Critical Judgment (1996) Read online

  His fury growing with every step, he stalked across the busy road without checking for cars. Horns blasted at him, but he didn't notice.

  The sparkling lights had begun again.

  He raced back to the motel. There was still time, he was thinking. Time to do what God had been telling him to do. Time to end the pain once and for all. The shimmering diamonds of multicolored light snapped against the inside of his eyes like hailstones. He fumbled with the lock, then threw the door open and snatched the rucksack out from beneath the bed.

  "Not this time," he said out loud.

  This time there would be no headaches. There would be no begging God to take him. This time there would be only vengeance. And then the headaches would be gone forever.

  CHAPTER ONE

  "Three hundred joules, please.... Keep pumping...."

  Abby Dolan tightened her grip on the defibrillator paddles as she pressed them against the front and left side of the man's massive chest. He was in persistent cardiac arrest despite two electrical shocks and medication. His face and upper torso were mottled violet, reflecting inadequate circulation despite the ongoing CPR. Clearly, time was their enemy.

  "Ready," said the nurse handling the defibrillator console.

  "Okay everyone, clear!"

  Abby pressed her thumb down on the square plastic button set in the handle of the right-hand paddle. Instantly, there was a muffled pop and an audible, visible spark from two spots where the paddles and skin did not make perfect contact. The man's body--250 pounds at least--stiffened and arched. His arms snapped upward like whips. Then, just as rapidly, he was still.

  "Pump, please," Abby said, checking the monitor screen.

  The paramedic, up on a stool for leverage, wiped the contact gel off the man's chest with a towel, set the heel of his hand over the base of the sternum, and resumed his rhythmic compressions. For several seconds there was a slashing up-and-down movement of the tracing on the monitor. But Abby knew from ten years of ER work and countless code ninety-nines that the pattern was artifact, not related to any effective electrical activity of the heart.

  She glanced up at the code clock started by the charge nurse at the moment of the man's arrival in room three. Nine minutes. So far, nothing. Abby had been working in the Patience Regional Hospital for over two weeks now, at once dreading and eagerly awaiting her first code. She had been busy, at times very busy, over those weeks. But no codes. Now it was happening. And "The Professor," as she knew some of the staff were facetiously calling her, was losing.

  The patient, a married insurance salesman with a couple of kids and some grandchildren, was only fifty-two. He had collapsed while playing golf on one of the public courses in the town. When the paramedics arrived, he still had enough of a heartbeat to generate a pulse and measurable blood pressure. Then, as the ambulance was backing up to the hospital receiving platform, he arrested. All Abby had learned was that his name was Bill Tracy, that he took medicine for high blood pressure, and that his daughter, who worked in the hospital's record room, was on her way in with his wife.

  Abby noted the low, irregular waves on the monitor. Persistent coarse ventricular fibrillation--the sort of electrical disarray that should have responded to a high voltage shock. But it hadn't. Something had to be off with the man's chemistry--something that had either contributed to the cardiac arrest or, more likely, was a result of it. But what? Abby fought a mounting sense of panic. At St. John's, where she had been an assistant professor of emergency medicine, there already would have been a cardiologist in the room to assist her. Maybe two. But that was a university-affiliated hospital in San Francisco. This was Patience, a landlocked mountain town with just two cardiologists, neither of whom was in the hospital today.

  She looked back at the paramedic who was doing the cardiac compressions. Too mechanical. He was well trained, but he was using the technique he had learned on the CPR mannequin, Resusci-Annie. This was a 250-pound bull of a man. Abby pressed her fingertips into Tracy's groin, searching for the femoral-artery pulse that the paramedic should have been generating. Nothing.

  "Harder, Tom," she said. "Much harder. You're not moving enough blood."

  "But--"

  "Please, I know you feel right with what you're doing, but you've got to do it harder. A little faster, too. That's better. That's it. Good. That's it."

