Tampered (7 page)

Vancomycin was very expensive — forty dollars a day, and the minimum duration of therapy was two weeks. Metronidazole, much cheaper at just twenty cents a day, was the government's preferred C diff drug. Trouble was, it often failed, and mild cases turned lethal. Vancomycin rarely failed if started early, but the provincial government's universal drug plan for seniors covered it only if C diff had taken the patient to death's door and back three times in the previous six months. It was a crazy false economy cooked up by heartless bureaucrats in a fancy office somewhere in Toronto.

“Oh yes,” Betty said, “the federal government generously rewards its faithful servants when it puts them out to pasture.”

“Good. We'll go straight to the best drug. Four capsules a day and you should be well on the mend by Sunday. Though I've got to warn you — you're still going to feel pretty rocky tomorrow.” He hoped he wasn't being overly optimistic about how she'd feel on Sunday. “Be sure you keep up with your fluids, and I'll check on you tomorrow.”

He passed her bathroom door, his hands still firmly in his pockets. The smell of para-cresol hit him again, this time with an alarming uneasiness. C diff in the elderly could be viciously unpredictable. The patient might not look too bad today, but tomorrow their large bowel could ignite into a lethal explosion of toxic megacolon — like those folks Betty had been reading about.

It was almost nine on Friday night by the time Zol got Max home from indoor soccer after dropping Travis off at his house. As usual, Travis slipped away without a word, and no one greeted him at his front door. He was an unusual kid. A large, purple birthmark covered the right half of his face, and he lurched to the left when he walked. He never said a word to any adult, certainly not to Zol, and according to Max, not to his coaches or his teachers either. When Travis wanted something, he whispered in Max's ear and relied on Max to provide a simultaneous translation. The poor kid stumbled awkwardly on the soccer pitch, usually right in front of the goalie. Still, he seemed to love the game.

The two boys had been drawn together since kindergarten, each with a physical distinction that set them apart: Max with his spastic left arm, Travis with his birthmark. Neither considered himself sick or handicapped, but Zol had always sensed the bond of
the other
between them. Calling the dark purple nevus on Travis's face
the map of Norway
was Max's way of describing it in complimentary terms, especially since Travis claimed his mother was descended from the Vikings. There didn't seem to be a father in the picture. As far as Zol knew, there was nothing wrong with Travis's intellect. The boy was a great gamer and had pulled his weight when he and Max did a project together on the Inuit.

Max was so tired he barely balked when Zol scrubbed the post-game orange drink from his face and handed him his pyjamas. He fell asleep on the second page of tonight's installment of Lemony Snicket, just as Colleen pulled into the driveway. Zol eased off Max's bed and turned off the light. After soccer, Max was always down for the count.

Zol rustled up a corned beef sandwich and a green salad for Colleen while she put her feet up in the sunroom. He never touched canned meat himself, but kept a couple of tins of Fray Bentos on hand for her. She called it bully beef and said it reminded her of happy picnics with her family in the Drakensberg Mountains, on holidays from Cape Town. Zol handed her the sandwich and poured two fingers of Lagavulin for himself. He loved how her eyes crinkled when she smiled, and the girlish way she swept her braided ponytail off her shoulder as she snuggled beside him on the loveseat. With the lights turned down, her hair glowed more copper than gold. But she looked tired. Watching Gus must have kept her up most of last night.

“How's Betty?” Colleen asked.

“Not so good. Hamish went to see her today. Says she's got C diff from the antibiotic the Lodge's family doctor prescribed a couple of days ago.”

“Is she going to be okay?”

“You know Hamish. Without ever saying it exactly, he lets you know he's prepared for the worst.” In the bloodless tone Hamish used whenever he was concentrating or anxious, he told Zol that only time would tell how things would turn out. Either Betty would get better soon, or she'd go fast. That's the way C diff worked in the elderly.

Zol took a swig of the neat Scotch and swallowed hard. He closed his eyes and let the fiery wave of peat and iodine bathe his throat.

“Tell me about Gus,” he said, after another scorching swallow. “You didn't say much in your phone message.”

“To be honest, after he stayed home last evening and the entire night, I wasn't hopeful when I started out this morning. I knew he wouldn't be Dumpster diving in broad daylight.”

“But?”

“Today he took me on a fascinating tour of the city. For three hours. First we went to Ancaster, for a stop at that coffee pub on Wilson Street — the place with the drive-through the neighbours made the fuss about.”

“Delia's Donuts?”

“That's it. He picked up a box there. Doughnuts, I'd guess.” She paused for a bite of salad. “And then he took the 403 down the Escarpment, got off at the Main East exit, and stopped at the Convention Centre and the Royal Hamilton Hotel. Then two more stops. The HamNorth Mission on Ferguson Street. And a nondescript house on Sanford Street North. The place has seen far better days.”

First the trendy heights of Ancaster, then the true grit of downtown Hamilton. Life could get pretty rough in Hamilton's north end. What was the manager of an exclusive home for wealthy seniors doing at a homeless shelter and a place that sounded like a halfway house?

