Death Rounds (3 page)

The resident hesitantly approached and asked, “Dr. Garnet, what do we do if he discontinues the erythromycin?”

Erythromycin was the treatment of choice for
Legionella.

“Ignore him,” I answered none too quietly. “He’s only a consultant giving an opinion.”

I watched the little man flinch, sign off his brief entry with a flourish of his pen, then rise and start back toward me. He was shaking his head and trying to smile, but it was his turn to look flushed.

“At this stage. Garnet, I think she’s SOL, whatever we do. Our next discussion about her will probably be at Death Rounds, when we’ll have the benefit of an autopsy and not have to endure some cock-and-bull scenario cooked up by you to assuage your own guilt. And by the way, chum, you did miss something yesterday that justified keeping her.” He abruptly wheeled about and walked swiftly toward the exit. As he hit the metal disk that activated the sliding doors, he glanced back at me. His bristly mustache, stocky body, and short legs usually reminded me of a video game character, but there was nothing comic in the triumphant glare he gave me before he stalked from the room.

Looking embarrassed, the resident was tugging at her stethoscope. “Excuse me. Dr. Garnet, but I have to round on the other patients,” she said nervously, then rushed off to one of the cubicles.

I exhaled, trying to release the knot mat was quickly tightening in my stomach again, and forced myself to go over to the desk where Rossit had left the chart. Cursing the little man’s hostility, I quickly reviewed the notes from yesterday’s visit, yet couldn’t find what he’d inferred—and what I’d been dreading—that I’d missed something basic. I was about to dismiss the accusation as a cheap shot when my eye fell on a circled passage in the nurse’s notes.

2
P
.
M
.
Patient discharged home by Dr. Garnet. Reported feeling dizzy on standing but complaint passed when sitting. Patient taken to front door in a wheelchair and helped into a taxi.

Orthostatic dizziness—the nurse should have recognized it was significant and taken the woman’s pressure standing. We would probably have picked up a drop and known she was becoming unstable. At the very least we would have started her on an IV to rehydrate her and observed her vital signs. We would have had her here when she decompensated, and earlier administration of antibiotics would definitely have increased her chances of survival.

Sanders herself must have known the dizziness was of concern. Had she protested, insisting that someone should take her pressure again, but only increased the antagonism of her nurse? Had she been ignored and hustled out the door in a wheelchair?

In any ER, the attitude of the chief sets the tone. Kidding and teasing aside, I knew my staff usually took their lead from me. Even though we’d all found Sanders tiresome, it was up to me to make sure my own attitude and dislike of the woman hadn’t implicitly signaled that the patient was a crock and that her complaints weren’t to be taken seriously.

Rossit was right. I’d missed a key sign of orthostatic hypotension that was clearly there to be found. Worse, I’d probably assured no one else would find it either.

I literally fled from ICU.

Chapter 3

Seeing patients was going to be difficult. As I headed down the stairwell from the third floor, I thought of signing out to Michael until I felt more collected, but the idea of sitting around and dwelling on things unnerved me even more.

When I arrived in ER I took Susanne to a quiet corner and explained what I’d learned. The expression on her face quickly registered the same anxiety I was feeling.

She groaned. “Oh no. Who was the nurse?”

In my confusion upstairs I hadn’t bothered to notice.

“Sorry, but if you go over the chart, her note is now plenty obvious. Rossit was kind enough to circle it.”

“You’re kidding!”

“You know how he is. Nailing the mistakes of others is a blood sport to him, and I’m afraid he can’t wait to wipe the floor with me over this one. The trouble is, in his eagerness to have my hide, he’s likely to smear everyone else in the department who went near Sanders.”

“Chiefs make for especially good hunting, do they?” she asked harshly, obviously angered by the prospect of Rossit’s legendary troublemaking hitting so close to home. “Christ, the man’s a menace. He makes everyone in the hospital want to cover up mistakes instead of learning from them.”

I gave a little laugh. “That’s exactly what some physicians think about my mandatory reviews of unexpected return visits.”

I must have sounded as miserable as I felt.

