Critical Judgment (1996) Read online

  Soon after, Abby sought out the nurse she had snapped at, Mary Wilder, and made amends to her for not explaining the rationale for IV potassium before ordering her to administer it. Wilder, ten years or so older than Abby, had been at PRH since well before the place was rebuilt a decade ago. The nurse was genuinely embarrassed by her hesitation in following Abby's emergency orders and told Abby how much it meant to her and the other nurses to have a doctor of her caliber working in Patience. The two women shook hands warmly, and Abby returned to her patients with the sense that she had made her first genuine ally in the ER.

  Gordon Clarke was the lone remaining ego casualty of the code ninety-nine. But righting things with him could wait until after her shift was over, and after her meeting with the chief of medicine.

  George Oleander had an office in the Medical Arts Building, connected to the hospital by a covered passageway over the main driveway. The hospital itself, a three-story jewel of plate glass, brick, and cedar, was set in a meadow at the easternmost tip of the valley, right at the base of the foothills. Whether the mountains beyond those rugged hills were the southern Cascades or the northern Sierras seemed to depend on whom you asked. To the west of the hospital sprawled Patience, a boom town during the gold rush, a mining town for many years after that, and then, from what Abby had been told, nearly a ghost town. Hikers and other outdoors lovers had always used the place as a jumping-off point and might have kept Patience alive. But it was the arrival of Colstar International, twenty-five years before, that had really turned things around.

  As she passed through the glass-enclosed walkway to the Medical Arts Building, Abby gazed at the huge gray concrete factory, set atop a plateau a quarter of a mile from the hospital and several hundred feet up. The largest producer of portable power sources in the world, the Colstar brochures proclaimed; they made lithium batteries, lead acid batteries, alkaline batteries, solar batteries, rechargeables. Having been inside the factory once to see Josh's department and office, Abby saw no reason to dispute the claim.

  The Medical Arts Building, clearly designed by the same architects responsible for the hospital, featured two dozen office suites with balconies facing the mountains or the town. George Oleander's second-floor office overlooked the flowering meadow, dotted with trees, that stretched out to the base of the Colstar cliff. It was a beautiful, pastoral view as long as one didn't look up. In addition to the usual array of diplomas, postgraduate certificates, and testimonials, there were pictures of Oleander with two governors of California, and another with longtime California Senator Mark Corman, a possible Republican nominee for President.

  The medical chief greeted her warmly. He was fifty or so, with graying temples and the soft, broad-shouldered physique of an out-of-shape athlete. The redness in his cheeks and nose suggested to Abby that he might be a drinker. He motioned her to the chair across his desk, where she had sat for two interviews before being hired.

  "So," he said, "that was quite a performance."

  "I hope you're talking about the code."

  "Of course I am. Abby, there's absolutely no need to be defensive. You've been a wonderful addition to this hospital."

  "Thank you."

  No comment seemed necessary. Abby knew she hadn't been summoned to be told what a bang-up job she was doing.

  "The nurses have been very pleased with the last three ER choices we've made--Lew Alvarez, you, and, of course, poor Dave Brooks."

  This time Abby nodded her appreciation, not bothering to comment on the obvious--that if Dave Brooks hadn't died in a rock-climbing accident, her own appointment would not have been necessary. The other four ER docs were husband-and-wife Chris and Jill Anderson, Ted Bogarsky, who commuted in from someplace twenty or thirty miles to the west, and Len McCabe, an aging GP. During her orientation week Abby had been assigned to double-cover with each of them and with Alvarez. None of the five was a liability in the ER, although skittish, insecure Jill Anderson was close. But only Lew Alvarez showed a genuine flair for the work.

  "The medical staff likes you, too," Oleander continued.

  "I have my doubts about that."

