Lethal Practice (16 page)

Nevertheless, I put Muffy on her leash to keep her near me until I made sure no one was still hanging around.
We
stepped outside. It was frosty, but the footprints disappeared where the graveled parking area ended, and the darker cinder road had already melted the snow. Muffy showed little interest. The hard surface refused to even hint where the intruder had headed. I shivered, this time because I was still in a robe and slippers. I let Muffy off her chain. Me, I needed the warmth of indoor plumbing.

* * * *

I refused to let my paranoia chase me back into the city after coming all the way out here to work.

Besides, the respite offered by working on the QA data for the next three hours was the only remedy I had at the moment for my paranoia.

Carole had saved me days by entering the data for our major diagnostic categories on a floppy disk. It was pretty routine stuff, and if I needed anything more esoteric, I could still refer to the original printouts.

Studies of lawsuits had identified that two-thirds of screw-ups came from six types of problems: chest pain, abdominal pain, missed fractures, nerve injuries, intra-cranial bleeds, and meningitis. Knowing where to look before going in always makes the odds better to find our flaws and to learn.

These major categories were behaving as they should. The classic—chest pain—presented about a hundred and twenty times a week. In this group, only four, statistically and on average, would be real heart attacks, but the trick was to know which four, and which weeks were not average. Sixty would be cleared right off, and be sent home with acetaminophen for sore muscles or antacids for indigestion. But in the remaining sixty, there would be four heart attacks and four unstable anginas about to become heart attacks, statistically speaking. To find one MI, it takes a workup on fifteen suspicious chest pains, according to studies on centers that get it right ninety-five percent of the time.

Out of more than two hundred proven MIs, we had mistakenly sent home only five in the last year. One died at home. The other four, each feeling increasingly worse after discharge from the ER, had made it back to our door. One arrested in the hallway and failed to respond. The other three had survived.

Each case was a different physician. The chart review had revealed an error in judgment, not negligence, in all five cases. Statistically, this was all acceptable. Individually, I felt pretty disgusted knowing we probably would miss another five this year.

Abdominal pain shaped up miserably, as expected. Our initial diagnoses were wrong, or right, fifty percent of the time. This was a national average no one seemed able to better. It just was a reality that initial presentations of abdominal pain were hard to pinpoint and required repeated reassessments and follow-up to finally nail the problem. Knowing this, we could act with appropriate care. Two physician numbers popped out of the norm here. I had no idea who; a code kept identities unknown in the raw data prepared by medical records and submitted to the state health department. An individual physician’s performance would then be known only to that doctor and myself, after I analyzed the statistics.

While one doctor had been correct in diagnosing appendicitis one hundred percent of the time, another was only sixty percent accurate. The first physician was actually the more dangerous of the two. Every patient this doctor had diagnosed as a possible acute appendicitis actually had an acutely inflamed appendix when they were opened. That pattern meant only the most obvious cases had been diagnosed and the subtler presentations had been sent home. In a good center where appendicitis was not usually missed, a competent surgeon would usually have to open five bellies to find four acute appendixes, and would take out a perfectly normal appendix twenty percent of the time. The doctor whose initial diagnosis was always right had not been referring enough patients to surgery. Sure enough, further down in the study, this same physician had a disproportionately high number of unscheduled return visits with a ruptured appendix attributed to his or her code number.

The second doctor was calling everything acute appendicitis. As a result, he, or she, wasted time, tests, and money, and had subjected too many patients to the dangers of unnecessary surgery. Of course, an overeager surgeon was partly to blame here too.

I also noted another problem. Too often the diagnosis for abdominal pain was constipation. Repeatedly, I’d stressed to staff and residents that constipation was a symptom and not a diagnosis. It could be caused by anything from colon cancer to not enough fiber in the diet and, if it was unusual for the patient, indicated the need for further investigation in a follow-up exam. Obviously, the message bore repeating.

