Life Support (13 page)

"Okay. Okay." Applying pressure to the groin puncture, Toby took a deep breath and allowed herself a precious moment to review the situation.

They had a patent airway, a heart rhythm, and an adequate blood pressure. They were doing all right. Now she could address the question, Why had the patient coded?

"You said he was seizing before he lost his blood pressure?" she asked.

A nurse answered, "I'm pretty sure it was a seizure. I found him on my ten o'clock med rounds. His arm was jerking and he was unresponsive. We have a standing order to give him IV Valium as needed, and I was getting the dose ready when he stopped breathing."

"IV Valium? Did Wallenberg order that?"

"For the seizures."

"How many has he had?"

"Since he was admitted? Maybe six. About once a day. It's usually his right arm that's affected. He's been having trouble with his balance, too."

Toby frowned at the patient. She had a sudden, vivid memory of Harry Slotkin's jerking leg. "What's their diagnosis? Do they know?"

"He's still being worked up. They've had a neurology consult, but I don't think he's figured out the problem yet."

"He's been here a whole week and they have no idea?"

"Well, nobody's told me." The RN glanced at the other nurses, and they all shook their heads.

They heard Wallenberg's voice before they realized he had walked into the room. "What's the status here?" he said. "Have you got him stabilized?"

Toby turned to face him. As their gazes met, she thought she saw a flash of dismay in his eyes. It was just as quickly gone.

"He was in V. fib," said Toby. "Preceded by a seizure and respiratory arrest. We cardioverted him, and he's now in sinus rhythm.

We're waiting for an ICU bed."

Wallenberg nodded and automatically reached for the patient's chart.

Was he avoiding her gaze? She watched him flip through the pages and couldn't help envying his unflappability. His elegance. Not a hair out of place, not one unseemly crease in his white coat. Toby, dressed in her usual baggy scrubs, felt like something dragged up from the dirty clothes hamper.

"I understand he's had a number of seizures," said Toby.

"We're not certain they are seizures. The EEG didn't confirm it."

He set down the chart and gazed at the cardiac monitor, where a normal sinus rhythm continued to trace across the oscilloscope. "It looks like everything's under control. I can take over from here, thank you."

"Have you ruled out toxins? Infectious agents?"

"We've had a neurology consult."

"Has he looked specifically for those things?"

Wallenberg shot her a puzzled look. "Why?"

"Because Harry Slotkin presented in exactly the same way. He had focal seizures. Acute onset of confusion�"

"Confusion, unfortunately, is something that happens in this age group.

I hardly think it's something you can catch like the common cold."

"But they both lived at Brant Hill. They both presented with the same clinical picture. Maybe there's a common toxin involved."

"Which toxin? Can you be specific?"

"No, but a neurologist might be able to narrow it down."

"We have a neurologist on the case."

"Does he have a diagnosis?"

"Do you, Dr. Harper?"

She paused, startled by his hostile tone. She glanced at the nurses, but they studiously avoided her gaze.

"Dr. Harper?" A nurse's aide poked her head in the doorway. "ER's on the line. They have a patient downstairs. Headache."

"Tell them I'll be right down." Toby turned back to Wallenberg, but he had put on his stethoscope, effectively cutting off any further discussion. In frustration, she left the room.

As she descended the stairwell, she kept reminding herself that Angus Parmenter was not her patient, not her concern. Dr. Wallenberg specialized in geriatrics, surely he was better qualified to manage the patient's care than she was.

But she could not stop fretting over it.

For the next eight hours she attended to the usual night-shift parade of ailments, the chest pains and the stomachaches and the babies with fevers. But every so often there would be a lull in the pace and her thoughts would snap right back to Angus Parmenter.

And to Harry Slotkin, who had not yet been found. It had been over three weeks since his disappearance. Last night the temperature had dropped into the thirties, and she had sat up thinking about the cold, had imagined what it would be like to wander naked in that wind. She knew it was just another way of punishing herself. Harry Slotkin was not suffering on that cold night. He was, almost certainly, dead.

