Lie Still (32 page)

Now that’s down-home.

A few weeks ago I was back in the Hoacham ER, seemingly condemned to relive a key clinical part of my story.

That weekend Hoacham was the Scenic Hub of Asthma and
its nasty little cousins. In the span of twenty-four hours I admitted to the hospital three little ones with unrepentant
wheezing.

The worst off was a baby of eight months, never before
sick but that night unable to adequately exhale. Probably set
off by a common virus, but in his body, life-threatening. We
gave heavy doses of nebulized inhaled drugs and crossed
our collective fingers. In an hour he was worse.

Never having actually given an epinephrine shot myself, I
asked the nurse to let me watch her do it. She was amused.

I did not bring up my experience in Glory.

When he continued to deteriorate I knew he needed to
be on a ventilator and flown to Lincoln. I knew he needed
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chemical paralysis. I looked up my med choices in a text,
chose one that would last long enough for a lengthy flight,
got him drugged and intubated, and the helicopter came
and rescued us all. As he sailed into the night I kept thinking how simple a sub-Q shot of adrenaline really is. I bet
in the old days Dad gave them all the time.

H E N RY RO J E L I O , DAY F O U R

Arriving home from my early hours with Miss Robin, I stumbled directly into bed and did not wake up until almost eleven. Despite rising to unresolved career trouble and finding the mailbox holding only the usual solicitations and bills—the Daily Disappointment—I felt the midnight beginning of Henry, Day Four, might turn out to be a gold-star harbinger of things to come. I hadn’t the faintest niggling that the whole encounter was more or less than it seemed.

I went to a downtown park for a pickup basketball game, then home for a shower and something canned for lunch. In the middle of the meal, as I was trying to relive certain moments from our “date,” I realized I’d left my jacket at Robin’s house with my notes about Henry’s code and billing records from the Scottsdale ER tucked into the inner pocket. The perfect pretense to call too soon. I caught her by phone just as she was leaving for her meeting with Sally Marquam.

“Hi, you sweet thing,” I said.

“Oh. Look, I’m running out the door. You know: The Meeting.”

I explained about the jacket.

“Yeah,” she said, all business, “it’s on the couch.”

“If you could bring it with you to the hospital, I can get it then. I’ve got a four o’clock meeting with those same folks.

Actually, though, I’d prefer to take you out to a late dinner after your shift.”

“Mmm. I’d love to but I can’t. Best thing would be for you to come by and get it sometime. There’s a key on top of the LIE STILL

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outside light on the wall over the front terrace. You walk by the terrace coming to the front door. Just step over the rail.”

“When will you be home?”

“Oh, any time. Just come by.”

“If I’m letting myself in, what will the neighbors think?”

“They would call the police, so you better be quick.”

“Should I have waited a day or two before asking for a date? You know, be a little harder to get?”

She laughed. “I’d have been heartbroken.”

“But you might have said yes.”

There was a pause. “Call me soon.” She hung up.

From that inauspicious start, Day Four really went south.

At three-thirty I drove back out to Glory, moderately deflated over Robin’s deflection of my date request, trying to re-inflate myself by imagining her acceptance of the next invitation and where that might lead.

Glory was an odd town. It sprang from nothingness in the 1880s as the hub for the three copper mines in the nearby mountains. When the ore ran thin, though, the only things the mine companies left behind were tailings—mountainous piles of ugly, sterile dirt and rock, as if whale-sized moles had run amok. The town shriveled.

Glory was resuscitated a decade before my arrival. Ultra-cheap land just over the hills from Phoenician sprawl and a developer’s whispered-to-be-corrupt permission to tap into a cross-desert water conduit had turned the key. Laws were ignored. Fortunes were made.

With putting greens green, tennis courts hosed off, and swimming pools sufficiently chilled, the “culture” of leisure moved in on top of the old tailings. My patient population there was a mix of the over-sunned, over-jeweled wives of the over-leisured, concerned about the pain and swelling under the new face-lift, and farm workers who brought to the ER their sore throats and sore backs because they had no other doctor to see.

