Diagnosis Death (9 page)

She dialed again. One ring. Two. Three.
Oh, please answer.

"Dr. Sewell."

"Cathy, this is Elena. Do you have a minute to talk?"

"Sure. What's up?"

How do I say this?
"Listen, there's a problem here. I hope it won't affect your decision to offer me the contract, but you need to know about it."

Elena told the story as unemotionally as possible. She started with Pulliam's presentation in the emergency room. She freely admitted that, because of the similarity to Mark's situation, she'd been drawn to Erma Pulliam and felt a need to counsel her. Elena told how she stood alone in Chester Pulliam's room and wrestled with the concept of putting an end to an existence that was hardly a life. "But I didn't do it."

"Elena, that's all understandable," Cathy said. "I'm glad you felt free to unburden yourself to me, but this isn't going to affect our relationship. Matter of fact, this was probably a breakthrough for you. Maybe it will help you get past Mark's death."

"Unfortunately, the story doesn't stop there. Yesterday afternoon, I met at their request with Pulliam's neurosurgeon, the chair of the neurosurgery department, and Amy Gross."

As she spilled out the rest of the story, Elena envisioned Cathy's face darkening, her thoughts already centered on how she could break the employment contract they'd signed. "So that's where I stand," Elena concluded. "They say I'm okay so long as I stay out of trouble, but it seems to me that trouble is actively seeking me out. If you don't want an associate who's tainted with a reputation for mercy killing, I'd understand. But I swear to you that I didn't discontinue Chester Pulliam's respirator."

The silence on the other end of the line spoke volumes to Elena. Cathy was about to cut her loose. And then what would she do?

"Elena, I accept what you tell me as truth. But let's look at it this way. Was there any hope for Chester Pulliam to live?"

"Maybe one chance in a thousand he could come off the vent, but even then he'd never be a sentient human being again."

"And his wife was leaning toward pulling the— Sorry. I've got to stop using that expression. She was about ready to discontinue life support?"

"Yes."

"So this isn't a case of murder, or manslaughter, or any other crime. What it represents is someone who wanted to get you in trouble professionally, for going outside protocol, for ignoring policy. Right?"

Elena found herself nodding. "Yes, I guess so."

"So the question we have to answer—"

"Right, it's the same one Amy asked. Why did someone want to blame me?" Elena reached for the cold cup of tea and drained it, but her throat was still dry. "Does this mean you still want me there?"

"More than ever. I think the sooner you leave Dallas and the medical school complex behind, the safer you'll be."

Hours later, as Elena lay in her bed, Cathy's words made her shiver. Was this more than harassment? Was she actually in danger? And wasn't it ironic that her escape from danger hinged on a move to Dainger?

She determined to keep a low profile for the next couple of weeks. If a patient with an intracranial hemorrhage presented to the emergency room, she'd get them into the hands of a neurosurgeon as quickly as possible, but there was no way she'd participate in their care. And afterward, she'd avoid their room like the plague. Matter of fact, she wouldn't even visit the ICU unless she was called there to help with a procedure. For the next two weeks and two days, she'd walk the straight and narrow.

She'd start packing tomorrow night. In a couple of weeks, she'd jam cardboard boxes with the remnants of her life into every available space in her little Ford and set out for a new life, a new chance.

Elena's positive thoughts crashed about her when the phone rang. She looked at the bedside clock. Midnight.

She brought the phone to her ear and held her breath. She expected to hear sobbing, but this time there was none. Only silence.

Finally, when she could stand it no longer, she said, "Hello?" Her voice shook, and she hated herself for it.

No answer.

"Hello?"

The reply came in the same rough whiskey alto as the other calls, but the words were different this time. "I know what you did, and you have to pay. This makes twice."

T
he night brought no rest. Elena tumbled and tossed, wracked by dreams of faceless women who chased her through dark winding corridors. Before she left her bedroom, she stripped the sweat-soaked linens from the bed and deposited them along with her still-damp pajamas in the laundry hamper.

Elena made coffee and decided to skip breakfast in favor of a donut on the way to the hospital. She was halfway to the front door when the envelope caught her eye. It peeked from the pile of bills and ads she'd chosen to ignore yesterday when she came in. Elena started to pick it up between her thumb and forefinger before she caught herself.
Don't be silly. No one is going to fingerprint this. Just open it.

It was like the other envelope—plain, self-sealing, available at a hundred stores—addressed in block capitals. This one bore only a single stamp. She squinted to read the smudged postmark—mailed from the central post office on Monday evening.

Elena ripped the flap and pulled out a single sheet of plain paper. The same block capitals, written in blue ballpoint, spelled out a new message:

THAT'S TWO STRIKES. WILL THERE BE THREE?