At dawn, the ER waiting room finally emptied out, and Toby retreated to the doctor's room. Over the desk was a bookshelf of medical texts. She perused the titles, then pulled out a neurology textbook. In the index, she looked up Confusion. There were over twenty entries, and the different diagnoses included everything from fevers to alcoholic DT's.

She scanned the subheadings, Meta7Volic. Infectious. Degenerative.

Neoplastic. Congenital.

She decided that Confusion was too broad a term, she needed something more specific, a physical sign or a lab test that would point her to the right diagnosis. She remembered Harry Slotkin's leg, thrashing on the gurney. And she remembered what the nurse had said about Mr. Parmenter's jerking arm. Seizures? According to Wallenberg, the EEG had ruled that out.

Toby closed the textbook and rose, groaning, to her feet. She needed to review Mr. Parmenter's chart. There might be some abnormal lab test, some physical finding that had not been pursued.

It was seven o'clock, her shift was finally over.

She rode the elevator to the fourth floor and walked into the ICU.

At the nurses' station seven EKG tracings fluttered across monitor screens.

A nurse sat staring at them as though hypnotized.

"Which bed is Mr. Parmenter in?" asked Toby.

The nurse seemed to shake herself out of her trance. "Parmenter? I don't know that name."

"He was transferred here last night from Three West."

"We didn't get any transfers. We got that MI you sent us from the ERNo , Parmenter was a post-Code Blue."

"Oh, I remember. They canceled that transfer."

"Why?"

"You'd have to ask Three West."

Toby took the stairwell down to the third floor. The nursing station was deserted and the telephone was blinking on hold. She went to the chart rack and scanned the names but couldn't find Parmenter. With mounting frustration, she went up the hall to the patient's room and pushed open the door.

She froze, stunned by what she saw.

Morning light shone through the window, its hard glare focused on the bed where Angus Parmenter lay. His eyes were half open. His face was bluish white, the jaw sagging limply to his chest. All the IVs and monitor lines had been disconnected. He was quite obviously dead.

She heard a door whish open and turned to see a nurse wheeling a medication cart out of the patient's room across the hall. "What happened?" Toby asked her. "When did Mr. Parmenter expire?"

"It was about an hour ago."

"Why wasn't I called for the code?"

"Dr. Wallenberg was here on the ward. He decided not to code him."

"I thought the patient was being moved to the ICU."

"They canceled the transfer. Dr. Wallenberg called the daughter, and they both agreed it didn't make sense to move the patient. Or use extraordinary measures. So they let him go."

It was a decision with which Toby could not argue, Angus Parmenter had been eighty-two years old and comatose for a week, with little hope of recovery.

She had one more question to ask, "Has the family given permission for the autopsy?"

The nurse looked up from her medication cart. "They're not doing an autopsy."

"But there has to be an autopsy."

"The funeral arrangements are all made. The mortuary's coming to pick up the body."

"Where's the chart?"

"The ward clerk's already broken it down. We're just waiting for Dr. Wallenberg to fill out the death certificate."

"So he's still in the hospital?"

"I believe so. He's seeing a consult on the surgery floor."

Toby went straight to the nurses' station. The ward clerk was away from her desk, but she'd left the loose pages from Mr. Parmenter's chart on the countertop. Quickly Toby flipped to the last progress note and read Dr. Wallenberg's final entry.

Family notified. Respirations ceased�nurses unable to detect pulse. On exam, no heartbeat noted on auscultation. Pupils midposition and.fixed.

Pronounced dead 0558.

There was no mention of an autopsy, no speculation about the underlying illness.

The squeak of rolling wheels made her glance up as two hospital orderlies came out of the elevator, pushing a gurney. They wheeled it toward room 341.

"Wait," said Toby. "Are you here for Mr. Parmenter?"

"Yeah."

"Hold on. Don't take him anywhere yet."

"The hearse is already on its way over."

"The body stays where it is. I have to talk to the family."

"But�"

"Just wait" Tolzy picked up the phone and paged Wallenberg to Three West. There was no answer. The orderlies stood waiting in the hallway, glancing at each other, shrugging. Again she picked up the phone and this time she called the patient's daughter, whose number was listed in the chart. It rang six times. She hung up, her frustration now at a boil, and saw that the orderlies had wheeled the gurney into the patient's room.

