibly have gone on between Lew and George Oleander to put off the medical chief so.

“Dr. Dolan!” Bud Perlow shouted from Hazel’s room.

Abby charged to the doorway with Lew close behind. Hazel Cookman was drifting into unconsciousness. Her monitor showed a heart rate of ten.

“She’s in complete heart block,” Abby said instantly, her own pulse pounding. “Lew, call a code. Bud, get a line in her. I’ll pump. As soon as we have another pair of hands, I want five-tenths of atropine IV.”

She kicked a low metal stool in place next to the litter and stepped up on it to give herself enough leverage for effective CPR. At that moment Hazel’s complete heart block reverted to a normal rhythm and rate. Abby checked both carotid-artery pulses and felt them easily. In seconds Hazel moaned. A few seconds more and she was wide-awake.

“Bud, get cardiology in here stat,” Abby said. “She needs a pacemaker. Do we have an external pacer?”

“Sure thing.”

“Set it up just in case.”

Abby’s suspicions about the woman’s fall were confirmed. Hardening of the arteries into Hazel’s heart was causing a blockage to the spread of electricity from her body’s natural, inborn pacemaker—the spot in the right atrium chamber where heartbeats are normally initiated. The result of the blockage was a pulse rate too slow to generate an effective blood pressure, and the pressure drop had caused her brief faint. For the moment the blockage kept reverting to normal. But that situation could change, quite literally, in a heartbeat.

The cardiologist would insert a guiding needle into the vein located beneath Hazel’s collarbone and then thread a wire through it until the tip made contact with the inner lining of her right ventricle chamber. The other end of the wire would be connected to a temporary pacemaker box, which would kick in any time the inborn pacemaker rate dropped below seventy per minute. Once she was stable, a permanent pacemaker could be implanted beneath her skin. But until the temporary wire was in, she was in the gravest danger.

Hazel blinked twice, still clearly unaware of the commotion beginning to swirl around her.

“Well, Doctor,” she said, “are you or are you not going to fix my arm?”

“Not just yet,” Abby said. “Mrs. Cookman, you and I need to talk.”

Bud Perlow finished inserting an IV. Then he wheeled over the external pacemaker. Strictly an emergency apparatus, the pacer had paddles that were placed beneath the spine and beside the breastbone. The electrical pulse would shoot through the patient’s chest, contracting all the muscles in her body, including her heart. Not at all pleasant, but lifesaving. Abby noted that, unlike almost all the equipment in the hospital, the rarely, if ever, used machine was quite an outdated model.

Her gaze never leaving the overhead cardiac monitor, she did her best to explain the situation to Hazel.

The octogenarian listened with surprising interest and patience. She even asked about what the permanent pacemaker would feel like beneath her skin.

Abby had just started her explanation when the large, regular waves indicating heartbeats vanished. Heart block again. Hazel’s eyelids drifted down.

“Give the atropine!” Abby ordered, again kicking the footstool into place. “Lew, do you know how to use that external pacer?”

“Not really.”

“I do,” Bud said as he injected the cardiac stimulant. “We had an in-service on it a year or so ago.”

“Start it up. Clear, everyone!” Abby called out. “The external pacemaker is being turned on.”

Abby positioned the heel of her hand just above Hazel’s sternum, ready to set it down and pump, just in case the pacemaker failed to produce an effective heartbeat.

“I can’t get this machine working, Dr. Dolan,” Bud said. “I think it’s shorted.”

Her mind racing, Abby set her hands down to begin pumping. Then, as it had before, Hazel’s heartbeat reverted
to normal. And as before, in seconds, the woman was wide-awake and completely unaware she had passed out.

“Have we reached the cardiologist?”

“It’s Dr. Price,” the head nurse said. “He’s not in-house. We’ve paged him, but no answer yet.”

“Doctor, I’m still waiting for you to fix my arm,” Hazel said.

“Soon,” Abby replied. “You had another one of those spells.”

“I didn’t feel anything.”

“I know.”

Abby told the nurse to keep a steady eye on the monitor and have more atropine and another drug, Isuprel, ready. Then she motioned Lew to one corner of the room.

“I don’t think we should be relying solely on the atropine or Isuprel.”

“Agreed.”

“How many pacemakers have you inserted?”

“One, a few years ago. You?”

“Same. I’ve always had cardiologists around. Well, that’s two between us, and I don’t feel like standing around waiting for disaster to strike.”