  "They do. I can tell. It's just that ... Abby, we're small town here. Until we know someone, and know them well, the way they say things is as important as what they have to say. You're big city--and big city university hospital to boot. That makes you threatening to some people right from the get-go. One person told me that you seem tense and short with people. He said that a lot of the medical staff were ... I don't know ... intimidated by you. I didn't really understand why anyone would feel that way until this morning."

  "Dr. Clarke."

  "Gordon's an extremely nice man, and devoted to his patients. He's been here for over twenty years, almost as long as I have."

  "And I made him feel like a jerk."

  "I don't think there're many physicians who would have plucked Cushing's syndrome out of the air the way you did."

  Abby stopped herself from pointing out that Clarke really should have paid attention to the two low potassium levels he'd gotten on Bill Tracy in his office. Oleander was right. She hadn't been relaxed about her job since the day she had accepted it. For the umpteenth time since then she wondered if she had made a mistake. As far as she knew, no one at St. John's, not even the good old boys who always had trouble accepting women docs in positions of authority, had ever felt anything but pleased at having her around. Now, just by being herself, she was a threat.

  She tried reminding herself that being with Josh, planning their life together, was worth the decision she had made. But even that thought didn't fit as comfortably as it once had.

  "The Cushing's was a lucky shot," she said. "Assuming it's even confirmed by the lab. A flat-out lucky guess. George, you're right. I have been too tense here."

  "About what?"

  "I don't know. Maybe just the newness of everything."

  "I understand. Are things okay at home?"

  "What do you mean?"

  "You told me in our first interview that you wanted to move here because your fiance had relocated to work for Colstar."

  Actually, he's not technically my fiance. We haven't really set a date. She could have said it but didn't. And yes, the tension has everything to do with how things are at home.

  "Things are fine with Josh," she said. "Thanks for asking. It's me. You know, you may not believe this, but I've been scared stiff about coming here since the moment you called to tell me I had the job."

  "I understand. Patience is a far cry from Union Street and Golden Gate Park."

  "Believe it or not, it wasn't the town. It was the hospital. I went from med school to training to a staff ER position at St. John's. Except for a little moonlighting I've always had the protective cocoon of knowing specialty help was never more than a few floors away. I have this overwhelming admiration for docs in remote ERs who have to do the whole thing themselves. Everything. The pediatric trauma and the adult codes. The stabilizing orthopedics and respiratory failure. Even the emergency neurosurgery."

  "We're not that remote, Abby. We have a helipad. San Francisco's just an hour or so from here by chopper."

  "Weather permitting. Don't misunderstand me, George. I love the feeling that no matter what happens, no matter what's thrown at me, I'll know what to do about it. It's just that for the last ten years I've always been able to call for help."

  "We've got a hell of a staff for a hospital this size."

  "I know. Hey, I don't mean to sound like a wimp. And I understand that the most any of us can ever do is our best. But I still don't like making errors."

  "None of us does."

  "For the four weeks between hearing from you that I got this job and actually starting it, I spent almost every free moment studying."

  "Judging from your resume and letters of recommendation, I would never have guessed that."

  "Well, it's true. And I think if I've seemed tense to people, that's the reason. A community hospital is uncharted waters for
me. I don't want to make a mistake. Reputations in hospitals, especially negative ones, are created very quickly and recast very slowly."

  "That's precisely why I called you in today. I want your reputation here to reflect the fine physician you are. Nothing else."

  Abby's page summoned her to the ER at almost the instant Oleander's receptionist knocked and peered in around the door.

  "That was the ER, Dr. Dolan," she said. "Just three patients waiting. Nothing critical."

  "Thank you."

  "I'm sorry I missed you when you arrived. I was over at the lab. I wanted to thank you for doing such a good job on my nephew Brendan's cut chin. He's only five. I'm sure you don't remember him, but--"

  "As a matter of fact, I remember him very well. We redheads pay attention to one another."

  "My sister said you kept whispering to him while you were getting ready to sew him up."