  The man, like every paramedic Abby had ever known, took a great deal of pride in his work and his technique. Correcting him in front of the staff was hardly going to increase her popularity, but neither would losing this patient. The CPR, as he had been performing it, wasn't helping. She directed one of the nurses to keep her fingers on the femoral pulse and to call out if it began to disappear.

  In addition to Abby, there were three nurses, a respiratory therapist, and the paramedic in the room. At St. John's there would often be that many physicians at a cardiac arrest. If the patient didn't make it, at least they all knew that everything that needed to be thought of had been. She wondered if anyone in the room knew how frightened she was about how this code was going--how concerned she was about missing something. Under the best of circumstances she was a worrier--meticulous in her approach to medicine and to life, always considering the potential downside of any move before making it. It was her best and worst quality, depending on whom you asked. But here, with no available backup, no one to bounce things off, and not much time left, she was very much on her own. In seconds she subconsciously but systematically flipped through dozens of possible sources of the trouble she was having.

  "Are those labs back?"

  "Three or four minutes, they say."

  Abby knew that three or four minutes often meant five or ten. Bill Tracy didn't have that kind of time. She looked down at the dark, stretch-scar-like markings over his lower abdomen, and the fullness of his face. Then she reached under his shoulder and placed her hand palm up at the base of his neck. There was a prominence there, a definite fullness. Over her decade as a physician, she had seen only five or six cases of Cushing's syndrome, but this man certainly seemed like a candidate. The syndrome was caused by a small, benign brain tumor that chemically told the body to produce an excess amount of the hormone Cortisol. The tumor itself wasn't usually fatal, but the high sodium, low potassium, and other derangements caused by the Cortisol often were. Among the physical signs of the syndrome were obesity, a moon face, purple stretch scars along the abdomen, and a prominent so-called buffalo hump between the shoulders. Bill Tracy had all of those. Of course, many thousands of markedly overweight people without Cushing's had all those findings, too.

  PRH had better-than-decent medical-specialist coverage, especially for a one-hundred-bed facility in a service area of twenty thousand. But there was no endocrinologist. And at the moment there was no cardiologist either.

  She rapidly processed the possibilities. Without lab results, especially a potassium level, she was running blindfolded. If Tracy had low potassium from Cushing's, none of their resuscitative efforts would work until the abnormality was corrected. If he didn't have Cushing's, if his potassium was normal and she gave him more of the electrolyte intravenously, he would be as good as dead.

  "Get ready for another shock," Abby said, struggling to keep panic out of her voice. "Three hundred joules again. Tom, keep pumping, please. As hard as you can."

  She hesitated. Giving IV potassium without a serum-potassium level was about the most un-Abby Dolan thing she could imagine.

  Just go ahead and shock him, the voice in her head insisted. Do it!

  "Mary, I want him to get some potassium right now," she suddenly heard herself saying. "Ten milli-equivalents IV."

  "But I've never--"

  "Please," Abby ordered sharply. "I don't have time to debate this."

  The nurse's cheeks flushed. She quickly filled a syringe. For a moment Abby thought the woman was going to tell her to inject it herself. But no.

  "Your potassium's in, Doctor," she said coolly.

  "Thank
you."

  First the paramedic, now the nurse. How many more people would she offend before this code was over? She checked the clock. Almost twelve minutes, plus a few minutes to get Tracy in from the ambulance. Too long for him still to be in ventricular fibrillation. She took the defibrillator paddles, accepted some contact gel from the nurse, and rubbed the two circular steel heads together to spread it out. A negative outcome and controversy--the last results she would have wanted from her first code in Patience. But, then, she would never have been in Patience in the first place if Josh hadn't--

  "Okay, stop pumping, please. Everyone clear!"

  Forty-five seconds since the potassium. Now fifty. There was no more time. Abby hit the button. Again the muted pop, the single spasmodic contraction of every muscle in Bill Tracy's body, the faint odor of searing skin. And, again, the tracing showed only artifact.

  "Resume pumping," Abby said, no longer trying to mask her dejection. "No. No, wait." The artifact had largely cleared. There was a rhythm on the monitor--slow, but regular. Abby felt her own heart skip some beats. "Check for a pulse, please."