Ten minutes late for my appointment with Sally Marquam, I pilfered a cookie and coffee from the doctors’

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lounge. I thought I was going there for a friendly review of a bad case. Even when outcomes are horrible, all the partic-ipants usually line up on the same side. As I searched out the administrative wing I asked myself how Dad would handle this. He would stand erect, speak carefully and accurately, disparage no one, and invariably be right. Being old school, he would also be better dressed than I was.

From the first open door I passed, a female voice called,

“Come in, Dr. Ishmail. Please have a seat. I’ll let her know you’re here.” Evidently the woman was Ms. Marquam’s assistant. I did not know her, though she seemed to know me.

She said, “I’m Valerie.”

I sat in her anteroom. “Hi. I’m Malcolm.” I smiled weakly in her direction. She was young, busty, and blonde with impossibly long fingernails painted meat red to match her ear-rings and necklace. She smiled back. I rubbed my eyes, then spread an arm in each direction along the back of the couch and rested my head backward against a concrete planter.

With my vision contained on either side by a small palm plant, I closed my eyes, trying to conjure a vision of Robin’s breasts, ignoring the silicone.

“Are you asleep?” There was a pause, then again, “Are you asleep, Dr. Ishmail?”

I saw ceiling and palms, just as before, blinked a few times, then lifted my dead-weight head. Through the blur I could see standing sideways in front of me a female, half bent over at the waist, one hand still pointing to where she had touched my knee to waken me.

“I guess I must have dozed off,” I said as I pulled my arms into my lap and stretched my neck to either side. “Too many long nights lately.”

“So I understand. Please step this way, into my office. I’m sorry to have kept you waiting,” she said over her shoulder.

The office door said “S. J. Marquam, Vice-President.”

“I don’t want to be curt, but they’ve had me booked rather tight all day. I’ve still got a lot of people to see—

please go on in and sit down—mostly about this incident of the other night.” She called to her assistant.

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I sat in an armchair by the only window. With my eyeballs clear I got a better look: Ms. Marquam was probably in her early thirties, just under six feet, trim, wearing lightweight flannel and gold-rimmed eyeglasses and good-looking in a handsome way. Valerie, as her backup, sat cross-legged, notepad in hand.

Ms. Marquam laid out the objective—get it down in detail while memories were freshest. She said, “Sometimes something like this will generate a lawsuit years after the fact, and it’s best to have as much detail written down as possible.”

“Yes, and whatever I say can and will be used against me,” I said.

“Actually, not so. This is done as part of the hospital’s quality assurance process and is protected under state statute from discovery in court. The law protects formal quality improvement work from being used in lawsuits. They made it that way to encourage people like us to speak freely when problems arise.” She looked at me. “You will speak freely?”

“Of course. There isn’t anything to hide. Nobody did anything wrong. There wasn’t any malpractice.”

“I’m sure that’s true, but that does not prevent lawsuits.

We may need to prove it, in other words. Why don’t you just tell us what happened, in narrative, then we can go back over specific issues.”

I sat back in the big chair and closed my eyes. I was tired.

“Henry Rojelio. Thirteen-year-old kid. Apparently crazy, but probably pretty normal physiologically—except for his asthma. Came in with a wheeze. Doesn’t seem to want to use his inhalers. Apparently prefers the ER. Some people like ERs. Dad brought him in, dropped him off, disappeared.”

Sally began to interrupt me but stopped herself. She took a sheet of paper from Valerie’s pad and scribbled something, then nodded to me.

I went on to detail my encounter with Henry and his crooked penis and our one go-round with a neb. “He told Robin he wanted sub-Q epi. He seemed to think that was what he had come in for, and he seemed to know all the rest 242

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was a waste of time. She suggested we jump to that. I mean, we could have tried more nebs or continuous nebs or changed to a different drug in the inhaler, but they all do pretty much the same thing. I checked his chart. He’d gotten good results with epi each of the two visits I checked on, so it seemed like a good idea to sort of jump to the end, especially if we knew it worked and he had tolerated it well before.”

Sally wrote again. Then she said, “Go on.”

“I told her to go ahead.”

