Death Rounds (8 page)

Particularly galling was that I’d absolutely no idea why Rossit was singling me out for such particularly vicious treatment in the first place. Damn him anyway, I thought, wondering how much damage the spiteful little man could do. To be honest, as much as I’d always considered him a loathsome nuisance and a nasty troublemaker, I’d never really believed until now that he’d be able to cause lasting harm to a physician of my standing.

Working ER—being there day after day and pulling the tough cases through year after year—gives a doctor a certain status in a hospital. In my case I’d come to take it for granted that I didn’t have to prove myself anymore. I knew my clinical judgment and diagnostic skills carried a certain weight with my colleagues, and I was used to them turning to me for help when they or their patients were in trouble.

In other words, for years I’d presumed my track record gave me immunity against having to defend myself in front of the likes of Rossit.

Apparently not anymore.

Could he actually help Miller convict me for negligence in a court of law? Miller’s behavior on the stairs and his mouthing off had made it pretty clear his bitterness hadn’t subsided any. Might the conviction lead to suspension, even a withdrawal of hospital privileges? I shivered and again felt a cold prickle of perspiration on my back.

I focused on threading my car through the traffic to get to St. Paul’s as fast as I could but seemed to hit every red light on the way. Listening to the wipers tick off the time only increased my impatience at each stop.

Michael had held fast to his theory that the
Legionella
cases must have originated from a source or case in the hospital that had been overlooked or missed. As lightning continued to send cracks through the morning gloom, part of me wanted to agree with him, wanted to dismiss the alarming possibility of a phantom as little more than a troubling fantasy fueled by thunderstorms, lack of steep, and too much caffeine.

But I couldn’t. Each time I recalled Janet’s unyielding insistence that the three women had been attacked, my fears for her own safety made my stomach clench like a fist. Michael’s arguing with her about a lack of proof had only increased that foreboding. He no more had proof for his position than she did for hers. Until
he
found hard evidence of an undetected source of
Legionella,
connected the three nurses with that source, then explained how they’d all contracted the disease just before leaving on vacation, I was going to find Janet’s suspicions impossible to ignore.

But my reasons for taking her suspicions seriously weren’t going to be enough to persuade others. No one would believe a murderer was on the loose simply because Janet had seen a trait of cruelty common to the three victims which everyone else had missed.

Except, of course, the killer.

Predictably, Janet and Michael had equally frustrated my concern for
their
safety. “If you’re probing the work of a maniac, it could be lethal,” I’d argued.

Michael had scoffed some more, and Janet, once again seething at him, snapped, “With reactions like that, who else
but
me could do the job?”

For my sake, they had at least promised not to fight anymore and to be careful. I’d ended up trying to ward off visions of someone prowling after them as they worked.

Michael
had
readily accepted Janet’s help. No matter how much their perspectives differed, there was a lot of work to do. Charts of the infected nurses, charts of the patients those nurses had come in contact with, records outlining the ID investigation into possible sources of the
Legionella
organism—all had to be reviewed. But Michael rejected my offer to stay and look through files with them.

“Are you kidding?” he’d exclaimed. “A lot of people were edgy about letting
me
snoop around.”

“You know, amalgamation paranoia,” Janet had added, sounding resigned to agree with Michael on this point. “If you got caught, they’d shut down the audit and call us all spies.”

As if to underline their caution, when I’d stopped at Madge’s desk to use her phone on the way out, I’d noticed a stack of files placed beside me with a piece of paper bearing Michael’s name on top. Waiting for St. Paul’s to answer, I’d been trying to see what the top folder contained, when a red-faced woman in a nurse’s uniform had whipped the entire pile away from me and off the counter. “Well!” she’d exclaimed and huffed off. Even Madge had protested,
“Dr.
Garnet!”

“Sorry!” I’d pleaded, putting down the phone. “Force of habit. I always check my charts when I’m on hold in my own office. I didn’t see anything—honest! Hey, Madge, please don’t tell Janet!” I’d added, backing out of the room and trying to act the harmless husband that Janet had introduced me as.