  "Go, baby," someone murmured. "Go ..."

  "I've got a pulse," the nurse called out as she pressed down over the femoral artery. Purposely looking away from the monitor screen to remain as objective as possible, she reported what she was feeling in her fingertips. "Now ....... now ....... now ... now ... now ... now ... now."

  The pulse she was chanting correlated perfectly with the monitor pattern. The heartbeats were speeding up; the electrocardiogram complexes were becoming narrower, healthier.

  "I've got a blood pressure at eighty, Abby," a second nurse announced. "Eighty-five. Hey, nice going."

  A successful code was everyone's victory. But more often than not, Abby knew, the failures were left to the doc.

  Bill Tracy's horrible, violet mottling rapidly and markedly improved. Tissue throughout his body was getting blood for the first time in fifteen minutes. No CPR, however well performed, could ever measure up to the real thing, Abby was thinking. Now all that mattered was getting him stabilized and praying that his brain had not been part of the tissue too deprived of circulation during that fifteen minutes.

  A pretty woman in her early twenties rushed in. She was wearing faded jeans and a designer T-shirt. Her face was gray with concern.

  "Dr. Dolan, I'm Donna Tracy," she said breathlessly. "I work part-time in the record room downstairs. That's my dad."

  Abby checked the monitor. The encouraging pattern was holding, although Bill Tracy was still unconscious. She lifted his eyelids. Midsize pupils, no wandering eye movements--both good signs.

  "Can't tell," she said. "But things are going in the right direction."

  At that moment the lab tech arrived, as breathless as Donna Tracy.

  "His potassium's only one point eight," he announced. "Checked and rechecked. One point eight."

  For the first time since the rescue-squad call had come in from the golf course, Abby Dolan smiled.

  "Not anymore," she said.

  Donna Tracy and her mother were at the bedside and Bill Tracy was beginning to regain consciousness when his private physician arrived. Tracy was still on a ventilator, but he was starting to buck against the tube. Before too long the decision would have to be made whether to sedate him or to take it out. Abby favored continued mechanical ventilation, but with the primary doc on hand, the decision was no longer hers.

  The physician was a tall, angular, somewhat nervous-looking man in his fifties named Gordon Clarke. Abby had cared for a number of his patients. His manner was earnest enough, and he was certainly popular with his flock. But his diagnostic and therapeutic skills were badly in need of updating. If he had been on the staff at St. John's, assuming he could have ever gotten admitting privileges there in the first place, he would have been assigned a monitor from the faculty to oversee his admissions and help him improve clinically. And, of course, he would have been exposed to weekly medical grand rounds and other academic presentations. But this was the boondocks, not academia. And although Patience Regional Hospital was incredibly modern and well equipped, modernizing a physician was often far more difficult than updating a building.

  Abby could see the relief in Clarke's eyes as he looked down at his patient.

  "The nurse who called my office made it sound as if he didn't have much of a chance."

  "He's still in some trouble," Abby responded, "but certainly less than he was."

  "I'm very grateful."

  "So are we," Donna chimed in.

  "What kind of coronary was it, anterior?"

  Abby glanced down at the EKG she had just had taken and then passed it over. It showed some evidence of cardiac strain, but no actual heart attack. Clarke studied it. He looked confused.

  "I don't see any damage," he said.

  "His potassium was one point eight."

  "Are you sure?"

  "Checked and rechecked. His chloride was down as well, and his sodium was elevated. His serum pH was high--seven point six."

  Abby hoped that when she recited the numbers, Clarke would come up with a list of diagnostic possibilities, including Cushing's and overmedication with diuretics. Now, she realized, she should have waited for a less public situation before bringing the whole business up. He was quite obviously clueless. The silence in the room was painful.

  Clarke cleared his throat and stared down at the office record he had brought in. A slight tic had appeared at the corner of his mouth.

  "I ... um ... I've gotten electrolytes on him twice in the last eight months," he said finally. "It appears his potassium was somewhat low on both occasions. I ... guess I just didn't think much of it."