Her eyes widened in surprise. “Earl Garnet!” she exclaimed. “How can you even think of yourself in the same category as a louse like him. You’re fair in those reviews, and everyone knows it, even, I suspect, the ones who resent having to look at their own errors. You help physicians be better doctors, Earl. Rossit doesn’t care about that. He’s vicious, pure and simple, and everybody knows that, too!”

Susanne hardly ever called me Earl, except when we happened to meet at a social function outside the department. At work, even after all these years, she insisted the chain of command be evident and clear to all our staff. The practice was one of the many fundamentals she adhered to that ensured we ran a tight ER. Realizing the damage Rossit could cause had obviously rattled her.

Still, I appreciated the spontaneous outburst of support. “Thanks Susanne,” I said, trying to sound a lot less worried than I was, but her frown deepened.

“Are you sure you want to work? It’s not that busy, and you could do the light cases.”

“Sanders had been a light case,” I muttered without thinking.

Susanne started, then slowly nodded. “Yeah,” she said quietly, “I know what you mean.”

In
ER, the so-called little cases were the sleepers—the ones that occasionally hid something rare but lethal. For most competent physicians, the sicker the patient, the more straightforward the treatment. The already dead—a cardiac arrest—were the most routine cases of all.

“The shape I’m in right now, Susanne, I’m probably safest in resus.” I left her standing there with a doubtful look on her face as I headed toward the triage desk to find the sickest patient we had.

For the next twenty minutes, a bad asthmatic in severe respiratory distress kept me busy enough to push away any thoughts of Sanders and Rossit, but when I got to more routine cases, those thoughts, always present at the back of my mind, came to the fore. Each time I began listening to a person’s complaint and attempted to seem empathetic, I felt like a fraud. I kept imagining Sanders’s eyes. Remembering her expression.
Are you going to disappoint me too ?

Then her son phoned.

I’d been sewing up the lip of a five-year-old girl who’d been dancing on a slippery staircase in her stocking feet.

“Dr. Garnet,” the clerk had summoned, poking her head in the door of our minor surgery room. “There’s a Mr. Harold Miller from University Hospital on line three inquiring about the Sanders woman.”

“I’ll be right there,” I said, tensing.

I finished my suture and got to a phone. “Mr. Miller, it’s Dr. Earl Garnet. No doubt you’re calling about your mother?” I kept swallowing, but my mouth was dry.

“Dr. Garnet! I was in the medical library at the university, and our lab secretary reached me only a few minutes ago. A nurse from your ICU called and said you’d admitted Mother with a diagnosis of pneumonia and septic shock?” His speech was fast and clipped. He sounded tense, but I couldn’t tell if he was also angry.

“I’m afraid she’s very ill, Mr. Miller. I’m glad you’re on your way,” I said as evenly as I could. I hated having these conversations on the phone, especially this one. Without seeing the face of the person I was talking to, I couldn’t fully judge the impact of my words. I wasn’t going to lie, but neither did I want to let something slip out that would hand my head to his lawyer.

“But Dr. Garnet, what happened? I talked with her around ten last night She said that she saw you yesterday afternoon and you told her everything was okay, that it was just the flu.”

“You saw her last night? And she was all right?” I’d assumed she must have deteriorated from the time she left ER. If she was still apparently not too sick after ten, she must have gone septic in less than twelve hours.

“No, I didn’t see her,” he answered. “I phoned her at home from the hospital. I was on call for the night. She sounded like you said, like she had the flu.”

Then wham, the kind of virulence we shouldn’t see in an otherwise healthy woman in her fifties. I suddenly felt more compelled to explain that riddle than to try to avoid being sued. Perhaps I’d do both.

“Mr. Miller, I apologize for questioning you on the phone about this, but your mother’s infection puzzles me. It’s not typical, and perhaps you can help us find the answers. Do you want to meet me in ICU?”

“Sure, but what do you mean ‘not typical’?”

“The prodrome was unusually quick.”

“What did the Gram stain show she has? Come on, Dr. Garnet, what are you not telling me?”

Damn! I’d really wanted to do this face-to-face, but I didn’t want to cut him off. He was sounding increasingly alarmed.

“I’m afraid the Gram stain of her sputum showed staphylococcus,” I said as calmly as I could.

