Second Opinion (3 page)

CHAPTER 4

Identifying feelings and then responding to them appropriately was an area Thea and Dr. Carpenter had worked on for years, along with a group of other teens and twenties with recently diagnosed Asperger's. Most of those with the condition had been born without the social and emotional filters that kept most neurotypicals from being labeled odd or inappropriate.

Those absent neurological pathways had to be created and then practiced repeatedly, just as if the Aspie, as many of them called themselves, had suffered a stroke and were learning how to walk all over again—only in their cases, the 'stroke' had probably happened to their developing brain before they were born or as the result of some environmental insult during the early years.

Karsten, Hartnett, and Musgrave approached, looking solemn but purposeful.

'There's a conference room at the end of the hall,' Karsten said. 'Would you three mind if we talked there?'

The six walked back down the hallway and into a small but elegant room paneled in dark wood, walnut, Thea guessed, although she knew next to nothing of the subject. The table in the center, same wood, had ice water and glasses set out for them.

'Well,' Karsten said to Thea after they had settled in, 'what do you think about what you saw back there?'

'It looks as if our father is getting excellent care.' 'Oh, he is,' Hartnett said. 'I promise you he is. As you might surmise, when a person as eminent as Petros has something as disastrous as this accident, it's like a three-ring circus of specialists, nurses, and technicians of various kinds. As his primary care physician, I have taken on the role of ringmaster, along with our best physician assistant. Petros never actually had a private physician until this hospitalization. In fact, it was a running joke here that his doctor was the man reflecting back at him from his computer screen. That's where he seemed to spend most of his time—reviewing patients' records.'

'The Beaumont has one of the most comprehensive and secure record systems in the country, Thea,' Niko said. 'Correction,' Karsten added, 'in the world.' 'I'm not surprised,' Thea replied. 'It's the law now, yes?' 'Exactly,' said the CEO. 'We've had an elaborate electronic medical records system in effect here for years. We call it Thor, because of its unbridled power. Now we feel that it's as near to perfection as such a system could be. Security built on individual patient control numbers, and achieved through a triple combination of password, thumbprint, and for some areas, retinal scan. It's really quite remarkable, as well as fail-safe. I suspect you know it, but your brother Dimitri was among those responsible for its creation and subsequent perfection. He participated on one of our research and development teams.'

'Dimitri participated on a team?'

Thea was incredulous, and at the same time sensed she needed to slow down and measure her words.

'Surprising, huh?' Niko said. 'And he did a hell of a job, too. Dad has insisted that he pay rent for the carriage house, so when he had to, Dimitri looked for programming work. Apparently he answered an ad here and spent more than a year working for the hospital.'

'That's terrific. I don't think I ever heard about it.'

'Ol' Dimitri may be a tad on the offbeat side, but when it comes to computers, there's absolutely no one like him.'

'I agree with you there,' Thea said. 'An IQ of a hundred and eighty can get you far in this world.'

Still, far didn't describe the distance her brother had come if he spent more than a year cooperating with others on a research and development team. She recalled him not emerging from his lair in the carriage house for days on end, during which he allowed no visitors except for the pizza delivery man, and at times, his little sister Thea. The job meant so little to him, and the rest of the family for that matter, that no one had even bothered to mention it when she last visited Boston two years ago.

'We think our electronic medical record system is the gold standard,' Karsten said, 'and the governments of a number of states, plus the federal government, are discovering that is true. Before too long, Thor or some variant might well be required of every hospital and health-care facility in the country. With the patents Beaumont holds, the system your brother helped invent could bring in billions.'

'That sounds wonderful,' Thea said. 'I'm afraid we at Doctors Without Borders haven't quite reached that level of sophistication. But then again, without managed care, HIPAA laws, and all those malpractice suits, it's quite possible we won't have to.'

An uncomfortable silence followed during which it seemed as if a poll was being taken to see who should be speaking up. Thea looked from her brother and sister to the others, and wondered if she might have said something wrong. Finally, Sharon Karsten cleared her throat and adjusted her half-glasses.

'Urn… Thea,' she began, 'I don't think it would be overstating things to say that we here at the institute are most impressed with the sort of physician you have become. Your father spoke very highly of you, and your brother and sister made it clear that we could search forever and not find anyone more capable of filling our needs.'

My
father spoke highly of me? Thea was so blindsided by the notion that she almost missed the words that followed.

'Capable of filling your needs?' Thea asked when she realized what had been said.