  Abby smiled. "I was just reminding him that he was in charge, and that I would stop anytime he told me to. When I was a kid, I used to hate the feeling of losing control of any situation, especially one in the hospital or dentist's office. In fact, I still feel that way. I always try to make sure kids know they still have power."

  "Well, my sister said you were just great with him. Do you have children?"

  "No ... no, my fiance and I hope to have some before too much longer, though."

  "Well, I hope you do."

  The woman smiled, pulled her head back, and closed the door.

  "I rest my case," Oleander said. "Everyone in Patience is connected in some way or other with everyone else. And no one is more important than the doctors. You've already made a great impression on the town. You just have to practice being a little gentler on the staff."

  "Consider it done."

  "Thank you."

  Abby stood and shook Oleander's hand.

  "I'm curious," she said. "Which doctor was it who said I seemed tense and short with people?"

  Oleander debated responding.

  "To tell you the truth," he said finally, "I think Dr. Alvarez said something to me in passing. Given that it was him, I probably shouldn't have even bothered mentioning it. Alvarez is an excellent physician, but if you'll excuse me for saying so, he's not much of a team player. He seems to have an opinion about pretty nearly everything and everybody. And he isn't the least bit shy about spreading it around. Sort of like fertilizer."

  Oleander enjoyed a laugh at his own humor. Abby smiled politely.

  Lew Alvarez. She supposed she should have known. Alvarez was clearly the top dog in the ER--at least until her arrival on the scene. But he was almost too self-assured. That and his irrefutable good looks had been something of a turnoff to her. It was hard to imagine his perceiving her as a threat, but she knew that was the sort of thing one never could tell about a person.

  "Thank you for telling me," she said. "I'll see what I can do about changing his opinion of me."

  "Suit yourself. Personally, though, I don't think Lew Alvarez's opinions matter all that much."

  Abby wondered why the medical chief was so skeptical of Lew Alvarez despite the nurses' high regard for him. But this wasn't the time to get into it. She thanked him for his candor and left the office.

  Heading back to the emergency room, she admitted to herself, perhaps for the first time, that of all those on the medical or ER staff, it was Alvarez she had most wanted to impress.

  So far it appeared she hadn't done a very good job of it.

  CHAPTER THREE

  Before returning to the ER Abby stopped by the ICU. Bill Tracy was extubated and propped up at a forty-five-degree angle, taking sips of water through a straw. His wife hovered over him from one side of the bed, his daughter, Donna, from the other. All things considered, Abby thought, he was looking damn good.

  She stayed by the nurses' station long enough to take in the scene, then left without going into the room. Mindful of the situation with Gordon Clarke, she was purposely shying away from contact with Tracy and his family. Besides, she realized how easily things could have gone the other way. This was a time for reflection and gratitude, not celebration--and certainly not smugness.

  It was almost five-thirty when she reentered the ER. Two and a half hours until her relief showed up. Ironically, it would be Lew Alvarez. She'd have a chance to practice her new, nonthreatening manner.

  There were now four patients to be seen--one in the waiting room, one in X ray, and two on stretchers. None of them seemed too complicated at first glance, but she could recall dozens of examples, secondhand and personal, of the folly of relying on your first glance. She rubbed at the gritty fatigue in her eyes and wished she was home. She wanted to call and check in with Josh, but it was doubtful he would be back from work yet. The ER was just a patient or two from becoming backed up, and the nurses had already begun ordering tests on the two who had been there longest. Abby decided to make sure things were going in the right direction before she called home.

  The evening charge nurse, Bud Perlow, met her at the chart rack. He was an imposing six foot four, but Abby had seen him use his puttylike face to put kids at ease. At five eight she had to step back several paces to make eye contact with him comfortably. She encouraged all the nurses to call her by her first name, but Perlow was one of the few who insisted on Doctor.

  "Dr. Dolan, rescue is on its way in with Old Man Ives," he said. "He's been beaten up. Primarily facial lacerations."