And so it went—injuries and deaths caused by our mistakes and errors dulled to the dry stuff of tables and numbers. Even then, whatever harm we did was statistically rare enough that we were no worse than physicians in other ERs. In other words, as long as we screwed up within national norms, we could claim enough competence to still go out there and perform.

And occasionally, just as rarely, we achieved those elusive miracles. Still, I was as depressed as I was fascinated. Looking at a year of our cumulative mistakes had a sobering effect on me. Until I broke the code, I didn’t even know my own performance. Maybe I was the one sending home the acute appendixes.

It was ten o’clock when I shut down and got ready to leave for the city. I’d gotten barely a third of the way through the main groupings of possible errors.

Outside, I welcomed the frost to clear my head. At least I’d kept myself from feeling afraid for a while. I’d grabbed an apple for a late breakfast and balanced a final cup of coffee on the way out to my car. The footprints had vanished to a glistening varnish on the stone walkway. It was still cold enough that the lawn and surrounding forest floor had stayed white.

I got Muffy into the car, and we headed down the mountain and back toward Buffalo. The prettiness was lost, however, as I started to dwell on those footprints again, and inevitably Kingsly’s murder. Even in a hospital where death was common, the grisly killing sickened me. Maybe it was a delayed reaction, postponed like so many other emotions in a doctor’s life by all the practical coping we’re forced to do. More likely, I’d been trying to deny another question I feared, but Bufort’s dressing-down had finally shamed me into facing it. I could still visualize Kingsly’s pathetic body, as dissolute in death as was his life. Would his fate have been different if I’d tried to help him? My mood became even more morbid as I swung through shrouds of mist so thick, the wipers had to part the droplets left by them on the windshield. Other memories of death crowded in uninvited like silent accusers in the fog. I remembered two little girls and their dead father. I shook my head and tried to drive away the unwelcome visions.

The practice of medicine could rip your heart out. Most people can mercifully ignore the parade of terrors happening to others and trust that the odds will keep such horrors away from them. But our job is closer to the front, and we see every day the ways life can go horribly wrong and sink into pain and death. Some days I can’t keep the images of it all out of my head. And sometimes it makes me think the worst.

I thought again of the footprints. Despite my previous dismissal of their relationship with Kingsly, I now felt a lot less glib here in the fog than I had in the clear beauty of the mountains. Because there was yet another possibility. If the killer feared exposure from me, then I might very well be a target. Had the menace really faded with the melted snow? Or had those prints marked the approaching steps of my own turn with a murderer?

* * * *

It was less misty by the time I’d reentered the outskirts of Buffalo. There was no vestige of snow here, just gray sludge. The prenoon traffic rescued me from dwelling any further on the darker thoughts I’d had on the way in. I flicked the radio to a traffic report; bad everywhere. I listened to a weatherman assure me this was the worst November in ten years for consecutive days without

sunshine. He proceeded to interview three experts who argued with one another over the cause. They couldn’t agree on global warming, pollution, or rogue volcanoes, but all of them predicted tomorrow would be more heavily overcast than today and warned that record smog levels would make breathing difficult for people with lung conditions. Janis Joplin then rendered a little bit of therapy with “Me and Bobby McGee.”

When I finally got to hear the news, Kingsly’s murder was the lead story. It was brief, contained little more than the essential facts, and said nothing about a cardiac needle. There was a brief statement by Hurst assuring the public that the tragedy in no way compromised St. Paul’s capacity to give proper care to its patients.

I drove directly to my private office beside the hospital. The patients that I’d kept in my general practice put up with the crazy demands on my time that went with becoming chief of the ER. At least they had me where it mattered for emergencies, if I wasn’t in some damn meeting. More than this, I’d known them so long, many had become friends.

Muffy wasn’t thrilled at being left in the car. I’d call geriatrics and see if they wanted some pet therapy that morning.

It was 11:55 when I entered the quiet of my still-empty waiting room. Barbara O’Hara, semiretired, a grandmother, and previously secretary to a half dozen former chiefs, was my receptionist here. It was her judgment and interest in the patients that let me be away so much. She looked up from her crossword.