The last thing in the world she wanted to do here was fill anybody's needs.

'Your father served as a physician and advisor to patients and doctors from around the globe,' Karsten said. 'He cared for royalty as well as for the poor and disenfranchised, whose care is paid for by foundations he has helped develop.'

'Yes?'

Thea felt sick at what she sensed was coming next. She looked over at the twins, but in concert they averted their eyes.

'Well,' Karsten continued, 'we would need approval from our board, but I suspect that will be no problem. Put simply, we want you to stay here at the Beaumont and take over your father's practice.'

Hartnett straightened up and took the baton.

'I can and will handle Petros's administrative responsibilities as medical director of the institute until you feel up to assuming them,' he said. 'And if by some… what I mean is if your father's condition should improve to the point where—'

Thea was on her feet, glaring at her brother. She felt as panicked as if she had just been asked to spend the rest of her life in a broom closet.

'This is your doing, Niko!' she snapped. 'You and Selene told them I didn't really have a job and would be happy to take over here. Why would you do that?'

'We didn't do anything, we merely—'

'Well, I
do
have a job. I have a job and friends and a life I enjoy, just like you normal people do! I'll stay here as long as I feel Father needs me, but you know that I have my reasons for working where I do.'

Without waiting for a response, Thea whirled and marched down the hallway and back into the ICU.

Embarrassed, the three hospital officials muttered apologies and left the conference room.

The twins stayed behind.

Petros knew now. He had brain damage. He had profound damage and he could not move or speak. The pain in his back and pelvis was unremitting and unbearable, but he was helpless to do anything about it. One of the nurses had said something about an accident, but then he must have faded out again before he could hear any more. An accident? If he had had an accident of some sort, with damage to his brain—his midbrain, probably—he had absolutely no memory of it. Was he driving? Walking? In someone else's car?

Thea was here. I he
ard her voice. She must be back from Africa. It's been so long. When she first left, she was so terribly angry at me. She thought I didn't care. That wasn't true. Why couldn't I make her understand how much I wanted for her? Dimitri had been a complete waste, and the twins were technicians—
bright enough, but technicians all the same.

Help me! For God's sake help me. I have to speak to my Thea. I have to help her understand that
I only want what's best for her. I have to help her see what she's done to me by leaving the way she did and how she can make it right.

CHAPTER 5

Handling stress had never come easily to Thea, especially in the area of athletics, where she had little ability, and also during interviews, which usually played into her insecurities and difficulty with language nuances. Before beginning treatment, when confronted with a pressured situation, she would usually become restless, defensive, and combative, and before long might melt down in a fit of anger. With the help of Dr. Carpenter, and an improvisation therapy group geared to being in tense situations, she practiced being interviewed until she could maintain her composure. Eventually, she was able to get a sense of whether her answers to the interviewer were appropriate or not, but even now, she often wasn't certain.

The twins knew that she had gone to work for Doctors Without Borders to avoid the pressure-cooker medicine and politics of a major academic medical center. Yet without consulting her, they had encouraged the powers at the Beaumont Clinic to offer her the practice and position that had belonged to their father, and to spring that offer on her when she was totally unprepared.

Had they meant to put her in a situation where she would humiliate herself as she had just done? Did they want to ensure that the hospital bosses knew that regardless of her intellect, Thea Sperelakis was most assuredly not her father's daughter? If so, they had most assuredly succeeded.

Thea entered the unit and stood on the other side of the glass sliders, breathing deeply, but unable to keep herself from trembling. She had come a long way in dealing with stressful situations, but obviously not far enough. Her difficulty handling pressure should have led her to a specialty like pathology or radiology or public health. But she loved people and wanted to feel she was directly helping them, much as she had watched her father do from her earliest awareness. In addition, her intellect and powers of deductive reasoning made her a natural for diagnostic medicine. To her, having to deal with an occasional true emergency was worth the trade-off to be an internist, and most of the time, especially if she had enough warning to ready herself for the situation, she could manage most emergencies quite well.

She had largely composed herself and started back toward Petros's high-tech, glassed-in cubicle, when the sliders opened again and Niko entered, followed by Selene. Through the glass Thea could see CEO Karsten and nursing supervisor Musgrave standing quietly by the waiting area in the corridor outside. Scott Hartnett was probably off someplace, she mused, implementing a switch to someone other than a Sperelakis to head up the institute.

'Thea, wait,' Niko said.

Thea continued to the bedside, at once embarrassed and still somewhat angry.