“Staph!” he exclaimed, incredulous. “My mother has a staph pneumonia?”

I listened to him breathing a few seconds as he presumably digested the odds against his mother’s survival. As a chief technician, he’d certainly have enough medical knowledge to know how grave her prognosis was. “Look, Mr. Miller, come over, and let’s talk here—”

“Do you think it was hospital acquired? You know she’d been on vacation for five days.” His voice was becoming much more agitated, but he seemed determined to continue on the phone. “Don’t leave me hanging,” he ordered.

I had to reply. “Yes, I
was
worried that it was a hospital-acquired organism,” I began, “and that she might have MRSA, so I covered her with vancomycin.” Let him satisfy his immediate need for answers, I decided. It might help him prepare for seeing his mother so ill. “Even with her being on vacation,” I continued, “she could have been carrying dormant organisms from the hospital in her upper respiratory tract, as you’re no doubt aware. Have you had any recent problems with staphylococcus infections at University Hospital?”

“Not lately, but we have had MRSA in the past. I know because I’m on the infection control board, along with your wife, Janet.”

I cringed at his innocent use of Janet’s name. It was like an unwitting rebuke, and I prayed he’d never know how I’d resented his mother for making the same reference yesterday. “Your mother said she was in good health until the morning of her first visit here. As far as you know, was that accurate?”

“Yes. She hadn’t anything wrong with her that I knew of, apart from her smoking.”

“Might she have minimized a five-day flulike illness? Ignored the symptoms? Not mentioned them to you?”

I heard a gentle chuckle. “Dr. Garnet, my mother never minimized anything.” His voice relaxed a little; it was lower, less strained. Perhaps having a clinical discussion, even over the phone, was helping him get over his initial shock.

So I continued with my questions. To be honest, I found myself especially wanting to know the details of what had happened to her after I’d sent her home. That her son had talked to her so many hours after I’d discharged her and she still wasn’t very sick somehow made me feel less guilty. “Last night, did she complain to you about dizziness?”

“Not really. She said she felt a bit unsteady. But I assumed it was the usual lightheadedness that went with the flu. Why?”

Careful now, I thought before answering, still not wanting to hang myself legally. “Her prodrome, and this may be off the wall, well, it suggested another not so common but very bad infection.”

“What are you talking about?” His voice rose sharply.

Damn! I was upsetting him again, I thought, as I tried once more to calm him. “Mr. Miller, please, it’s all supposition right now. Come over, and we can talk further, right after you see your mother.”

“What rare and very bad infection?” he demanded, his anger now clearly evident.

Great choice of words, Garnet, I cursed to myself. “Mr. Miller, I repeat, I have no proof, and ID thinks I’m nuts even bringing it up—”

“Answer me!” he snapped.

“It reminded me of Legionnaires’ disease,” I finally admitted.

“Oh Jesus!” he said, and hung up on what sounded like a sob.

* * * *

I’d retreated to my office, a cubby hole located in a back corridor away from ER. My secretary, Carole Lamont, had phoned in sick for me day, so thankfully I was alone.

I sat at my desk without the lights on and wondered what else I could do wrong. A small window in my outside wall was too grimy to see through, but it let in a little gray illumination. The effect was positively cheery compared to my mood.

I’d botched Sanders’s first visit. My attempt to comfort her son was worse than a disaster. Instead of reassuring him as I’d hoped, I’d frightened him even more with my questions and talk of Legionnaires’ disease. Why hadn’t I just kept my goddamned mouth shut?

Because I was increasingly impatient to know everything about this infection that had tricked me.

Maybe Rossit was right. My guilt was making me overcompensate and screwing up my judgment.

I’d better warn ICU that Mr. Miller was on his way over, nicely primed, I thought, reaching for my phone. Stewart Deloram, their chief, would have to deal with him personally. If there was any hope of settling him down, Stewart could do it. I’d learned firsthand when I’d once been a patient of his how supportive he could be. Perhaps, despite the mess I’d made of things. Miller could still trust the ICU staff enough to help him cope with what lay ahead for his mother.

“Dr. Deloram is in the main auditorium attending an administrative meeting,” his secretary announced.

“Shit!”

“I beg your pardon!”