Sleight of Hand (11 page)

"Figured you're the only one not actually doing any real work around here so you had time to tackle a tough case like that.  By the way, I just got back from seeing your girlfriend," Spanos told him, a sneer twisting his mouth.  "Guess she learned better than to try to do a cop's job."

Drake narrowed his eyes at the patrolman.  "What are you talking about?"

"You haven't heard?  Me and Johnson took this crackhead over to Three Rivers, and he got hold of a nurse.  Hart went in and almost got herself killed."

"Is she all right?"  Drake felt his fists clench even as he fought to keep his voice level.  "What was she doing in the middle of a hostage situation?  Why didn't you follow procedure?"  

Spanos shrugged as if they were talking about the weather.   "Hart's fine.  She pulled rank–said it was her ER and she knew what she was doing.  What was I supposed to do, shoot her?"  

"You were supposed to do your job!" Drake started toward the door.  

As much as he disliked Spanos, he felt certain that the patrolman was telling the truth–it was exactly what Hart would do.  Rush in, not think twice about the consequences or the fact that someone else might be better equipped to do the job.  Why could she never learn to stand back and observe from the sidelines where she'd be safely out of harm's way?  It was just like last time, just like before.  Sooner or later, someone was going to get hurt. 

"At least I'm allowed on the streets with a gun," Spanos shouted at his back.

Drake slammed the door behind him, tried not to flinch at the sound that reverberated through his memory like a gunshot.

CHAPTER 9

Cassie pulled her yellow Tyvek trauma gown closer around her, shading her eyes from the bright April sun.  She heard the ambulance before she could see it.  The constant howl of the siren was  punctuated by a screech of brakes and scream of a horn as they reached the intersection.  Med Five was bringing in an unresponsive child, Code Three, no other report given.

The guys working Med Five were good; time-tempered pros who'd seen the worst the streets of Pittsburgh could offer.  If they were too busy to call in report, there was reason for her to worry.

Time to rock and roll.  

The squad pulled into the Emergency Department's drive and quickly backed up.  Cassie already had her staff preparing the resuscitation room, but she preferred to meet critical patients herself.  It gave her precious extra seconds to assess her patient.

When Med Five stopped moving, Cassie rushed forward to open one of the rear doors.  "Glad to see you, doc," the medic said, jumping down and pulling the gurney forward.  

"What've you got?" 

"Three year old, healthy until Sunday when he complained of cold symptoms, ear ache and low grade fever.  Developed progressive fever and vomiting.  Today was unable to retain any fluids.  Mother found him unresponsive this afternoon.  Responds only to pain for us, went apneic in route, so we started to bag him."  He gave her the bullet as they hurried down the corridor into the critical care room.

She focused on her patient.  A skinny little boy, his pulses weak, abdomen distended from the oxygen forced down his throat, eyes wide open but not focusing on anything. 

"Let's move him, gently now," she instructed her team.  "Set up for intubation, five-oh ET tube.  Two of Versed and give him two grams of ceftriaxone."  

Cassie assessed her patient from head to toe.  His neck was rigid, his pupils sluggish but equal.  Other than the abnormal vital signs, the only other finding was a ruptured right ear drum with purulent material coming from it.

"Foley, monitor, he'll need a head CT.  Let's draw a CBC, blood culture, lytes, glucose and call for a chest X-ray.  Who's on for Peds today?"

"Sterling again."

Oh great.  Another chance to irritate the patronizing department head.  Well, she wasn't going to give him anything to complain about with this resuscitation.  "Call him."

She moved to the head of the bed and prepared to insert the endotracheal tube.  Cassie hated it when kids were this sick–it just didn't seem natural.  He was a cute kid, too.  

Then she looked again and realized she recognized him.  Antwan was his name.  He had smiled when she gave him a sticker yesterday morning.  He'd been her first patient of her first shift back.  

Could she have missed something?  Her stomach dropped as she remembered Adeena's warning that she wasn't in any shape to be caring for patients.  

Cassie glanced away, trying to regain her perspective, to slow her racing thoughts.  Focus.  She raised the bent metal blade that would hold Antwan's tongue out of the way while she intubated him.  Before she could proceed, a banshee's wail came from the hall.