“Any idea what he was doing?” Colleen asked.

Zol sipped his Scotch and shook his head.

“Playing Robin Hood,” she said.

“What?”

“Taking from the rich and giving to the poor.”

“I don't get it.”

“He collected food at the first three stops and dropped it off at the last two.”

“He hauled it out of Dumpsters?”

“No, no. They gave it to him.”

“Gave it to him? Just like that? What sort of food?”

“I didn't dare blow my cover by getting too close. But I managed a few pictures with my telephoto.” She opened the bag at her feet and lifted out a camera. Not a point-and-shoot, but a hefty single-lens reflex. She pressed a few buttons and showed him the image on the screen.

“That's Gus, all right,” Zol said. He was standing at the rear of his blue Dodge van and holding a large tray. “What's he carrying? Are those sandwiches?”

“It's hard to see on the screen, but yes, I'd say a gourmet assortment. This is taken at the service entrance to the Hamilton Convention Centre. He carried out seven similar trays — five of sandwiches and two of fresh fruit — and loaded them into his van.”

Colleen pressed a button and up came another photo. This showed Gus Oliveira from a distance, carrying a large cardboard box toward the same van parked in a lane beside a large building. Zol recognized the striped green awnings of the Royal Hamilton Hotel. Colleen pressed the button again to show a closer view of the box. The photo angle didn't give a view inside, but the box was full, and silvery objects were projecting through the open top.

“It was a big box, and Gus was puffing quite heavily as he carried it. Looked like it was full of odd-shaped packages wrapped in aluminium foil.”

“What did he do with this stuff?”

“He dropped the trays from the convention centre, and one of the boxes from the Royal Hamilton, at the HamNorth Mission. There were too many people milling around the sidewalks for me to take pictures. They were waiting for the place to open for lunch.”

She pressed the button again. The next shot showed Oliveira on the front porch of a typical north Hamilton house. Battered wooden steps led to a cluttered porch; the roof sagged heavily to one side. Gus had two boxes in his arms. Zol could just make out a female face peering through the partly open door.

“She doesn't look too pleased to see him.”

“I think it's a women's shelter. See the stroller and the tricycle in the corner? They don't have those in halfway houses for cons.”

“What about the box from Delia's Donuts?”

She fiddled with the camera then showed him the screen. The shot caught Gus at Camelot's kitchen door. He had a large smile on his face and was carrying a colourful flat box and a large, foil-wrapped package. There was no mistaking the pink and green logo of Delia's Donuts, nor the packet from the Royal Hamilton Hotel.

“What's all this about?” Zol asked. “Doesn't sound like Gus is a freegan.” He'd looked up freegans on the Internet, after Hamish had mentioned them for the second time. “They don't take handouts. They'd rather dig their food out of Dumpsters when no one is looking. Late at night, I imagine.”

“I've got my hunches, and I'm going to keep following him. But first, you've got to let me finish my supper.” She paused, her fork poised over her salad, then laughed. “Am I wise to trust the proven-ance of all the ingredients?”

Hamish tiptoed into Betty's room on Saturday morning and opened the curtains a crack. Art said she'd fallen asleep barely five minutes ago after a restless night. Phyllis had sat up with her until dawn, helped her to the bathroom so many times she couldn't count. The air reeked of the para-cresol from Betty's C diff–infected stools. Her lips were dry, her eyes sunken, her pale face dissolving into the pillows.

Hamish lifted her bony hand and felt her pulse. The beat was feeble, her heart rate far too fast. Her vital body fluids, lost in all those liquid stools, hadn't been replaced. Too weak to drink, she was withering like the desiccated geraniums forgotten on her windowsill.

She needed IV fluids as soon as possible, before she slipped into shock and her kidneys shut down.

He called Reception and told the woman to page Gloria, tell her he needed to meet her in the Mountain Wing in five minutes. Art had said there'd been a death on that wing overnight. That meant at least one empty bed over there for Betty. He'd get some IV fluids into her immediately, then see about transferring her to a hospital bed at Caledonian University Medical Centre.

Fifteen minutes later, Gloria strode into the Mountain Wing. Dark circles ringed her eyes, and her hair hung limp about her face. Her blouse looked like she'd hauled it straight from the washer. According to Art Greenwood, Phyllis had heard the Oliveiras arguing about Gloria's mother's funeral arrangements, something about charter flights from Lisbon. The body was on hold in the funeral home pending the arrival of relatives from Portugal. It seemed Gus wanted to follow tradition and see his mother-in-law buried immediately, but Gloria insisted on waiting for her family to arrive. The strain of the delay was obvious on her face.

“I know you've got your hands full, Mrs. Oliveira,” Hamish said, pointing to the charts scattered on the counter, “which makes me surprised Dr. Jamieson didn't transfer these gastro cases to Caledonian before he left on holiday.” While he'd been waiting, Hamish had checked on the patients and found three of them, like Betty, dangerously ill, on the brink of organ failure.

“My staff do excellent job, Doctor. After Dr. Szabo inspected, we hired an extra nurse.”