I smiled, recalling this performance, then quickly lost patience again as I missed yet another green light. But instead of once more sitting there and fuming over the slow pace, I thought of a call I could make. I dialed the number for our ICU.

“It’s Dr. Garnet,” I announced when one of the nurses answered. “Could you tell me the status of Phyllis Sanders, please?” Had she survived the night was my real question.

“One moment, I’ll give you the doctor who just saw her.”

I braced myself. Normally a nurse would simply give me the report. Passing me on usually meant bad news.

“Dr. Rossit here,” snapped the unpleasant voice.

Shit!

“Uh, it’s Dr. Garnet, Dr. Rossit. I just wanted to have the nurse give me a report—”

“She’s as good as dead. Garnet. Calling in and wringing your hands over a near corpse isn’t going to make you any less negligent. And it sure isn’t going to make any difference when this case is reviewed. I promise you I’ll take care of that personally!”

He was practically screaming, his voice crackling through the receiver and sounding ten times as venomous as what I’d endured yesterday. I could even hear him breathing hard over the noise of the rain. Christ! Susanne and Michael had been perfectly right. No matter how bad his reputation was, this was definitely over the top. Nailing me to the wall must be pretty lusty stuff for the little prick. A nasty afterthought flashed through my mind. Maybe his loathsome practice of hunting doctors who’d screwed up was the man’s substitute for sex—the result of small equipment.

“Rossit, either keep this professional or get off the line and put somebody on who can!” I ordered. I knew that he’d had his own problems with the ethics committee as a result of other witch hunts he’d launched and been reprimanded several times for unprofessional conduct. However he planned to get me, I could at least make sure he was going to have to do it by the book.

I listened as his breathing slowed down. “Now, Rossit!” I insisted. The light changed. I had trouble concentrating as I picked my way through the traffic. There was still no reply. I was about to hang up in disgust when I finally heard him say, “What do you want to know?”

I want to know how she is, you asshole, I nearly screamed, but instead I replied coldly, “How are her vitals?”

“Not much change. Her systolic’s floating around ninety, the central pressure’s still down, and despite the ventilator, she’s increasingly hypoxic with respiratory acidosis. Did I mention her bicarb’s falling by the hour? You can guess the rest—low white count; rising BUN, creatinine, and liver enzymes; decreasing urinary output—like I said, she’s kaput.”

My anger at his callous description was quickly replaced by a sense of hopelessness. Rossit had described the laboratory findings of unchecked septic shock and circulatory failure. Her immunity was being wiped out, her respiratory function was deteriorating, and she was sliding into complete renal shutdown. I knew it was unlikely she’d ever regain consciousness. “What about a trial of rifampin?” I asked, knowing it would probably be a futile measure. Rifampin was an antibiotic initially used decades ago against TB. Some recent articles had suggested it was effective in nonresponsive cases of
Legionella.

The unguarded suggestion absolutely ended our truce. “Christ! You hand out drugs like candy!” he exploded.

“What!” I exclaimed.

“It’s hot dogs like you who are mostly responsible for drug-resistant infections in the first place!” he screamed. “From the beginning of this case you’ve shown a clear tendency to overuse antibiotics, and I intend to order a full chart review of your prescribing competency. Such abuse is the main cause of virulent new strains—”

I hung up on him.

* * * *

I arrived back at St. Paul’s at 8:15. Casualties from a five-car pileup on the expressway inundated ER.

“We need you in resus!” Susanne said, rushing by me with bags of blood under her arm.

“Dr. Garnet,” called the clerk from the nursing station, waving a phone at me. “Dr. Carrington wants to know if you need him down here.”

“Yes!” yelled Susanne, answering for me over her shoulder.

I was pulling off my wet coat and running to catch up with her. “What have we got?”

“Six casualties, two critical, this one’s the worst,” she summarized as we entered the tiled, echoing room where we managed major trauma. The chatter and noise matched the confusion. Residents and nurses in surgical greens were circled around the pale lifeless body of a middle-aged man, busily sticking him with needles and attaching him to a web of tubes, catheters, and monitor wires. A high white cervical collar immobilized his head and neck while a respiratory technician struggled to pass a ventilation tube through his nose and on down into his trachea. Yet another tube, this one transparent, was sticking out of his upper left side and draining pure blood into a bottle under the stretcher. These were all lifesaving procedures, but to the uninitiated, the scene might have been a tableau depicting the agony of torture.