"Antwan!" a thin woman in her early twenties screamed as she rushed in.  "My baby!"  She tried to go to her son, but Jason, the ward clerk, intercepted her.

"Please, Mrs. Washington, you have to let the doctors work on him."  He tried to gently move her from the room, but she refused to leave.

"Mrs. Washington, Antwan is very ill.  We're doing everything we can for him, but we need a few minutes before you can see him.  Go with Jason down to the family room, and we'll let you see him as soon as possible."  Cassie tried to make her voice as firm and level as possible.

"My baby, take care of my baby," the mother sobbed, but she allowed Jason to move her.  

"I'll call social services," Jason said over his shoulder.

Cassie merely nodded, she didn't have time for anything else.  She quickly pulled the oxygen mask off Antwan's face and inserted the metal blade.  Cassie held her breath.  It wasn't as easy as it looked on TV, especially in kids.  They tended to have big tonsils that could bleed easily.  And lots of secretions, like now.  

"Suction," she called.  She cleared the mucus from Antwan's airway and his vocal cords popped into view.  Cassie slid the silastic tube through them into his trachea.  The respiratory tech secured it  and took over ventilating him.

"Get a gas in five minutes," Cassie ordered.  She glanced up at the monitor.  Heart rate was up, blood pressure was down, all good signs.  She checked his pupils again, much more reactive now.  "Did he get the antibiotics?" 

Rachel nodded.  "And CT is ready anytime you are."

"Let's get a chest X-ray first.  I'll go talk to the mom, let me know when that's back."

Cassie moved down the hall to the family room.  She paused before entering, trying to squelch the churning in her gut.  What had gone wrong?  Why had this happened?  When she'd seen Antwan on Monday morning, he'd been a happy boy with a cold and ear infection.  How could he be lying in her ER now, fighting for his life?

She took a deep breath and pushed the door open.  The family room was a tiny, claustrophobic space containing four chairs, their upholstery peppered with cigarette burns, and a telephone.  There wasn't enough room to pace, but this forced people to sit while speaking with staff–a simple intervention designed to prevent violent outbursts.  The room was sound-proofed, to give grieving family privacy, but there was also an emergency panic button tied directly to security.  You never knew what might happen in here where circumstances forced people to the extremes of emotion.  

Over the years Cassie had noticed that no matter what the outcome for the patient, there were always two dominant emotions in their family members: guilt and anger.

Adeena was already there, trying to calm Mrs. Washington.  Both women looked up when Cassie entered.

"Is my boy okay?" Mrs. Washington asked, her voice strained and cracking with tears.

Cassie pulled a chair close to the mother and reached over to touch her hand.  Mrs. Washington was young, but her face had a pinched, guarded look that told Cassie that she'd already been through a lot.  

"Antwan is very, very sick," Cassie started.  "I think he has a serious infection called meningitis.  It's an infection of the tissue around the brain, and sometimes the brain can swell because of it.  This can be very dangerous."

"Is he going to be all right?"

"The next few days will tell. One way to treat the brain swelling is to put a tube into Antwan's lungs and breathe for him, so that he doesn't have to work so hard.  That's what I just finished doing.  We're going to take a CAT scan to look at his brain and then he'll be going to the Pediatric ICU."

"Is he brain damaged?" Mrs. Washington gasped.

"I don't know.  I can't answer that yet."  Cassie paused to see if the mother had any other questions.  She hesitated to ask about what was on her mind.  The lawyers would surely advise her not to, but she had to know.  "Mrs. Washington, do you remember me from yesterday?  I saw Antwan for his earache."

Mrs. Washington looked at Cassie, then nodded.  "Yeah, you gave him medicine and a Sponge Bob sticker."

"Did Antwan take his medicine?  It was called Augmentin, he was supposed to take it twice a day and see his doctor if he wasn't better."

The mother looked at Cassie and then Adeena, her eyes filling once more with tears.  She bowed her head so that Cassie could barely make out her next words.  

"I couldn't afford it," she whispered.  "I made his appointment at the clinic, but their first opening was in two weeks.  He felt better after that ibu medicine that you gave him.  I gave that every eight hours, just like you said, until he started to throw up."  She looked back at Cassie, her eyes pleading for understanding.  "What else was I supposed to do?"