  "I don't know any Old Man Ives."

  "Oh, sorry. I forgot you're new. Just about everyone in Patience knows him. He's a hermit. Very weird--retarded, I've heard. Lives in the woods. Someone told me he actually lives in a cave. He comes into town every few weeks to sell his carvings and pick up supplies. Usually people leave him alone, but apparently this time someone didn't."

  Abby took two charts from the rack.

  "I'd better get a move on, then."

  "It may not be a problem," Perlow said. "Dr. Bartholomew's on backup for surgery, and he's in-house. I just saw him."

  "Great."

  The word came out more sarcastic than she had intended. Martin Bartholomew, one of four general surgeons on the staff, insisted on suturing every laceration that came in while he was on backup. Although Abby had yet to have a run-in with him, she had been warned by the other ER docs that it was only a matter of time. Bartholomew had an ego as bloated as his waistline, and unique requirements for even the most mundane procedures. It was sport for him to chastise a nurse in front of one of his carriage-trade patients for forgetting his special clamps or for opening a 6-0 instead of a 7-0 packet of suture.

  "Shall I call him now?"

  "Better let me at least check over Mr. Ives first."

  Through the waiting room Abby could see another patient enter, this one a middle-aged woman, pale but ambulatory, supported by her husband. Probably a GI bug, she guessed. It was definitely time to get in gear.

  The patient in X ray had a straightforward, nondisplaced wrist fracture. Plaster splint, a few Tylenol number threes, and an orthopedic referral. But the two patients on stretchers were both enigmas. Neither was a true emergency, but their insurance probably didn't charge them a penalty for using the ER instead of contacting their primary doctor. One complained of fatigue and a low-grade cough, the other, a flamboyant fifty-year-old redhead, of chronic severe itching with no noticeable skin rash. Physical exams on both were negative, as was the chest X ray Perlow had obtained on the cougher. Abby ordered some additional laboratory studies but suspected that they, too, would be unrevealing. Two more in what was beginning to feel like a series of ill-defined or unusual conditions.

  Was it her imagination, or had she been starting more and more of her discussions with patients by saying something like, "At this point I don't really know what's wrong with you, but ..."? The challenge with cases like these, maybe the most difficult in ER medicine, was to be certain that no one was discharged feeling that his symptoms were being taken lightly. Patients like that were lawsu
its waiting to happen. Abby was constantly reminding herself that although a particular problem might not have been the worst thing she had seen that day, it was certainly the worst thing the patient had had.

  While the two remaining patients from the waiting room were being evaluated by the nurses, Abby closed herself in the small doctor's office and called home, expecting to get the answering machine.

  "Hello?"

  Not only was Josh home, but it sounded as if she'd awakened him. Lately it had been more and more like that. For the two years they had dated, before he'd moved to Patience, sleep had been something of an enemy to Josh. Even during his months of unemployment he had stayed upbeat and energetic. Maybe those ten months had taken more of a toll than she'd realized, though. Or perhaps the expectations and pressures of his job at Colstar had been more than he had bargained for.

  Over the five weeks they had been together in Patience, and even before she had moved up to join him, Josh had been irritable, distracted, easily fatigued, and bothered by headaches. A checkup with lab tests at the Colstar employees' clinic, done at Abby's insistence, had turned up nothing. But the disturbing changes in him had persisted. Recently, she had begun to wonder if she had wanted so badly for their relationship to work that she had never allowed herself to see Josh's darker side.

  "Hi, honey," she said. "Are you okay?"

  "What's that supposed to mean?"

  "Nothing. You just sounded tired."

  "I'm sorry. I was on the couch. I ... I guess I must have fallen asleep."

  On the couch ... fallen asleep ... The Josh Wyler she had fallen in love with probably hadn't taken a nap since he was two months old.

  "Well, you left for work at five-thirty this morning," she said. "Maybe you should start a little later."