“He’s in shock with a flail chest on the left,” continued Susanne. “X rays have just been taken, but we don’t have the developed films yet. I added a pelvis; there’s blood at the mouth of his urethra, and we can’t get a catheter up more than a few inches. OR’s notified, and ortho and urology were called as well as Dr. Carrington.”

She’d just told me the man had broken enough ribs to detach a section of his chest wall from the rest of his rib cage. I could see the piece—like a deli side of ribs the size of my hand—still held in place by muscle and sinew, flopping in and out uselessly as he tried to breathe. Shock meant he was bleeding from somewhere, and with blood pouring out of his chest cavity, the source could be a lacerated lung, a major vein, or even a ruptured aorta. The trickle of blood from the man’s penis suggested a severed urethra, probably caused by the jagged ends of a pelvic fracture. Susanne’s clinical savvy was better than any other nurse’s.

“You should have been a doctor,” I told her, not for the first time, as I quickly finished gowning and gloving up.

“Who’d be here to tell you what to do then?”

“Speaking of telling me what to do, thanks for calling Michael last night.”

She blushed but smiled her acceptance of my rather awkward acknowledgment, then moved in to hang up the blood she’d brought.

Expressions of profound loyalty and deep friendship could hinge on an instant in ER.

Seconds later I strode up to the head of the gurney and took over the intubation from the struggling technician.

For the next short while the harsh world of blood, sinew, and broken bones chased away any thoughts of Rossit or shadowy notions of a phantom killer. It was particularly satisfying when I secured the man’s airway, an intubation far too difficult for the tech, especially after I’d had to step aside during Sanders’s intubation less than twenty-four hours ago.

Once the patient was properly ventilated, I started firing the questions—the tools of teaching since the time of Aristotle—to focus the residents on what needed doing next. “Okay, gang, where’s he bleeding?”

While they shot back answers about the left lung, I rapidly palpated the sternum, auscultated the rest of the chest, then tossed out more questions. “Is he still in shock?”

“Seventy-five over zip,” answered one of the nurses.

“What about this chest tube pouring blood?”

“Clamp it?” a young man across from me answered hopefully.

“Good show.” I grinned, moving on to palpate the abdomen and to select my next pupil. “Did anyone clear his cervical spine?”

“We took X rays, sir,” replied a young woman on my right. “They’re not back yet.”

“Did you do a rectal?” I asked her.

She flushed above her mask. “Not yet.”

“Now I’m going to show you where else this guy is bleeding out on you.” I slipped on some lubricant and inserted my index finger through the man’s anus. I felt a prostate bobble as free as a floating olive in a martini.

I slipped out and let her perform the same maneuver. Her eyes widened as she confirmed a transected urethra for the first time.

Then I squeezed the pelvis. Both halves slid free of each other and gave a sickening grind.

I stepped back, “Your turn.”

More wide eyes.

“Bottom line, folks: this patient needs a surgeon.”

The nurses busied themselves recording neurological signs, and I slipped yet another needle catheter into the man, this one through his belly to check for free blood in the abdominal cavity. Negative.

Sean ran into the room as I was flipping X rays up on the viewer, and together we confirmed our clinical impressions. “Let’s go!” he cried, reaching through a forest of IV lines and grabbing the head of the stretcher himself to lead the rush to the elevators. The nurses had piled portable monitors and an oxygen tank onto the bed between the patient’s legs and were still securing drainage bottles when they started off. The respiratory technician was on the bed itself, straddling the patient’s chest with her knees, bagging as they all went out the door and disappeared down the corridor.

I stood for a moment in the empty room, savoring the triumph that always follows a successful resuscitation. This is what I do and do well, I thought. There was no other job in medicine I found sweeter than saving a life. But the delicious glow of accomplishment was quickly being replaced by a spreading sense of dread because two days ago I’d sent the wrong woman home. Foul play at University Hospital may have started the infection. Missing it was my fault.