Cassie wished she had the words to comfort the mother.  She grasped Mrs. Washington's hand, noticing that the woman had no wedding band and that her hand was roughened and calloused.   What could she say to this hardworking mother who made too much money to qualify for free care, but too little to afford a two hundred dollar prescription?

"I'm going to check on Antwan," she said.  "Then we'll try to get you down to see him, okay?"

The mother nodded, wiping her tears with a torn tissue.

Cassie returned to the critical care room.  Karl Sterling was there, completing his assessment of Antwan.  She told him what she'd learned from Mrs. Washington.

"I'll pull the chart from Monday for you," she finished.

Sterling tapped his pen against the X-ray view box.  Antwan's chest looked fine, but Sterling continued tapping an irritating rhythm, scowling into space.  It was obvious that Karl Sterling was not happy with this case.

"CT is ready," she reminded him.  "I'll go get the mom, so she can go up with you."

Sterling turned his gaze onto her.  "I really don't want to see the mother right now," he said in a tight voice.  "I'll have Adeena notify CYS when we get upstairs."

"Children and Youth?  Dr. Sterling, this mother loves her child, she never meant to harm him."

The department head sighed.  "Cases like this make my job as a pediatrician very difficult, Dr. Hart.  But no good comes of ignoring the situation.  You know the law as well as I do.  Any suspected case of abuse or neglect must be reported.  It's not up to us to decide anything–but in my mind this is a clear-cut case of medical neglect."

"At least talk to the mom before you decide.  She was doing the best that she could."

"Well, that wasn't good enough, was it?" He gestured to the comatose child on the gurney.  "It's my duty to protect that child, whatever the consequences for the adults involved.  And if I were you, I'd prepare for a lawsuit.  After all, you did see him yesterday."

Cassie glared at the pediatrician.  "What are you trying to imply?  He was fine–just a cold and an ear infection.  No signs of meningitis."

Sterling shook his head in disbelief.  "You really are naive, aren't you?  Believe me, I've seen cases like this before.  You should thank me for calling CYS.  If they find the mother guilty of neglect, it will take you off  the hook."

"I'm not on the hook, I did nothing wrong.  And that's no reason to threaten a mother with taking her child away.  Dr. Sterling, don't rush into this–"

"I'm taking my patient up to CAT scan now.  Your services are no longer necessary, Dr. Hart.  Thank you."  With an imperious wave of his hand, Sterling led the way from the room.

Cassie watched as the nurses pushed the gurney out the door.  She balled her fists in frustration, clamping her teeth together to avoid screaming. There was nothing more she could do.  Sterling had his mind made up and nothing she said would change it.  She blew her breath out.  She'd talk to Adeena, she'd know how to handle it.  

She opened the door, never noticing the chaos that swirled outside of the now silent critical care room.  It all seemed ordinary to Cassie. 

Drake parked the Intrepid in one of the restricted spaces in front of the ER entrance.  He ignored the security guard as he stalked through the ambulance bay and into the tile-walled corridors that framed Hart's world.  

An old man dragged his IV pole with one hand and held his gown closed with the other as he shuffled down the hall.  In the curtained alcove beside the nurses' station a college-aged  girl vomited into an emesis basin as a friend held her hair back from her face.  Clorox and Betadine fought to overcome the smell of dried blood, vomit and urine–one of the never ending battles fought on this ground.

He ignored all this, his vision tunneled to a form about five-four and slight of build, not looking left or right until his gaze locked onto Hart.  She was leaving one of the resuscitation rooms, her gait heavy and slow compared to her normal rapid stride.  One hand pulled her hair back out of her face, the barrette that restrained it long lost.  She froze when she saw him, hand still tangled in her hair, mouth open like a small child caught in a forbidden act.

Drake inhaled deeply, imprinting the image on his mind–he would paint it later, he was certain–and moved to her.  He took her arm, pulled her past the gawkers at the nurses' station and into her office, closing the door behind him.

"What the hell do you think you're doing?" she flared before he could say anything.  Her eyes blazed as her unfettered hair fell around her shoulders.  "Get out of my way, I've work to do.  I'll deal with you later."