“That's still not enough. Your staff can't keep up with the workload.” The poor fellow who just died would have consumed all the attention of the nurse and personal support worker on the night shift. “These patients need IV fluids. And so does Betty McKenzie. I'm bringing her over in a few minutes so we can get that started now.”

Gloria crossed her arms and shook her head. “Intravenous treatment is against nursing-home policy. Nursing council says we can't do it.”

“But you have RNs on duty.”

“I cannot guarantee an RN for every shift.”

Same old story: RPNs — registered practical nurses — weren't allowed to supervise a simple IV, no matter how experienced they were. “Well then, these people have to be transferred to Caledonian.”

Gloria frowned and donned her reading glasses. She shuffled through the charts then held up two of them. “These clients have advanced directives — no transfer.”

She pointed to the first page on the top chart. It read:
Routine care and oral medications where possible. No intravenous therapy. No transfer to an acute-care hospital under any circumstances. Above all, comfort measures. No resuscitation in the event of cardiac arrest.

The no-transfer order certainly didn't apply to Betty, nor to the Mountain Wing's third dehydrated patient, who had crippling arthritis that kept her bedridden but didn't stop her solving stacks of Sudoku puzzles.

Hamish picked up the phone and punched in the number for Caledonian University Medical Centre's emergency department. He had at least two patients to send them, but if he didn't warn them, the nurses would have a fit and make things difficult the next time he showed his face there.

He asked for the MD on duty.

Jeff Suszek, the department's assistant chief, came on the line. “Hey, Hamish. What's up? Got a case headed our way?”

“I've got two for you, maybe more. Bordering on shock.”

“You at a bus crash?”

He told Jeff the story.

“Can't help you, Hamish. Patients who fail the ministry's new CCAE policy have to stay where they are.”

A new policy had started two weeks ago, on the first of March. Doctors and nurses had taken to calling it the Deep Six rule. A cohort study out of Toronto had shown that nursing- and retirement-home residents who were older than
eighty
, or had been hospitalized within the past
twelve
months, or were taking more than
six
drugs, were just as likely to die after transfer to an acute-care hospital as they would be if cared for in their residential facility. In the interest of saving money and hospital beds, and practising medicine based on scientific evidence, the ministry was insisting that the new Community Care Algorithm for the Elderly, the CCAE, be applied without exception.

“Your folks are over eighty, Hamish. So there's no way we can allow them in. Besides, I've got nowhere to put them. Our isolation rooms are full. Twenty-seven patients are lined along the halls of our department, waiting for beds upstairs. I spend the whole day running interference and —” A siren screamed in the background.

“Hell's bells, Jeff. These folks are going to die if they stay here.”

“The ministry and the latest studies both say they'd be no better off if we take them. Why don't you shove IVs into them and give them your antibiotic
du jour?
”

“They don't do ivs here. Against nursing council policies. No trained staff, no supplies.”

“Sorry, man. The dean, the CEO, and the VP Patient Services are all over us on this one. We gotta keep the beds clear for our elective hips and knees. And the new pancreas program.”

The mandatory targets for hip and knee replacements, imposed by the Minister of Health, were sore points with everyone except the orthopedic surgeons who were putting new joints into vote-rich baby boomers. And the pancreatic islet-cell transplant program was the university's brand new poster child. Everywhere you looked there were ads asking the public for donations to
Help Cure Diabetes, the Epidemic of Our Age
. Pancreatic transplantation was a high-tech initiative, and purportedly revenue neutral: curing diabetes would stop the need for dialysis units filled with diabetes-induced kidney failure. Caledonian University was in a race with the University of Alberta to develop a slick, fail-safe transplant procedure that didn't require patients to take toxic anti-rejection drugs for the rest of their lives. Everyone knew that at least one Nobel Prize was on the line. A cure for diabetes would be huge.

“So what am I supposed to do with these people?” Hamish said. “Let them go into shock and die?” In almost every other country on the planet, there would be a private hospital down the street he could transfer them to. But not in Canada. In 1984 — had the irony attached to that year dawned on the country's politicians? — big-brother government had outlawed private health care, except for cosmetic procedures. When Canadians got sick, they got government-issue health care or nothing — unless they were rich and could make it to the States.

“Tell you what,” Jeff said. “I'll send you a taxi filled with all the IV stuff you need. You find someone to look after the infusions. Here — I'll pass you on to the unit clerk. Tell her what you need.”

Hamish looked around the Mountain Wing's nursing station in disbelief. Was he actually going to turn this place into an acute-care ward? He'd need backup. He couldn't manage a ward full of IV drips, day and night, for who knows how long, by himself. Jamieson's on-call replacement, Dr. Awad, wasn't going to be any help: Hamish had paged him three times last night, intending to tell him about Betty, but Awad had never answered. It was probably just as well, he figured. An office GP couldn't be expected to know much about septic shock, toxic megacolon, and running IVs.

One way or another, he'd have to handle this mess himself.

But sooner or later, if no one found the source of the gastro, the effluvium was going to hit the fan in the Belvedere Wing, and they all might need IVs.