She ran after them. "I told you, the patient stays."

"Ma'am, we were ordered to pick him up and bring him downstairs."

"There's been a mistake, I know it. Dr. Wallenberg's still in the hospital. Just wait until I can talk to him about this."

"Talk to me about what, Dr. Harper?"

Toby turned. Wallenberg stood in the doorway.

"An autopsy," she said.

He stepped into the room, letting the door slowly whoosh shut behind him. "Are you the one who paged me?"

"Yes. They're taking the body to the mortuary. I told them to wait until you could arrange for the autopsy."

"There's no need for an autopsy."

"You don't know why he coded. You don't know why he became confused."

"A stroke is the most likely cause."

"The CT scan didn't show a stroke."

"The CT may have been done too early. And you wouldn't necessarily see a brain stem infarct."

"You're guessing, Dr. Wallenberg."

"What would you have me do? Order a head scan on a dead patient?"

The orderlies were watching the heated exchange with fascination, their gazes bouncing back and forth. Now the men's eyes were focused on Toby, waiting for her answer.

She said, "Harry Slotkin presented with identical symptoms. Acute onset of confusion and what appeared to be focal seizures.

Both these men lived at Brant Hill. Both of them were previously healthy."

"Men in that age group are prone to strokes."

"But there could be something else going on. Only an autopsy can determine that. Is there some reason you're opposed to one?"

Wallenberg flushed, his anger so apparent Toby almost took a step backward. They eyed each other for a moment, then he seemed to regain his composure.

"There'll be no autopsy," he said, "because the daughter has refused.

And I'm honoring her wishes."

"Maybe she doesn't understand how important this is. If I spoke to her�"

"Don't even think about it, Dr. Harper. You'd be invading her privacy."

He turned to the orderlies, his dominance fully reasserted. "You can bring him downstairs now." He shot a last dismissive glance at Toby, then he left the room.

In silence Toby watched as the orderlies wheeled the gurney toward the bed and braked it in place.

"One, two, three, move."

They slid the corpse onto the gurney and secured it in place with a chest strap. It was not for safety but for aesthetics. Gurneys could be bumped, ramps could be steep, and one didn't want dead bodies accidentally tumbling onto floors. Above the corpse, a false mattress pad was clamped into place, then a long sheet draped over the whole contraption. A casual observer passing it in the hall would think it was merely an empty stretcher.

They wheeled the body out of the room.

Toby stood alone, listening to the receding squeak of the wheels. She thought of what would happen next. Downstairs, in the morgue, there would be paperwork to complete, authorization forms and releases to be signed. Then the deceased would be loaded into a hearse and transported to the mortuary, where the body fluids would be drained and replaced with embalming fluid.

Or would it be a cremation? she wondered. A fiery reduction to carbon ash and trace elements, leaving behind no answers?

This was her last chance to learn Angus Parmenter's diagnosis.

And maybe Harry Slotkin's diagnosis as well. She picked up the phone and once again called the patient's daughter.

This time a voice answered with a soft "Hello?"

"Mrs. Lacy? This is Dr. Harper. We met last week, in the Emergency Room."

"Yes. I remember."

"I'm very sorry about your father. I just learned the news."

The woman gave a sigh, more a sound of weariness than of grief. "We were expecting it, I suppose. And to be perfectly honest, it's something of a . . . well, a relief. That sounds awful. But after a week of watching him . . . Iike that . . ." Again she sighed. "He wouldn't have wanted to live that way."

"Believe me, none of us would." Toby hesitated, searching for the right words. "Mrs. Lacy, I know this is a bad time to talk to you about this, but there's really no other time to do it. Dr. Wallenberg told me you didn't want an autopsy. I understand how hard it is for the family to give permission for something like this. But I really feel, in this case, it's vital. We don't know what your father died of, and it may turn out to be�"

"I didn't object to an autopsy."

"But Dr. Wallenberg said you refused one."

"We never discussed it."

Toby paused. Why did Wallenberg lie to me? She said, "May I have your permission for an autopsy, then?"