'You didn't have to do that, Niko—certainly not just a few hours after I got here.'

'We didn't say anything,' Selene said, 'except to agree with what Hartnett and the others had heard from Father, that you were a very brilliant doctor.'

'The name Sperelakis is worth millions in referrals,' Niko added. 'They asked us if we thought you'd agree to take over Petros's practice, and all we could tell them was to ask you, but that you were a great doctor. We had no idea they'd charge in and bring it up right after you've stepped off the plane.'

'You know I'd never succeed in this setting, Niko.'

'I'm not so sure,' Selene said. 'You've managed to succeed in almost anything you've ever done. Please don't be angry with us, baby. We've got enough to deal with right here.'

Thea looked over through the forest of tubes. Petros, his raccoon eyes and battered face making him a grotesquerie of the powerful man who had ruled their home, was lying peacefully on his back, being attended to by a tall, young unit nurse named Tracy. Vernice, the nurse who had volunteered to help with his bed care, was gone.

His splinted hands were restrained to the sides of the bed against the remote chance that he might suddenly wake up and pull out his arterial line or IVs or his tracheotomy tube. The top bedsheet had been pulled aside, exposing him and revealing his penis and urinary catheter. One indignity piled on the next.

High on the wall, the monitor protruded on a mobile arm, displaying various parameters as continuous tracings and numbers in different colors. Blood pressure and mean arterial pressure were red; heart rate yellow. Central venous pressure, indicating the volume of blood returning to the heart, was blue. Oxygen saturation, core body temperature, respiratory rate, and spinal fluid pressure were being continuously recorded as well. Many times over her years in medicine, Thea had seen overwhelmed, impotent, often bored visitors to patients in the ICU staring up at the monitor screen as if it were televising some sort of sporting event.

Almost subconsciously, she herself scanned the screen, making a mental note of the various tracings. Details, always details. Three of the tracings resonated to a mild extent—a drop of five in the mean blood pressure, the appearance of occasional extra heartbeats (one or two every minute), and also what seemed like a slight change in certain portions of the individual heartbeat tracings. The observations were not enough to trigger any alarms, and also not the sort of thing neurotypicals were likely to pick up on. They were just… there.

'Okay,' she said to the twins. 'I'm sorry to have gone off at you like that. You're right. We do have our hands full.'

The extra beats were of little concern to her, and in many instances, at a rate of only one or two a minute, were the result of stress, mucus in a bronchial tube, or even a stimulant such as caffeine. In fact, Petros was on some IV theophylline, a bronchial tube dilator for wheezing that often stimulated heart muscle irritability. But Thea felt certain that the subtle changes in what was known as the PQRST complexes of Petros's cardiogram were new from when she first arrived in the unit.

'… starting with the health care proxy Father left,' Selene was saying.

The news startled Thea's focus away from the monitor.

'He left a proxy?' she asked, surprised that no one had mentioned it before now. 'What does it say? Who did he appoint to administer it?'

'Actually,' Selene replied, sweeping a wisp of errant hair back into place, 'it doesn't say much. It turns over all decisions regarding his treatment to the four of us.'

'The four of us?' Now Thea was incredulous. 'Did he leave a living will?'

Selene shook her head.

'None that anyone's been able to find. His secretary had the proxy in a file with our names on it. We have the power to decide if heroic measures should be instituted or continued, but only if we four are in agreement.'

'Including Dimitri?'

'Including Dimitri.'

Selene's expression and tone made it clear what she thought about including their oldest sibling.

'Petros Sperelakis, the master of control,' Thea said.

'Right to the grave,' Niko added. 'There's a copy of the proxy in his record. We've already signed off on it.'

'Did Dimitri sign?'

'Not yet. I don't think he's even been here more than once. The proxy doesn't really say anything other than we four must concur on any action.'

'In that case I'll be happy to sign.'

'But you're not certain what you want to do about instituting heroic measures?'

'Niko, look at him. We've already instituted heroic measures.'

Out of the corner of her eye, Thea saw an increase in the frequency of the VPBs (ventricular premature beats) from one or two a minute to four or five. Something was irritating the electrically charged cardiac muscle, possibly the theophylline, she was thinking, although a number of other possibilities began marching through her mind. She glanced about for the intensivist—the specialist in critical care medicine—but he didn't seem to be in the ICU.

'I see what you mean,' Niko was saying, 'but that still doesn't answer the question of what to do if—'

'Tracy,' Thea cut in, 'what's up with these extra beats?'

'I just saw them, too, Thea,' the nurse said.