Elena made it through the morning on autopilot. Clinic was mercifully light. At noon she took her bowl of soup to a quiet corner of the cafeteria. The bowl was empty when she returned her tray to the moving belt, but she had no recollection of what she'd eaten. All she could think about was "two strikes."

This changed everything. The person who made the phone calls was connected with the circumstances of Chester Pulliam's death. Maybe they were the same person, maybe not, but they were certainly connected. Did Lillian's reach extend to the hospital? Could she know the effect of the cloud cast over Elena's professional reputation by recent events in the ICU? And if Lillian was behind this, how had she managed it?

Elena consulted the large clock that hung over the door of the cafeteria. She had half an hour before she was due in the neurosurgery department's monthly M&M conference. She'd been in medicine so long she no longer thought of candy when she heard those initials. No, this was the Morbidity and Mortality Conference, the meeting where the menu centered on complications and death, neither a sweet subject.

One of the "mortality" cases was that of Chester Pulliam. Matney promised that her possible role in the termination of his life support wouldn't come up, but although her attendance was
pro forma,
it was necessary. Now she had twenty-five minutes to make it across campus for the conference. Ten minutes to the shuttle bus stop, ten or more for the ride to the building that housed neurosurgery, another five to make it to the conference room. No, there was no time for what she wanted to do.

Elena started for the door. First the conference, then the phone call. She promised herself she wouldn't forget it. She dreaded making it, but she had to know. This had to come to an end.

Twenty-seven minutes later Elena opened the door of the neurosurgery conference room a cautious six inches and peered inside. A huge conference table occupied at least two-thirds of the room. A mixture of faculty and residents filled the chairs around it, with Matney at the head. Dr. Clark sat immediately to his right with the department vice chairman, Dr. Bruce Mickey, on Matney's left. The chairman whispered something, and the three men laughed. Elena took the opportunity to ease into the room and slide into a vacant chair along the back of the room.

Two junior faculty members were seated to Elena's right. She wasn't particularly trying to eavesdrop, but their whispers came through as though channeled through a megaphone.

"Did you hear about Dr. Matney?"

"Yeah. Dunston's leaving, and Matney's the prime candidate to succeed him as dean. The Search Committee's giving him the once-over right now."

The first doctor looked around. Elena casually directed her gaze to the bound journals lining the walls. Satisfied, he continued. "Matney's already given the word to the faculty. He wants this department squeaky clean. Anything that might look bad, sweep it under the rug or deep-six it some way. If it could bring attention, don't do it."

"I know. He caught me in the surgeon's lounge and told me to stop giving a particular IV med to patients with cerebral edema because that was off-label usage."

"Man, I'll be glad—"

"Let's get started." Matney's eyes swept the room. All conversation stopped as though someone had hit a "mute" button. The chairman leaned back in his chair, apparently relaxed and comfortable.

"Gershon?" This was a first-year resident, who presented the case of a patient who'd developed an infection at the operative site after an otherwise uneventful craniotomy. Elena knew that the most serious neurosurgical complications were vascular— either hemorrhage or obstruction to circulation. This one was unexpected but not what she'd consider major. Indeed, the patient responded well to antibiotics and had no further problems. Nevertheless, Matney spent fifteen minutes questioning the resident and his staff surgeon about how they might have prevented this postoperative infection.

Elena felt her stomach doing flip-flops. If Matney handled the morbidity portion of the conference this way, what would he do when the mortality discussions started? She tried to dry her palms on her white coat, but it didn't seem to help. Her throat was parched, her heart was in her throat. She hardly heard Matney's next words.

"Dr. Neely, tell us about Mr. Pulliam."

This was the resident whose name Elena hadn't been able to recall, the one who had pronounced Chester Pulliam dead. He presented the facts in a monotone more appropriate for delivering an annual report to stockholders than a description of the death of a human being. Elena wondered if this was a coping mechanism adopted early in their training by neurosurgeons because they dealt every day with matters of life and death. She hoped she'd never become that callous about the loss of a human life. Then the irony of that thought brought her up short.

Neely ground to a halt with, "The patient was maintained on life support, but showed no effective respiratory efforts and required IV dopamine to maintain his blood pressure. He had a diffuse dysrhythmia on EEG, showed a positive Babinski reflex, and we observed early decorticate rigidity developing. We discussed withdrawal of life support with his wife. Subsequently that was done and he expired quietly."

That was it. No mention of an unidentified person disconnecting the respirator, or of the questionable DNR order. No finger-pointing by Clark or Matney. Instead, Clark encouraged the residents to maintain a high index of suspicion for arteriovenous malformations, the snake-like tangle of blood vessels around the brain that had ruptured and sent Chester Pulliam to his death. For the first time he looked at Elena and said, "Dr. Gardner, who's joined us today, did all the right things in getting immediate treatment for Mr. Pulliam. Unfortunately, his intracranial bleed wasn't a survivable one. That's why it's imperative to find these before they rupture."