“Who?”

“The nurse. Robin.”

“Did you write it out? The order?”

“No, I don’t think I did. Verbal order.” She wrote again. “I think I was on the phone.” I waited. She looked up. I went on. “Next thing I know, Robin says he’s turning blue, and all hell broke loose.”

Another pause. “That’s it?”

“Pretty much.”

“Could you explain about the code?”

“Well, not much to explain. He was in full arrest—we ran a code. Took a while but we got him back.”

“You thought things went pretty well?”

I hesitated. “I guess you can’t say things ever go well at a code. That would be like saying you had a really nice funeral. But the procedural stuff went okay. They got a line right away. The drugs went in. I got him intubated.” I waited, but they were just looking at me. “He eventually responded.

In fact, we were about to quit. It had gone on too long. We tried one last round of drugs and that time they worked.” She reached over toward Valerie, who handed her several photocopies in a stack. She flipped two pages.

“Doctor, these are copies of the ER record and the code sheet. The originals, of course, are in the locked file.” I nodded. “The nurse’s notes on the code sheet are fairly unremarkable. Who was the recording nurse again?” she asked Valerie.

“Dianne Tonneson.”

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“Right. Miss Tonneson wrote in times and drugs and over here in the Comments column in several places she wrote ‘EKG—asystole,’ then ‘EKG—fib,’ then ‘shock times two,’ then ‘sinus tach.’ That sort of thing.” She handed me the copies. “Look that over and see if that’s how you remember it.”

I read the drugs, times, comments. I shrugged. “It seems right. I mean, that’s why we have someone at codes who does nothing but take notes. You can’t remember all the details afterward.”

“I’m sure.” She leaned forward and pointed to the bottom of the page with her pen. “Read the next page.”

I flipped it over. Stapled to the code sheet was a copy of a note originally entered on a blank page as an “Adden-dum to Code Sheet.” The date was identical, but the time would have been an hour or so after Henry’s ambulance had left Glory. It was in a different hand from the notes of the recording nurse. Heavier. Swirly and loopy. “Informed Dr. Ishmail of arrest at 2055. Slow to respond. In face of cyanotic patient appeared uncertain how to proceed. I suggested Code 99. Dr. Ishmail had trouble intubating patient. Refused DC countershock. Note also, he ignored my question during asthma treatment about advisability of epinephrine in boy already on Ritalin. R.B.”

I felt my face burning. I felt what was left of my career being skewered. I felt like the flesh was falling off my bones. I closed my eyes. I tilted my head toward the ceiling.

When I opened my eyes Sally was watching me. She said,

“The initials R.B. refer to Robin Benoit, the nurse who was caring for Henry. That was her chart entry, her writing, her initials.” I stared. “I think you can see why I need your version of the events in greater detail,” she said.

I leaned forward, breathing heavily, struggling to restrain myself. I closed and opened my hands and bit my lip, replaying our night, looking for clues. I loosened my jaw barely enough to speak. “No one writes that in a patient chart. No one. I mean, it’s an engraved invitation to a lawyer to take your firstborn son.” They stared at me. “Christ, I’ve 244

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known of doctors practically killing people and no one will even talk about it, much less put it in writing. Forget about putting it in a legal document.”

“I am sorry to have to go through this with you, Dr. Ishmail, but it is for your protection as well as the hospital’s.

Who is your malpractice carrier?”

“Um, Twentieth Century Casualty, I think. It’s through the ER group.” She was calming me by getting me back to an-swerable questions.

“You’ll probably want to contact them soon and get them involved, too. I imagine they’ll want you to create a report just like this one, but they probably have a specific form you would need to put it in, like a letter to an attorney.”

“Yes, I’d better be calling them.”

“But let us try to get your accounting of the code.”

“Absolutely.”

“She writes first that you were slow to respond.”

“Oh Jesus,” I said. I took a deep breath. “That could mean anything. If I saw that in a chart I would probably figure the doc was on the golf course or getting laid in the call room and ambled in an hour after the call.”

“That might be one version.”

“I was sitting right there. At the charting desk in the ER.”