'His pressure's dropped as well.'

'He's been having some VPBs all day, but this is more. I've been here with him all afternoon. I can page the intensivist. He's at din-ner.

'I think it's okay if he's not going to be too long, but do what you're comfortable with.'

'What's happening?' Selene asked.

'There are some very small changes in his monitor—widening of the QRS complexes and also some subtle changes in the QT interval and the PR interval.'

'You are too much.'

'I'm not sure I agree with you about the changes, sis,' Niko said.

'Well, Niko, you're the cardiac surgeon, but I have the tendency to notice such things. Something could be off with his electrolytes, maybe his calcium. He's on theophylline, which can contribute to that, and also a diuretic that can do the same thing. Is he on any kind of antacids?'

'He's been getting ranitidine IV,' Tracy said. 'Dr. Kessel likes to use it in patients on steroids.'

Thea felt a tension materialize in her throat. Something was definitely wrong.

'Well, I think you should order a full twelve-lead EKG,' she said to the nurse. 'Also, I would stop the theophylline for the time being and send off a tube to the lab for electrolytes—sodium, potassium, C0
₂
, and chloride—as well as for free or ionized calcium, whatever they call the test here; just not total calcium.'

'Right away,' the nurse said. 'I am going to page Dr. Kessel. It's a hike from the cafeteria to here.'

'Fine. Selene, perhaps it's worth paging Dr. Hartnett as well. He's Dad's primary care doctor.'

'What do you think is going on?' Niko asked.

'I don't know, but something's different than it was earlier today. I'm almost certain of it.'

'Whatever it is, don't you think we should just let it happen?'

'What?' Thea was incredulous.

'Look at him, Thea. He's a vegetable. Existing like this is nothing he ever would have wanted.'

'Then why didn't he say so? He took the time to write a proxy. He could have written a living will.'

'Honey, he was always so busy and so distracted,' Selene said. 'He probably meant to and just never got around to it. We need to just let him go. We've all encountered enough patients with severe head injuries to know where this is going. This isn't the man who was our father, Thea. It never will be again. Why torture him?'

'It's too soon,' Thea said.

The twins glared at her.

'If he could speak,' Selene said, an edge to her voice, 'he'd scream at us to just let him go. This may be the chance to do it.'

'You know the man, sis,' Niko said, 'and you know where this is headed. Be reasonable.'

'Niko, I
don't
know where this is headed. I agree that the odds favor a poor outcome, but we only have one father and he only has one life. Is there any reason we can't see this through for a little while longer?'

'Let me think,' Niko said. 'For starters, he could be in terrible pain. We have no way of knowing that. For seconds, a great life is grinding to a halt in total humiliation. Catheters and bed baths for a man known around the world for his brilliance and caring. For thirds, the worst thing that could happen is something truly terrible. We could succeed in keeping him alive. One of the greatest medical minds of our times reduced to being lashed to a chair in the hall, soiling himself, drooling on himself, incapable of speaking, and unable even to hold his head up straight. It would be a hell of a lot easier for everyone if we just choose to throw our lot in with benign neglect— with choosing
not
to intervene. That way we don't have to plug in the morphine drip and take an active hand in his end.'

'It's only been eight days. There's something going on here, Niko.

Right now. Whatever it is could very possibly be reversible. We need to try and figure out what that is and treat it. We don't have enough information to make the decisions you're asking us to make.'

'Thea, we understand where you're coming from,' Selene said, 'but we've been here with him every day. You haven't.'

'That's exactly the point, Selene. I just got here. I need more time with him before we… before we let him go. Can't you understand? Niko, look. Look at his neck veins. I think they're becoming distended. Do you think the chest trauma could have caused bleeding around his heart?'

'Tamponade?' Niko said, with no more than a glance at their father's neck veins. Distension of them was one of the first signs that blood or other fluid was accumulating and causing life-threatening pressure to build up between the pericardial membrane and the heart muscle itself. 'After eight days? Doubtful. Almost impossible. Besides, I don't think there's any distension at all.'

'But look,' Thea said. 'His blood pressure's dropped and his venous pressure has gone up and he's having those extra beats. It could be tamponade.'

'Or too much calcium or too little potassium or a drug reaction or an internal hemorrhage, or just an old man's old heart giving up. Thea, be reasonable.'

At that instant, with no increased warning whatsoever, one of the errant premature beats fired off precisely on the ascending portion of the following T-wave, and Petros Sperelakis's heart stopped.