Matney and Clark engaged in a low-key debate about the best surgical approach to AVMs, as they called them, and one of the residents had a follow-up question. Then Matney called on the next presenter, and the discussion moved on.

Elena let out a breath she didn't know she'd been holding. That was it. Could she slip out now? The clock was on the wall behind her. If she looked at her watch, Matney might see it. She decided to sit quietly until the conference ended. She might even learn something.

After another half-hour the last presentation wound down. Matney made a few perfunctory announcements, and the conference was over. Faculty members and residents moved toward the door, most with pagers and cell phones at the ready. Elena insinuated herself into the crowd and inched out of the room, her shoulders hunched as though she could make herself smaller and avoid further contact with Matney or Clark.

Once she was safely in the hall, she took a deep breath and strode rapidly toward the elevators. Three paces from safety, an all-too-familiar voice brought her up short. "Dr. Gardner. May I see you for a moment?"

Elena followed Dr. Matney into his office.

"Please have a seat." He hung his white coat carefully on a hook behind the door and took a seat behind his desk. "Thanks for coming to the conference. Your input wasn't necessary, but I wanted you to see for yourself that we are making an effort to put behind us the controversy about how Chester Pulliam's life ended. In the final analysis, whether you or someone else disconnected the respirator, the result was expected. Mrs. Pulliam remains convinced you were responsible, and tells Dr. Clark she hopes to see you again to thank you."

Elena inclined her head, although she wasn't sure why she would be thanking Matney. After all, he hadn't yet said anything that indicated a belief in her innocence.

"I spoke with two of the ICU nurses this morning," he continued. "One is new at St. Paul, a transfer from the Zale Hospital ICU. I didn't catch her name. She saw you go into Pulliam's room. She has no recollection of when you came out, or of anyone else going in until he was found dead."

"So that doesn't help," Elena said. "What about Ann?"

"I talked with her. She recalls speaking with you in Pulliam's room. She left you alone there when she was needed elsewhere in the unit. She doesn't know when you left. The emergency kept her tied up until the time Pulliam was found dead."

"So no one saw anyone enter or leave Pulliam's room after I was there?"

Matney's expression was that of a teacher sorely disappointed in a star pupil. "Although neither of these two nurses saw anything, there remain fully half a dozen people who might be interviewed." He held up a warning finger. "But I've chosen not to go further. As I told you, it's immaterial whether you or someone else wrote that DNR order and disconnected Pulliam's respirator. It's not homicide or manslaughter. It's not even malpractice. The acts merely brought to an inevitable end an unfortunate chain of events. Therefore, we plan to let the matter drop."

Anything that might look bad, sweep it under the rug or deep-six it some way.
Elena couldn't believe this. "What about the person behind this, the one who wants to cast suspicion on me? Aren't you going to look for them?"

"We have no desire to keep this going and risk any hint of scandal for our department or the medical center. And, as for your reputation—because I know that's foremost in your mind—Dr. Gross and I talked earlier today about the best way to handle the problem. I was adamant in my insistence that the incidents be allowed to fade away without further mention." Matney looked down at the immaculate surface of his desk." To this end, Dr. Gross will give you a terminal leave for the last two weeks of your training. Your certificate will show a graduation date of June 30, but as of now you're relieved of all clinical duties."

"I don't—"

The chairman steamrolled on, apparently anxious to get this done. "Since the doctor whose practice you're entering is pregnant, it's likely she'll be grateful for your early arrival. Perhaps a change of scene will be beneficial to you. It would, after all, take you away from a setting that was the scene of a very traumatic event in your life—an event that could possibly have influenced the way you react to subsequent patients in that same situation."

Elena tried unsuccessfully to wrap her mind around this change. "You're treating me like I'm the guilty party in all this. You're sending me into exile just to get me out of the way."

Matney cleared his throat and put on his best hyper-administrator manner. "I am neither affirming nor denying any culpability you have in the matter. What I am doing is protecting the reputation of the department and this institution by avoiding an investigation into a matter that, although the outcome was in no way unexpected or even improper, is best left alone."

"So I'm out of here," Elena said.

"Actually, when I first approached her, Dr. Gross was inclined to let you continue your residency to its conclusion. However, I felt it best that you leave the campus and managed to convince her to go along with my recommendation. You may consider yourself on probation under the supervision of Dr. Sewell for the next three months. If, at the end of that time, we find no further incidents of this nature, I will accept that you were blameless in the ones about which we've already talked. On the other hand, if a pattern emerges of—shall we say—early termination of life, I will turn the matter over to the authorities for investigation."