“Coffee? Or messages first?”

“Coffee, please, and good morning to you too.”

“Good, because your first appointment isn’t until twelve-fifteen, and I want to hear about Kingsly.”

I hadn’t seen her since the murder and had forgotten that among the many regimes she’d marshaled, she’d had a short stint as Kingsly’s secretary. When he put a move on her, she quit.

I settled into a chair with the cup warming my hands and gave her only what I had seen on the night he was found and later at the autopsy table. I left out my own speculations about Hurst and Gil Fernandez, but when I described how Bufort was starting to focus on the ER physicians, she stopped me with a question.

“What about you? Do you think someone in your own department did it?”

Right to the center of what I’d been avoiding. But my instinctive answer came without hesitation. “No. I don’t, and talking to you now, I just realized why.”

“You mean besides your not wanting to believe it?”

She was one cagey grandmother. “Yeah.” I smiled a little sheepishly. “I mean, Bufort is focused on who had the means, the skills to accomplish the killing, but not on who had the motive. I neither know of nor can imagine any connection between Kingsly and one of my staff that could be a motive for killing him. Until someone finds that link, if it exists, then the fact that we can all needle hearts doesn’t amount to much.”

She thought for a moment and then commented. “I bet it was one of the women he molested, because it’s what I would have done, with anything handy, if he had actually tried to force me into sex that night he came at me.”

It was after that encounter that she had come and offered to work for me. She was way overqualified, and I needed someone only part-time, but she’d had it with the seediness of hospital politics and a lifetime of keeping its secrets. Working for me freed her for her husband, garden, and grandchildren. Yet now her voice had a steel in it I’d never heard before, but it left no doubt. If Kingsly had stirred such fury in this gentlewoman’s soul, the list of possible killers could have gotten a lot longer.

Except that secretaries and cleaning women didn’t know how to use cardiac needles.

“You know, Mrs. O’Hara, it’s exactly what I thought at first. But the autopsy didn’t show he’d been stabbed blindly by someone trying to keep him from attacking. It was done by someone with the knowledge and skill to needle a heart.”

She looked a little surprised, then thoughtful, and was about to say something when my first patient arrived.

General practice is the minutia of medicine. Blood pressure checks, controlling angina, healing ulcers, managing pain, consoling, comforting, and above all listening. It’s the opposite of attempts to save a life in a matter of minutes. In general practice, patients’ stories are told at the pace of life unfolding. The visits and checkups over the years slowly reveal more than sickness and health.

I marveled at the courage, humor, and toughness of some of my patients who had survived great losses and yet managed to have fun between the disasters. Calamities hit everyone, but these special few showed me that escaping from a life of melancholy to a world of laughter and friends was sometimes a matter of choice. Even the uneventful lives with no big upheavals were fascinating. Visit by visit, a glimpse at a time, I came to know who lived with vigor and joy and who just moodily endured.

The slow pace of the afternoon was restorative. Who was healer and who was healed blurred. As three o’clock approached, however, the distant howl of ambulance sirens began penetrating the inner calm of my office. Each was a reminder that emergency was still getting hit and I was due back soon. The last patient barely got my attention.

At 3:01 my phone rang. I’d taught our doctors and nurses enough that emergency could solve its own problems and leave me uninterrupted when I was at my private office two times a week. Today the deal ended at three. “You on your way?” Susanne asked. No effort wasted; no need to identify herself.

“Nah! I got tickets to Cuba instead.”

“Must be the same flight I’m on. See you.”

* * * *

Ten seconds in the place and I wanted to resign. Stretchers ran double down both sides of the hall. I could barely pass. The stench of body dirt had trebled since the day before, and the noise was worse. There was nothing I could even pretend to do, and it scared me. Waiting relatives were looking at me with the expectancy that here was someone, finally, who was in charge and could allay their fears.

“Holy shit!” was all I could say. It wasn’t Churchillian.