  Abby was not surprised. Her inner voice was warning her to let the matter drop, to curb her redheaded-Irish temper and take this up at another time. But she had never been tolerant of incompetent physicians. Making mistakes was one thing. Every physician made them at one time or another. But ignoring abnormal laboratory results because they weren't that abnormal was quite another. Bill Tracy's death would have been her failure. And the two women standing beside him would have suffered a horrible loss. Horrible and quite probably unnecessary. Once again the small voice went unheeded.

  "He has a moonish face, high blood pressure, those purplish streaks on his belly, and a pretty prominent buffalo hump."

  "I'm afraid I don't know what you're driving at," Clarke said, his cheeks as red as the nurse's had been.

  "Dr. Clarke, I'm sorry. Maybe we should talk about this later. They should be here to take Mr. Tracy up to the unit any moment."

  "No, that's okay. Go ahead. Tell me what I missed."

  Abby saw the tiredness in the man's eyes. Never had she been out in a community caring for a busy, demanding general medical practice. And, in fact, until a few weeks ago, she had never even been detached from the university-hospital umbilical cord. She felt as if a sluice gate had opened, and all her feelings of irritation and impatience toward Gordon Clarke had instantly washed out.

  "Dr. Clarke," she said, "I'm sorry."

  "That's all right." Now it was Clarke who seemed irritated and impatient. "Just tell me what you think is going on."

  "Okay. He looks like he might have Cushing's."

  Clarke closed his eyes for a moment and then nodded and sighed. Abby was saddened by what she knew he was thinking.

  "That's a heck of a pickup to have made under fire like that, Dr. Dolan," he said. "You certainly saved Bill Tracy's life." Wearily, he met the gazes of Tracy's wife and daughter. "Sorry Edith, Donna. I should have paid more attention to those potassium levels. I'll see you up in the coronary unit."

  Quickly, he turned and left. As he passed through the door, Abby realized that George Oleander, the chief of medicine, had been standing there, taking in the whole scene. Oleander had been one of the staunchest supporters of her application to fill the ER vacancy at PRH.

  He watched Gordon Clarke hurry away, then turned back to the room
. His eyes met Abby's.

  "That was a great save, Abby," he said, with much less emotion than the words warranted. "Perhaps when you have a few minutes, you could stop by my office."

  CHAPTER TWO

  It was nearly three before a lull in the steady stream of patients allowed Abby to clear out the ER and call George Oleander. Besides Bill Tracy's resuscitation, the day had brought two more new cases of adult-onset asthma and one more of a skin condition that might have been hives, but really didn't look like any hives Abby had seen before. The asthma cases raised to five the number she had treated in just over two weeks. Most of them had responded reasonably well to standard therapy and had been referred back to their own physicians. One had required hospitalization in the ICU.

  Asthma beginning in adulthood was fairly unusual. Five cases in six months would have been more like it. Abby's history taking had gotten more and more detailed, but so far no pattern had emerged. And no one on the medical staff seemed concerned or even interested. Allergy Valley was the way Oleander had referred to the area. Pollen Central.

  The skin condition--raised, hard red welts that burned more than itched--was the second such case Abby had seen since starting at PRH. Dermatology was never her strongest suit, but at St. John's it didn't have to be. There was a derm clinic available during business hours, and derm coverage twenty-four hours a day for anything beyond the mundane. The welts looked to her more like vasculitis, an inflammation of the small blood vessels in the skin, than like hives. But, in truth, they really didn't look precisely like either. At their private doctors' request Abby put both patients on oral cortisone and antihistamines, probably the best initial treatment for any inflammatory or allergic condition.

  After Bill Tracy had been taken to the coronary unit, Abby had some fences to mend. She began with an apology to Tom Webb, the young paramedic. The tension of the moment had caused her to be more brusque than she had intended, she explained. He was damn good at what he did, and his skill in the other emergencies they had shared matched the best she had known in the city. The young man claimed he understood, but his expression made it clear he was still smarting.